Paying for Long-Term Care
You or your loved ones may be wondering about the ways that a stay in a long-term care facility can be financed. Below is general information on the payment methods offered. For specific information on payment methods, please contact our Business Office Manager.
Medicare
Medicare is a federal program administered by the Center for Medicare and Medicaid Services (CMS). Anyone who has had sufficient work history and has paid into Social Security is eligible. Persons 65 years of age or older or disabled persons may qualify. If you do not have traditional Medicare with a supplement insurance, you may have Managed Care. See what Managed Care covers below.
Part A covers hospitalization and skilled nursing costs, hospice services and home healthcare for a certain amount of time, which is determined by your insurance and the therapy department.
Part B covers physician services, related medical services and supplies, outpatient hospital treatment, x-rays, lab tests, ambulance services, physical, occupational, and speech therapies, etc.
Part D covers a drug prescription plan, offering a wide range of providers to choose when enrolling, based on your personal needs. If you or your family member needs to remain in the long-term care facility after a Medicare stay, an alternative payment source must be found.
Eligibility requirements for a Medicare A stay in a long-term care facility include:
- Resident has to have been in the hospital for three midnights within the last 30 days prior to the admission.
- Resident must require skilled care, which includes physical therapy, occupational therapy, speech therapy, wound care, specialized nursing care, etc.
- Medicare does NOT cover non-custodial care, which consists of receiving basic care and supervision in a long-term care facility, such as, bathing, dressing, meals, medication management, etc.
Co-Insurance
If you have traditional Medicare and a supplement, Medicare will pay 100% of the coverage for the first twenty (20) days of skilled care services whether those are in the hospital or in a skilled long-term care facility. On the twenty-first (21) day, Medicare will no longer pay 100% of the coverage. If on the twenty-first (21) day, the resident is still determined skilled care, and if the resident has a Medicare supplement policy (co-insurance), the policy may pay a certain amount per day. (The co-insurance rate changes annually, please check with the Office Manager or your Insurance Agent for the correct daily rate or any other questions that you may have).
Medicaid
You or your loved one may be eligible for Medicaid upon meeting certain financial eligibility requirements. The maximum amount of assets, including the bank account, is $17,500.00 to be eligible. Contact the Illinois Department of Healthcare and Family Services for more information regarding qualifications. The Medicaid application may be obtained in the Business Office at our facility.
At Oak Lane, if you are on Medicaid, you or your representative will receive a reminder statement for your portion of your Social Security income or other income at the first of the month. Payment of your portion is requested by the tenth of that month. Lack of payment is determined an abusive or neglectful situation. In this case, by law, we must notify the Department of Healthcare and Family Services.
If you, a Medicaid resident, are hospitalized, the Nursing Home Care Act requires us to hold a bed for up to ten days. After that time period, your representative may choose to continue holding the bed at 75% of the room rate, or we may release the bed to another resident.
Managed Care Health Plans
Managed care is a method of delivering health care through a system of network providers. The State’s managed care plans include Health Maintenance Organizations (HMOs) and Open Access Plans (OAPs). There are differences in the premiums and copayment amounts among the managed care health plans offered; however, these plans provide comprehensive medical benefits at lower out-of-pocket cost by utilizing network providers. Managed care health plans coordinate all aspects of a plan participant’s healthcare including medical, prescription drugs and behavioral health services. An annual $100 prescription deductible is applied for each individual covered on the plan each plan year.
In order to have the most detailed information regarding a particular managed care health plan, you may ask to receive a plan’s Summary Plan Description (SPD) which describes the covered services, benefits levels and exclusions and limitations of the plan’s coverage. The SPD may also be referred to as the Certificate of Coverage or the Summary Plan Document.
Pay particular attention to the health plan’s exclusions and limitations. It is important that you understand what services are not covered under the plan. If you decide to enroll in a managed care health plan, it is essential that you read your SPD before you need medical attention. It is your responsibility to become familiar with all of the specific requirements of your health plan.
In most cases a referral for specialty care will be restricted to those services and providers authorized by the designated PCP. In some cases, referrals may also require pre-approval from the managed care health plan. To receive the maximum hospital benefit, your PCP or specialist must have admitting privileges to a network hospital.
Health Maintenance Organization (HMO)
HMO Members must choose a Primary Care Physician or Provider (PCP) who coordinates the medical care, hospitalizations and referrals for specialty care.
HMOs are restricted to operating only in certain counties and zip codes called service areas. There is no coverage outside these service areas unless pre-approved by the HMO. When traveling outside of the health plan’s service area, coverage is limited to life-threatening emergency services. For specific information regarding out-of-area services or emergencies, call the HMO.
Like any health plan, HMOs have plan limitations including geographic availability and limited provider networks. Most managed care health plans impose benefit limitations on a plan year basis (July 1 through June 30); however, some managed care health plans impose benefit limitations on a calendar year basis (January 1 through December 31). Contact the managed care health plan for additional information.
Alternative Payment Sources
Private Pay
Individuals who do not qualify for Medicaid because of too many assets would be considered a private pay resident. At Oak Lane, the room and board portion of the month is due upon the day of admission. Prior to this first payment, the month’s charges will be submitted to you or your representative on the first of each month. Full payment is to be made by the tenth of each month. If the payment is not made within thirty (30) days, 1.5% interest per month will be charged. If the account remains unpaid for more than 90 days, 3% interest per month will be charged. In addition, any days not used in the month due to discharge or death will be refunded to the resident or the resident’s representative.
We regret the need to raise room rates on occasion; however, increased cost does require occasional room rate increases. You or your representative will be notified thirty (30) days in advance of any room rate increase.
If you require hospitalization or want to make a home visit, you may hold your bed by paying 75% of the room rate while you are away.
Based on staff availability, if you need us to transport you to your doctor, you will be charged $50.00 for the use of our vehicle, and $20 per hour for any staff to accompany your loved one.
Long Term Care Insurance
Some people have long-term care insurance policies, which pay a certain amount each day for long-term care, based on the person’s policy. Check with your agent if you have any questions.
Resident Fund Account
You or your representative, may place up to $100.00 in a personal account, called a resident fund account, with our business office. Money from this resident fund account may be withdrawn upon request during business hours – Monday-Friday, 8:00 a.m. to 4:00 p.m.
Ancillary Services
- Prescription drugs as billed by the pharmacy (Medicare residents are an exception.)
- Blood chemistry and laboratory fees billed directly by a laboratory (Medicare residents are an exception).
- Physical, occupational and speech therapies as prescribed by a physician (Medicare residents are an
exception) - Other charges exclusive to the residents as medically necessary.
- Beauty shop/barber shop charges.
- Incontinence care.
- Supplements prescribed by a physician.
Resources
Here are some websites that may be helpful:
