Medicaid penalty period. Has anyone dealt with applying for Medicaid LTC before it is actually needed?

I should think the first steps you'd want to take is to find out all the Medicaid rules for YOUR state. Although it is a Federal benefit, every state has their own rules about max income, #years lookback, max assets, etc. IF spenddown will be needed, check with them as to what is eligible - necessities like hearing aids, burial plans, eyeglasses, etc are okay, but you don't just spend it on anything!

Also check on medical eligibility - as rovana says, not everyone qualifies for NH. You said she "would qualify now for nursing home care" - is that confirmed by doctor and NH or just what you think? In general (there are a few exceptions), Medicaid only covers SNF/NH, not AL or MC.

For her to use Medicaid to pay for her bed, means she has depleted her money in bank or other liquid assets. House excluded by indicating her desire is to return home. Her income and whatever is left in the bank, svgs, etc will be used to pay for her bed. If she doesn't have enough income, then NH would help you to apply for the Medicaid - they all have social workers or employees who know when to approach family about need to apply (because they want to get paid).

A doctor would determine her medical necessity that requires NH care. It's probably best to continue on as you have and apply for nursing home bed when it's time to do so. The look back is 5 years, so if she's with you for another few years, the look back is only going to be for the period of time she's been with you. Make sure you keep records of what she had when she came to your house and how money/savings has been used since then. Easier to do it now than to try and remember what some big payments were for later on.

My understanding is the lookback date is set based on date of the LTC Medicaid application and the transfer penalty amount is based on # of days ineligible by your states daily room & board reimbursement paid. It’s a math problem, division.

Say healthy & fit mom gifted $50k to Sonny 6/10/2017. It’s clearly $ as a gift to him and in her bank statement for June, 2017. Then mom falls last mo. So hospitalization in January & now in moms in rehab in the NH and realistically cannot return to her rented apt to live independently. Mom now definitely needs skilled care and has a fat medical chart that shows “at need” medically. Mom is going to transition from a mediCARE rehab patient in the NH to a LTC resident with an application to Medicaid to pay for her long term room & board stay in a SNF as mom has no real $. Mom just has $1600 savings & her SSA $ 1400 mo; so she’s under 2k in assets & $2100 or so that most states set as income maximum. Her Medicaid application will likely want 3-5 years of all financials. The 50k gift is within a 5 yr lookback based on February 2021 application filing. Her state pays a daily R&B of $185.00 to NH.

Transfer penalty = $50K divided by $185 = 270 days of ineligiblity.

So basically 9 months of private pay needed. Now the NH is getting her SS$ each month as required copay by Medicaid, but there will be a balance due difference btw Medicaid rate vs private pay. Some states pay $300+ a day for room&board so in those states the ineligibility period will go quicker. The issue gets to be as you have to be in a NH to apply for LTC Medicaid, there's a bill getting created each & every day. So if it takes 4 mos for the application to get processed & the transfer penalty determined, that NH is going to go after whomever to pay those 4 months balance due which Medicaid won’t & private pay for month 5 onwards.

FWIW, the NHs my mom & mil were at, all did their own in house review of the documents submitted to Medicaid ahead of thier submitting them to the State along with thier bill. NH admissions is pretty good at ferreting out bigger transfers. They may heavily lean on family to sign a financial responsibility contract just in case there ends up being a Medicaid eligibility issue.

She’d need to wait to apply till July, 2022 to be beyond 5 yr lookback.

I am in SC. I called Medicaid and I also went to an elder attorney. The elder attorney explained to me that if there was money gifted. ...The penalty period would then start on the date that money was given away. So for instance say she gave $20,000 away... On January 1, 2020 and then on January 1, 2024 she needed to go into a nursing home. So say the monthly amount for a NH in SC is $5,000 a month. Since in SC there is a 5 year look back period...Medicaid would take that $20,000 ÷ the $5,000 monthly amount of a NH and it would be 4 months before she would be eligible for Medicare. This is the formula that would be used anytime during that 5 year look back. So the look back would end on January 1, 2025. On January 2, 2025 , the gift of $20,000 would be a mute point. It would not be taken into consideration when applying for Medicaid.
Also, the SC Medicaid office in SC advised me that I could apply for Medicaid for my mom once she got down to about $5,000 in her account.
Bit I would still see an elder attorney and also call your main Medicaid office. My local Medicaid office was no help.

It will probably depend on which state you live in. Seeking an Elder care attorney is probably the right move.

The next best thing might be to call Medicaid and ask them. That is what I did, many years ago. The answer they gave me was that the eligibility date would be pushed back by a certain time that was figured out by the amount of money that was set aside within the window. They have to figure out how to convert the $20,000 to a number of penalty months. So, let's say the average cost of facility that your Mom would be in was $2,000/month (probably a lot more than that in reality), then $20,0000 divided by $2,000 is 10 months, meaning, the penalty would be that your Mom would have to wait an extra 10 months to be eligible for Medicaid. Also, I would assume that the penalty takes effect when you apply for Medicaid regardless of where your Mom is or where you are or if you are taking care of her. It seems that Medicaid just cares about your Mom's assets and income, and really not much else.

Also, applying before it is needed wouldn't really work right? because they will certainly say no if the assets and income are too high. There is usually a window of time where you can apply beforehand, something like 90 days. There has to be a window or else everyone would be destitute at the time they apply, Medicaid at least allows a person to be on the verge of destitution when they apply.

Don't take my word for it though, I would try to figure this out with Medicaid/Lawyer. I guess in the end, they will figure it out for you, but then you might be stuck waiting just when you don't want to be waiting. Timing of the whole thing can be tricky.

Sorry to hear about your issues. It will get better someday.

In NYS there is a 5 year look-back for Nursing Home Medicaid, and soon to be 2 1/2 year look-back for in-home Community Medicaid care. Laws are changing rapidly. It's in your mom's best interest to book a consultation ASAP with a good elder law attorney. It's worth the time and the fee to get professional advice to set you on the right course.

You don't apply for Medicaid ahead, not in my state anyway. You apply about 90 days before its needed. Thats the period of time allowed to get necessary paperwork to the Medicaid caseworker, spend money down to the cap required (2k in my state) and find a facility who will take her. If not done in that 90 days, you start all over again.

Frances suggestion is a good one. See what the look back period is in your State, mine its 5 yrs but some states less. What is the asset cap (like I said 2k in my state) and what is the monthly income cap. In my state its a little over 2300. If Mom brings in more than that with SS and a pension then you are going to have to consider a trust that the overage will go into. In my state that's a Miller Trust.

Good that ur looking ahead.

You really need to call your local Medicaid office and set up an interview with a case worker. Each state has different rules for how they determine Medicaid eligibility.

Medicaid is chiefly concerned that money might be given away to hide assets, there is generally a 'lookback' of 5 years to account for where the applicant's money has gone. Some might be considered legitimate, you would need to discuss this with the CW.

You can go the their website and download all the forms to get an idea of what information is needed. Even if you can’t file now you can start filling out the forms and gathering all the information and documents. You can update it as needed until your Mom qualifies. When I did this for Dad it took me about 6 weeks!