As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
Article Photos
Q: My wife was just admitted to a nursing home, and I don't know what to do about the bill. She is currently covered by insurance. What do I do when the insurance coverage runs out?
A: Thank you for asking this question. I have run into a large number of couples in this situation lately. Hopefully this answer will help many facing this now or in the near future.
This can be a difficult time for you, your wife and your family. First talk with the social worker in the skilled nursing facility. This individual social worker and the other staff of the skilled nursing facility should be a wealth of support and knowledge for you. Also reach out to your pastor or the pastor of the facility you are working with. This individual can also be a wealth of support to you and your spouse.
Second let me tell you about the New York State Spousal Impoverishment Provisions. This is a Medicaid program designed to help couples pay for long-term care. It is administered through the Department of Social Services like other Medicaid programs, but the rules are different. This program takes a "snapshot" of the finances of the couple when one of them has been admitted to the skilled nursing facility. It also can help pay for hospital, ambulance and other medical bills. It then evaluates the financial situation of the couple and limits their financial liability for the institutionalized spouse, the spouse in the skilled nursing facility. This allows the community spouse, the spouse living at home, to maintain the home and a reasonable lifestyle.
The income limits and resource limits for this program are very different from other programs at Medicaid. The community spouse is allowed to keep up to $2,841 in monthly income. The institutionalized spouse gets $50 monthly. This means that if the combined income of the couple is above this amount, the overage income (the number of dollars above $2,891) is paid to the skilled nursing facility each month. If the combined income of the couple is less than $2,891, the community spouse keeps the income to meet the financial need in the home.
The Resource Limits are as follows, and are somewhat more complicated. The institutional spouse is allowed to have up to $14,250. The community spouse is allowed to have up to $74,820, plus the house they live in, plus the car they drive. This means the community spouse does not have to give up everything they have to take care of the institutional spouse. There are situations where the community spouse can have a higher level of resources, but this is a basic understanding of the benefits.
Remember that each of you can have a prepaid burial fund, and this is a good way to spend some of the overage money if appropriate. This prepaying of your burial expenses allows you to set aside this money now, when you still have it, as opposed to leaving that expense to your family. This prepaid burial can be a lump sum that you and your funeral home director feel is an adequate amount. You can also sit down and not only prepay, but also preplan your funeral. This provides a way for you to reduce the burden left to your family when you are no longer with them.
This Spousal Impoverishment Medicaid benefit requires an application be completed, five years of financial records be proven and a face-to-face meeting at Department of Social Services. Please work with the nursing home social worker to enroll in this program. It will help you immensely and take many worries away from you and your family.
This Spousal Impoverishment Medicaid can also help with those hospital bills if your spouse is in the hospital, or getting services at home.
The Medicaid process may change some of the ways you handle your income and your bills, but it will go a long way toward helping you pay for this nursing home stay. Feel free to ask questions during this process with all agencies you work with. The more questions you ask, the more you will understand what is happening. Asking questions does not indicate you don't understand; it indicates your sincere interest to learn from this process.
I would also recommend reaching out to support programs, like caregiver support services, your pastor, the facility's chaplin and other supports in your life and community.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.
You may submit questions to be answered in later columns to Janell Sluga at Senior Life Matters, 737 Falconer St., Jamestown, NY 14701, or call 716-720-9797, or by email at janells@lutheran-jamestown.org. Please remember that not all questions can be answered in this format, but as many as can be, will be.