Don’t Wait Until It’s Too Late: Know Your Medicare and Medicaid Coverage for Nursing Home Fees

Russell Fracassa
February 10, 2023

When it comes to long-term care, it is important to understand the differences between Medicare and Medicaid coverage for nursing home fees. Medicare is a government health insurance program for those who are 65 or older, as well as younger people with certain disabilities, while Medicaid is a health and human services program that provides health coverage for those appearing to have low-income and assets. In this blog post, we will discuss the various aspects of Medicaid and Medicare coverage for nursing home fees and what you need to know to make an informed decision.

The Basics of Medicaid and Medicare Coverage for Nursing Home Fees

Medicaid is a joint federal and state program that provides healthcare coverage to people with low incomes, the disabled, and those over 65 years old. It is jointly funded by the state and federal government and administered at the state level. Medicaid pays for long-term care services, such as nursing home care. However, there are specific requirements that must be met in order to qualify for Medicaid coverage. Generally, applicants must have a low income, minimal assets, meet the medical eligibility criteria, and meet the financial eligibility criteria.

"Know the rules" written on a white board — Medicaid is a joint federal and state program that provides healthcare coverage to people with low incomes

Medicare is a federal program that provides health insurance to people over 65 years old and certain people with disabilities. Unlike Medicaid, Medicare does not pay for long-term care services such as nursing home care. Instead, it covers certain medically necessary services such as hospital stays, limited rehabilitation, and doctor visits. Medicare does not provide any benefits towards nursing home fees.

Individuals can be eligible for both Medicaid and Medicare. This is referred to as dual eligibility. In this case, Medicare typically covers the medical expenses, while Medicaid will pay for the nursing home fees. The requirements for dual eligibility are different from the requirements for single eligibility, so it is important to understand both sets of rules before applying.

For individuals who don’t qualify for either Medicaid or Medicare, there are still other options for paying for nursing home care. These include private insurance, out-of-pocket payment, certain veterans’ benefits, some organizations such as the Masons, or a combination of these. It is important to do research into the various options available in order to make the best decision for your particular situation.

Medicaid Helps Pay for Care in Nursing Homes

Medicaid may pay for up to 100 percent of a qualifying individual’s nursing home costs in a Medicaid-certified facility. However, an applicant must meet strict income and asset requirements set by their state’s Medicaid program in order to qualify. Assets such as the applicant’s primary residence are typically exempt from these limits in qualifying (however, it is not usually exempt from later reimbursing Medicaid). To be eligible, the applicant must also meet their state’s level of care requirements.

Not only is Medicaid helpful with nursing home costs, but in some cases, it can provide different types of long-term care for seniors who have medical needs like home-based services or assisted living.

Being Able to Get Both Medicare and Medicaid

When it comes to the costs of long-term care, such as a nursing home stay, many individuals rely on both Medicare and Medicaid. Those who qualify for both programs are known as “dually eligible beneficiaries.” In this situation, Medicare pays for covered medical services first, and Medicaid is the “payer of last resort.” This means that if there are any costs associated with a medical service that Medicare does not cover, Medicaid will help pay for them.

For instance, Medicare covers doctor’s visits, durable medical equipment, and hospitalizations. If there are any remaining expenses, such as Medicare premiums or cost-sharing requirements, Medicaid can help with those. Medicaid also covers any long-term care services not covered by Medicare. However, it is important to keep in mind that coverage and benefits available for dually eligible beneficiaries vary by state. For example, some states may cover a broader range of services than others. It is important to research and understand your state’s policies in order to get the most out of your dual eligibility. In addition, it is also important to know the rules around dual eligibility when it comes to appeals or filing complaints about denied claims. A dually eligible beneficiary must follow the process for filing appeals and complaints with both Medicare and Medicaid in order to get their claim approved.

By understanding what you’re eligible for and the process for filing appeals, you can ensure that you get the most out of your dual eligibility when it comes to covering nursing home fees.