Roscommon Financial Information

telephone: 617.469.5543

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Much has been written recently concerning health care costs and cut backs in government entitlement programs such as Medicare and Medicaid.

Individuals are responsible for paying for their own care to the extent that they have the means to do so and are not covered by insurance. Paying with personal funds is known as private pay. Private pay, insurance and the various government programs are outlined below.

If an individual has assets, he or she is expected to pay with personal funds until the money and assets (other than those funds excluded by law) runs out. A spouse has a legal obligation to pay for nursing home costs unless the ill spouse qualifies for Medicaid. Children and other family members (other than the spouse) are generally not required to pay in most states, but they may choose to in some cases.

Medicare covers the cost of a nursing home stay only under certain circumstances.
The criteria are as follows:

1. The individual requires skilled care (i.e., nursing care other than general custodial, intermediate or personal care).
2. The care is provided only after a three (or more) day hospital stay for treatment of the same illness or condition that was treated in the hospital.
3. The nursing home is a Medicare-approved skilled nursing facility with a registered nurse on duty 24-hours a day.
4. The patient is assigned to a bed that is Medicare-certified for reimbursement.
5. Only a nursing home can provide the skilled care required. Even if these criteria are met, Medicare only covers the costs of care for up to 20 days. An additional 80 days may be provided on a co-payment basis.

For more information on Medicare benefits, visit the Medicare web site.

Medicaid regulations allow nursing home care to be provided for the poor or those that become poor. Different states have different rules that define "do not have the means." Divesting assets in order to qualify for Medicaid has been a continuing problem for state administrators resulting in regulations that limit the period in which an individual may divest assets prior to entering a care facility. Rules for Medicaid eligibility vary between states. However, the primary qualifications for Medicaid to provide for long-term care in a nursing home include the following:

1. Be at least sixty-five, blind or disabled as determined by the state;
2. Be a resident of the state which would provide the Medicaid benefits;
3. Need the type of care provided by a nursing home;
4. Meet the income limitation test;
5. Meet the assets limitation test.

You may learn more about Medicaid benefits in your state by contacting the
Massachusetts Department of Medical Assistance.

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