Nursing Facility Services for Individuals Age 21 and Older
Nursing facility services for individuals age 21 and older is a mandatory Medicaid benefit. Nursing facilities are institutions which primarily provide:
- Skilled nursing care and related services for residents who require medical or nursing care;
- Rehabilitation services for the rehabilitation of injured, disabled or sick persons; or
- Health-related care and services, on a regular basis, to individuals who because of their mental or physical condition require care and services, above the level of room and board, which can be made available to them only through institutional facilities. A nursing facility that participates in Medicaid must provide, or arrange for, the full range of services for residents who need them. Nursing facilities are required to meet a number of requirements relating to provision of services, residents' rights, provision of information, and administration. Certain items and services are included in the facility payment, and others may be charged to the resident.
For Specific Information
The Medicaid program is a state/federal partnership, administered by state Medicaid agencies. Contact your state Medicaid agency for information about specific nursing facility services. Information for state Medicaid agencies including web sites and toll free telephone numbers is available at http://www.cms.hhs.gov/medicaid/mcontact.asp. You may also contact the Department of Health in a particular state. You will find the listing in the government section of the telephone directory.
Mandatory versus Optional Benefits
Medicaid is a state and Federal entitlement program that finances medical assistance to certain persons with low income. Each state has a great deal of flexibility to design and administer its Medicaid program within broad Federal guidelines. There are services the state is required to provide (called mandatory services) and services the state may choose to provide (called optional services). Prior to October 1, 1990, Medicaid had a mandatory skilled nursing facility (SNF) benefit that was comparable to the Medicare SNF benefit. In addition, it had an optional intermediate care facility (ICF) benefit that a state could choose to include in its Medicaid state plan. The ICF benefit included health-related care and services for persons who required care and services above the level of room and board that could only be available through an institutional facility.
The nursing home reform provisions that were enacted in 1987 repealed the skilled nursing facility and intermediate care facility benefits (except for the intermediate care facility benefit for persons with mental retardation or related conditions) and replaced by a new mandatory nursing facility (NF) benefit. This new benefit combined the total services that had previously been covered under the ICF and the SNF benefits.
Items and services included in the facility payment which may not be charged to the resident
During the course of a covered Medicare or Medicaid stay, facilities may not charge a resident for the following categories of items and services:
- Nursing services.
- Dietary services.
- An activities program.
- Room/bed maintenance services.
- Routine personal hygiene items and services, as required, to meet the needs of residents, including, but not limited to: hair hygiene supplies, comb., brush, bath soap, disinfecting soaps or specialized cleansing agents, when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins, and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry.
- Medically-related social services.
Items and services which may be charged to the resident
Items and services that the facility offers which are not included in the facility payment may be charged to the resident. The resident must be informed when changes are made to the items, services, and costs. General categories and examples of items and services that the facility may charge to residents' funds, if: they are requested by a resident, the facility informs the resident that there will be a charge, and payment is not made by Medicaid or Medicare:
- Telephone
- Television/radio for personal use.
- Personal comfort items, including smoking materials, notions and novelties, and confections.
- Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare.
- Personal clothing.
- Personal reading materials.
- Gifts purchased on behalf of a resident.
- Flowers and plants. Social events and entertainment offered that are not part of the activities program.
- Non-covered special care services, such as privately hired nurses or aides.
- Private room, except when therapeutically required (for example, isolation for infection control).
- Specially prepared or alternative food requested instead of the food generally prepared by the facility.
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Contact:
Jan Earle (410) 786-3326 or jearle@cms.hhs.gov
Last Modified on Thursday, September 16, 2004
