Looking for information on Medicare and assisted living. Any tips?

Mike, maybe think of it as options more narrow & focused & you / dad not having to deal with spend-downs, transfer penalties worries, yeah! or deal with selling a house filled with stuff and decades of delayed maintenance.

I bet your dad could do a HUD section 202 congregate housing program. Often theses are mated with a PACE day program & the PACE is health care nexus. If NJ doesn’t do AL waivers, I’d look into 202s. Slightly different than section 8 which are individual apartments. But if he’s eligible for Section 8, he should be good for a 202. The sticky will be finding one.

Where I am, the 202s are kinda like large board & care homes & quietly run. Tend to be retro fitted old Catholic schools & convents. Run by division of Catholic Charities. So bedrooms with seperate conversation areas (think Comfort Suites rather than Comfort Inn), meals twice a day done out of central commissary, communal activities. And everybody goes 1-3 days a week to PACE adult day center & the PACE is their gatekeeper for their health care. Technically everyone is supposed to be a “dual” so on Medicare and Medicaid for their health insurance. Being a dual just makes billing easier, like flu shot MediCARE pays for but the PACE bills Medicaid an administrative fee to do, so both M&M bill for flu.
Medicare is thier primary and Medicaid is their secondary health insurance (some don’t & keep old retiree secondary like BlueCross). Sometimes folks enroll in Medicaid community based programs as well, IHHS aka in home health services is community based Medicaid program & it is not health insurance BUT some of the things the IHHS workers do for a client will get billed to Medicaid/ Medicare health insurance, yeah confusing.

The 202 would - imo - be a band aid till he can go into a NH and show to be medically at need for skilled nursing care. At 94 imho a NH thats ideally where he needs to be & he files for LTC Medicaid to pay for it. If he’s Section 8, he’s totally good financially for LTC Medicaid. It’s a different program but similar criteria he’s already qualified at.

The NH he was in when he was recovering from pneumonia/ post Covid, if they have any open beds and they do Medicaid Pending, it might be worthwhile for you to set an appointment with admissions to see if dad could possibly meet the “at need” standards for admission that will pass Medicaid review & have him move in there. They have his old chart to use. They have or can know of an assessment team to evaluate your dad. Even if you don’t like this particular NH, once he gets approved for LTC Medicaid, you can move him to another open Medicaid bed in a closer / nicer Medicaid facility. I moved my mom from NH #1 to eons better NH #2 within her first year, it definitely was a bit of a ballet to accomplish but can be done & if this might be the case, DO NOT LET the NH become your dads representative payee for his SS income.

fwiw most NH admits come from rehab. They go from rehab Medicare patients to custodial LTC Medicaid or private pay resident. They have a huge detailed medical chart. Your dad doesn’t have this as he’s quietly living in his rented apt, seeing his doctor once or twice a year, taking as little meds as possible. He’s not showing “need”. He may need couple of MD visits, lab tests, changes to medication and now he can show sufficient “at need” for skilled nursing care. Like a RX change to one that’s compounded which realistically your dad can’t do on his own, or a medication done by a patch applied on his back, again which he can’t do on his own. It’s really challenging to get them into a NH directly (rather than coming in via hospitalization discharge for rehab) and have LTC Medicaid approved “at need” eligible cause that huge health chart doesn’t exist. If that NH he was in could possibly have a plan to get him eligible for LTC Medicaid medically and the do Medicaid Pending, you may want to seriously consider that.

Mike,

Assisted living is not going to be the solution, you need to plan to get him placed in long term care covered by LTC Medicaid. This likely will mean a SNF (nursing home). He also may be able to be placed in memory care if your state has waivers for Medicaid for MC. As Igloo said, to be eligible for Medicaid coverage in a NH, you generally need to meet both Medical and financial requirements, and your father may not Medically need NH care yet. Eventually, he will meet Medical requirements when he cannot perform daily ADL's, or if he becomes a danger to himself being alone. Visit your local Agency on Aging and get a needs assessment done. Also, get him on the radar of a state social worker. If he is deemed in danger to himself, they will take action and find a solution.

So medicare pays for short term rehab and Medicaid pays for long term, however, my understanding is that once you are over 64 in NJ you are not eligible for Medicaid.

LSS MediCARE does not pay for AL. or IL, or MC or any custodial.

At 94, dad has outlived any ability 4 asset planning. Not that you were necessarily thinking about that…. but folks have a tendency to tell you to do Trusts, do annuities, yada yada. Dads 94, there is no 5 yr window for him. Would have needed to have done paperwork back in 2017 or b4.

MediCARE is all about paying for hospitalization or post hospitalization rehab (via Original Medicare Part A) & direct health care vendor bills - physician, physical therapist, speech therapist, PA / physician assistant or NP / nurse practitioner (if allowed in your state) - for labs & testing & prescription drug costs. MediCARE is about paying patient & drug costs. It does not and will not pay custodial care cost, eg room & board in a AL or MC, or a NH. Custodial is private pay or LTC Medicaid.
LTC Medicaid is an “at need” program both medically and financially eligibility based program run by your state but under overall federal guidelines. Some states do LTC Medicaid waivers for AL and for MC.

If your dad is on a Medicare Advantage Plan, that a glitch in all this and a whole separate discussion.

As a first step, I’d suggest that you look to see if his State at all does a Medicaid “waiver” program for AL or for MC. LTC Medicaid $ for NH is federally mandated funding but States can shift some $ to waiver programs. So $ shifted to pay for AL. If so, find the AL which take the waiver and go visit these and see what the waiting list is like for his placement onto them for his likelihood of getting a Medicaid waiver bed. Is it feasible for him to move there, private pay for AL till his name hits the waiver placement? Ditto for MC.

Most states do zero AL waivers. MC more of a crap shoot as to what’s done. AL& MC end up being all private pay.

Does dad have a needs assessment? If not, I’d suggest has one done. Im going to guess based on how you described your dad that he will not be able to meet the “at need” medical standards for skilled nursing care. Like that he needs a NH will flat not be in his health records. If he’s like alot of elders he goes once or twice a yr to his doc and it’s not enough to have a fat health chart. Most come into a NH and onto LTC Medicaid from a post hospital rehab discharge from breaking a hip and cannot return home again so they have a fat chart.

Has you dad ever gone to rehab at a SNF/NH post hospitalization?
If so, how long ago did this happen? Asking as they may have useful records on him.

Dad owns a home and outright, correct? Is it readily sellable with a weekend or two of simple clear up and clean out? Or would it be challenging to sell? Like it has something - it’s location, it’s structure- that would make it hard to actually sell at whatever his last tax assessor bill has as it value? Has there been something done that may have made it exempt or excluded from actions in probate? Or is his home a total albatross? Would he have the $ to pay for 6-8 mos of AL and 6-8 months also on all of his property costs?

Assisted living is private pay. Medicare does not pay for for residential care. Medicare will only pay for skilled nursing home care rehab for a limited number of days. Medicaid, if eligible, will pay for long term nursing home care.

NJMike, you might start looking at MediCAID programs for your dad:

https://www.payingforseniorcare.com/new-jersey/medicaid-waivers/global-options-for-long-term-care#:~:text=GO%20provides%20for%20a%20broad,well%20as%20minor%20home%20modifications.

If he is over the Income limit, a visit with an Elder Law attorney or Medicaid planner can help with that.

Are all the important legal docs in place, POA, Medical POA and will?

In most instances Medicare will pay only for nursing homes, not for ALF and ILF (independent living facilties), or MC (memory care). These are usually much more expensive than nursing homes, and medicare doesn't cover them. Some few ARE covered by medicare when a resident runs out of funds, but this is unusual and can only be answered by the faciliity itself. In general, when a senior has some assets when he enters care, his assets are used for his care; when they run out Medicaid is applied for. Being a joint structure of funds from federal and state governments, the rules of medicaid are dictated by the state you are in. If the facility the senior is already in has a social services connection they may be able to help in application for medicaid. Then the funds of the senior (SS and any pension, etc) goes directly to the Nursing Home, and Medicaid picks up the remaining costs.
That is kind of the bird's eye-flyover view of things, but they can vary according to facility, according to state. An elder law attorney or social worker in private practice may be able to help you further.