Specialized Information for:

Nursing HomesAssisted Living/Board & Care Home and Community Based Services
Back to Issues

Medicare and Medicaid

Medicare and Medicaid are two federal programs administered by the Centers for Medicare and Medicaid Services (CMS) that provide medical and health-related services to specific populations within the United States.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease.  Medicaid provides coverage for people with lower incomes, older people, people with disabilities, and some families and children.

Medicare Resources

Jimmo Settlement Agreement Webpage (August 2017)
CMS has launched a new webpage on the Jimmo Settlement Agreement.   The Jimmo Settlement agreement clarified that the Medicare program covers skilled nursing care and skilled therapy services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline.  Specifically, the Jimmo Settlement required manual revisions to restate a "maintenance coverage standard" for both skilled nursing and therapy services.  The Jimmo Settlement may reflect a change in practice for those providers or others who have erroneously believed that the Medicare program covers nursing and therapy services only when a beneficiary is expected to improve.  The new Jimmo Settlement Webpage provides background on the settlement, links to resources and Frequently Asked Questions.

10 FAQs: Medicare's Role in End-of-Life Care  (December 2015)
Created by the Henry J. Kaiser Family Foundation. This FAQ sheet can help better understand the largest insurer of health care provided during the last year of life. This information will help explain the coverage that is offered, changes to be made in the future, and cost. In addition, these FAQs describe recent relevant rules released by the Administration and additional proposals from Congress regarding advance care planning and care for people with serious and terminal illness. 

Medicare Interactive - Created by the Medicare Rights Center, Medicare Interactive can help find answers about Medicare benefits.

Return to Top

Medicaid Resources

NORC Resources

Fact Sheet: Medicaid Therapeutic Leave (March 2011)
This factsheet produced by the National Long-Term Care Ombudsman Resource Center answers the following questions:

  • Can residents receiving Medicaid leave their nursing home for overnight visits?;
  • What is a bed-hold policy?; and
  • How can I get information about a nursing home’s bed-hold policy?

Additional Medicaid Resources

Medicaid Bed Hold Policies by State (October 2012)

Return to Top

Managed Long-Term Services and Supports

NORC Resources

Medicaid Managed Care 101 for Ombudsman Programs
On January 11, 2017, the National Association of States United for Aging and Disabilities (NASUAD) hosted a webinar on Medicaid managed care for State Ombudsmen and Ombudsman program representatives. This webinar covered basic information about the current status and future directions of state Medicaid Managed LTSS programs; key policy and operational considerations for professionals working with older adults enrolled in these programs; and future directions for these programs. Visit the NASUAD website for more information and use the links below to access the slides, recording, and transcript.

Medicaid 201: Managed Long-Term Services and Supports (MLTSS) for State Ombudsmen and Program Representatives
The National Association of States United for Aging and Disabilities (NASUAD) hosted a webinar on Medicaid managed long-term services and supports (MLTSS) and the new Federal requirements for states to offer ombudsman services to managed care enrollees. Building on the groundwork laid in the January 2017, this webinar provided an overview of Medicaid managed long-term services and support (MLTSS) programs across the country; explained the new Federal requirements for MLTSS programs to offer managed care ombudsman services to enrollees; discussed opportunities and challenges of operating a managed care ombudsman program within a State LCTO office; and highlighted the work of the Iowa SLTCO in managing both a State Long-term Care Ombudsman Program and a managed care ombudsman program. 

Advocates’ Guide to Accessibility in Medicaid Managed Care Grievances and Appeals (June 2018)
As states begin to incorporate new federal regulations into their Medicaid rules, there’s opportunity for advocates to help shape those rules to ensure that older adults and people with disabilities have equal access to the grievance and appeal and state fair hearing systems, as mandated by Section 504 of the Rehabilitation Act (“Rehab Act”), the Americans with Disabilities Act (“ADA”), and Section 1557 of the Affordable Care Act (“ACA”). This Advocates Guide to Accessibility in Medicaid Managed Care Grievances, Appeals, and State Fair Hearing, provides guidance on how the federal framework can be made fully accessible to Medicaid beneficiaries who are older and/or have disabilities. 

Advocacy Strategies Through Managed Care (November 2015) 

  • PowerPoint Presentation
    • Presented by: Heather Bruemmer, State LTC Ombudsman, Wisconsin; Gwen Orlowski, J.D. Legal Services of New Jersey

Duals Demonstration Projects (November 2014)

Return to Top

Personal Needs Allowance (PNA)

The Personal Needs Allowance is the monthly sum of money that residents who receive Medicaid may retain from their personal income. Any income above the allowance is applied toward the cost of their care. This allowance is intended for residents to spend at their discretion on items such as telephone expenses, cigarettes, a meal out with friends, cards to send to family, reading materials, or hobbies. Federal regulations prohibit long-term care facilities from charging residents’ PNA for services that are included in Medicaid payments such as toothpaste, tissues, shampoo, and incontinence products,
among others.

Nursing Home Personal Needs Allowance (PNA) by Year (2010)

Return to Top

Information to Share with Consumers

QIO Program: Beneficiary and Family Centered Care – Quality Improvement Organizations

Frequently Asked Questions (FAQ) for Medicare Beneficiaries: What to do if you have a concern about care you received while on Medicare

Newsletter Insert
Information about the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Program for your newsletter

Medicare Changes for Transgender Older Adults

Marriage, Medicare, and Medicaid: What Same-Sex Couples Need to Know

Accessing Information on Medicare Benefits for LGBT People

10 FAQs: Medicare’s Role in End-of-Life Care

Medicare Interactive

Factsheet: Medicaid Therapeutic Leave

Return to Top


View archive here

Medicare Prospective Payment in SNFs and its Impact on Nursing Home Residents: Questions for Ombudsmen Considering the Care of Medicare Patients in Nursing Homes (2001)
This paper reviews what is known about the Prospective Payment System's incentives for nursing homes to admit – or refuse – Medicare patients, and to provide too little – or too much – care. This information will help ombudsmen understand the Prospective Payment System and its impact on Medicare beneficiaries’ ability to get the services they need under Medicare.

Bedhold for Nursing Home Residents: Know the Facts (September 2012)

Medicaid and Long-Term Care (Bradley Gellar 2011)
This pamphlet contains questions and answers, copies of forms to help consumers know what to expect when it comes to Medicaid and Long-Term Care and lists of agencies to contact.

A Reporter’s Toolkit: Medicaid (November 2007)
This toolkit will help you understand who the Medicaid program covers, how it is financed, how it differs from Medicare, how states can alter Medicaid through federal waivers, and what the future holds for the program. This resource also offers story ideas, selected experts with contact information, selected websites and a glossary.

Support for Demonstration Ombudsman Programs Serving Beneficiaries of Financial Alignment Models for Medicare-Medicaid Enrollees (November 2013)
This webinar presented by the Administration on Aging provides an outline of the funding opportunity announcement for demonstration ombudsman programs to help States and other stakeholders better understand the goals as well as requirements under this opportunity.  The webinar also discussed examples of successfully funded proposals, and provided opportunity for States and other stakeholders involved in designing and implementing other integrated care models to learn about these ombudsman programs and why they are important for any integrated model to support and protect beneficiaries that will be served by these programs.

Managed Long-Term Services & Supports: What Does it Really Mean for Consumers? (October 2013)
This session at the 37th annual Consumer Voice conference talks about how states are jumping headfirst into contracting with managed care companies to provide long-term services and supports. But what does this mean for consumer choice, protections, quality and coordination of services, and cost? Get a national perspective and hear about the trends in states’ plans and what these managed care contracts mean for quality and evaluation of care and services. Engage in dialogue around how consumers and their advocates can impact plan development and implementation in their states and at the national level.

Session Materials:

State Dual integration Projects—What’s Going On? (October 2013)
This session at the 37th annual Consumer Voice conference talks about how states are implementing their Dual Integration Projects. Hear an overview of the different components of the project including implementation and oversight, the three-way contracts and MOUs, and opportunities for consumer involvement and advocacy. You will also hear how one state long-term care ombudsman program has been written into the dual demonstration project to fulfill the required ombudsman role.

Session Materials:

Personal Needs Allowances for Residents of Long-Term Care Facilities: A State by State Analysis  (March 2009) National Long-Term Care Ombudsman Resource Center Brief


Hide text

Return to Top

Back to Issues