Nursing Home Information
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Types of Facilities:
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When admitted, residents are not usually acutely ill and do not require special facilities such as an operating room, x-ray or laboratory facility. Nursing homes generally provide 24-hour medical care as well as room, meals, activities and some personal care. Nursing homes ARE required to have licensed nurses on site, and usually offer two levels of service—skilled nursing and intermediate care. Many times, both services are offered within the same nursing home.
- Skilled Nursing Facilities (SNF) offer 24-hour, continuous service by registered nurses, licensed practical nurses and nursing assistants who provide care based upon treatment prescribed by the resident’s physician. The emphasis is on nursing care with restorative, physical and occupational therapies available.
- Intermediate Care Facilities (ICF) offer less direct nursing care than that afforded by SNFs. They provide some medical, social and rehabilitative services in addition to room and board for persons who are not capable of fully independent living.
A nursing home that offers more than one level of care is called a combination home. Combination homes may include a mixture of skilled nursing, intermediate care and assisted living. Residents eligible for placement in the assisted living section of combination homes include aged and disabled adults whose principal need is a home with the shelter or personal care their age or disability requires. Continuing planned medical and nursing care to meet the resident’s needs may be provided under the direct supervision of a physician, nurse or home health agency.
Nursing homes are licensed and regulated by the state Division of Health Services Regulation Nursing Home Licensure and Certification Section in accordance with General Statute 131E, Health Care Facilities and Services. The Division of Health Services Regulation also carries out the routine monitoring of nursing homes to determine compliance with state/federal licensure and certification rules. Failure to comply with state and federal rules may result in loss of Medicare/Medicaid certification in addition to other sanctions up to and including license revocation. Reports generated by state surveyors are public record and are available to anyone upon request. Current compliance information about any licensed nursing home can be viewed online at www.medicare.gov.
Other programs that have oversight responsibilities for nursing homes include the state Long-Term Care Ombudsman Program, the Regional Ombudsman Program and the Nursing Home Community Advisory Committee. These three programs work together under the auspices of the North Carolina Division on Aging to maintain the intent of the Residents Bill of Rights, to promote community involvement and cooperation with nursing homes, to help nursing home residents and providers resolve complaints and concerns, and to educate the public about the long-term care system. The Nursing Home Community Advisory Committee is composed of volunteer members appointed by the Wake County Board of Commissioners to visit each nursing home quarterly. The committee makes recommendations to nursing home administrators and the Regional Ombudsman based on their findings. Committee reports are public record and are available to anyone upon request.
To be admitted to a nursing home, an individual must be in need, per physician’s statement, of 24-hour nursing care and supervision. Payment for monthly cost of care is made in one of two ways. 1) Financially needy adults may be eligible for financial assistance through the Medicaid program. Application for Medicaid is made through the Adult Medicaid section at the local county Department of Social Services (Wake County Human Services). 2) Residents who are not Medicaid recipients negotiate their monthly cost of care charge on an individual basis with the care provider. Rates are set at the discretion of the provider and are usually determined by the personal and health care needs of the resident.
Nursing Home Care – Long-Term Care (LTC)
Medicaid will pay for medically necessary nursing home care for a Medicaid-eligible individual who is either a patient in a nursing home or in an Intermediate Care Facility for the Mentally Retarded. If Medicaid coverage for nursing facility care is needed, the following information is helpful for families to know:
I. General
The nursing facility must inform the resident of his or her rights during the stay and the items and services that are included in the facility services. The facility staff will evaluate their ability to provide the care needed before a decision is made about admission.
The nursing facility beds reserved for Medicaid patients are approved by a state licenser and survey agency. Medicaid will pay only for nursing care in the Medicaid-approved beds. You should discuss the need for financial assistance, for Medicaid to pay cost of care, with admissions staff in advance of placement or prior to exhaustion of private funds, and ensure that the patient will be in an approved Medicaid bed when he is approved for Medicaid coverage.
A Prior Approval/Continued Care Review Form (FL-2/MR-2) must be completed by the attending physician to describe the medical condition and need for nursing care in a licensed nursing facility. Medicaid must approve the need for care in a nursing facility before the program will pay cost of care.
II. Financial Eligibility
The Medicaid recipient must use his/her income to help pay for nursing home care. Medicaid pays the difference between the income of the recipient and the nursing home rate. Each recipient keeps $30 of his/her income for personal needs not provided by the nursing home's services. An additional amount of the recipient's income may be set aside for special needs or for a spouse living at home. Special needs include things like health insurance premiums and physician or prescription charges not covered by Medicaid. The case manager will explain these.
The recipient is notified in writing of the exact amount he/she must pay to the nursing home each month. This payment is called the "Patient Monthly Liability" or "PML." Medicaid payment is made only after the PML has been applied to cost of care. This means that the patient's income pays for the first few days of care and then Medicaid pays for the rest of the month.
The maximum community spouse income allowance is currently $2,541 per month.
III. Resource Eligibility
There are limits on the amount and type of real and personal property a person may have and be eligible for Medicaid. If you have any questions or need more information about Medicaid resource requirements, please contact the County Department of Human Services immediately. When excess resources are reduced to the limit allowed, Medicaid begins the day resources are reduced.
The resource limit for an individual is $2,000, and for a couple in the same room, $3,000. If there is a spouse remaining at home, some assets can be protected depending on the value of the countable assets the first moment of institutionalization.
The figures in the table below are effective 1/07:
Total
Assets |
Protection
Amount |
| $20,328 or less |
Protect All Assets |
| More than $20,328, but not more than $40,656 |
Protect $20,328 |
| More than $40,656, but not more than $203,280 |
Protect One Half |
| More than $203,280 |
Protect $101,640 |
The above chart is a guideline. If you are married and your spouse is in a nursing facility, contact your County Department of Human Services, and a case manager can complete an assessment to determine exactly what your total assets are and how much can be protected.
IV. Transfer of Resources
If an applicant/recipient, spouse or legal representative gives away or sells assets belonging to the applicant/recipient for less than current market value, he/she may not be eligible for payment of cost of care in a nursing facility. Discuss the transfer of any assets with the County case manager to determine if it results in a sanction.
V. What Medicaid Pays For
Some nursing home services included in the Medicaid payment are :
- Room charge
- All general nursing, dietary, medical and psychiatric services
- Reusable items/equipment such as ice bags, canes, crutches, walkers and wheelchairs
- Personal items such as shampoo, combs, razor blades, soap and lotions
- Medical supplies such as diapers, bandages, dressings, aspirin and antacids
- Laundry services
- Hair trimming which is hygienic (there may be fees for permanents, hair coloring or special styles)
- Special dietary supplements used for tube feeding, such as a supplemental high-nitrogen diet [even if written as a prescription item by a physician]
Nursing home services not included in the Medicaid payment are:
- Private telephone
- Television
- Private duty nurses or sitters
- Tobacco products
- Medicaid pays for up to six prescriptions in a month unless the individual has certain life-threatening conditions. Prescriptions over the six-prescription limit can be paid with the recipient's income. If the applicant/recipient has a life-threatening condition, the attending physician who prescribes medicine must indicate the condition on the prescription. The pharmacy can waive the limit and dispense necessary prescriptions.
VI. Nursing Facility and Patients Responsibilities
The nursing home is responsible for arranging or providing non-emergency, non-ambulance medical transportation for all Medicaid recipients who do not have family assistance. Family members are encouraged to provide transportation, when they can, as a means to provide critical family and social support.
Medicaid eligibility must be reviewed every six months. Prompt response to the review letter is necessary to ensure continuation of Medicaid coverage.
Please notify the County Department of Human Services immediately if your family member's income, resources or place of residence changes, or if the recipient is admitted to a hospital. Failure to notify the County Department of Human Services (or to obtain prior approval for certain types of care) could result in the patient being responsible for the cost of care.