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Sunday, November 22, 2015

Can relatives supplement Medicaid covered nursing home care by paying for private nurses and private rooms?

Even though this concept appears reasonable (after all, most nursing homes are short on staff and rooms are semi-private at best), Medicaid does not permit it.

Medicaid is a payor of last resort: if there are any available sources of payment then these sources must be used first. If a resident, or anyone else on resident’s behalf pays for private nursing services, then it is considered a payment for a service for which Medicaid is already paying. As a result, Medicaid would then have to reduce its payment to the nursing home by the amount being private paid for the nursing services. This reduction would be unacceptable to the nursing home.

Similarly, Medicaid and Medicare pay a fixed fee to the nursing home for any room in the facility. As a result, Medicaid rate for a private room would be the same as the rate for a semi-private room. Therefore, most nursing homes reserve private rooms for private paying residents. Some relatives want to supplement the nursing home by giving additional payment for a private room. However, Medicaid would look to the private payment and reduce its payment to the nursing home by the amount of this private payment. The end result would be a nursing home receiving a similar rate for a private room and a semi-private room, which is not an acceptable business model. 

If a nursing home would accept a privately paid supplement on behalf of a Medicaid resident, either for a private room or for a private nurse, and if this payment was not reported to Medicaid, the nursing home would be committing Medicaid fraud. The consequences, both civil and criminal, are such that nursing homes are usually unwilling to discuss these supplements.

The one method that is available to supplement the nursing home care is to hire a “companion” to a Medicaid resident. Companion services are not considered medical, as a result they are not provided in the Medicaid nursing home rate. Placing a companion with a Medicaid resident will not have an effect on Medicaid payments. A skilled companion may provide various services to the resident, including bathing, toileting and feeding the resident.

Disclaimer: This article only offers general information.  Each situation is unique. It is always helpful to talk to a specialized attorney, to figure out your various options and ramifications of actions.  As every case has subtle differences, please do not use this article for legal advice. Only a signed engagement letter will create an attorney-client relationship.


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