What is a nursing home?
A nursing home is a long-term residential facility for people who need around-the-clock medical care. It is usually staffed with skilled nurses and aides 24 hours a day. It is often considered the next step after an assisted living facility (though many residents enter nursing homes directly, without having been in assisted living first). Some people also stay in a nursing home for a short period of time to recover from surgery and/or go through rehabilitation (after a fall, for example).
Some nursing homes have special floors, wings or even buildings dedicated to those with memory issues, including Alzheimer’s disease and other forms of dementia.
In order for nursing homes to bill services to Medicare and Medicaid, they must comply with the federal Nursing Home Reform Act, a set of standards enacted in 1987 that ensures each resident receives high-quality care. The standards, adopted after reports of widespread abuse and neglect in nursing homes nationwide, include such stipulations as having enough staff on hand and the development of comprehensive care plans for each resident. Many states also have their own regulations.
Some basic services provided by a nursing home may include:
- Room and board
- Meals, including nutrition care
- Medical and diagnostic services
- 24-hour skilled nursing care
- Access to a pharmacy
- Medication disbursement and monitoring
- Assistance with dressing, bathing, going to the bathroom, eating
- 24-hour emergency medical care
- Social activities
- Social services, including counseling
- Therapies, including physical, speech, occupational
Cost and how to pay for it
The 2017 national median cost for a semi-private room in a nursing home was $7,148 per month, with a private room costing $8,121 per month, according to the Genworth Cost of Care Survey. The actual cost varies widely from state to state. For example, in Tulsa, Oklahoma, the median was $5,323 per month for a private room, while in Fairbanks, Alaska you could spend a whopping $24,333 per month.
Most people who enter a nursing home start by paying out of pocket at first, and when their assets run low, go on Medicaid. Medicaid eligibility requirements are different in every state, but for those who qualify, Medicaid pays for 100 percent of nursing home costs. In fact, Medicaid pays for around half the total nursing home costs in the U.S. Some people also use long-term care insurance to pay for nursing home care.
You can only use Medicaid at nursing homes that are certified as a Medicaid Nursing Facility (NF) or a Medicaid Skilled Nursing Facility (SNF). Although states have their own separate laws, the federal government mandates that Nursing Facilities that bill to Medicaid must provide, without charge:
- Nursing and related services
- Specialized rehabilitative services
- Medically-related social services
- Medication services
- Dietary services individualized to the needs of each resident
- Professionally directed program of activities
- Emergency dental services (and routine dental services to the extent covered under the state plan)
- Room and bed maintenance services
- Routine personal hygiene items and services
In general, Medicare does not pay for long-term nursing home care, but some medically-necessary skilled care, including services and or supplies needed to diagnose and treat an illness, may be covered. Medicare may also cover care in a certified skilled nursing facility for a short period of time, but it will not cover custodial care (assistance with daily activities like dressing and bathing) if that’s the only kind of care you need.
People who have Medicare Advantage plans, or private health plans that have a service agreement with Medicare, should look into what nursing home services are covered. Many nursing homes accept prescription drug coverage called Medicare Part D. Figuring out what services Medicare pays for is quite confusing. You can get free information from your state’s health insurance assistance program (SHIP). This program provides trained counselors to answer your questions about Medicare.
What to look for
It’s certainly daunting to figure out which nursing home will provide your loved one the best care, services, and atmosphere, all under one roof. Ask for recommendations from trusted family members and friends, as well as consulting (if you have them) elder care social workers, lawyers, and financial planners.
It’s always best to visit several nursing homes to get the feel of the place, but generally speaking, you should be asking yourself:
- What type of care does the facility offer?
- How does the facility bill its residents? Get a list of services and the fees upfront and in writing.
- Is the facility Medicaid and Medicare certified?
- How long do residents typically stay there?
- What qualifications do the nursing and other skilled staff have?
- How do they deal with emergencies?
- Has the facility received any federal or state citations? If so, for what and how was it resolved?
Other concerns with nursing homes
Many facilities will require the resident to sign an admissions contract. If you can, consult an elder care attorney before signing any contracts. Many contracts are extremely long and certain provisions should raise red flags, elder law professionals warn.
For example, watch out for a provision in the contract that cites anything about a “responsible party.” Many times this provision is included in the contract because the facility wants to be able to bill you if your parent runs out of money. It is illegal for nursing homes to ask you to sign something that makes you a financially responsible party as a condition of admitting your loved one to the facility.
In addition, some contracts include provisions that require all disputes with the nursing home go through arbitration. By agreeing to this, you give up the option of going to court, if necessary. Some nursing homes will try to restrict visiting hours, or include clauses that limit the nursing home’s liability if your loved one gets injured while living there. Some have even asked to take over the resident’s personal finances — which never should happen. Consult an elder care lawyer for assistance in negotiating certain terms with the nursing care facility.
Fraud, abuse, and neglect
Unfortunately, complaints made against nursing homes for fraud, abuse, and neglect are quite prevalent. Each state keeps their own statistics, many through the Long-Term Care Ombudsman program. The program identifies, investigates and resolves complaints about elder abuse that happened in long-term care facilities. More than 7 percent of all complaints to the ombudsman program involve abuse, neglect or exploitation.
One way to check out the nursing home you’re considering is via the Centers for Medicare and Medicaid Services’ Nursing Home Compare tool. You can search for every Medicare- and Medicaid-certified facility in the country and see a rating that includes information on health inspections, staffing levels, and whether or not the facility has been penalized for any reason for the past three years, among other things. The rating is not the only thing you should consider when choosing a nursing home, but it’s a good place to start.
Written by Kaya Laterman