Insurance coverage is an option for many patients and may apply to LTC and SNF care costs, as it would any other medical procedure, hospital stay, or visit with a doctor or specialist. Each patient’s coverage will depend on the provider and coverage package they opted for through their individual or family plan package. Just like visits with a primary care physician, the amount of coverage provided will also depend on annual deductibles met thus far, and classification of treatments prescribed. Insurance is commonly combined with other payment options to provide a comprehensive financial plan for coverage of required care.
Generally speaking, private pay comes into play when all other payment options are exhausted. It may also be the primary or sole payment option for some patients. When Insurance coverage is maxed out and Medicare/Medicaid coverage is depleted, private pay is usually where patients and their families bridge any gaps out-of-pocket. Some patients may only be eligible for private pay, depending on the classification of their medical conditions and the nature of their specialized care plan. It is important to note the certification level of a facility when selecting a care center, to ensure it can support the type of payment plan that should apply, and to avoid any unforeseen expenses not covered in your payment elections.
Beyond Insurance and Private pay, there are two government funding sources that may provide additional payment contribution to a patient’s financial plan. One of these is Medicare, intended to assist those over the age of 65, and some young people with long-term disabilities. Up to 100 days stay in a Skilled Nursing Facility are mostly covered with Medicare, and then requiring insurance or private pay for any extended period of stay beyond 100 days.. LTC however, is commonly classified as “non-medical custodial care,” and therefore not provided for under Medicare coverage. The only exception to this lack of coverage, is when a Long Term Care facility is also classified as a SNF and may allow for up to 100 days of coverage.
In addition to Medicare, there is a second form of government funding called Medicaid that may contribute to financial planning for low income patients and families. It is important to note that facilities must be uniquely certified for Medicaid and Medicare coverage separately, for each to apply. Medicaid may apply to LTC if it is proven that long term care is “medically necessary” for the patient, and if the selected facility is properly certified to accept Medicaid payments. While SNF stays are commonly covered under Medicare, a facility must be additionally certified for Medicaid, or the patient must transfer to another qualifying location to benefit from both payment types in their financial plan elections. Selecting a facility that is certified for both care types will reduce payment planning complexities and streamline the patient’s care experience.