CLASSIFYING NURSING HOMES

Clients have frequently been confused (for good reason) about how nursing facilities (a NF) are classified in terms of whether they offer skilled versus unskilled services. First, there could be a facility in NY that is unskilled only- but you would need to look pretty hard to find one. Second, almost all NFs in NY contain elements that are both skilled and unskilled. Third, the skilled area must be segregated from the unskilled area. Little overlapping is permitted.

Skilled care is paid for by Medicare and unskilled care is paid for by Medicaid. If Medicare benefits run out and a person is eligible for Medicaid, Medicaid will also pay for skilled care. The rates, however, are different for each. For example, as a general rule if Medicare is available a person can not occupy a skilled bed and be paid by Medicaid. By the same token a person can not occupy an unskilled bed which is paid for by Medicare under any circumstances. You will see that the Medicare program, as good as it is, is more limited than the Medicaid program. As a guiding principle, Medicaid will pay for any kind a care a person needs so long as the person meets the financial eligibility tests and there is no other source of payment.

Lets use another example. Say, John goes into a NF in NY for rehabilitation for hip surgery at a local hospital. Rehabilitation is a skilled service. It will be paid for by the Medicare program subject, of course, to copayments and deductibles. When John no longer needs rehabilitation, he may return home or he may need a NF indefinitely because he can not handle his needs on his own at home. He can stay at the same NF but he will be placed in a different area of the NF where the unskilled beds are located. The NF may or may not have an unskilled bed available at that time. The NF must make clear to John what the bed policy rules are. When a Medicare resident's Medicare benefit period is nearing its end [Remember, the first 20 days of rehabilitation care are paid for in full by Medicare and up to the next 80 days (depending on the person's need for continued rehabilitation) the person receiving care must pay a daily copayment of $97 a day], the NF must inform John that he will need to qualify for Medicaid and be moved to an unskilled area of the NF. (Under certain circumstances John can insist on retaining the Medicare bed, receive unskilled services at the NF and still be eligible for Medicaid.) The NF must ascertain John's ability to pay privately or to become eligible for Medicaid. Some beds could be dually certified for both Medicare and Medicaid but that is unusual.