Answers to Frequently Asked Questions About Long-term Care in Georgia

Georgia Council of Community Ombudsmen

INTRODUCTION

The decision to enter a nursing home can be an extremely difficult one for individuals and their families to make. The best strategy for making informed decisions and selecting the right facility is to plan ahead by examining all available options, determining the costs of long-term care, and learning how to recognize quality care in nursing homes.

Unfortunately the decision to enter a nursing home is frequently made in a time of medical crisis often at the time when an individual is ready to leave the hospital after a serious illness, surgery or a fall. If the person needs extensive rehabilitative care or can no longer live independently, decisions about care options must often be made within a period of days. Often there are few options available and there isn’t adequate time for individuals and their families to make informed choices. There are also fewer options available to the individual who does not have adequate financial resources to pay for nursing home care. It is often very difficult to find nursing home placement for a person who qualifies for public financial assistance from Medicaid.


The questions that follow are those frequently asked about long-term care by individuals and their families. For additional information, contact the following:

*** Your Area Agency on Aging assures the provision of a range of services for older adults in your area, provides information about available services, and distributes lists of nursing homes and personal care homes. Call the Office of your local Area Agency on Aging to learn how to find out more about the programs in your area.

*** The Community Long-Term Care Ombudsman Programs advocate for residents of nursing homes and personal care homes by investigating their concerns. The program also provides general information about long-term care services.

*** GeorgiaCares is a statewide coalition of programs offering low-cost prescription savings. It helps Medicare and other health insurance beneficiaries understand benefits and solve problems. A volunteer based program, it is administered by the Department of Human Resources, Division of Aging Services in partnership with the local Area Agencies on Aging.  GeorgiaCares is the State Health Insurance Assistance Program and Senior Medicare Patrol Program.


SECTION ONE: GENERAL QUESTIONS

1.   What is a nursing home?

A nursing home is a facility that provides long range, comprehensive, medical, personal and social services to chronically ill and disabled individuals. The care provided may be skilled nursing care on a 24-hour basis by registered nurses or intermediate care on a less than 24-hour basis by licensed practical nurses, or both. More specific examples of the types of care provided include routine nursing care, assistance with bathing and grooming, supervision of diet, supervision and administration of medication, assistance with transferring and ambulation, etc. Nursing homes also provide physical, speech and occupational therapies.


2.   Is a nursing home the same as a personal care home?

No. A personal care home (PCH) is a dwelling that provides housing, food service, 24- hour watchful oversight, and one or more personal services for two or more adults who are not related to the owner(s) or administrator by blood or marriage. These facilities are sometimes referred to as residential care, assisted living, group home, or board and care facilities. A PCH provides such personal services as assistance with essential activities of daily living (bathing, grooming, dressing, and toileting, for example) and supervision of selfadministered medication. PCHs are not licensed to provide medical or nursing care, but are required to provide individual residents with protective care and watchful oversight.


3.   Are there any alternatives to nursing home care?

Yes. In addition to the personal care home (PCH) setting, there are other services available that might allow an older person to stay in his or her home rather than necessitating a move to nursing home care. Such alternatives include:

1) The Community Care Services Program (CCSP) provides community-based services to functionally impaired persons who meet certain Medicaid eligibility requirements. Services available through this program are adult day health, alternative living services, home delivered meals, personal support services and respite care. Persons must be Medicaid eligible or potentially eligible to receive services under this program. To apply for this program or to get additional information, please contact your local Area Agency on Aging (AAA).

2) In addition to services offered by the CCSP, a variety of home health and home care agencies provide a range of services to assist elderly and disabled persons in their own homes. These agencies send skilled and non-skilled personnel into the homes of people who are incapacitated or recuperating from an illness. Services may be provided by RNs, physical, occupation and/or speech therapists, home health/home care aides and companion sitters. These services are sometimes reimbursable under Medicare, Medicaid or private insurance.

3) Other agencies in your local community may provide services such as home delivered meals, transportation to medical appointments, homemaker services, senior centers, nutrition, programs, case management and other related senior services. You may obtain information about such agencies by contacting your local Area Agency on Aging (AAA).

4) To obtain information about Medicaid waiver long-term care services (see the following categories), visit the Department of Community Health website at http://www.communityhealth.state.ga.us or contact your Area Agency on Aging (AAA).

--- Independent Care

--- Mental Retardation

--- Model Waiver for Oxygen or Ventilator-Dependent Children

--- Community Habilitation and Support

--- Traumatic Brain Injury


SECTION TWO: PAYING FOR NURSING HOME CARE

4.   What is the cost of nursing home care?

Nursing home costs in Georgia range from approximately $75 to $360 per day. This fee generally includes room, board, routine nursing care, general toiletries such as soap, shampoo, and tissue, and flat laundry (linens). There may be additional charges for other items such as medications, personal laundry and incontinent supplies.

Depending upon the resident’s source of payment, and/or the facility policy, the average cost may vary. Additional charges should be specified in the nursing home’s written admission agreement.


5.   What kinds of financial assistance are available for persons needing either nursing home care or alternative home care?

1) Medicare and Medicaid will pay for both nursing home and in-home care under certain circumstances. An individual’s eligibility for payment by these programs depends on the person’s financial situation and on non-financial criteria, such as health care needs and age. (Refer also to question #s 14 and 16).

2) The U. S. Department of Veterans Affairs (VA) (http://www.va.gov/) and Georgia Department of Veterans Service (http://www.state.ga.us/dvs/), under certain circumstances may pay for nursing home care, personal care, or in home care for a veteran. Please contact social services at the VA to apply.

3) Long term care insurance may pay a portion of these costs.


6.   Will Medicare pay for nursing home care?

Yes. Medicare Part A can help pay for certain inpatient care in a Medicare-participating skilled nursing facility if all of the following requirements are met:

1) The individual is a patient in a hospital for at least three days (not counting the day he/she leaves) before being transferred to the nursing home;

2) The individual is transferred to the nursing home because he or she requires care for a condition that was treated in the hospital;

3) The individual is admitted to the nursing home within a short period of time, generally 30 days, after leaving the hospital;

4) A doctor certifies that the patient needs and that he or she actually receives, skilled nursing or skilled rehabilitation services on a daily basis; and

5) The Part A intermediary or the nursing home’s utilization review committee approves the patient’s stay.

---If an individual is eligible, Part A will help cover services for up to 100 days per benefit period. A benefit period begins the day the patient is hospitalized and ends after he/she has been out of the hospital or skilled nursing facility for 60 consecutive days. If the patient is hospitalized after 60 days, a new benefit period begins. There is no limit to the number of benefit periods a person may have.

---Medicare pays all covered expenses for the first 20 days and if additional days are approved, all but $109.50 per day (in 2004) from the 21st day to the 100th day. Beginning with the 101st day of skilled nursing facility care in any benefit period, the resident and/or the responsible party is responsible for all charges.


7.   Will Medicaid pay for nursing home care?

Yes, if a doctor certifies that the person is in need of nursing home care, and if he/she meets Medicaid’s financial eligibility guidelines. (See question #s 10 and 20).


8.   What is the difference between Medicare and Medicaid?

---Medicare is a federal health insurance program for people 65 years of age or older and certain disabled people. Social Security Administration offices take applications for Medicare and provide general information about the program.

---Medicaid is a medical assistance program jointly financed by the State and Federal governments for eligible low-income individuals. Medicaid coverage and eligibility vary among states, and eligibility depends on both financial and non-financial criteria. (See question # 10 for contact information.)


9.   How do I become eligible for Medicaid?

An individual may apply for Medicaid at the county Department of Family and Children’s Services (DFCS) in the county where the nursing home is located. (DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html.) Medicaid eligibility in Georgia includes both non-financial and financial criteria.

To meet the non-financial criteria for Medicaid in a nursing home, an individual must:

--- be age 65 or older, totally disabled, or blind;

--- reside in a Medicaid approved nursing home;

--- be a citizen of the U.S. or lawfully admitted alien;

--- be a resident of Georgia;

--- agree to assign all health insurance benefits to the Division of Medical Assistance;

--- apply for and accept any other benefits which might help pay medical expenses.


To meet the financial criteria for Medicaid:

--- An individual’s income must be less than the 300% of the federal benefit rate for Supplemental Security Income (a total of $1,692) (for 2004) or less than the cost of the nursing home.

--- Countable assets must not exceed $2,000 (for an individual).

--- If married, combined assets of individual and spouse must be $92,760 or less (for 2004). (See question # 17 re: transfer of assets to spouse living in the community).


10.  Do I have to spend all of my money to become eligible for nursing home Medicaid?

No. A nursing home resident is allowed to retain $2,000 in countable assets. Countable assets do not include the nursing home resident’s home, automobile, or personal property.

Countable assets do include any real property other than the resident’s home, saving and checking accounts, investments such as certificates of deposit, stocks, bonds, mortgages and promissory notes, life insurance, inherited property, and jointly owned assets. Any life insurance policies with a face value of $5,000 or less are not counted. An individual also is allowed to pre-pay funeral expenses and to have a separate burial account with up to $5,000.

Any individual who gives away assets (except to a spouse) within 36 months of entering a nursing home in order to become eligible for Medicaid is subject to a penalty. (See question # 13. Call the local county Department of Family and Children’s Services for additional information. DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html.)


11.  Do I have to sell my home to qualify for Medicaid?

No. An applicant does not have to sell his or her home to qualify for Medicaid because the home is not a countable asset.

Effective October 1, 1993, states were mandated by the federal government to actively seek estate recoveries and to impose liens against properties owned by individuals who were Medicaid recipients residing in nursing homes at the time of death.  Persons with further questions may call the Department of Family and Children’s Services in their county. (DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html.)


12.  If a nursing home resident has applied for Medicaid, can the nursing home require that person to pay out of pocket until Medicaid is approved?

If it is apparent that the resident will be Medicaid-eligible, the nursing home may not require out-of-pocket payment while approval is pending. If it is not clear that the resident will be eligible for Medicaid, the nursing home may charge out-of-pocket fees. However, should the resident then become Medicaid-eligible, the nursing home will be required to reimburse the resident for fees collected since the date that the Medicaid application was made.


13.  Will transferring my assets to my children or other family members affect my eligibility as a Medicaid nursing home resident? An applicant for nursing home Medicaid may not transfer assets to any family member other than a spouse within 36 months of entering the nursing home without incurring a penalty. The penalty will result in denial of all Medicaid payments to the nursing home during the penalty period. Persons with further questions may call the Department of Family and Children’s Services in their county. (DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html.)


14.  What happens if I run out of money while in a nursing home? Where do I go for help? How do I pay until I get help?

If a private pay nursing home resident runs out of money in a Medicaid certified nursing home, the resident may apply for Medicaid. The nursing home social worker or admissions staff should provide information about Medicaid eligibility requirements and assistance with applying for Medicaid benefits. (See question # 10). The Medicaid certified nursing home is prevented by regulation from discharging a resident for nonpayment while a Medicaid application is pending. If the resident qualifies for Medicaid benefits, Medicaid reimburses the nursing home for the resident’s care retroactive to the date of application for benefits. If the nursing home in which the resident resides is not Medicaid certified, the resident can be discharged when nursing home bills are no longer being paid. Nursing home staff are required to assist in finding appropriate placement for the resident being discharged and provide adequate notice.


15.  How does a nursing home that is Medicaid-certified determine its costs for private pay patients?

The private pay rate in any nursing home is determined by the facility and is generally higher than the Medicaid reimbursement rate. By regulation the private pay rate cannot be lower than the Medicaid rate.


16.  What happens if I do not qualify for Medicaid or Medicare to pay for nursing home care?

If an individual needs nursing home care according to Medicaid guidelines, but is ineligible because of income or resources greater than the allowed limit, it may still be possible to qualify for Medicaid by “spending down” countable income or determining which resources are exempt. Call the county Department of Family and Children’s Services or an attorney with experience in Medicaid planning for additional information. (DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html.)


17.  Will my being in the nursing home affect my spouse’s finances?

If the nursing home resident has a spouse who is not institutionalized, the assets of the spouse must be considered in determining the resident’s Medicaid eligibility. Total combined assets for the resident and spouse must not exceed $92,760 (for 2004). The spouse living at home is allowed to keep enough of the nursing home spouse’s income to make the at-home spouse’s total monthly income $2,319 (for 2004). The spouse’s financial situation is not considered when Medicare pays for nursing home care.


SECTION THREE: NURSING HOME ADMISSION

18.  Will I need a primary physician in order to be admitted to a nursing home or one to care for me after I become a nursing home resident?

A physician must determine whether an applicant requires nursing home care and complete a DMA-6 (see question #s 23, 24, and 25). A resident needs to have a physician who is willing to provide services in the nursing home setting. Even though residents frequently want to maintain relationships with their family doctor, not all doctors are willing to visit patients in nursing homes. The nursing home staff may be able to give you names of physicians who will provide medical care to residents.


19.  What is the procedure for transferring a resident from an out-of-state nursing home to a nursing home here in Georgia?

Some of the specifics will depend upon which other state is involved. If the individual receives Medicaid, he or she should contact the county Department of Family and Children Services in Georgia (DFCS county office listings are on the World Wide Web at http://dfcs.dhr.georgia.gov/02/channel/0,2188,3815890_3819758,00.html) as well as the corresponding agency in the other state. Eligibility for Medicaid may vary from one state to another. This factor may affect the potential transfer. If the individual will pay privately, he or she need only check with the current nursing home and the Georgia nursing home regarding their requirements for transfer.


20.  What is the procedure for transferring a resident from one local nursing home to another?

Check with each home regarding the facility’s requirements for transfer.


21.  What are the best nursing homes and which nursing homes would you recommend? (How do I find out if a nursing home has a poor reputation)?

Staff of the Area Agencies on Aging, the Long-Term Care Ombudsman Program and the Division of Aging Services may not endorse or recommend one nursing home over another. However these agencies can provide some information about facilities that may be of some help as persons are seeking to evaluate nursing homes, including lists of facilities in their service area. A list of facilities can also be found at the website for the Office of Regulatory Services (ORS) (http://www.ors.dhr.state.ga.us/).

There are several sources of information regarding the quality of nursing homes. ORS, which is a part of the Georgia Department of Human Resources (DHR), makes periodic unscheduled visits to all nursing homes to survey medical and patient care. ORS will provide copies of survey findings upon request (a copying fee may be charged). For facilities that participate in Medicare or Medicaid, this survey information can be found at the Nursing Home Compare page of http://www. medicare.gov. The Long-Term Care Ombudsman Program also can share information about the types of complaints it has received and verified, and advise consumers about what to look for in choosing a nursing home.

One of the very best ways to determine quality is to make visits to nursing homes both during the week and on weekends to observe the care provided to residents. Mealtime is a good time to visit; it is also helpful to visit different times of the day.


22.  Where can I find information about nursing home vacancies?

Currently no agency maintains a nursing home vacancy list that is available to the public. Therefore, it is necessary to call facilities that you are interested in to determine whether they have vacancies or not.


23.  What is a DMA-6?

A DMA-6 is a Division of Medical Assistance form which provides a physician’s verification of the individual’s need for nursing home care. All applicants to nursing homes that receive Medicaid funds must complete the DMA-6. This form must be signed by the prospective resident’s physician to verify that the resident needs nursing home care before Medicaid payments can be made.


24.  How do I obtain a DMA-6?

If your physician does not have this form, please check with the nursing home.


25.  Will the nursing home accept a DMA-6 that has been completed by a physician from out-of-state if the prospective patient is relocating to Georgia?

A DMA-6 must be completed by a physician who is licensed by the state of Georgia.


26.  What recourse do I have if staff of a certified Medicaid nursing home state that the facility has no available Medicaid nursing home beds but that it does have beds available for private pay or Medicare patients?

Nursing homes are prohibited from discriminating based on source of payment. However, it is difficult to regulate this type of discrimination. Should such a circumstance occur, you should contact the local Long-Term Care Ombudsman Program for assistance. In a Georgia Medicaid-certified nursing home all beds are certified as Medicaid beds. However, the reality is that it is often difficult to find nursing home placement for an individual on Medicaid.


27.  If I am a nursing home resident and my physician admits me to the hospital, how long is the nursing home required to hold my bed?

The nursing home is required to hold the bed for seven (7) days for Medicaid recipients and to provide the first available bed after that time should the hospital stay be longer. Private pay residents will be required to pay the nursing home for their bed during their hospital stay if they wish to have the nursing home hold the bed for them.


28.  What is Respite Care? Is it available in nursing homes?

Respite care provides time off for caregivers who provide care for a chronically impaired person. Respite care might be offered on a regular basis, such as adult day care or for longer periods intermittently. Some facilities provide short-term respite care if space is available.



This paper prepared by the following members of the Department of Human Resources Consumer Information Work Group:

--- Barbara Fraser, Office of the State Long-Term Care Ombudsman

--- Becky Kurtz, Office of the State Long-Term Care Ombudsman

--- Mary Ball, Gerontology Center, Georgia State University

--- Joy Lankford, Aging Connection, Atlanta Regional Commission

--- Annette McNaron, Division of Aging Services


(For additional information contact your local Representative of the Georgia State Long-term Care Ombudsman’s Office. See that listing on the About Us page of this website.)