If you or a loved one may be facing admission to a skilled nursing facility, you should understand the basic facts of long term care, how to pay for a nursing home stay, and, perhaps most importantly for most of us, how to avoid going to the nursing home. Planning cannot start soon enough.
Paying for Nursing Home Care
Generally speaking, if you are admitted to a nursing home, you may have some very limited Medicare coverage (not more than a couple of months of full coverage). Once Medicare coverage runs out, your choices are (1) to pay the nursing home’s private pay rate, or (2) to become eligible for long term care benefits through the Medicaid (MassHealth) program.
If you are paying privately, you will owe the nursing home between $12,000 and $14,000 per month, depending upon how much the specific facility charges.
If instead you are MassHealth eligible, you will pay only a portion of your monthly income (this is called your “Patient Paid Amount,” or PPA), and MassHealth will subsidize the difference, using its own rate of reimbursement (which is always lower than the facility’s private-pay rate) to determine the balance that is owed to the facility.
The subsidy that MassHealth pays each month for your care is equal to:
The daily rate of reimbursement that MassHealth sets for the facility
The number of days in the month
Your available PPA
Your PPA can vary quite a bit, depending upon how many deductions you have. Everyone gets a monthly deduction of $72.80 for personal needs. If you pay for private health insurance, that’s a deduction, too. There are a few other small deductions, too varied to list individually. After deductions, all of your monthly income is owed to the facility, as your PPA.
In addition to PPA rules, the exact daily reimbursement rate that MassHealth pays for your care is affected by the amount of nursing care that you need each day. This variance is due to the fact that MassHealth pre-sets six different levels of payment (which are, confusingly, tied to ten—not six—levels of medical care) for each nursing home separately. The highest level of payment often is as much as 90% of the private-pay rate for that facility, while the lowest level of payment can be as little as half of the private-pay rate for that facility. It is a strange, and complicated, reimbursement system.
If all of this seems confusing, that’s because it can be. So if the answer to the title question—whether you or someone you love may be facing admission to a nursing home—is “Yes,” contact your local Council on Aging or Aging Services Access Point (ASAP) for guidance. You may be eligible now for coverage for the services you need.
Home Care through MassHealth
In addition to paying for nursing homes, sometimes MassHealth benefits can help you stay out of a nursing home. One of the most important home-care options offered by MassHealth is the Frail Elder Waiver (FEW) program. This program may be available if you need enough care to be a candidate for nursing home care, but it is possible to meet your needs with extra care at home.
The FEW program requires you to create a viable plan for care in your home. Viable means that it is possible to care for you at home, within the financial limits that MassHealth is able to pay. The ASAP will come to your home, evaluate you and your circumstances, issue a report, and make a decision about whether it is possible to care for you at home, based upon what amount of services MassHealth would be willing to pay for. Getting a positive decision is a critical first step.
The services that are available for home care include visiting nurses, personal care attendants, home health aides, Meals on Wheels and many, many other specific types of services. The ASAP is the hub for delivering all of these services. They know what is available, and can match your needs to the services that they can provide.
ASAPs are strong advocates for home care. They cannot, however, approve home care in every instance. If you would need round-the-clock nursing care, i.e., more than just a home health aide, it may be simply too expensive to pay for that much home care. MassHealth is required, unfortunately, to treat all applications for benefits as both a financial concern and a medical concern. If it would be significantly more expensive to provide care for you in your home than in a nursing home, you might be denied the amount of services under the FEW program that would enable you to stay home.
If you have family or friends who can cover parts of your home care, it may become much easier to qualify for the FEW program. For instance, if the only help that you need during nighttime is something that family member or a home health aide can provide, MassHealth may be able to pay for that service as an FEW program benefit. But if you need a skilled nurse to be available to you at all times throughout the day and night, it is less likely that the FEW program would be able to provide that much skilled nursing care at home. You would probably have to go to a nursing home for that level of care.
To summarize, the criteria for the FEW program are:
(1) The ASAP determines that you are a candidate for a nursing home placement;
(2) It is medically (“clinically”) realistic that could remain at home with a combination of skilled and unskilled home care;
(3) You are financially eligible for MassHealth benefits,
Details about the income, asset and clinical eligibility rules for FEW benefits can be provided by a “SHINE” counselor (“Serving the Health Insurance Needs of Everyone”), who have offices in your local ASAP.
Other Home Care Services
Other home-care options are available through MassHealth. For example, there is a PCA program that can pay a family member to stay home and provide care. The wage that is paid is modest (generally less than $1,500 per month), but if someone is available, these payments can make it affordable for that person to give up other income options in order to provide home care.
If you or a family member are facing nursing home placement, there are options. Follow these steps:
- Contact your local ASAP (Find your local ASAP).
- Work with ASAP to determine coverage eligibility under any of the home care options (including, but not limited to the FEW program) that are offered through MassHealth.
- With the assistance of the ASAP, determine a Care Plan.
- If you have significant assets, consider consulting with an elder law attorney. Visit the MassNAELA website to find an experienced attorney to work with.
Long-Term Care for People of All Ages with Disabilities
There are also long-term care services and planning available for people with disabilities, regardless of age, through the Aging and Disability Resource Centers, ADRCs, which include Center for Independent Living. Contact your local ADRC for guidance. Disabilityinfo.org
About the Author
John J. Ford, Esq., is Senior Attorney and Director of the Elder Law Project at the Northeast Justice Center in Lynn, Massachusetts. John has forged case law, shaped public policy and inspired countless others to protect seniors in Massachusetts throughout his distinguished, five-decades long career in legal services.