OK, right now I'm beginning the Medicaid application process (in NJ, BTW). It's taken me longer than expected to gather together all of Mom's pertinent documents (Mom's always been notorious about not keeping everything in one place) and I'm still waiting on some paperwork re: her pension income.
Right now the current medical advice has her in short-term rehab through the 22nd. She's in the "days 21-60" phase of her Medicare insurance and we're paid up through that date (paid in full through the 11th, agreement to make payments monthly through 2015 to cover the rest).
Unfortunately, rehabilitation has not gone as expected. I genuinely thought she'd make enough progress to come back home eventually, but right now I cannot see that happening, as in some ways she's actually regressed. IMO LT care is going to be a must for Mom. Aside from her SSI, her pension (state, from her late husband) and her house (maybe 100K-125K) she has no assets to speak of.
I guess my main question is: can they "force" me to bring her home after the specified date? I've been advised that maybe I can place her LT "medicaid pending" but what if she isn't accepted? I am currently living in the house as I've been caring for her (PT from roughly 2010-2013, FT since then) and right now I don't have the resources to move anyplace else. If I can place her LT (or even get them to extend her ST stay) I can begin to rebuild my own life and move on, but right now that's just not possible as even having her in a ST rehab is almost a FT job in and of itself.
Anyone else have a similar situation? is there anything I absolutely should or shouldn't do or say? At the moment I am pressing her doctors for some sort of diagnosis, as her faculties are obviously slipping (and IMO very quickly). Does it even matter re: a diagnosis? Thanks in advance for any and all tips, appreciate it.
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The POA is going to be tricky if she can't understand it. You should definitely talk to a lawyer about it, once you find one you like. She may or may not be able to pay for this herself with her assets, which you can ask about.
She's definitely over the income limit, so you're going to have to set up a trust in order for her to qualify financially for Medicaid. I found a page that talks about that here: http://www.state.nj.us/humanservices/dmahs/clients/QIT_FAQs.pdf
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It's been awhile since I've worked in the medmal practice area, so this is based on what the standards were sometime ago.
1. Medmal plaintiff's attorneys in Michigan (and probably elsewhere) have become more focused on the bottom line, which is what the damages are and possible judgments. And the damages need to meet certain criteria.
A friend of a friend's doctor misdiagnosed her with a defective lung, or it might have been lung cancer (this was sometime ago as well and I don't remember all the specifics) and removed the lung. Biopsy was negative - no disease. Bottom line; errors in interpretation or more caused this woman to lose a healthy lung.
I gave her names and numbers of good medmal plaintiff attorneys for whom I had worked, or knew of. Not one would take her case. The damages weren't that significant because she could still breathe and live with one lung. Horrific? Yes, absolutely. Actionable? Maybe, but maybe not - there might have been some nuisance value (see below) but the attorneys I recommended weren't interested, and these were the ones I knew to be successful and prominent attorneys.
Would someone just out of law school and struggling have taken the case? Perhaps. Would he/she have the expertise to handle it properly? Unknown.
2. Treatment rendered or not rendered, and tests not undertaken need to have been outside the "standard of care" existing for that particular medical field/specialty/issue in the geographic area. E.g., if someone breaks an arm, it might be standard for hospitals and ortho surgeons to get a MRI, or maybe it's just standard to do x-rays. If the latter is the standard of care in the area of treatment, someone claiming malpractice because an MRI wasn't done would not be within the standard of care expected.
I say again this may have changed through case law over the years.
3. Medmal attorneys will first order the medical records and generally have them reviewed by specialists in the field to corroborate the existence of malpractice. If they don't have a medical specialist to eventually testify in court, b/c none believe malpractice exists, the attorney has 2 choices: (a) decline to take the case, or (b) take the case and milk it for nuisance and harassment value with the medical malpractice insurance carrier.
4. Another standard is the issue of longevity: how did the alleged failure to treat or mistreatment affect the longevity of the patient?
Actuarial standards used to be applied. I don't know if they still are.
This can make it difficult for older patients since they don't have the longevity or expectations of life and earnings that younger people do.
So, in the long run and even if people often think "I'll sue!", it isn't that easy, practical, or financially justifiable (for the attorney) in the long run.
What can be done though is filing a complaint against specific doctors with the state's medical review board.
You can check the website AVVO, there are attorneys in every sort of practice with client and peer ratings. Maybe a good place to start. Also, since mom is not able to sign you can go through an emergency guardianship proceeding since there is not POA's in place. You may be able to do this yourself. Once or twice a month at our courthouse attorneys volunteer to meet with people on issues such as yours.
Good luck!
Current problems: I need her to sign the POA forms however right now she isn't capable of understanding them and possibly physically unable to initial them too. I tried to get her to do this years ago (same with signing over the house) but she refused at the time, which I now deeply regret. Just like her own mother, always suspicious of everything.
I've already contacted the Medicaid office however I'm still waiting for the return call. Anyone know how long this normally takes? They just transferred me to a VM box.
Her assets are limited to her house (probably in the 100-120K range) and SSI plus pension totaling around 2700 monthly, plus a couple of small insurance policies. I'm already authorized to access her bank account so getting the records won't be a problem in that regard.
While I'm not expecting the rehab to ID her medical issues, I was expecting the doctor there to assist in ordering more tests. Right now transporting her anywhere is a task and a half, she requires a stretcher and restraints to safely be moved anywhere so getting her to "regular" doctor appointments is impossible. I just spoke to the doctor at the hospital and he expressed concern as her agitation is making it difficult to even examine her.
Also, they should've given you statement from Medicare about "discontinuation of care" or something like that. There is a number on it to initiate a "Medicare Dispute of Discharge." Once you get this paper, the clock is ticking. You only have a short window of time to make a dispute with the Medicare QIO agency in NJ. Tell them that there is not an adequate plan of care in place for her transition. They may or may not accept this, so be sure to find out what the rules are for whether she will have to pay herself if they deny her appeal.
In the mean time, tell the nursing home you want to transfer her to long-term care immediately (as soon as her rehab days end). See if they have a bed available. If not, see if there is somewhere else she can be transfered to. You can call your county Medicaid office, and ask them who you have to speak to, to come evaluate her medically for long-term care. Keep communicating with the social worker at the Rehab. There may be a different social worker they have you talk to about ling-term care. Be friendly, but persistent, and ask them what you need to do to make the transition without sending her home. You are not limited to the Nursing Home where she is located, but you will want to choose one that accepts Medicaid, even if she doesn't have it yet. Just don't sign any of their paperwork yourself, because of the reasons I listed in my other reply. Have her sign herself, even if it looks like chicken scratch.
As someone else mentioned, the first thing you need to get is a durable POA. The Medicaid application process involves getting a lot of financial documentation, so you will need that in order to request it. If your Mom has a lot of assets, it might be better to consult an eldercare attorney. If she has little or none, it's possible to do it on your own, but it's not for the faint of heart.
To be eligible for Medicaid, you have to qualify both medically and financially. If you haven't already, tell the social worker at the Rehab that you want to begin the process. They will give you the number for your county Medicaid office. DO NOT WAIT. Call them immediately, and make an appointment. You'll have to go in person, and bring a lot of documentation. They will give you (or you should ask them) for a list of the documentation you need. This will include her identification, like a birth certificate and social security card, proof of income, like the social security statement of benefits and pension statements, and proof of assets, like a deed if she owns a home and any investments and insurance policies and similar.
Then, they are looking to determine 2 things: what her income is, and what her total assets are. There is an income limit in NJ, but recently they "sort of" eliminated it. If she makes over a certain amount, she'll need to start putting any amount OVER this number in a "Miller Trust". Then she will meet the income limit. You'll most likely need a lawyer for this, and you should check the name of the trust, in case I'm wrong.
She will also go through a financial "lookback," which involves getting 5 years worth of statements from any bank, retirement, investment, etc. accounts she has had in the last 5 years. This can take time to collect. They go over the records with a fine tooth comb to make sure she didn't transfer anything to friends, or family, or hide it in an account somewhere else. They will come back to you probably a couoke of times at least looking for additional documentation, like check images and deposit slip images.
Once they determine what her assets are worth, they will come up with a formula that tells you how much of them have to go to pay the nursing home, before Medicaid will start to pay for it. So, and this is VERY IMPORTANT, don't spend any of her money. She will be able to keep a certain amount of her assets (I think it's $2000 and has a certain amount of time when she can spend down and buy things like pre-arranged funeral expenses, and other personal needs. If you think she will have any assets, you should definitly go to a lawyer.
In the mean time, when she switches from Rehab to Long Term Care, they will have another Admissions Agreement and other paperwork to sign. If you are able, have a lawyer review it and DON'T SIGN ANYTHING YOURSELF if she's of sound mind. Even as Power of Attorney, they have tricky language in those things which will make you liable for any balance she has left after she leaves, or passes on. This can be tens or hundreds of thousands of dollars. Have her sign ALL of her paperwork herself, so only she is liable for payment.
Also, the formula for what she will owe the nursing home as her "cost share" each month if she qualifies for Medicaid, is her entire income, minus whatever the amount her Medigap supplemental insuance policy premium is each month, minus $35 she gets to keep for "personal needs." Figure this number out, and start making payments to the nursing home the very first month she is in it in the Long Term Care section. You don't want this to sit and accumulate in her account while you are going through the financial determination process.
They basically give you very little time to get rid of her car if she has one, so start thinking about that. Technically she's allowed to keep it, but you'd have to pay for insurance because she's not allowed to use her assets or income to pay for it. Other assets, like property, have different rules, and you should definitely consult an attorney about them.
If there are any assets, she'll go into a "spend down" period, where she pays for the nursing home until it's all gone, then Medicaid will kick in and she'll only owe her income (minus the deductions I listed before). This all happens while she's already in long-term care.
Try to be as organized as you can, and get going on it right away. The sooner you get it settled, the sooner you won't have to worry about it. Feel free to send me a private message if you have any questions. Best wishes!
I spoke to an attorney (way out of our price range) and an advocate as well as the center's ombudsman today and my understanding is that I can absolutely refuse to take her home on Friday regardless of what they have to say about it. I'm telling them tomorrow that until I have a proper diagnosis and a realistic long term care plan in place that I simply can't do it AND that it's their job to help me accomplish those things as opposed to worrying about dollars and cents. IMO they've done a pretty good job regarding daily needs and care but not so good as far as identifying Mom's bigger issues, like why she can't walk, why she's always leaning to one side and how she became so out of it so quickly.
You can refuse to bring her home simply stating you are unable to provide the care she needs.
So mom does not have a secondary medi-gap type policy to share the cost of rehab? Bummer....The contract /payment agreement is it just for doing the rehab copay for Medicare 20% match? Review it clearly, you may have signed off to cover full 100% private pay NH rates that would go into effect once she is no longer "progressing" in rehab.
Is all moms legal current? If not, speak with elder law about getting updated if mom is still competent enough to do so. As far as mom being able to divert $, well IMHO once they are at immediate need of a facility those planning options are moot. There is no 5 year window to make this work.
Now mom can use her spend down $ on her care & her property. It does not all have to be paid to facility. Say mom has 30k spend down, so she could private pay 10k a mo to NH for 3 mos. But she could also pay 1k house insurance for a year, months of utilities, yard work for 3k; get a plumber in to do repairs 6k; get roof replaced 10k; and get a fully prepaid funeral & burial policy 10k. Same 30k.
Spend down before applying has this flexibility more easily, comprende?
If the house just has to be sold, you want to get moms SOC diverted to pay for house costs while on market. Can be done but you may have to press on this. Usually for 6 mos and you have to show a MLS listings agreement. having a house on the market is going to have increase costs of utilities, yard care and perhaps a rider or new policy to moms insurance. Who is to pay all this?
Have a reality check on the value of the house. If moms house has decades of delayed maintenance in a neighborhood that has seen lots of renos
If you find in your nancy drew search for paperwork, that mom is over medicaid limits, you should speak with elder lawyer about getting a miller trust done to make her eligible. Use moms $ to do this.
You do need to establish if her life insurance policies have any cash value. Whole life usually do, but term usually doesnt. If they do have cash value, they will need to be cashed out - if your DPOA this should be fairly straightforward to do but allow 60 days. For my mom, policy was old school type and not screaming TERM, was like over 30 legal size pages front & back, now medicaid caseworker does not have time or ability to review policy so I got a broker to do a letter stating policy was term & NCV (no cash value) so all ok for life insurance. It's stuff like this that makes you loco & being organized helps your sanity.
Moms house does not enter the asset formula - their home & a car should be an exempt asset for their lifetime for medicaid if they do an "intent to return" statement. If you have been a caregiver for 2 yearsor so and can document that your caregiving kept mom out of the ltc and off of medicaid, You can file for the caregiver exemption to MEdicaids MERP program. Although that sounds just fabulous, what happens is that once on Medicaid or Medicaid pending all their income will be paid to the NH as their required co-pay or SOC ( share of cost) required by Medicaid. They will be allowed a small ($35-105 a mo) personal needs allowance. So everything house will need to be paid by family. Do you have the availability to pay on all on the house from now till mom dies and through probate or property transfer process??
One thing that comes up over & over on this site is the caregiver works for free for parents in parents home, spends their retirement in the process or leaves their paying job. Then years later parents need higher level of care & moves to Nh, caregiver finds themselves impoverished, worn out and unable to pay house items. A frightening crisis for well intentioned caregivers.
1) Medicare is not set up for the transition, nor LT care, only rehab.
2) Even though the SW, PT, OT all agreed that Grams shouldn't be at home alone, it was really up to us to figure out what to do...as she was going to be discharged because she had reached a "plateau".
3) Applying for and going through the appeal process was a great deal of extra work for the rehab staff...and they were not happy they had to do that. It was denied of course due to reason 1 above.
4) We wondered if no one showed up to pick her up, what would happen...and pretty much were told that they would call a cab, put her on a bus and send her on her way. (We opted for the rehab staff to train/show us proper ways to move her from the rehab room to getting her in the car and back out.)
5) You do have the option of keeping her in the rehab facility if they do have room...its just a great deal more expensive than a regular CBRF or ALF. But if you do need a day or two or a week, it is an option. (The spend down would go real quick like then of course)
6) While going through the application process for Medicaid (many ALF's have persons trained in the process, we worked with DOA referrals/staff, or you can fumble through it yourself of course) we temporarily set up her up with FT care back at her home once again.
7) Team Grandma members then toured about 3 CBRF's/ALF's each day for a week until we found one we thought best for her LT care. Worked out a rate for private pay until the Medicaid program we applied for through the county began to cover a good deal of it.
8) The last I heard, the tricky word and statement as far as a diagnosis for one with Dementia/Alzheimer's needs to say "cognitively disabled" since those other terms are tossed around so much I imagine.
Continued best to you!