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Are Nursing Homes Covered by Medicare and Medicaid?

Posted March 23, 2015 | Uncategorized

Few domestic issues are more controversial than the national healthcare system, and with good reason: recent studies have shown that medical bills are the number one cause of consumer debt and bankruptcy in the United States.  With healthcare costs continually rising, many seniors worry about how they will pay for for their nursing home stays.  Fortunately, there’s good news: many nursing homes accept Medicaid and Medicare coverage.  In this blog post, Philadelphia nursing home abuse attorney Brent Wieand will explain elderly citizens’ legal rights when it comes to receiving care at Medicaid- and Medicare-certified nursing homes.

What’s the Difference Between Medicare and Medicaid?

It’s a common misconception that Medicare and Medicaid are one in the same, probably due to the fact that these programs do share some significant traits in common.  Both were designed to help senior citizens and low-income individuals pay for healthcare expenses, both were created during the 1960s, both are administered by the federal government, and both are funded by taxpayer dollars.

However, despite their many similarities, there also important distinctions between Medicare and Medicaid.  Medicare is part of the broader social security program administered by the Social Security Administration or SSA, and is broken down into four separate “Parts” as follows:

  • Part A — Hospital Insurance
  • Part B — Medical Insurance
  • Part C — Medicare Advantage or Medicare Advantage Plan
  • Part D — Prescription Drug Coverage

Parts A and B together are called “Original Medicare,” and may be substituted by Part C.

All U.S. residents automatically become eligible for Medicare coverage as soon as they reach 65 years of age.  Additionally, monthly disability beneficiaries will be automatically enrolled in Parts A and B of Medicare once they have been receiving SSDI, or Social Security Disability Insurance, for two years (with some exceptions for serious illnesses).  Beneficiaries of SSI (Supplemental Security Income) are not eligible for automatic Medicare coverage, as the SSI program is associated with Medicaid. 

Medicaid has stricter eligibility requirements than Medicare, such as limitations on income and liquid assets.  Depending on which state you live in, up to 50% of your Medicaid coverage may be provided by the federal government, while the remainder is covered by the state.

medicaid medicare coverage

The FNHRA: Coverage for Nursing Home Care

Nursing homes are not required to participate in the Medicaid or Medicare programs, and at homes which do not participate, patients may pay through a combination of out-of-pocket expenses and long-term care insurance.

However, if a facility does choose to participate in Medicaid or Medicare, then that facility must also adhere to the provisions supplied by the Medicaid Act (formally known as Title XIX of the Social Security Act), and/or the Medicare Act (formally known as Title XVIII of the Social Security Act) where applicable.

These compliance requirements are provided by a law known as the FNHRA, or the Federal Nursing Home Reform Act, which was passed by Congress in 1987.  In addition to penalizing Medicare- or Medicaid-certified nursing homes which are non-compliant with the Medicaid and/or Medicare Acts, the FNHRA was also designed to accomplish three primary objectives.  In accordance with the FNHRA:

  • Residents must not be required to waive their rights to Medicare or Medicaid benefits.
  • Nursing homes are not allowed to require residents to waive such benefits.  This prohibition extends to both oral and written agreements.
  • On the contrary, nursing homes supply with residents with information about how to apply for and utilize Medicare and Medicaid benefits.

In addition to establishing legal requirements for nursing homes themselves, the FNHRA also outlines numerous legal rights for nursing home residents.  Unique among other pieces of federal legislation, the FNHRA was drafted in clear and unambiguous language so that it could be easily understood by nursing home patients and their loved ones.

The legal rights supplied by the FNHRA apply regardless of the county, state, or other jurisdiction where the nursing home is located.  A few examples of these rights include:

  • The right to privacy.
  • The right to voice complaints without fear of eviction or retaliation.
  • The right to balanced meals which account for all nutritional needs.
  • The right to freedom from abuse, neglect, and corporal punishment.

However, it’s important to reiterate that these stipulations, while rigorous, apply only to nursing homes which are Medicare- and/or Medicaid-certified.

On a final note, it is also worth mentioning that Medicare provides an excellent nursing home rating system which allows users to compare homes nationwide on criteria points such as:

  • Percentage of residents who develop bed sores (pressure ulcers).
  • Ratio of staff members to residents.
  • Any previous violations and penalties.

To get started using Medicare Compare, simply enter your zip code and click the green “Search” button.

If you’re concerned about issues like elder abuse, caregiver neglect, financial exploitation, or a violation of your loved one’s legal rights, Bucks County nursing home injury lawyer Brent Wieand can help.  To set up a free and private case evaluation, call Brent today at (800) 481-5206.