Medicare, Medicaid, and Long-Term Care: Key Concepts

Medicare: federal health insurance for people 65+, permanent kidney failure, or certain disabilities; covers what is medically necessary; not for cosmetic procedures.
Four Medicare parts: $A$ (hospital and skilled nursing facility), $B$ (doctor visits and medical equipment), $C$ (Medicare Advantage/ supplemental private plans), $D$ (medication).
Medicaid: jointly funded by federal and state governments; coverage varies by state; generally serves low-income individuals, pregnant women, and children, plus many long-term care residents.
Key Medicaid thresholds (varies by state):
- Pregnant women and children up to age 18: up to $200\%$ of the federal poverty level (FPL) in many states; some programs use $133\%$ FPL baseline.
- Many states require additional factors (e.g., employment status) for eligibility.
Costs and funding reality: hospitals cannot refuse care due to lack of insurance; insured subsidize the uninsured via higher premiums; long-term care funding depends on admission assessment and ongoing evaluations.
Typical long-term care costs (illustrative):
- Semi-private SNF room: $82{,}000$ to $92{,}000$ per year.
- Home health generally more affordable than facility care.
- Adult day care: most affordable option.
- Assisted living: about $43{,}000$ per year.
Social determinants of health influence care setting choices.

Care settings vary by level of need and setting:
- Home health care: care in the patient’s home; often most affordable option.
- Skilled Nursing Facility (SNF): long-term or short-term skilled care; higher cost.
- Adult day care: care during the day; resident returns home; most affordable.
- Assisted living: residential option with varying levels of help.
- Interplay of floor levels in facilities (e.g., independent living vs. assisted floor) influences cost.
Intergenerational care: adult day care that combines seniors with younger participants to provide stimulation.
Care types by acuity:
- Acute care: 24/7 hospital or ambulatory surgical center; inpatient admission may be required.
- Subacute care: middle ground between acute and long-term care; bridge for ongoing needs.
- Outpatient/ambulatory care: procedures or treatments with same-day discharge (e.g., mole removal).
Palliative care vs hospice:
- Palliative care: shift from curative to comfort and symptom management (for serious illnesses).
- Hospice: a form of palliative care focused on pain relief and comfort for those with less than ~ $6\text{ months}$ to live.
Umbrella term: palliative care includes hospice as a specific service.

Focus: the resident (patient) first; all staff support the resident’s needs.
Holistic care: consider physical, emotional, social, spiritual, and cultural aspects; avoid labeling by diagnosis alone.
Empathy definition: identifying with and understanding the feelings of others.
Person-centered care: personal preferences and individual choices are promoted.
PHI and consent: sharing of personal health information requires patient/resident consent; involve family with respect to patient preferences.

Common rehabilitative specialists:
- Physical Therapist (PT): focuses on lower-extremity function, mobility, gait, and independence with mobility devices.
- Occupational Therapist (OT): focuses on upper-extremity function and activities of daily living (ADLs) like grooming, feeding, dressing.
- Speech-Language Pathologist (SLP): addresses swallowing, speech, and communication.
CNA scope of practice:
- Primary role: observe and report; essential eyes and ears on the resident.
- Cannot insert/remove tubes, perform sterile dressings, or administer medications.
- Report to RN/LPN; documentation is critical.
Social worker / case manager:
- Provides psychosocial support, advocacy, and connects residents with community resources to ensure continuity of care.

Medicare parts recap:
- Part A: hospital and skilled nursing facility coverage.
- Part B: physician services and equipment.
- Part C: private plan option (Medicare Advantage).
- Part D: medications.
Medicare vs Medicaid fund scope:
- Medicare: nationwide, standardized; benefits mostly for those 65+ or with certain disabilities.
- Medicaid: state and federally funded; coverage varies by state.
Common resident demographics and flow:
- Typical resident: over $65$ , often female.
- About $1/3$ come from private residences; roughly $50\%$ come directly from hospital or another facility.
- Length of stay: often $6\text{ months}$ or longer; developmentally disabled residents may have the longest stays due to lifelong needs.
- Approximately $62\%$ of nursing home residents are covered by Medicaid.
Diagnoses requiring skilled care:
- Short-term: cancer, heart attack/heart failure, fractures, post-surgical recovery.
- Long-term/degenerative: dementia, Parkinson's, MS, ALS; many have progressive decline with few cures.
Long-term care eligibility under HIPAA-related definitions: disability meeting the HIPAA definition and requiring assistance with at least two ADLs for at least $90\text{ days}$ , or substantial supervision or severe cognitive impairment.

Core professionalism: on-time, dependable, team-oriented; health care is a 24/7 job.
Team sport mindset: successful care relies on collaboration across nurses, CNAs, and other staff.
Documentation rule: if it isn’t documented, it wasn’t done.
Practical CNA reminders:
- Jewelry: a simple watch is best for time-stamped documentation.
- Gift etiquette: CNAs should politely decline gifts; thank the resident for the gesture.
Grooming guidelines:
- Wear a simple waterproof watch and ID badge.
- Tie hair back for safety; cover visible tattoos to respect resident comfort.
Ultimately, residents are people first; care should be respectful and person-centered.