A Guide for Families
Caring for Someone with Alzheimer's

Paying for Care

Following are some facts about paying for care:

• Contrary to popular belief, Medicare does not cover the cost of long term care. Medicare only provides limited coverage for long term care with many rules to qualify, such as requiring a 3-day hospital stay.
  
  
• Medicaid - the health insurance program for the poor - pays for almost 65% of the patients in nursing facilities, yet offers only limited, if any, funding for assisted living services in many states.
  
  
• Long term care insurance, depending on the policy, pays a daily rate and may cover a variety of long term care settings, possibly including home care.

Private Pay and LTC Insurance
Paying for care with your own funds provides you with greater choice as to the setting where care is provided, such as an assisted living residence, a nursing facility or your home. You may have the same choices if you own a private long term care insurance policy. (Request the AHCA/NCAL publication Understanding Long Term Care Insurance. See page 11 for details.)

Medicare
Medicare, administered by the federal Centers for Medicare and Medicaid Services (CMS), is a health insurance program for people 65 and over and certain disabled people under 65. Medicare covers only those services rendered to help a beneficiary recover from an acute illness or injury. While many persons with Alzheimer's and related dementias have significant chronic care needs, they often do not require the services of a skilled health care professional. As a consequence, the individual may not qualify for Medicare payments.

Nursing facility coverage under Medicare is very limited. If a person qualifies (see previous description) and has a 3-day hospital stay, Medicare may pay for up to 100 days of care in a skilled nursing facility (SNF) if that many days are needed. Medicare will cover 100 percent of the first 20 days (if that many days are needed) in a SNF; for days 21-100, the individual pays a daily coinsurance amount, which is over $100 per day.

Assisted living costs are not generally covered by Medicare, but it may pay for short-term services (e.g. physical and other therapies) contracted through a home health care agency and provided to the resident at the assisted living facility.

Home care coverage under Medicare is available only if a patient:

• Is confined to the home; and,
  
  
• Requires physical, occupational or speech therapy, or skilled nursing care, which will be provided from a home health agency under a doctor's plan of treatment. The duration and number of visits will depend on the treatment care plan written by the attending physician.
  
  
• The homebound patient may see his or her physician, psychiatrist, psychologist or social worker on an outpatient basis.

Hospice coverage under Medicare is available if:

• The person has Medicare Part A (Hospital Insurance).

• The person has Medicare Part A (Hospital Insurance).
  

• A physician certifies that the patient is terminally ill - that life expectancy is six months or less, assuming that the illness runs its normal course; and,
  
  
• The person chooses to receive hospice care.
  

The National Hospice and Palliative Care Organization has published guidelines to help identify which patients with dementia are likely to have a prognosis of six months or less to live. Individuals who do not have other medical complications must show all of the following characteristics in order to be eligible for a hospice program:

• Incapable of ambulating without assistance;
  
  
• Incapable of dressing without assistance;
  
  
• Incapable of bathing properly;
  
  
• Experience urinary and fecal incontinence; and,
  Unable to speak or communicate meaningfully.
  

For more information about Medicare or to request a Medicare Handbook, call 1-800-633-4337.

Medicaid
Medicaid is a joint federal-state program to provide health services to low-income people. It has become the major funding source for nursing facilities, covering nearly 65 percent of patients. Medicaid is administered by the states under broad federal guidelines. Reimbursement rates per day of care are also set by the states.
o Eligibility - Medicaid will pay for individuals who meet a state-determined poverty level.
o Benefits - Medicaid will pay for care in a nursing facility (NF) and Intermediate Care Facility for the Mentally Retarded (ICF/MR). States may offer Medicaid funds for Home and Community Based Service (HCBS) waiver programs.

Be a Wise Consumer
As a consumer you need to find out exactly what costs are included in the monthly or daily charge given by the long term care facility or service. There may be extra charges you need to know about. Read all forms carefully and ask questions so that you understand the provider's services and costs.