|
Tip Sheets
What do I need to know about nursing home fees?
What do you pay for in a nursing home? Who decides what the rates should be? How do you know the charges are correct?
The following information will explain the basics of understanding nursing home charges.
Basic Definitions
Setting the rates
Nursing homes that are certified to receive Medical Assistance funds have their rates set by the Department of Human Services. The rates are based on the home's care-related costs, operating costs and property costs.
Because the rates are individually set, each home's rates are different.
There are a small number of homes that do not participate in the Medical Assistance program. These homes set their own rates and only accept individuals who pay on a private basis or have insurance to cover the costs of their care.
Equal rates law
Minnesota Law requires that all residents in one home, regardless of payment source, be charged the same rate for the same care. This means that residents who pay privately and residents who have their bills paid through Medical Assistance, insurance policies, or HMO's cannot be charged two different rates.
Facilities are allowed to charge extra for private rooms. In most cases, Medical Assistance or insurance will not cover the additional fee, but residents who want a private room can choose to pay it from their own funds.
Case mix
In Minnesota, the rate an individual pays is determined by a "case mix assessment." The assessment is completed for the resident upon entering the nursing home and periodically thereafter. There are eleven different classifications under the case mix system, identified with the letters "A" to "K". Each case mix level has a different rate. "A" residents need the least amount of help and have the lowest rate, "K" residents need the most help and have the most expensive rate.
What does the daily rate cover?
| Included in the Basic Rate | May Be Charged Extra |
| Room and Board | Private Room |
| Hygiene items (soap, shampoo, toothpaste, toothbrushes, razors, shaving cream, tissues, incontinence supplies) | Special resident request or other brand name hygiene items which the facility does not normally supply |
| Over-the-counter supplies used occasionally (aspirin, antacids, cough syrups, body lotion | Prescription medications
| | Rehabilitation nursing, including range of motion exercise and assistance with walking |
|
Nursing home bills can be confusing. If you have questions about the charges on your bill or are being asked to pay extra for something that you think should be included in your daily rate, you can get help.
Meet with the bookkeeper at the facility to clarify the billing, or contact your local Ombudsman program for assistance.
What payment sources are available for nursing home bills?
Medicare (Part A)
Medicare will pay for up to 100 days of nursing home care per benefit period. A benefit period begins when a Medicare beneficiary has been in the hospital for at least three days and then moves to the nursing home for treatment of the same condition.
The person must be in a Medicare-certified bed at the nursing home and must receive skilled nursing or rehabilitation services.
Medicare will pay for up to 100 days of nursing home care per benefit period if the beneficiary meets all eligibility requirements. A benefit period ends when the person has been out of the hospital and nursing home for 60 consecutive days.
A beneficiary may have more than one benefit period per year.
Medicaid (Medical Assistance)
Medicaid helps pay medical bills for people with limited income and assets. Nursing home costs, as well as other medical bills, can be covered under this program.
Understanding eligibility for Medicaid can be complicated and it may be best to consult with someone familiar with the subject (an attorney familiar with Medicaid, an ombudsman or your county's Medical Assistance Office, for example).
Veterans benefits
If you are a veteran or the spouse of a veteran, you may be eligible for nursing home and other care benefits. Contact the veteran's service officer from your county for detailed information.
Insurance
Some policies are now available for nursing home care. Minnesota law has established minimum standards for long-term care insurance policies.
If you are purchasing a policy, be careful of policies with maximum lifetime benefits, prior hospitalization requirements, waiting periods before benefits begin, and premium increases.
Specific information on policies can be obtained from the Commissioner of Insurance at (651) 296-2248.
Private payment
Nursing home residents that do not qualify for any of the above programs and have the assets and/or income to cover the expense of nursing home care must pay privately.
Be aware: Even if you do not currently qualify for the Medical Assistance program, you may in the future. And, if you are in a facility that accepts only private payments, you may have to move when your assets run down.
It's wise to make an early request for information about the Medical Assistance program so you can plan ahead and best protect your assets.
Other payment considerations
Of course it can't be that simple! There may be other questions that present themselves.
Admission Fees
At the time you or your family member apply to a nursing home, you may be charged an "admission fee."
Minnesota Statutes specifically state that it is illegal for nursing homes participating in the Medical Assistance program to require an applicant for admission or the guardian of the applicant to pay any fee or deposit in excess of $100.
Special Services
Special services units or amenities programs have been established by some homes to provide services to residents over and above what is covered in the daily rate. For a fee, the resident may be able to have special linen, flowers on dinner tables, a separate dining area with additional food choices, a greater choice of activities, etc.
The home must follow certain guidelines when offering special services:
- Special services must be available to all residents in all areas of the nursing home. Each resident must be free to choose whether he/she wishes to purchase the special service.
- The facility must provide the applicant and resident with a detailed explanation of the special services and the additional cost. The cost for special services must be charged separately.
- Applicants and residents must not be discriminated against in admissions, services offered or in room assignment based on the decision to purchase, refuse, or discontinue special services.
Retroactive Billing or Refunds
The Department of Human Services sets the rates for most nursing homes; facilities often disagree with the established rate and file an appeal asking for a higher rate.
When the appeal is settled (months or a year later), the rate in question may stay the same, may increase, or in some cases, is lowered. The facility will then either send you a "retroactive billing" or a refund for the period of time the adjustment pertains to.
The nursing home may not bill you retroactively unless you were given 30 days advance notice in writing that the rates were being appealed and that you might be billed extra once the appeal was settled.
You may also be retroactively billed or refunded for a change in your Case-Mix level. This type of billing can be appealed within 30 days. The facility should inform you in writing when a change occurs and help you with any concerns or questions. Your Ombudsman can also assist.
Who do you call for help?
If you have concerns or questions about charges at a nursing home, you may contact the following agencies for assistance:
- Office of Ombudsman for Older Minnesotans, Office of Ombudsman for Older Minnesotans, 121 E. 7th Place,
Suite 410, St. Paul, MN 55101. 651-431-2555 or toll free at 1-800-657-3591.
- Department of Human Services, Surveillance and Integrity Review, Dept. of Human Services, 444 Lafayette Rd., St. Paul, MN 55155-3865. (651) 297-1102.
- Office of Attorney General - Medicaid Fraud Division, 1400 NCL Tower, 445 Minnesota St., Saint Paul, MN 55101 (651) 296-7575.
- Legal Aid. Check the phone book or call the Ombudsman Program for the office in your area.
|
