HEARING - U.S. Senate Special Committee on Aging

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II. NURS-NG -OME CARE
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The Medicare program pays for less than three percent of the
nursing home care our citizens need. Although Medicare nursing
home coverage is often unfairly denied, even if every patient
received the full coverage to which he or she is entitled, we
estimate that Medicare would cover no more than approximately 20
percent of all nursing home charges. The remaining 80 percent
would still have to be paid by the patient privately or, once the
patient is poor, by Medicaid.
Medicare nursing home coverage is restrained by several crucial
statutory conditions. First, coverage is available only if the
nursing home stay is preceded by a hospital stay of at least
three days. Thus the many patients who require nursing home care
without having first been acutely ill will be denied all
coverage. Second, Medicare pays only for a 'skilled nursing
facility' level of care. Unless a patient requires daily skilled
nursing or rehabilitation services, Medicare coverage will once
again be unavailable. Many people residing in nursing homes do
not require daily skilled care. Their institutionalization is
required because of their need for 'custodial' care such as help
with meals and feeding, ambulation, dressing and bathing, and the
accurate dispensing of prescription medications. These services,
although essential to a patient's well-being, are not considered
skilled, and no Medicare coverage is permitted. Third, even when
patients d2 need skilled care, as certified by their attending
physicians, HCFA's restrictive coverage policies lead to routine
Medicare denials based on the unsubstantiated pretense that the
care is 'custodiaI.'
Nor does private insurance assist with the cost of nursing home
care once Medicare coverage is denied. The 'supplemental'
insurance now available on the market is supplemental to
Medicare; such policies will pay the co-insurance for those days
for which Medicare coverage is granted. If Medicare coverage is
denied, the supplemental insurance coverage will also be denied.
Although there has been much talk about long term care insurance
which would cover nursing home expenses even where Medicare
coverage is not awarded, these policies are intended for people
still working. They will generally not be available to those who
are already aged or disabled.
The practical effect of the huge gap in Medicare nursing home
coverage is devastating. Every day we speak with beneficiaries
and family members who are undergoing the 'spend-down' process.
At a monthly rate of $2,000 or more, nursing home care will soon
exhaust the resources of all but the most affluent. In fact, a
recent study in Massachusetts showed that a typical nursing home
resident in that state was reduced to indigency after only 13
weeks.
III. ROME MHALTH CARE
As is true in the nursing home context, Medicare coverage for
home health care is often unfairly denied. Even if Medicare home
health coverage was granted in accordance with the statute,
however, a huge and destructive gap in the financing for home
health care would still exist. The Medicare Act stipulates that
home health coverage will be available only where the beneficiary
is confined to the home, and requires part time skilled care. If
a patient is able to leave the home without assistance, or if no
need for skilled care exists, no Medicare coverage is possible.
The effect of this limitation is to burden many beneficiaries
with the cost of the supportive services they require if they are
to continue living in the community. Many patients can live at
home if they receive just a few hours a week of assistance by
home health aides. Rome health aides can help with medications,
bathing, and meal preparation, for example. The private rate for