Pros and cons of Medicaid/private pay?

Should the LTC Medicaid program be something y’all are thinking can be tapped into to pay for your moms care, please pls keep in mind that it is an “at need” program both financially AND medically. What folks get all worked up & into a lather about is the financial aspects (and for NH / Community Spouse situation having a CELA level of atty is mucho importante as it’s involved segregation of assets) BUT her being “medically at need for skilled nursing care” in a facility is equally important. And unlike the $$ part, this part is kinda out of our hands to do as all very interdependent upon her health chart to clearly show “need”. An elder not being not always cognitive, having sundowning, needing help in ADLs, needing help in medication management may not be enough to reach the “at need for a SNF” requirement for LTC Medicaid eligibility.

The vast majority of NH admits are a post hospitalization discharge to a NH for rehabilitation. Both are covered under Part A Medicare benefits and Medicare pays way waaaaay more than whatever your State pays a NH as the room&board day rate preset by State run LTC Medicaid program. So NH happy to have rehab patients! And an additional benefit is there is a nice fat current health chart from hospital stay and rehab to clearly show a legit and detailed need for skilled care. So the day when they exit Medicare paid rehab patient at the NH due to “not progressing in rehab” and segueway to becoming a custodial care long term resident at the NH, the documentation of “need” that LTC Medicaid will be looking for is all there. Big fat chart & w/a bow on it!!

Unless your mom has had a series of recent hospitalization with follow up rehab, she is probably going to be like most elderly living in their home or in IL with a twice or 4 times a yr doctor visits as her chart. Not showing need for skilled.
So if this is your mom, what I’d suggest y’all do is have an assessment done on your mom. A better elder law atty should have the names of those who do these. Tends to be a duo of geriatric RN and a SW and they come to your home to do an evaluation as to level of care & ability and do a report. In addition to its being able to be used for LTC Medicaid, it also is flat out good to have for when shopping around for placement for her. You do so NOT want to go through all this and move mom into an AL and then get a phone call & letter 2 months later saying “we so love your mom but she really needs a higher level care and consider this your 30 Day Notice”. You’re gonna be pissed and panicked if that happens.

Really get an assessment done. If it comes out that she is absolutely not needing skilled care, then that changes the options for placement. She’s either AL which most are purely private pay as States do not have to include AL for their LTC Medicaid program (if they do it’s on a waiver which = limited # of beds) OR she goes into a NH as private pay with the goal to get her health chart to show “at need” for skilled care for a in the future filing for LTC Medicaid. A NH won’t care if she really isn’t yet “at need” for skilled if the admission is private pay.

Plus private pay is a good and legit way to spend down $ if that ends up what’s needed as there is just too much in a$$ets between them and too much income for your Dad as a CS as to how your State LTC Medicaid program evaluates Community Spouse financial support and its equations for doing CSRA and MMNA. A good elder law atty should off the bat be able to explain to your Dad & to you what those 2 acronyms mean and why super mucho importante. If they don’t, I’d be cautious.

Ok so actually Mom is in a facility currently, right? & 2 months?
I’m assuming she is in a NH, right?
It is not that she’s still @ home & her cognition is way waaaaay too much for Dad to deal with daily so the kids casting about for ideas type of situation.

IMHO her being in a facility moves decision making onto a different gameboard, so to speak. & you are lucky this is it as so often a spouse will be all “she needs to stay at home” and refuse to consider AL or NH.
- so to me, 1st Q & A is: how did mom get into the NH?
Was it as a post hospitalization rehabilitation patient?….. like something happened- a fall, an infection - so she went into the hospital and after a stay was discharged to rehab at a Nh? If it’s this, then her hospital and rehab is covered via her Part A of Original Medicare. First 20/21 days @ 100% and can be up to 100 days at 50% if “progressing” in rehab (most w/dementia won’t be as cannot do follow through on directions).

-2. or did she come into the facility “off the street” and been NH private pay and now your Dad is getting worried on costs? As NH pressing on him to sign admissions contract?

whichever, she is staying in a NH whether this 1 or another.

-3. imo first step is to find out if she is there as a rehab patient and then where she is for her “progress”. Ideally you want her to be progressing as long as possible as Medicare is paying & gives y’all (& an elder law atty) time to figure out a plan. Fwiw Medicare will pay anywhere from 2X to 3X what the LTC Medicaid program ever does for custodial care residents, so NH super happy to have Medicare $ rehab patient.

- 4. If she’s not rehab, then find out exactly how both their health insurance and LTC insurance policy reads. Like for LTC policy what exclusion period is before it will start paying. & precisely the date when mom will hit the sweet spot (for it to kick in). And what LTC policy $ payment will be and what the shortfall is that Dad needs to private pay.
You need to know the exact $ amount LTC policy will pay per day AND what policy requires for a facility to be considered “Qualfied” for terms of the policy. If it’s Genworth, they tend to be pretty good on being client friendly.

if LTC policy exclusion period 90 days of private pay for custodial care then she may not even yet be at this point if she entered NH 2 months ago. Usually only after going from rehab patient to custodial care resident that policy’s will start the count down. It’s private pay during the countdown.

- 5. Once you know LTC policy details, speak with billing as to how they manage dealing monthly with these. Some NH will do filing for their residents and deduct it from a residents bill; while others fully expect it to be done by residents family completely so Dad / POA expected to private pay in full and it’s on yall to get the $ from the policy which he then keeps. There is a (horrors) 3rd option which my moms 2nd and eons better NH did…. they did NOT take any LTC insurance at all… that for them (smallish group of NH) dealing with paperwork needed to be “qualified” & be paid was just too cumbersome and really they could as easily make their #s work by having a balance of Medicare rehab patients and LTC Medicaid residents as both pay in real time.

6. Does current facility participate in LTC Medicaid? Will they accept your mom as a resident under Medicaid Pending? Pending could be anywhere from 3 to 6 mos (my mom’s application took 5.5 months). Nh do not have to participate in LTC Medicaid program. However almost all NH take Medicare for health insurance, some accept Medicaid as their secondary / supplemental health insurance but absolutely no LTC Medicaid for custodial care billing so Custodial 100% private pay.

Unless Dad has mid six figures, placing your mom in a NH that does not take LTC Medicaid could be problematic… they can outlive their $.

So Aloha, how did the atty sit down go? Even more overwhelmed and confused? Dad as well?

Adding to what NeedHelp has said....
When looking for a facility look for one that WILL retain her as a resident if she has to rely on Medicaid. The last thing you need is to have to look for a place that will accept Medicaid when funds run low.

Your Dad needs to see an Elder Lawyer. Medicaid allows for splitting of assets. Moms split will go for her care and when almost gone she applies for Medicaid. Once on Medicaid, there is no guarentee ofa private room. I have heard of family paying the difference.

If you chose to go the "spenddown" route - my only advice is to do your homework first. Research the procedure completely prior to signing any agreement with an elder law attorney. I made the mistake of just hiring the attorney, then could not get straight answers. In fact I was told at one point to "stop reading", when I asked about something I read online. Ask questions, learn as much as you can about the process AND about the attorney.

The idea of my mom sharing a room bothered me too.....at first. If your mom is far enough along in the disease to need to be in a memory care facility, being around others is not a bad thing. Even if she was in a private room, there is no way to prevent other residents from walking into her room and sitting in her chair or lying in her bed. A memory care unit is a world of it's own and a very uncontrollable one at that. My advice to your dad is to save his money and visit her often.

This isn't do it yourself stuff. This is a need for an attorney as it is crucial that the father not spend down all the money he may need in future for his own care. Dementia that is severe is almost always under the purview of either a Nursing Home or memory care facility and there is almost never a private room in those circumstances. It is easy to understand what dad may now WANT for his beloved wife, but it may not be possible.

It is crucial that dad see an attorney about a division of assets, finances, and etc. or he well could be left with nothing for his own care.
Do see an Elder Law Attorney and I wish you the best of luck.

Definitely meet with an elder care attorney. Also, choose the facility wisely. Look at the level of care that they will provide over whether or not she will have a roommate.

If there is an issue with a roommate that crops up, cross that bridge when you get to it. Don’t look for problems that may never arise.

Why is your dad so adamant about your mom not having a roommate?

Wishing you and your family well.

My MIL is in LTC in a wonderful facility here in MN. She's on Medicaid and has her own room. We're not actually sure why she has one: the facility is faith-based, non-profit so they see the care as a mission, not a business. During the first awful round of covid, they lost 9 people on her floor along. They had just finished a remodel/expansion, so I'm wondering if they just have a "glut" of Medicaid beds. Or, is it because our family purchased and assembled 1000 face guards during the worst of the pandemic and didn't hound them with unreasonable demands like some other families? Or, is it because she mostly has short-term memory loss and is still a sweet person to be around? We have no idea and we're not gonna ask -- all this to say it is possible to have a private room on Medicaid but I'm not sure what determines this.

It is possible that the facility can get reimbursed by Medicaid and then he pays the remainder of the private room charge, rather than paying the entire thing?

I agree that if he moves her, it needs to be someplace that has a lot of Medicaid beds. Look for faith-based facilities supported by a larger religious organization (her facility is run by the Presbyterian Church and they have a lot of locations and have been in NH care for over 40 years). My MIL was in 2 different faith-based facilities, and both were very good experiences. The first one was run by just a single church (Moravian) but they don't have the resources like a very large, national church. Hope this info helps you.

There might be - MIGHT BE - a workaround on “solo” room depending on the facility. Not private room per se but a single room would be the type of placement for any LTC Medicaid terminology.
Like IF the place is historic or in an area with historic designation then changing the footprint of the facility may not be done. And older NH were more a smallish room designed for a single person with a shared Jack & Jill type of bathroom between them. Or even each has it own private bathroom. And for these LTC Medciaid waivers the shared room requirement. For my late Mil, her first Nh was this and everyone had their own room with a shared bathroom and some of the rooms opened onto an outdoor walkway (hers did). Not at all what the usual Nh look like but it was post Civil War era building.

And for some NH, they end up with an end of the hallway room or rooms that abut the emergency stairwell or the rooms footprint is used by the service elevator so the residents room is flat not big enough for two residents. Voila! Single room and ok for LTC Medicaid. My moms second NH had these and they tended to be occupied by a still married individual who’s community spouse came to visit A LOT and it was ahem! best they had a single room. Just sayin’….