Help Paying for Care
Paying for Nursing Care
Resources are available to help pay for nursing home costs, including Medicare or Medigap insurance, medical assistance, U.S. Veterans benefits, and out-of-pocket plans.
Medicare
The Kane Community Living Centers accept both Medicare and Medical Assistance. The state oversees nursing home licenses, contracts with Centers for Medicare and Medicaid Services, and regular inspections of facilities accepting Medicare and Medical Assistance.
Medicare Part A
To receive nursing home benefits under Medicare, individuals must meet the following criteria:
- A three-day hospital stay within the previous 30 days
- Need for continuous skilled nursing care
- Receive care from a qualified doctor
For those qualifying for coverage under Medicare, nursing home care is covered up to 100 days if the person continues to require skilled nursing care. The first 20 days are covered in full, and a 20% co-pay is required for the remainder of the 100-day coverage period. There is no Medicare coverage after the first 100 days, until a new benefit period begins based on the qualifying criteria noted above.
Medicare Part B
A limited number of nursing home services are covered under Medicare Part B, which may include doctor services, specialized tests and equipment, renal dialysis, blood transfusion, emergency transport to a hospital. This coverage continues for a person who has exhausted all or does not qualify for Part A services while staying in a nursing home.
Any individual in a nursing home with an end-of-life condition may opt for Hospice care under the Medicare program. When a person opts for Hospice benefits, traditional Medicare benefits are available only for unrelated conditions. The person will receive all Hospice benefits, except for room and board, which must be paid privately. If a person opting for Hospice benefits is also on Medical Assistance, then Medical Assistance will cover room and board, while the other benefits will be covered by the Hospice benefit.
Medigap
Many older adults choose to purchase a Medigap policy in addition to Medicare Part A and/or Part B. Medigap policies can cover co-payments, deductibles, and non-covered services such as pharmacy services. A Medigap policy may cover some initial long-term care co-payments and deductibles. Please note that Medigap is not a long-term care insurance policy.
A Medigap policy is not required if a person decides to join an HMO. Most HMOs include pharmacy coverage and small co-payments or deductibles. Additional information about Medigap policies is available through the Pennsylvania Agencies on Aging.
Medical Assistance
Medical Assistance (MA) is the largest payer of nursing home care in the country. Medical Assistance reimbursement is all-inclusive, just like Medicare. Medical Assistance is accepted at all four Kane Community Living Centers.
To qualify for Medical Assistance, an elderly individual must meet the income criteria set by the PA Department of Human Services. A person over 65 years of age may qualify for Medicare, as well as Medical Assistance, and be enrolled for dual benefits. Medicare and the PA Department of Human Services have implemented "waiver programs" to delay nursing home placement and reduce the health care expenditure incurred by the dual benefits.
An individual must be assessed by the PA Area Agencies on Aging (AAA) to determine if the person is eligible for nursing home placement. In Allegheny County, an assessment can be scheduled by contacting the Allegheny County Area on Aging (AAA) Senior Line at 412-350-5460. This assessment is referred to as the "OPTIONS Assessment." Once a person is deemed eligible for nursing home care, they are eligible to receive nursing home care indefinitely.
Additional Coverage Options
Commercial Insurance
Commercial insurance companies may have policies with provisions for nursing home care.
Managed Care Insurance
Managed Care: Medicare and Medical Assistance requires that benefits provided under a beneficiary’s HMO must be equal or greater than covered under traditional Medicare or Medical Assistance. The benefits remain the same with minor variations from one HMO to the other. Under the mandated Medical Assistance managed care in western Pennsylvania, a patient in a nursing home reverts to traditional Medical Assistance after the first 30 days of nursing home care.
Managed care insurance companies identify their “network” health systems. Individuals interested in Managed care insurance must contact their representatives to discuss how that may impact reimbursement. Kane Community Living Centers work with a variety of managed care insurers. Please contact Kane Admissions at 412-422-6800 to determine if an insurance carrier participates with Kane.
Long-term Care Insurance
Most long-term care insurance policies may cover nursing home care, either after Medicare coverage has been exhausted, or to fill the gaps where Medicare coverage is unavailable. The benefits vary depending upon the policy.
U.S. Veterans Benefits
U.S. Veterans Benefits may provide coverage for nursing homes. Call the Veterans' Affairs office at 877-222-8387 for more information.
The Kane Community Living Centers are contracted with the VA system.
Out-of-Pocket Costs
Nearly half of nursing home care is covered privately by individuals, families, and private organizations dedicated to providing quality care.
Care may include room and board, pharmacy, private sitters, medical supplies or assistive equipment, nourishment, supplements, and more.