Long term care is a continuum of maintenance, custodial, and health services to the chronically ill, disabled, or retarded. Services may be provided on an inpatient, outpatient, or at-home basis.
Gillian I. Russell, Terminology, in FUNDAMENTALS OF HEALTH LAW 1, 23 (American Health Lawyers Association 5th ed., 2011).
All states require licensure or its equivalent to operate a nursing home. The majority of states require licensure to operate an assisted living facility or residential care facility. Licensed nursing facilities are subject to certain staffing, provision of services and physical plant requirements, as set forth in the applicable licensure statute and regulations.
Approximately two-thirds of the states require a certificate of need (CON) or its equivalent to develop or construct a new health care facility (such as a nursing home); to incur a capital expenditure by or on behalf of a health care facility above a specified expenditure threshold; to add beds/services to an existing health care facility; to change the location of a facility; and, in some cases, to acquire or change a majority of ownership of an existing health care facility.
Nursing homes participating in the Medicare program are known as SNFs. A SNF may choose to have one wing or floor that is a Medicare-certified SNF (a “distinct part certification”), or the whole facility. The services offered by SNFs generally include: nursing care; room and board; physical, occupational and speech therapy; social services, and other necessary services, supplies and equipment. 42 U.S.C. 1395x(h). Medicare SNF coverage applies for Medicare beneficiaries who have been in a hospital for at least 3 days and enter a SNF within 30 days of discharge. The benefit only extends for 100 days per spell of illness; Medicare pays 100% for the first 20 days, and beneficiaries are responsible for a daily deductible for the next 80 days. Residents must also require a skilled level of care.
Nursing homes participating in a state Medicaid program are known as nursing facilities (NFs). A nursing home may have one wing or floor that is a Medicaid-certified NF, or the whole facility. Many states require facilities to certify the whole facility for Medicaid participation (e.g., Ohio). As with SNFs, the services offered by NFs generally include: nursing care; room and board; physical, occupational and speech therapy; social services, and other necessary services, supplies and equipment. The amount and degree varies based upon each particular state’s Medicaid program requirements. State Medicaid programs are required by federal law to provide coverage for NF services. See 42 U.S.C. §§ 1396a(a)(10), 1396d(a)(4)(A). Consult state law for the amount and scope of coverage as based upon the Medicaid state plan.
Increasing focus on nursing home quality information has resulted in CMS publication of Quality Measures (QMs) for facilities in all states, the District of Columbia and some U.S. territories. The purpose of the QMs is to make people aware of the performance of individual nursing homes. The information can be used by Medicare beneficiaries and families to make placement decisions and for nursing homes to improve the quality of care.
Excerpt from Carol Colborn Loepere, Post-Acute Providers and Suppliers, in FUNDAMENTALS OF HEALTH LAW 401, 432-433, 436, and 439 (American Health Lawyers Association 5th ed., 2011).