Chapter 11 Long-Term Care
Reimbursement
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
