In Episode 2 of The ROADS Podcast, Kristen and Jill break down one of the most confusing parts of caregiving: understanding how senior care is paid for. From Medicare and Medicaid to private insurance, Medicare Advantage plans, rehab stays, assisted living, nursing homes, and home care, they explain what families need to know when navigating healthcare decisions for a loved one.
The Roads Podcast Episode 2: Who Pays for What in Senior Care?
Listen to the episode
Episode Highlights
In this episode, Kristen and Jill walk listeners through the most important financial aspects of senior care planning.
- Clear explanation of Medicare, Medicaid, private insurance, and Medicare Advantage differences
- Breakdown of how short-term rehab coverage works, including Medicare’s 100-day benefit
- Insight into copays, deductibles, and why insurance costs vary from person to person
- Comparison of home care, assisted living, rehab, and nursing home payment structures
- Discussion of Medicaid eligibility rules for long-term care and common misconceptions
- Helpful guidance on using resources like HHS, MAMAP counselors, elder law attorneys, and Area Agencies on Aging
Key Takeaways
The biggest lesson from this conversation is that understanding coverage ahead of time helps families make better care decisions with fewer surprises.
- Insurance coverage for senior care depends heavily on the type of plan and service needed
- Families should review benefit booklets yearly to understand changes in coverage
- Medicare rehab benefits do not guarantee 100 consecutive days—they are based on medical necessity
- Assisted living is often private pay, while nursing homes are commonly funded through Medicaid
- Medicaid planning should never be handled casually—professional guidance is essential
- Planning ahead before a crisis makes care decisions less stressful and more financially manageable
## Episode Transcript
Prefer to read instead of listen? The full episode transcript is available below.
Welcome back to TheRoads podcast with Kristen and Jill. Hi, Jill. Hi, Kristen. We’re so glad
to have you back for episode two. We had a great discussion last time about being a patient
advocate and what that means for you as the advocate and some tips and tricks I’m getting
services for your loved one. So we’re going to build off of that and this time we are going
to be talking about, okay, so now you’re the advocate of someone and so now the next thing
you need to know is who pays for what, when and where. So you’re the patient advocate for
someone, you’re a DPOA, you’re a guardian, you’re a loved one and so now your loved one
is going to the doctor or they have to go to the hospital or a rehab facility or they
need home care and so we wanted to kind of delve into find the financial piece of this
so that you’re empowered when those kind of things happen to know what is what you need
to do in your role either as the patient or the patient advocate when it comes to who
pays for certain things because not all insurances are alike and so we really wanted to sort
of get into that today. So one of the things that I think we need to talk about is the differences
between Medicaid, Medicare, private commercial insurance, advantage plans, like all that kind
of stuff and sort of what the differences are. So Jill, if you want to start us off by let’s say
I was in the hospital for a few days and they’re going to send me home with home care. What do I
need to know when, because the case manager at the hospital, which we kind of touched on last
time, is the one that’s going to send that referral there. And so what happens next from a financial
perspective for someone who might need home care. So what we’re looking at when someone’s in the
hospital, we’re looking under their Medicare insurance of what your Medicare insurance will pay,
your Medicare Advantage plan will pay or if you have a commercial plan or even Medicaid what they
will authorize for you to have in the home. And this, a lot of this stuff will happen behind
the scenes, your case managers will be sending out referrals, the companies will be running your
insurances, they get these things that print it off, they say what deductibles are,
what the out of pocket expectation is going to be. And it’s beginning of the year. So as a home
care company, what we see at the beginning of year is people haven’t started, haven’t used their
insurance yet. So we see higher deductibles, higher out of pockets, which is a determining factor
for a lot of folks if they are able to cover that cost. If there is a cost, each insurance is very
different in what you paid for in that plan. So it’s important to know them stuff and I promise you
whatever agencies you’re working for, they will do that legwork for you. Which is hugely helpful.
Yeah, no one wants a surprise bill. No, I thought we were good. I thought my Medicare would cover
everything. I always go back to my grandmother, which was 20 years ago. She had a traditional
Medicare in the back up Blue Cross Blue Shield plan and that covered everything. And the one
time she got a $2 deductible on a prescription cost, she was livid. Nowadays I think we all would
pray for a $2 deductible. So understand that you have Medicare Part A, you have Medicare Part B,
and different services will build different things under that.
Yeah, so okay, so just for clarity, do you ever recommend that a patient calls their insurance
company to get all that information? Or is it like you said, like the patient should really
just buddy up with the case manager and also the representative from the home care agency like you
and to be that person to say, okay, your insurance is going to cover. Is it a per day charge for
home care or is it hourly? So each insurance, there is a per visit charge and some
insurance is paid for episodic charge, which means, okay. You have, you’re coming in on a CLPD
diagnosis and there’s a one time payment to the home care company to do them sort of things.
Or depending on your insurance, the home care company may build per visit. It’s really set
on the insurancees. What I would suggest, one of the things we can put in our tool kit is I know
in December and January, every insurance company sends you all a booklet that has your list
of benefits that has it broken down. Medicare sends that really big one that says Medicare new.
Yes. It’s good just to have that handy of, okay, what’s covered, not covered, because it does
vary from year to year. Every time you re-enroll in a plan, things change from year to year.
Right. So that’s always a nice tool to have. Most of your medical entities,
have billing offices, have folks that will run them insurances for you also and then usually they
will reach out to you and say, this is, just so you know. This is where you’re at. This is what
you’re looking at. Yeah. Because you know, it’s just good information. But yeah, if you don’t pay
the bill, they get stuck the bill too. Right. Everybody is wants to make sure everybody wants to make
sure exactly. Now, there are differences between straight Medicare, Medicare Advantage plans,
Medicaid. So I will talk a little bit about from the short term rehab perspective. So if you’re
a person who’s in the hospital for a little bit, maybe not well enough to go home quite yet,
but you’re not sick enough to stay in the hospital, usually they’ll transition you for something
called a short stay at a subacute rehab. So that’s one of the things that we do here at Dolby Road.
So a short term stay is usually, I think the average length of stay right now here is around 12 to
15 days, something like that. Obviously, people can stay shorter. We’ve had people stay for two to
four days. We’ve had people stay for 60 to 80 days. It just depends on what’s going on. So usually
with straight Medicare, there’s something called a 100 day benefit. Okay. So let me, yeah, let’s just
talk about that for a second, because sometimes I think people think that means that they will be
in a rehab setting for 100 days. That is not the case. What that means is that you have 100 days. So
let’s say you got for bid fall and you’re in the hospital and they say, boy, you’ve got 25 steps
to get up to your apartment. We really just feel like you need some more therapy in order to be able
to do that. So we are going to send you to a short term rehab where you’ll get that extra therapy
before you go home. And then let’s say you’re at the short term rehab for 20 days. And then they say
great, you’re able to do 25 stairs. You can go home. This is great news. You have then the remainder
of days left on your Medicare advantage or I’m sorry, you’re straight Medicare 100 days. So
so and then let’s say later on in the year, you fall again and they you go to a different facility.
That facility will usually try or want to know if you’ve used days at other facilities so they
can know how many days you have left because what what never ever wants to what you never ever want
to happen is that you get very close to that 100 days because after the 100 days, you have a 20%
copay, I believe. Is that right Jill? So if you if you have a traditional Medicare plan and again,
if you have the traditional Medicare plan, the first 20 days is a harm set.
100% covered 20 days. Yes. There’s a copay if you have a Medicare advantage plan, which is your
humana’s your at knows your PHP’s all them. Each one of them is is very different in the copay
and then Popeyes and then world and then timeline. So yeah, just be. So yeah, so be aware because
usually the case manager will be able to help you say, okay, your first 20 days. So let’s say
so on day 21 is when that copay starts. So if you have humana, they might pay a certain percentage
of that copay or whatever. There might be a patient pay them out, there might not be. These are
all things to know that could potentially happen if you have to stay past those 20 days.
Now Jill, can you talk a little bit about what happens if they have a if you’re within the 30 days.
So let’s say you went to a rehab and 15 days later, you feel like, man, I’m just not doing well
at home. Can they go back to a short-term rehab facility? They can. Yes. So everything is done
by episodes in the insurance world. Yes. And there’s 30 days, seems to be a big marker. Yes.
Yes. Yes. You see days, seems to be a big marker. Yes. So a lot of times if in nursing homes and
rehab centers really do prefer this because the goal is to keep you out of the hospital if possible.
Right. And all of this stuff is also based on medical usability. So there’s this whole medical
piece that goes with it too that you can’t just go hang out at the rehab center because they
food. Right. Right. You know, they’re medical necessity. Yes. Yes. Yes. Yep. Yep. So
I almost forgot the question there. Well, I was just saying like if you have another episode or
another thing or you’re within 30 days of being discharged, let’s say I discharged from Dobie Road
two weeks ago, but me and I just feel like I’m not I’m not doing great at home. So you can return
back to the rehab or nursing home facility within 30 days of that discharge under your
Medicare rules. Yes. And it has to meet medical qualifications. But if you get home and
something happens, maybe you’re you thought you were doing good physical therapy and the hip
just isn’t cooperating. Yep. You need to go back in for then you’re still under that same
episode. Right. That works really well. Yep. And my advice for that would be to call your PCP,
explain what’s going on or call the facility that you were at and say, Hey, I’m home,
but things just aren’t going well. What what do I need to do? And we can help you through that.
So. And they’ll usually guide you very well. Yes. And also they might if you get a hold of the
nurse that is working with you. And they they may direct you to that, you know, this sounds more
like you need to get to the ER because there’s something different medically going out. Yeah.
So yeah, use them resources. I always say anytime you use a service, whether it’s a rehab or a
home care or wherever the doctor’s office always try to make a friend with a nurse because
befriend a nurse day. We should make that a day. That’s right. And that’s always good to have
that person just to call for advice on that medical side of. Yeah. These are the symptoms that
there’s change in condition. I’m having a moment. Yeah. What what should I do? What should we do? Yeah.
And you know, just to go back to something that you mentioned a second ago about, you know,
the hospital isn’t, you know, necessarily the place that you want to go. But, you know, first of all,
hospitals obviously have a huge role in the acute world. So by acute, we mean, boy, you need help
right now. You obviously want to go to the emergency room. You need to be admitted. All those kinds
of things, absolutely 1000%. But as we all know to hospitals are, is, you know, hospitals are the
place where you might get a secondary infection. I mean, just happened. You have a lot of people
in one space. And so I’m not saying that could happen just as a caveat. I am not saying that.
I’m just saying like that and the hospital will tell you to you. Like, you know, if you have
the opportunity to be home, that’s sometimes better than in the hospital. So, or in a rehab
facility or, you know, something like that. And I think that that ER state, again, when in
doubt, go to the ER 1000%. No, please go to the emergency room. Yeah. But for older folks that
may be suffering from some dementia or just having a rough time, I mean, all of us. Yeah.
Then wait times in the ERs can get, you know, cause a lot of stress things out of it. And because
you are waiting a lot of time, it cares are also a good option. Yes. Something like we’re just
coughing. There’s spring. There’s something. I was a minor, but it’s not the bone sticking out
or, you know, yeah, things like that. There’s a change in, in their cognitive issues where
who they just seem like they’re off go to the ER. Yeah. Make sure there’s not infections and stuff
like that. Yeah. No, we definitely are saying go to the ER. That is what we are saying. Go to
the emergency room. If you’re not sure what to do, go to the emergency room. And so, but I just
back to some of this pay or stuff. So I think a lot of people are maybe not sure of the difference
between a nursing home and assisted living and a rehab. So let me just go through those very
quickly. So a rehab like we sort of said already is a short stay. It’s very, it’s very similar to
the hospital setup usually. And that is like I said, short stay. Their goal is for you to be here
to get therapy, to get nursing, to get well and to go to your next destination. Sometimes that’s
home with home care. Sometimes it’s back to, you know, your independent living situation with
your family. Sometimes it’s too an assisted living. So an assisted living is not a nursing home.
So an assisted living, the differences are going to be a assisted living is typically going to be
a private pay situation. If they’re a licensed facility, they also accept Medicaid. But if
they’re not licensed, help me, Jill, if I’m not saying this correctly, we don’t do assisted living
here at Dolby Road. So I’m not always, you know, as the big difference with this is living license
and adolescents is if they take the long term care insurance policies. Got you. Okay. It’s
sometimes Medicaid will pay for an AFC home or assisted living if you’re part of a paste program
or my choice waiver program. Okay. All the moons and stars have to line up for that to happen.
It’s a whole process. It’s being part of that agency and their case managers that feel that that’s
and that’s the right option for you. It’s usually where you’re on the program, they’re doing home
care at home and then moving into the assisted living because we’ve just been staying at home just
not okay. This is working more. Again, that is not the norm. Yep. I just want people to know that
because we always use to say or we say, you know, it’s what you want, what you can afford and what
you need, finding that perfect combination for families and ones. It is the challenge. Yeah.
And learning what, working with folks who know them systems to get you the best answer. Yeah.
Money is always options. Yep. assisted living, memory care units, AFC homes, they all take,
they all take cash. Yeah. They all take private pay dollars. So them are,
them are places that is an option for some folks and they really run the gamut of care they provide,
the cost of that care, size. There’s a whole bunch of them out there. Yeah. I was going to say there’s
a lot in the Lansing area. So there’s a, there’s a, you know, and I will say the same about nursing
homes. Go visit. Go take tours. See what feels like a good fit for you. Like Jill said, there’s
so many in our area. You have so many options. It’s worth it to go visit. You know, what’s
closest to your family? What’s, you know, it’s just worth it to go visit. Yeah. When we,
when I, I always tell people and to go out and see places before the crisis hits.
Because you, if, when you’re in the hospital, there’s lots of lists out there. There’s lots of
Google for lots of agencies. They’ll help you with placement. But if someone, right now,
if someone hands you a list to all the assisted living in Lansing, that’s what it’s overwhelming.
Oh, I mean, to 25 now. Oh, easily. Yeah. Or they, they’re popping up like, like, they’re popping
up everywhere. Yep. Go and visit them. Learn about their different levels of care. Yeah.
Prices. They’ll share that with you. Some of them will do an allocate where this is your rent
and then depending on what service you need, then we’ll, we’ll increase your cost based on that.
Some of them do just a one, the cost is this per month and it includes all your care.
There are important things to research based on your loved ones needs, based on how much
resources you do have. Aging in place is a big term. A lot of places use. Again, we don’t want to
move people more than we have to. That’s right. So there’s a lot of thought that goes into it.
Because if I have enough money to pay for six months, and again, move again in six months.
Yeah. That’s, that’s, that’s a, that’s a hard thing for our loved ones to do. Yeah, absolutely.
And, and the nursing home setting is different. So the nursing home setting is different.
Nursing homes are, or long-term care. Those are 24 hour facilities. They have nurses on staff,
24 hours, multiple nurses usually. We have multiple nurses, lots of nurses on staff.
24 hours a day. We have certified nursing assistants here. They have to be certified nursing
assistants. They can’t be texts. And, and just a lot more of a regulated environment than
assisted living. And I don’t mean that in any kind of way. That’s just what, that’s just how it is.
And, and also nursing, the nursing home population is mostly your Medicaid population.
So Medicaid pays for the nursing homes typically. Nursing homes also accept private pay.
And, but, but I would say medicates the primary payer of a nurse, at least here at Dolby Road.
We’re over 90% Medicaid here. And so, and we do have beds available.
Just as the little plug. We do have Medicaid beds available now. So, but yeah, again, definitely
know what your income source is and what that is going to cover. Because I think some people get
shocked at the price of a nursing home versus assisted living, but you have to remember the care
is completely different. So, it’s what Jill is talking about. Like, what are your needs? Because,
if you need 24 hour nursing care, you should be going to a nursing home and not necessarily
an assisted living. When you, when you go to all these places, there is a sticker shot factor.
Yes. I think for most folks, if it’s your first time going down this road. Yes. You’re, you’re
nursing homes. Most of them do, they all take Medicaid. That’s usually the main payer source for
most of them. I think there’s some stigma of Medicaid. Understand the rules to long-term care
Medicaid is very different than it is for our younger folks on Medicaid. Yes. Community Medicaid
is not the same as nursing home Medicaid. You’re right. There’s is some confusion about that.
There’s lots. Yeah, I worked in the Medicaid world for a very long time. I’m not an attorney.
Nor did I stay at a holiday at last night. So, I won’t give too much. But seek out folks that can
help you with that eligibility before you move in your money, before you try to put in the mattress,
do not get divorced. The rules for our married folks are are generous here in Michigan.
Michigan does not want this healthy spouse to be impoverished if they have to put their loved one
into the nursing home. Right. Our single, our folks that are single, the rules aren’t so forgiving,
but you need to seek legal advice of a law attorney or a map counselor and how to get that
qualified. Yes. There are penalties. There’s Medicaid fraud. The state don’t play. No,
with you qualifying for that government benefit. Right. It is manageable. There are some resources
out there that can really help you navigate that. Don’t be scared of it. And the rules for Medicaid
are they change constantly. So, what Millie told you at the senior center five years ago,
probably doesn’t apply today. Yep. And I won’t talk about the manuals and all that good stuff,
because if you’re that important, go read the manuals. But yeah, what’s someone who was on top of
that piece of, because I’m afraid of what I see occasionally as people are not getting the
care they need for someone because they’re afraid of the costs, they’re afraid of losing their
house, they’re afraid of all these things. Right. A lot of that is urban legends. A lot of it
can be worked around. And it’s not something you want to try to navigate on your own. No. No,
it’s a it’s a complicated world, but it is there’s so many resources out there to help you. And
Jill and I have talked to we we’d love to have a local attorney that’s going to join us. Hopefully
maybe next podcast because I think this is a great segue and have them really join us just to give
you some of their tips and tricks and how they can help because a lot of people do end up going
that route because they are and and and remember, too, there’s a look back. How far is the look back
now? Is it five years or three is five years? Five years. Okay. And they they I recommend doing this
a long time. I remember the technology wasn’t so good 20 years ago. So we could slide some stuff
through. Not that I ever would. But now with all the check and balances systems in place. Right.
You know, where you’re one of the things that always surprised me is the department of Health
and Human Services gets statements of things that have accumulated interest. So if there’s a bank
account you forgot about or CD you forgot about property that you forgot about. It will come back.
Yes, they’ll find if they might have found it the first time around, but then it will come back
in their system of hey, we see this and we see that again. The DHS workers can be very helpful.
They’re the first place to try to reach out to if you’re that’s where you follow your
application. They’re the ones that kind of hold the gatekeeper to Medicaid. And they know it
backwards and forwards. That’s their whole job. That that literally is their whole job. Make an
appointment and I agree with you. The DHS Department of Health and Human Services are are that’s what
they do. That’s what they do. And they’re the ones. Yeah, they’re the ones that are going to
greenlight it or ask you for more information. But they’re the great resource. You can ask them
questions. They can help you and also try county office on aging. I think we’ve talked about that.
They can help with some of that too and direct you to the right place or give you the phone number
to call. Yeah. And there’s and there’s map counselors throughout Michigan. So even if you
may be listening outside of the Lansing area. Yep. Your Department of Agings have the map
counselors. And can you say really quick what a map counselor is? What does that stand there? Oh,
boy. Medicare Medicare Medicaid AP. Oh my goodness. Application. I don’t remember. Assistance program.
Yes. Medicare Medicaid assistance program. Yeah. And map is the acronym for that. And it’s
actually MAMAP, right? Correct. Yeah. But like Jill said, every area on aging in the state would
have that. And they’re a good place to start. But again, DHS is going to be your resource.
And they’re free resource. Yes. MAMAP counselors are free. I’m obviously I’m a big fan of
all the law attorneys because my disclaimer I worked for one for many years. Most of them don’t do
this for free. But it’s it’s worth it if you have assets and things that you want to make sure
everything gets passed down the right way or protect as much as we can. Okay, I went in there.
No, that’s good. We’re getting close to the end of our time here. So I just want to say that
this is I think this piece is a very important piece. We’re going to have an elder law attorney
that’s going to come join us. And I think we can really delve into this a lot deeper and talk about
you know, how do you afford a nursing home or how does your loved one afford a nursing home
or assisted living or you know, home care that’s private pay or an adult day center that can
also be private pay. We haven’t even touched on those because those are options as well. And I
think the other options we didn’t we didn’t touch on yet is there’s if you’re a veteran. Yes.
That the veteran and I’m not going to start talking about veterans benefits because each program is
a little bit different. Yeah. Each one’s dependent on service related or disabilities. There’s
it’s a monster. Yeah. The veterans, but they are there to help our veterans. Yes.
And they may have really good resources. The VA can help with long-term care costs, whether it’s
home care, whether it’s assisted living, whether it’s rehab. Yes. That’s also an option for a lot
of our folks that are out there that don’t forget to use that. So it’s always trying to get I always
want to say you want to be insurance rich, right? Yes. The more insurance as you have, the more
options you have. Yep. The more choices you have. Love it. And the what’s the other caveat I was
going to say if you’re a Mason. Oh really? You’re a Mason. This isn’t a balancing area about all my
heads, the Masonic home. Yes. And that’s a whole option for our folks that are Mason’s, which I
don’t know a lot about the Mason’s. Yeah. It’s another option for helping with long-term care
and options up there too. Yeah. I agree. Insurance rich. I love it. Well, that to me is a great note
to end on. So we’re going to end on that and we’ll have a lot more for you in our next podcast. So
stay tuned. Jill was great to see you again today. And everybody have a great day. We’ll talk soon.