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Chapter 11 Long-Term Care

Reimbursement

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Learning Objectives

1. Understand how long-term care services are reimbursed

2. Identify and define public sources of reimbursement

3. Identify and define private sources of reimbursement

 

 

Learning Objectives (continued)

4. Understand how managed care works and its impact on long-term care

5. Understand the trends affecting long-term care reimbursement

 

 

Long-Term Care System Development

Little government involvement until welfare (Social Security) in 1935

Major involvement with Medicare and Medicaid in 1965

Has evolved since then

 

 

Current Reimbursement Options Government (public) sources:

• Medicare • Medicaid • Other

Private sources: • Out-of-pocket payments • Private long-term care insurance • Managed care organizations

Public/private partnerships

 

 

Medicare

Title XVIII of the Social Security Act Covers elderly and some disabled No means test Covers (with some limitations):

• Skilled nursing in nursing facilities and subacute care

• Home health care • Hospice

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Medicaid Title XIX of the Social Security Act Covers “medically indigent” Funded partly by federal and partly by state

governments Run by the states under federal guidelines Covers (depending on the state’s program):

• Nursing care facilities • Assisted living • Home health care

 

 

Medicaid (continued)

State efforts to reduce costs: • Divert funds to less expensive forms

of care (community-based) • “Spend-down” requirements • May be greatly expanded by the

Affordable Care Act

 

 

Other Public Funding Sources

Supplemental Security Income program Department of Veterans Affairs Older Americans Act Others

 

 

Private Reimbursement Sources

Out-of-pocket payments Private long-term care insurance Public/private partnership programs Managed care

 

 

Public/Private Partnerships

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