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Mandatory Services – Nursing Facility Services

Medicaid is a federal entitlement program that provides health care coverage to Americans with low income and assets. Although the states administer Medicaid for their residents, there is a core group of services, known as mandatory services, they must provide. One of these services is the provision of nursing facility services for individuals who are at least 21 years old. The federal government dictates that only certain types of costs may be charged to residents of these facilities.

What Type of Institution Qualifies as a Nursing Facility?

Nursing facilities usually provide at least three types of care: skilled nursing care, rehabilitation services, and health-related care. The first type, skilled nursing care, includes services that can only be provided by a licensed nurse. The second type, rehabilitation services, includes rehabilitation care provided to residents who are sick, disabled, or injured. They include both services designed to improve skills and services designed to maintain abilities a resident already possesses. Health-related care is the third type of service usually provided by a nursing facility. This consists of items of care that cannot be provided other than in an institutional setting. Nursing facility services such as these must be provided to individuals 21 years or older by every state’s Medicaid program.

What Items and Services May Be Charged to a Resident?

Several types of items and services may not be charged to Medicare or Medicaid residents of nursing facilities. The most obvious services that must be absorbed by the facility are room and board maintenance services, nursing services, and dietary and meal services. However, nursing facilities must also provide, at no cost to these residents, medical social services, activities, and routine personal hygiene items and services. Some of the personal hygiene services that cannot be charged to Medicaid residents are assistance with bathing, personal laundry, and hair and nail hygiene. Routine personal hygiene items that may not be charged to them include hair, body, and tooth hygiene supplies, including denture supplies, dental floss, and lotion; tissues, cotton balls and swabs, incontinence supplies, and sanitary napkins; and towels, washcloths, and gowns.

What Items and Services May Not Be Charged to a Resident?

Certain items and services may be charged to Medicaid or Medicare nursing facility residents if three prerequisites are met: (1) the resident must request the item or service; (2) the facility must tell the resident that the item or service will be charged to him or her; and (3) neither Medicaid nor Medicare pays for the service. If changes are made to the cost of these items or services, residents must be told.

Examples of services that may be charged to residents include private nurses and aides and private rooms that are not therapeutically necessary; appliances such as televisions, telephones, and radios; personal comfort items, such as smoking supplies, sweets, and reading materials; cosmetic and hygiene items or services greater than those provided by Medicaid or Medicare; and clothing.

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