Private Rooms and Nursing Home Residents on Title 19
Many elderly Iowans enter nursing homes after living privately in their own homes or apartments. When entering a nursing home, some maintain a degree of privacy by getting their own room as long as they can pay the higher cost of a private room. After using up their savings, people must apply for Medicaid to pay for nursing home costs. Once on Medicaid, most of the time the resident must live in a shared room.
It can be very difficult and emotionally painful when an elderly person suddenly must share space with a stranger. This is especially true if the stranger does not have the same interests or habits. Imagine how disturbing and unpleasant it might be when a person who enjoys quiet reading now must live with someone constantly watching television at a loud volume.
Iowans in nursing homes on Medicaid may have a private room if they or family members pay the extra cost. This is possible because of a change in the law in 2011. So if your mother, father or other loved one is on Medicaid and wants to have a private room, it is an option as long as someone pays the extra cost. Important Note: If someone decides to help with the extra cost, their payments must go directly to the nursing home and not to the resident.
This information is from the Legal Hotline for Older Iowans. The Hotline is a project of Iowa Legal Aid and is funded in part by the U.S. Administration on Aging. The Hotline is a free, confidential service for all Iowans 60 or older with questions on many non-criminal legal matters. To reach the Legal Hotline for Older Iowans, call 1-800-992-8161.
Iowa Legal Aid provides help to low-income Iowans.
To apply for help from Iowa Legal Aid:
- Call 800-532-1275.
- Iowans age 60 and over, call 800-992-8161.
- Apply online at iowalegalaid.org
If Iowa Legal Aid cannot help, look for an attorney on “Find A Lawyer” A private attorney there can talk with you for a fee of $25 for 30 minutes of legal advice.
*As you read this information, remember this article is not a substitute for legal advice.
Last Review and Update: Apr 22, 2021
July 7, 2020
A family was recently referred to our services seeking Medicaid for a private room and so we obliged. But how? I will explain…
Most people are aware that Medicaid will not pay for a private room in a long-term care facility. Medicaid does cover a so-called semi-private room at a rate pre-negotiated individually with each facility.
For years this family paid out of pocket and was approaching their final $100,000 in savings. Upon entering our office, they declared “we don’t care about the money” “we only want to ensure he stays in a private room for as long as possible.” After doing some simple math, we determined the $100,000 of remaining savings would pay for fifteen more months in a private room at this specific facility. But this gentleman, being blessed with a family history of centennials, would likely need many more years to come.
Using our transfer of assets program, we facilitated a one-time gift of approximately 65% of the assets to the immediate family. The remainder of the resources were placed into a Medicaid Compliant Annuity and then we applied for Medicaid since he was now below the $2,000 allowable asset limit.
We then negotiated with Medicaid an appropriate transfer of assets penalty period commensurate with the amount of the gift and the daily penalty divisor. The most important step was to ensure the length of time the Medicaid Compliant Annuity private paid the nursing home, coupled with the client’s income, already equaled that estimated Medicaid transfer of assets penalty period which it did.
Medicaid will allow for an individual to upgrade into a private room if someone other than the applicant is paying the difference. In this instance the family decided to use the gift to pay the difference between the semi-private room paid by Medicaid and a private room. At a difference of $35 per day, using some simple math, we calculated the gift would stretch for approximately four years.
In this example our transfer of assets program helped stretch a client’s savings to stay in a private pay room instead of fifteen months on private pay, to four years on Medicaid.
Nursing Facility Services are provided by Medicaid certified nursing homes, which primarily provide three types of services:
- Skilled nursing or medical care and related services
- Rehabilitation needed due to injury, disability, or illness
- Long term care —health-related care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition
A nursing facility is one of many settings for long-term care, including or other services and supports outside of an institution, provided by Medicaid or other state agencies.
Where Nursing Facility Services are Provided
Medicaid coverage of Nursing Facility Services is available only for services provided in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility (NF). See NF survey and certification requirements. Medicaid NF services are available only when other payment options are unavailable and the individual is eligible for the Medicaid program.
In many cases it is not necessary to transfer to another nursing home when payment source changes to Medicaid NF. Many nursing homes are also certified as a Medicare skilled nursing facility (SNF), and most accept long-term care insurance and private payment. For example, commonly an individual will enter a Medicare SNF following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long-term care insurance they may have. If the individual exhausts assets and is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid NF benefit. If the nursing home is not Medicaid certified, he or she would have to transfer to a NF to be covered by the Medicaid NF benefit.
Who May Receive Nursing Facility Services
NF services for are required to be provided by state Medicaid programs for individuals age 21 or older who need them. States may not limit access to the service, or make it subject to waiting lists, as they may for home and community based services. Therefore, in some cases NF services may be more immediately available than other long-term care options. NF residents and their families should investigate other long-term care options in order to transition back to the community as quickly as possible.
Need for nursing facility services is defined by states, all of whom have established NF level of care criteria. State level of care requirements must provide access to individuals who meet the coverage criteria defined in federal law and regulation. Individuals with serious mental illness or intellectual disability must also be evaluated by the state's Preadmission Screening and Resident Review program to determine if NF admission is needed and appropriate.
Nursing facility services for individuals under age 21 is a separate Medicaid service, optional for states to provide. However, all states provide the service, and in practice there is no distinction between the services.
In some states individuals applying for NF residence may be eligible for Medicaid under higher eligibility limits used for residents of an institution. See your state Medicaid agency for more information.
Services Included in the NF Benefit
A NF participating in Medicaid must provide, or arrange for, nursing or related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
There is no exhaustive list of services a NF must provide, in that unique resident needs may require particular care or services in order to reach the highest practicable level of well being. The services needed to attain this level of well-being are established in the individual's plan of care.
Specific to each state, the general or usual responsibilities of the NF are shaped by the definition of NF service in the state's Medicaid state plan, which may also specify certain types of limitations to each service. States may also devise levels of service or payment methodologies by acuity or specialization of the nursing facilities.
Federal requirements specify that each NF must provide, (and residents may not be charged for), at least:
- Nursing and related services
- Specialized rehabilitative services (treatment and services required by residents with mental illness or intellectual disability, not provided or arranged for by the state)
- Medically-related social services
- Pharmaceutical services (with assurance of accurate acquiring, receiving, dispensing, and administering of drugs and biologicals)
- Dietary services individualized to the needs of each resident
- Professionally directed program of activities to meet the interests and needs for well being of each resident
- Emergency dental services (and routine dental services to the extent covered under the state plan)
- Room and bed maintenance services
- Routine personal hygiene items and services
Residents may be charged for:
- Private room, unless medically needed
- Specially prepared food, beyond that generally prepared by the facility
- Telephone, television, radio
- Personal comfort items including tobacco products and confections
- Cosmetic and grooming items and services in excess of those included in the basic service
- Personal clothing
- Personal reading materials
- Gifts purchased on behalf of a resident
- Flowers and plants
- Social events and activities beyond the activity program
- Special care services not included in the facility's Medicaid payment
Additional information
This summary is for general information. Specific requirements for Medicaid nursing facilities may be found primarily in law at section 1919 of the Social Security Act, in regulation primarily at 42 CFR 483 subpart B, and in formal Centers for Medicare & Medicaid Services guidance documents. Also see:
- Nursing Home Compare
- How to choose a nursing home
- Hospital discharge checklist