It’s a question that I’ve been asked numerous times over the years. It’s also one that has caused a lot of confusion. I’ve spoken with some nursing homes who have told me their belief that it violates Medicaid rules. That is incorrect.
Here’s the scenario. Mom receives Medicaid, which pays for a semiprivate room, that is, one with a roommate. If the family wants a private room for Mom, they can pay the additional charge, provided of course that the home has a single room available.
And what is that charge? Usually, $20 to $30 per day which is the difference between the private room rate and the semiprivate room rate that the general public is charged. In other words, Medicaid is picking up the semiprivate room rate but based on the much lower Medicaid reimbursement rate. Medicaid is billed at a rate that is approximately 40-50% less than the rate that the general public pays. But, while you and I must pay the much higher rate than does Medicaid, the good news is that the difference between a semiprivate and a private room is small.
If your loved one is in an assisted living facility it works the same way. Medicaid will pay for a double but not a single. Provided the facility makes a single available, the family can pay the difference between a single and a double at the private non-Medicaid rate. Medicaid will cover the double rate.
Keep in mind that with both nursing home and assisted living Medicaid Mom must contribute some or possibly all of her income to the cost of the facility and Medicaid will pay the rest up to the reimbursement rate. It is, therefore, rare that Medicaid pays the entire cost, even at the reimbursement rate.