HA545 Unit 4 Nursing Home Coverage Analysis Example

One Hundred Days, Then the Means Test: A Public Insurance Program Analysis of How Medicare and Medicaid Divide Nursing Home Coverage, and What That Design Does to Patients Waiting in a Composite Hospital for a Long-Term Bed Their Medicaid Application Has Not Yet Secured

[Student Name]

Purdue University Global

HA545: Health Policy

Unit 4 Public Insurance Program Analysis

[Instructor Name]

[Date]

The program rules are real and general; the hospital and every figure are composite and bracketed for the writer's own data.

The Design Question

What happens to a patient who needs nursing home care for the rest of their life when the program that pays for short stays ends and the program that pays for long ones requires proof of poverty first?

Medicare's Design

Medicare is federal, entitlement-based and tied to age or disability, with no means test. For nursing homes, Part A pays a skilled nursing facility for daily rehabilitation or nursing that requires licensed staff once the patient has been a hospital inpatient for three days in a row, not counting the day of discharge (42 C.F.R. § 409.30, 2024). Coverage lasts up to [100] days in a benefit period, with a daily coinsurance after day [20], and only while the patient needs and benefits from skilled care. Custodial care, the daily personal help that most permanent residents actually require, falls outside the Medicare benefit.

Medicaid's Design

Medicaid is a joint program: Washington and the state share the cost, and each state administers its own version under a federal framework. Nursing facility care is a mandatory benefit, but eligibility depends on income and assets, typically a few thousand dollars in countable assets for a single person. Federal law requires states to review asset transfers made in the [60] months before application and to impose a waiting period for transfers below fair value, and it requires states to seek repayment from the estates of many recipients after death (42 U.S.C. § 1396p, 2024). The usual path is to spend down savings on private nursing home bills first and file for Medicaid once little remains.

Side by Side

Financing: Medicare federal; Medicaid federal and state. Eligibility basis: Medicare age or disability; Medicaid income, assets and need. Nursing home benefit: Medicare a time-limited skilled stay that must follow hospitalization; Medicaid open-ended residence, custodial care included. Administration: Medicare national; Medicaid by each state, with its own application systems. Verification: Medicare once; Medicaid a detailed application with five years of financial records. Because custodial care sits outside Medicare, the bill for most long-term services has shifted to Medicaid (Kaye et al., 2010). The two programs fit together on paper, but the seam between them is a paperwork process that can take months.

Why the Seam Causes Delays

A patient who will need permanent nursing home care often reaches that point in a hospital. Nursing homes accept new long-term residents when a payer is secured or likely. If the patient has used up Medicare skilled days or never qualified, and Medicaid has not approved the application, many homes will not admit. The application requires bank statements, property records and proof of transfers for five years; family members may not have them, and some patients lack anyone authorized to apply. States have [45] days to decide on most applications, often longer when information is missing.

One Patient's Path Through the Seam

Consider a composite patient, [Mrs. R.], [84], admitted with a hip fracture and early dementia. After surgery and a [five]-day stay, she qualifies for Medicare skilled nursing coverage and moves to a nursing facility for rehabilitation. By day [38], she has stopped improving, and therapy ends; her skilled coverage ends with it. She cannot return home safely. Her savings will pay privately for about [four] months. Her son starts a Medicaid application but cannot find statements for an account closed three years ago. When she is readmitted to hospital with pneumonia in month [three], her application is still open, and her nursing home will not hold her bed. She becomes one of the hospital's pending patients.

At a Composite Hospital

At a composite [280]-bed hospital, case managers identified [26] patients a month on average who no longer needed acute care yet could not move to a long-term bed because their Medicaid application was unresolved. Their median wait after readiness was [11] days, about [9.4] beds held every day. Research on delayed discharge finds such waits bring functional decline, infection risk and distress for patients and families (Rojas-García et al., 2018). Common causes in the hospital's log: missing financial records ([41] percent), no authorized representative ([22] percent), state processing time ([28] percent) and transfer penalties ([9] percent).

Levers

State levers: faster processing for hospitalized applicants, accepting electronic verification of bank balances, and guidance for nursing homes on admitting patients with complete applications. Hospital levers: a Medicaid application specialist who starts the application at admission for likely long-term patients, early guardianship referrals and partnerships with nursing homes willing to accept pending cases in return for hospital help completing applications.

Conclusion

Medicare's design ends where most long-term needs begin, and Medicaid's begins only after proof of need. The seam is administrative; the cost falls on patients waiting in hospital beds.

References

42 C.F.R. § 409.30 (2024). https://www.ecfr.gov/current/title-42/section-409.30

Kaye, H. S., Harrington, C., & LaPlante, M. P. (2010). Long-term care: Who gets it, who provides it, who pays, and how much? Health Affairs, 29(1), 11-21. https://doi.org/10.1377/hlthaff.2009.0535

Rojas-García, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2018). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expectations, 21(1), 41-56. https://doi.org/10.1111/hex.12619

42 U.S.C. § 1396p (2024). https://www.law.cornell.edu/uscode/text/42/1396p