Financial Answers About Long-Term Care

Financial

Answer
About Long

Ca

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g-Term
are

HELPFUL

Phone Numbers

Middlesex County Board of Social Services
(8:30 a.m. to 4:15 p.m. Monday to Friday)
732-745-3500

Social Security Administration
(7 a.m. to 7 p.m. Monday to Friday)
1-800-772-1213

Pharmaceutical Assistance to the Aged
and Disabled
PAAD and Senior Gold
(8 a.m. to 5 p.m. Monday to Friday)
1-800-792-9745

Medicare Part D Prescription Drug Coverage
1-800-MEDICARE

Roosevelt Care Center Business Office
(8:30 a.m. to 4 p.m. Monday to Friday)
732-321-6800 ext. 4013, 4012 or 4011
Fax: 732-767-4033

HELPFUL Websites

Social Security Administration
www.ssa.gov

New Jersey Department of Health
and Senior Services
www.state.nj.us/health

Financial Answers About Long-Term Care

The decision to have yourself or a loved one enter a
long-term care facility such as Roosevelt Care Center is
a difficult one to make and often made during a time of
stress. No matter how prepared you feel you may be,
questions may still be unanswered.

One of the more pressing issues you may be facing is
how to pay for the stay and other associated expenses.
How will it impact your finances and those of your
loved ones? Will federal programs help pay? How do
you apply? Will private insurance cover any of the
cost?

Since funds may come from various sources, piecing
together the financial puzzle of skilled care can be
complicated. Be assured that we at Roosevelt Care
Center are willing and able to discuss your payment
options and help you through the process.

Whether you are a prospective resident or patient, a
family member or a responsible party, use this brochure
as a starting point, something to refer to while discussing
payment with a social worker or business office
counselor. While not a comprehensive reference, this
booklet will answer some questions and also help you
form others for our staff.

PAYMENT MEDICARE

Options Medicare A and B may
stay if certain criteria ar
PRIVATE PAY & government has establis
COMMERCIAL INSURANCE requirements for the pro
plan, our staff will prov
If you are paying privately for room and board, that make determinations an
is, using your own funds, you will be billed in deadlines. You will not h
advance for the month. Payment is due by the
10th of the month, covering your stay through the To be eligible to receive
end of the month. Any charges incurred in addition (benefits that cover room
to room and board appear on your bill the next tests and other medical
month, after the service was performed. We accept been hospitalized for 3
credit and debit card payments. admission to our Center
rehabilitation services re
We also currently accept most commercial stay must be needed and
insurance plans and HMOs, such as Aetna and from the intervention. M
Horizon Blue Cross and Blue Shield, if they cover primary payer, only if n
skilled nursing services. Each plan has different any other insurance plan
requirements, co-pays and deductibles. We will
assist you in sorting out which services are covered Once you are eligible to
and which you will be responsible for paying. benefits, Medicare will p
100 days for each benefi
Any charges not covered by your commercial days, Medicare pays for
insurance will be billed to you each month and are with certain restrictions.
due upon receipt of the bill. Please note that Medicare requires the res
supplemental Medicare insurance is not considered pay (a portion of the stay
commercial insurance. Business Office for the d
Co-pay may come direct
commercial insurance or
you may have, such as A
Shield Medigap insuranc
that not all secondary ins
nursing care. Please chec
carrier directly and make
nursing care.

Financial Answers About Long-Term Care

pay for some or all of your When you no longer need skilled care as
re met. The federal defined by Medicare, Medicare will no longer
shed a number of eligibility pay for your stay, even if you have not used 100
ograms. As part of your care days. You will be notified by telephone or in
vide you with information, writing when it is determined t h a t you are no
nd assist you in meeting longer eligible for Medicare benefits based on
have to do this by yourself. the Medicare guidelines. You will be notified
why your benefits have been denied, and you
e Medicare A benefits can request that Medicare review our decision.
m and board, medication,
services), you must have Once your 100 days of Medicare coverage
midnights within 30 days of have been used or you have been notified that
r. Daily skilled nursing or you are no longer eligible for Medicare benefits
elated to the hospital based on the Medicare guidelines, you must
d you must be benefiting pay with your own funds, use commercial
Medicare is considered your insurance or Medicaid (see below), if you
no benefits are available from qualify.
n.
Medicare B insurance covers certain services
receive Medicare A when you are not being covered under Medicare
pay for a maximum of A. There is an annual deductible you must pay
it period. For the first 20 first, then Medicare B will pay 80 percent of the
skilled care in its entirety, charges for those covered services. You will be
For days 21 through 100, responsible for the remaining 20 percent. If you
esident to pay a per diem co- have additional insurance that covers your
y). Please check with the deductible or 20-percent co-pay, we will bill that
daily co-pay. That insurance plan for you. Covered services under
tly from you or from any Medicare B include rehabilitation therapies,
r other secondary insurance certain equipment and certain
AARP and Blue Cross/Blue medical supplies. Medicare B does not pay
ce. It is important to note room and board.
surance covers skilled
ck with your insurance
e sure you refer to skilled-

1

Financial Answers About Long-Term Care which he or she is accus
spouse will not be displa
MEDICAID eligible for Medicaid. Th
eligibility and payment a
Medicaid, a federal- and- state-funded program for be discussed with the ap
the needy, may pay for the cost of a stay if certain staff or an attorney speci
asset and income tests are met and if the resident refer you to the proper a
is determined to meet the clinical eligibility
requirements of Medicaid. The clinical Due to the fact that many
requirements are determined by a nurse from advance, there i s also a
the New Jersey Department of Health and Senior account. Residents or th
Services Long-Term Care Office or by your purchase a pre-need, irre
Medicaid HMO if you are enrolled in one. Rest This contract then will no
assured, our staff will help you sift through the eligibility for Medicaid.
complicated rules and eligibility requirements.
Our Business Office wil
There are time limits that must be met in order application if you wish,
to receive Medicaid coverage in a nursing home. To someone speaking on hi
ensure those deadlines are met, our staff will assess the point of contact for
the daily life of the resident. Our staff will t h en of Social Services.
determine the approximate amount and length of
skilled- nursing care needed. It would be determined A number of documents
if a resident will be discharged home or to another Medicaid, including, bu
community setting. If discharge is not possible, a birth date, Social Securi
long-term care plan must be in effect, and a proof of residency, a ma
resident’s financial status will be reviewed in order decree, spouse’s death c
to submit a timely Medicaid application. If a check and information o
resident is not financially or clinically eligible for of the required informat
Medicaid, other payment options will be reviewed Business Office.
to pay for the long-term stay. Our staff will assist
you in planning a course of action and meeting all At this time a resident m
deadlines. of attorney naming an a
affairs on his or her beh
Rules exist as to which assets you may own and for health care can also
which need to be liquidated to pay for a nursing- allow a health care repre
home stay prior to becoming eligible for Medicaid. the resident to make any
Please note that if your spouse is still living in the
community, allowances are made to ensure that he
or she can continue living in the same manner to

2

stomed. Your community There are a number of elder law professionals in
aced in order for you to be the community that can assist you in planning for
he rules to determine long-term care issues.
are complicated and should
ppropriate state agency Once an application has been approved, the state
ializing in elder law. We can will determine what income you can keep and what
agency. must be paid to the Center. You must pay the Center
the amount determined by the state each month as
y families choose to plan in soon as you are eligible for Medicaid and
an allowance for a burial immediately when you are no longer covered under
heir loved ones may another insurance plan or Medicare. Medicaid will
evocable burial contract. pay our Center directly for its share of the bill.
ot be counted in determining
. DIRECT DEPOSIT OF FUNDS

ll assist you with the Roosevelt Care Center allows direct deposit of
but the applicant or any monthly funds that are received to pay for
is or her behalf must act as a stay here. You may choose to have your Social
the Middlesex County Board Security and pension checks or any other form of
income sent to the Center. These funds will
s must be remitted to be allocated to room and board, coinsurance and
ut not limited to: proof of a personal needs account as directed by Medicaid
ity card, Medicare card, or, in the case of private funding, you. It also
arriage certificate or divorce relieves families of having to track payments or
certificate, a Social Security continually write checks to the Center.
on all assets. A complete list
tion is available in our

may wish to execute a power
agent to conduct all financial
half. An advance directive

be considered that would
esentative to be named by
y and all decisions

OTHER Costs If a resident has coverag
union group, they may b
TRANSPORTATION Medicare Part D. If you a
have Medicare, you can c
Most insurance plans, including Medicare, cover the in the Medicare Part D P
cost of emergency transport to a hospital or other Enrollment takes place an
acute-care facility. However, transportation to and
from doctors’ appointments and other office visits PERSONAL NEEDS A
is not covered. Many times family members bring
residents to their appointments. If that is not Each resident of Roosev
feasible, transportation to and from the Center can a Personal Needs Accou
be arranged at a cost to you. Office. Residents may u
checking account of sor
Please note the Center does allow your doctors to withdrawing from it to p
visit you on-site, alleviating the need for holiday and special occa
transportation. The Center also contracts with incidental expenses that
specialists, such as dentists, ophthalmologists and
podiatrists, to visit residents on-site. Please call If you are eligible for M
your social worker for more information. designate the Center to
Security checks. The am
PRESCRIPTIONS Medicaid for your perso
deposited into your Pers
Changes in federal programs have resulted in
the Medicare Part D Prescription Drug Program. The Your family may contrib
most significant change is that everyone that is Personal Needs Account
Medicaid eligible must be enrolled in a Medicare convenience, hairdresser
Part D Plan. If you are applying for Medicaid, you deducted from the balan
must enroll in a Medicare Part D Plan by contacting statement of your balanc
1-800-MEDICARE. While pending Medicaid is also available by conta
approval, a resident can apply for the low-income
subsidy for Part D coverage by contacting Social DISCHARGE PLANS
Security at 1-800-772-1213 to assist with premium
payments or pharmaceutical assistance for the Aged & Upon the conclusion of
Disabled (PAAD) at 1-800-792-9745. with several people — a
a social worker and mem
Office. The Business Of
obtaining balances in yo
Account, and any balanc

ge through an employer/ Financial Answers About Long-Term Care
be advised not to enroll in
are paying privately and you will be reviewed for final payment. Any balances
choose to participate due to you will be reconciled for reimbursement.
Prescription Drug Program.
annually in December. There are additional Medicaid programs available to
you once you return to the community. More
ACCOUNT information on these programs may be obtained
from your County Board of Social Services.
velt Care Center may set up
unt through the Business RESIDENT RESPONSIBILITIES Though
use the account as a
rts, depositing to and our staff will assist you with understanding rules,
pay for personal-care items, completing various forms and meeting deadlines,
asion gifts or any other please remember that you are responsible for paying
t may arise. for your stay or the stay of a loved one. To that end,
we will bill an insurance plan only if you authorize
Medicaid, you may us to do so. You also must inform us immediately
receive your Social of any changes in insurance status because
Medicare, Medicaid and commercial insurance
mount designated by (including HMOs) have different benefits and
onal needs will be requirements in a skilled nursing facility. In all
sonal Needs Account. cases, the resident and any responsible party remain
responsible for the cost of your stay if payment
bute additional funds to a is not received from Medicare, Medicaid or any
t as needed. For your third-party payer.
r fees are automatically
nce in your account. A A PLACE OF CARING
ce is sent quarterly and
acting the Business Office. Our staff here at Roosevelt Care Center considers it
a privilege to be caring for you or your loved one.
S Please reach out to us if you have any questions
whatsoever. We’ll do our best to provide you with
your stay, you will meet the most accurate and timely information in a
a discharge planner, compassionate yet professional manner. Thank you
mbers of the Business for making us a part of your life.
ffice will assist you in
our Personal Needs
ces due to the Center

3

Financial Answers About Long-Term Care Q. Don’t I automatically ge
coverage if I have been
FREQUENTLY
ASKED A. No. If you have had a
stay, are admitted to a
Questions within 30 days of disc
and you have days rem
Below you will find answers to several questions receive coverage only
residents and their loved ones have raised in the past. you are receiving skil
hospitalization. Skille
Q. How do I know what my commercial insurance only be provided by a
will pay? such as dressing chan
A. Each insurance company is different in terms of intravenous therapy, t
levels and limits of coverage. We will review, occupational or speec
on an individual basis, what is and is not coverage when you re
covered by your insurance carrier. recovery or require on
assistance with dressin
Q. What happens if an insurance company eating.
denies my claim?
A. The insurance companies have stated that all Q. Will Medicare Part B co
claims are subject to review prior to once I go off Medicare A
authorization for payment. If your claim is
denied, you will be responsible for payment. A. Part B will cover certa
However, there are appeal procedures that each within the Medicare g
insurance company has if you are not satisfied given your health stat
with the decision. We do follow up with complex; therefore, w
insurance companies on your behalf and coverage based on yo
resubmit claims. We will communicate with you With this in mind, gen
throughout this process. will cover:

4 • Therapy services (p
and speech therapi

• Medical supplies th
the body, such as urol
(catheters), enteral sup
(feeding tubes), some
ostomy supplies (colo
tracheotomies)
You must meet an ann
20 percent of the char

et 100 days of Medicare There also is an annual cap on the amount of
in the hospital? therapy services Medicare will pay for. Part B
a 3-day qualifying hospital does not pay room and board.
a skilled-nursing facility
charge from the hospital Q. How does the facility determine if my
maining, then you will Medicare benefits should stop?
y for the period of time that
lled care related to your A. The facility has a Utilization Review
ed care is a service that can Committee that meets regularly to review
a skilled nurse or therapist, those patients covered under Medicare A.
nges for a healing wound, The committee is made up of nurses,
tube feedings, a physical, therapists, social workers and physicians.
ch therapy. Medicare stops The committee reviews each patient’s health
each a plateau in your status, the services the patient is receiving
nly custodial care such as and the patient’s progress. A determination
ng, bathing, toileting and for continued coverage is then made based
on the Medicare guidelines.
over any of my stay
A? Q. Do I need to be discharged once
ain services if they fall Medicare benefits no longer pay?
guidelines for coverage
tus. The guidelines are A. No. The decision to be discharged is based
we would discuss on your health status, level of independence
our specific situation. and your home situation. If you are not
nerally speaking, Part B ready to be discharged when Medicare will
no longer pay, then you can pay privately or
physical, occupational if you are eligible and require continued
ies) skilled care, Medicaid will pay for your stay.

hat replace a function of Q. How do I apply for Medicare
logical supplies Part D Prescription Drug
pplies and nutrition coverage?
wound supplies,
ostomies and A. Call 1-800-MEDICARE and have a list of
the current drugs you are taking available
nual deductible and pay when you call. If you are on Medicaid,
rge for the services. there is annual list of Medicaid-approved
$0 premium plans. A copy can be obtained
from the business office.

Q. Can I get assistance with Medicare D premiums?
A. You may qualify for a low-income subsidy
through Social Security or you can apply for
PAAD.

Q. My husband/wife has been admitted to Roosevelt
Care Center and we are eligible for Medicaid.
Will Medicaid take all of our assets?

A. Medicaid will perform a spousal-allowance
calculation, which determines how much the
community spouse is entitled to keep. The
remainder of the assets will need to be “spent
down” by paying for things such as our bill,
personal items for the resident, prepaid
burials, etc.

Q. I have a dependent child and am eligible for
Medicaid. Will Medicaid provide an allowance
for him or her?
A. If you receive Social Security benefits or other
income, Medicaid will consider if there is a
dependent child in the community and determine
if a monetary allowance can be made for the care of
that child.

Q. Will Medicaid take my home?
A. If there is a spouse in the community,
Medicaid may not touch the home where the
couple had been living together (joint
tenancy). There are also allowances for
caregivers and dependent children who have been
living in the home. The allowances will be
determined by the Middlesex County Board of
Social Services.

Financial Answers About Long-Term Care

Roosevelt Care Center Social Worker
Name:
Direct-Dial:
Beeper:
Fax:
Other Numbers:

Roos

Roosevelt Care C
118 Parsonage Road
Phone: 732-321-6800 I Fax: (732) 32

Roosevelt Care Ce
1133 Marlboro Road, O
Phone: 732-360-9830 I Fax: (732) 36

Operated by the Middlesex C

sevelt

Center at Edison
d, Edison, NJ 08837
21-1452 I Web: www.rooseveltcarecenter.com

enter at Old Bridge
Old Bridge, NJ 08857
60-9897 I Web: www.rooseveltcarecenter.com

County Improvement Authority