Nursing Homes (Nursing Facilities)
Nursing homes, or nursing facilities, represent the fundamental link in the continuum of long-term care. Nursing homes are places to live where care is available for people who need 24-hour nursing care and supervision outside of a hospital who are chronically ill or injured, have health care needs as well as personal needs and are unable to function independently.
Although all nursing homes must provide certain basic services, some homes provide special care for certain types of clients. For example, some homes provide services for the head injured, some for those who are ventilator-dependent, some for people with AIDS and some specialize in the care of children.
In addition to the higher level of care and services they provide, nursing homes are separated from other types of long-term care providers by an extremely high level of oversight by both state and federal governments. Specific federal regulations apply to all nursing homes that participate in the Medicare and/or Medicaid programs. These regulations include everything from patient rights to fire safety to patient care provisions for quality of life and quality of care.
Compliance with all state and federal regulations is ensured through annual inspections, known in the long-term care industry as “surveys.” These are performed on an unannounced basis by the staff of the Health Care Facilities division of the state Department of Health. Surprise inspections typically involve a team of three to five inspectors who spend several days in the facility. The survey system is designed to make sure that long-term care facilities meet professional quality standards and that care is provided in a clean, safe and properly-managed environment.
Paying for Nursing Home Care in New York
Few people can afford to pay for nursing home care out of their own pocket for very long (costs range from $3,000 to $10,000 or more a month). Ninety percent of New York State nursing home residents are or become reliant upon state and federal subsidies.
Nursing homes charge a basic daily rate for the services they provide and these vary from home to home. Some homes have all-inclusive rates; others have a rate for room and board and add additional charges for physician’s services, laboratory tests, physical therapy, prescription drugs, etc.
Private pay rates are not regulated. Homes may charge their private pay residents whatever they wish. These rates can be expected to go up at least once a year. If you are planning to pay for nursing home care out of your own pocket, ask for a list of services that are covered by the basic daily rate. Also ask how the rates are adjusted and how residents are notified of adjustments.
In New York State, the basic daily rate must cover room and meals, housekeeping, linen, general nursing care, medical records and services, recreation and personal care. There may be extra charges for items that vary from resident to resident, such as physical therapy and medications. Discuss with the home’s admissions director, administrator or social worker what services are standard and what additional services might be required and what they cost.
Nursing Homes are permitted to ask for a prepayment or a security deposit. The home can ask for no more than three months’ prepayment. Prepayment used as security must be deposited by the home in an interest-bearing account. If you leave the home or die, any amount paid to the home over and above the cost of services already provided must be refunded.
It is illegal for a nursing home to demand or accept donations (to a building fund, for example) from family members to assure placement of a relative.
Most homes require full financial disclosure from residents who will be paying privately. Since many nursing home residents who enter as private pay residents eventually use up their funds and go on Medicaid, the homes want to know how long the resident will be able to pay privately and when to apply for Medicaid. Once you are eligible for Medicaid, you have the right to have Medicaid pay for your care (if the home accepts Medicaid). When this happens, the nursing home should assist in completing the necessary forms.
In New York State, you may not be moved out of a nursing home because you have exhausted your personal resources. Also, your spouse need not spend all of his/her personal resources on your care if you are institutionalized.
Some homes suggest that funds be placed in a trust that the home controls, or that the resident’s Social Security checks be made payable directly to the home. The law guarantees residents the right to control their own financial affairs as long as they are willing and able to do so, or to assign that responsibility to a friend or family member. The nursing home may be given control over a resident’s finances if no one else is willing to handle them.
Medicaid in New York
Medicaid, established by Congress in 1965, is a government health insurance program for people of all ages whose income is too low to provide for routine health care costs, or whose health care costs are too high to be covered by their income. This health insurance covers the cost of nursing care for as long as the care is required if a resident is eligible.
A comprehensive application process is used to determine eligibility for the Medicaid program. This process requires that applicants provide detailed information and documentation regarding income and assets. A Medicaid applicant must be a citizen or permanent resident in the United States, must meet New York State income and resource limitations and must show medical need.
Currently, a Medicaid recipient in a nursing home is allowed to retain $50 of monthly income as a personal needs allowance to meet personal expenses that are not covered by Medicaid. Call your local Department of Social Services office for additional information on Medicaid.
Medicare is a federal health insurance program for disabled people and people over age 65. Skilled nursing services must be needed on a daily basis to be eligible for Medicare. Medicare will pay a maximum of 100 days of care in an approved nursing facility for patients in need of skilled care following a hospitalization of at least three full days. To qualify, the patient must be admitted to the nursing home within 30 days of discharge from the hospital.
Many people leave a hospital and enter a nursing home expecting Medicare to continue to pay for health services. This is not the case. Medicare will not pay for a nursing home stay if it is determined that only custodial care is required, or if skilled nursing home care and/or rehabilitative services are needed only on a periodic basis. Under Medicare rules, the need for skilled nursing care must be daily. The program has a number of specifics about what services are included and requires that you be responsible for a co-payment. For further information, contact your local Social Security office or call 1-800-772-1213 for a copy of the Medicare Handbook.