In California, nursing homes are considered health care facilities and as such are licensed and scrutinized by the California Department of Health Services. As medical facilities they are allowed to provide services that cannot be dispensed in assisted living or board and care homes. Typically these services involve managing complex and potentially serious medical problems such as infections, wound care, IV therapy, and coma care. They offer both short and long term care options for those with serious problems and disabilities such quadriplegics, MS patients, ALS patients and others who are bedridden and are unable to do anything on their own.
Nursing homes also provide a host of rehabilitation services that are typically utilized on a short-term basis after a hospitalization for injury or illness. Patients can receive almost any kind of rehabilitative therapy in nursing homes these days, most of which will be covered, in whole or part, by Medicare or Medicare HMO's, with the requirement that there is hospitalization for 3 days prior to a discharge to a nursing home. However, the implementation of the Prospective Payment System limits payments to nursing homes and allows them to choose who they admit.
So who needs a nursing home? Only those individuals that have serious disabilities to the extent that the services that they need cannot be found through residential care (aka board and care) or home care. Unfortunately, economics rather than the availability of services often dictate the choice. It works like this; if you're on a limited budget and cannot afford $4,000 to $7,000 a month for 24 hour home care or $2,500 to $5000 for residential care you may have to be placed in a nursing home with the cost paid for by the state under the Medi-Cal long term care program (California's Medicaid program for those with no financial resources of their own). For more information regarding qualifications for this program, contact Senior Advisors Network at 800-640-5626 (California only).
What Medicare Will Pay
Many people still believe erroneously that Medicare picks up the tab for nursing home stays. Medicare only pays for your stay while you are receiving actual medical services for up to 100 days, provided you had met the hospitalization requirement. Medicare will only continue to pay for skilled care as long as the patient is responding to that care. Once the patient has reached a plateau where the Doctor feels that the patient will not benefit from any further care, Medicare will stop making payment. Also, no matter what the needs, Medicare will only pay 100% for the first 20 days. From day 21-100, the beneficiary will pay $133.50 per day (2009 amount) and the full cost after 100 days. Medi-Cal will take over only if the individual qualifies both financially and physically for long-term care.
How to Avoid the High Cost of Nursing Homes
One easy way to avoid the high costs of nursing homes is to take out a long term care insurance policy. It is difficult to say too much on this subject, as it is both complex and legalistic. There are many insurance companies advertising that they can save the family fortune for a fee. This only works if you take out the policy before you need nursing home care. In addition, most companies want you to be relatively healthy at the time they issue the policy.
Some people think that they can beat the cost by getting themselves or their family member qualified under the Medi-Cal program. And there are many attorneys and quasi attorney-like services that advertise that they can get you qualified on Medi-Cal and save your assets. Beware of these promises. There are rule changes happening all the time regarding who qualifies, what they can divest themselves of and what they can keep in their own name and still qualify for Medi-Cal benefits if they are hospitalized in a nursing home. Some schemes that may be legitimate today may not work next month or next year. Your best bet is to seek out someone who has a firm understanding about the laws in this regard. Your family lawyer may not be the best source, but he or she probably knows a lawyer who does know the ins and outs of Medi-Cal laws and regulations. This is one area where solid legal advice is advisable because the financial stakes are high.
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