We at Sage PLUS Program/Hawaii SHIP (State Health Insurance Assistance Program) often get calls on our hotline from individuals who are confused about “who pays for what,” especially when it comes to care facilities (nursing homes, care homes, assisted living facilities and foster family homes). Let’s take a look at each care facility option, and the payment resources.

Long-term care is often thought of to refer to all kinds of assistance to the the elderly or the disabled, whether that care is given in a patient’s home, a community care home or nursing home. This is a common mistake.

Long-term care includes a wide range of support services for patients with a degenerative condition, prolonged illness or cognitive disorder. Also known as “custodial care,” long-term care primarily involves assistance with the activities of daily living (walking, personal hygiene, dressing, eating, etc.) or supervision of someone who is cognitively impaired.

Common Payment Sources:

  • Medicare (federal health insurance for those 65 years and older or with certain disabilities who qualify through Social Security Administration). Medicare does not pay for “custodial” care.
  • Medicare may pay for “Skilled Nursing Facility Care”- the individual has to meet the guidelines for coverage. Medicare will only cover inpatient care in a certified Medicare Facility.

There is also a “home health care” benefit that may cover for a short period of time, again if the person meets the guidelines for coverage. For more information you can check the Medicare & You handbook, go to www.medicare.gov or call the Hawaii SHIP.

Medicaid (Hawaii’s Medical Assistance Program)

Individuals qualify based on income and assets. They have a program for long-term care and also for medical coverage (coverage for someone living at home who needs help paying for doctor’s visits, x-rays, lab tests). In Hawaii the program
is administered by the Department of Human Services. Programs are currently provided by QUEST Expanded Access Plans.

If a person qualifies for long-term coverage, Medicaid may pay for a skilled nursing facility, community care home and foster family home. In some cases if the person chooses to stay at home Medicaid may pay for services to be delivered there.

TriCare for Life (military benefit for those with 20 years of service or other eligibility).

May pay for skilled nursing care in a Medicare certified facility or home health care, but it does not pay for custodial care.

Veteran’s Administration Benefits (VA)

VA may provide coverage in certain approved facilities. You may have to qualify to be eligible for these benefits. Call your local VA office for more information.

Long-Term Care Insurance

Depending on the plan purchased, insurance may provide coverage in skilled nursing facilities, assisted living facilities, foster and community care facilities or for services brought into the person’s home. Each plan is very individual, and coverage and price vary.

For more information on coverage for individuals with Medicare, call the Hawaii SHIP/Sage PLUS Program at 1-888-875-9229 or go to the National Clearinghouse for Long Term Care Information at www.longtermcare.gov.

Sage PLUS - Generations Magazine - June-July 2013