Medicaid: transferring to another nursing home. Any advice?

Trevor, just to clarify, Medicaid does not cover the cost between patient income and nursing home cost. Medicaid pays one rate for everyone, and the nursing home has to take it if they take Medicaid patients. It is not negotiable. So for example, nursing homes in NY are $12,000 a month. Medicaid may pay $8000. As a Medicaid recipient in nursing home care, a patient must also surrender their social security check to the nursing home. So the person with a $500 SS check is worth $8,500 to the NH while a person with an $1800 social security check is worth $9,800. When they see those 2 numbers on an application, they are a business that wants to stay in business. They will take $9800 every time. $8,500 will be told there are no open beds. Sad.

Bob, it really should be a non-issue, but it's not since in addition to the standard rate that Medicaid pays per resident, the nursing home is also entitled to receive that resident's social security check as a "copay" in addition to the Medicaid amount. That adds to their bottom line, and believe me, they're watching. They will use that criteria to decide which Medicaid patient to accept. Sad.

The county social services is just that: Social services...here I think they are called Division of Social Services, DSS. It would be in a public building, likely along with Probate court offices and others such entities.

Grace + peace,
Bob

Bob, I get what you are saying but it seems to conflict with what Christine says. I am talking about a transfer from nursing home to nursing home, so the issue of qualifying for Medicaid has been determined. Mom is already on Medicaid. Also if the nursing homes are in different counties, which county social services do you talk to?

When applicant to Medicaid has an income over a certain annual amount, it is my understanding they do not qualify. When my wife applied several years ago, the nursing home never asked about her income..That was addressed by the County Social Services staff. (agents, so to speak, of Medicaid). The amount of allowable income for "mom" may differ by state..if there is a spouse still at home (community spouse) then the income of said spouse has no bearing on mom's application.. Much more to it...The "difference" in income among various applicants should be a non-issue with the nursing home. Their role is: Medicaid bed available? yes/no. End of conversation. Remember, one does not "apply" for Medicaid through the nursing home. I would deal first with county Social Services.

Grace + Peace,
Bob

Christine, I guess I did not understand how Medicaid works. I thought that Medicaid paid the difference between what the resident can pay (Social Security, pensions etc) and the nursing home's actual monthly cost up to a certain limit ...for example, resident contributes $1,000. NH costs $8,000. Medicaid pays $7,000. What you said is different. Medicaid pays a set amount (any idea what an average is?) and then resident pays their share as I stated earlier, so the resident with the higher income will be favored. Have I got this right?

Christine - just reread your post. You mentioned the other family was railroad retirement. I'd bet that was a factor too. RRRB pays really high. Like it isn't unusual for a retiree to get 3k, 4k, 5k a month. Their lifetime benefits especially if they were professional or the widow of one will be quite quite high. Like enough to pay in full or come so close to it that NH will waive the difference. RRRB pays like clockwork. Their Medicare payment system is different too. Palmetto processes RRB Medicare (totally different coding) and they too pay really fast. Most NH now in the US probably don't get RRRB residents as there just aren't as many RR retirees. But for those that know how it's structured, a RRRB is a windfall.

The NH cannot require the residents monthly income (their SS, retirement check) to be paid to the NH. The DPOA can keep their monthly income as a direct deposit to the elders bank account & the DPOA snds a check for the SOC required to the NH & the bank account buildsceach month by thier personal needs allowance. So the eiders bank account builds each month by their needs allowance (from $ 35 -$ 105 a mo) that enables you to buy things for them that you know they need or would like or let It build to under 2k pay to offset future funeral costs.

The NH wants their income as they get to control the funds AND they also get to build the residents trust account & NH coffers by whatever your state has as its personal needs allowance. One thing that has surprised me in this adventure of elder care is that often family does NOT even know about the personal needs allowance trust fund at the NH. The NH implies that all income has to go to them...it's all so much easier for family to do it this way.....so much less worries for family. Yeah sure & I have some gulf front land on the Louisiana coastline I want to sell to you.

In theory, the NH is supposed to provide a statement on the trust account regularly. My moms first NH didn't; her second NH did every 90 days & with interest. There have been a couple of posters on this site who were unaware of the trust account & how it builds & had their moms NH used it to buy wheelchairs for them from the trust account to get it zero'd out.

Also if they should move to another NH, getting the direct deposit switched will be a cluster to do. Probably a month /6 weeks to accomplish. Getting the $ from old NH may not be simple....

I'd like to add my thoughts about the SOC & the appearance of facilities preferring those with higher SOC/higher monthly income....In theory there should be no preference for higher monthly income applicants as Medicaid pays the same reinbusement day rate for room & board for all Medicaid residents.

But here's my experience with this "reality" based on my mom @ $ 1,800 in mo income & MIL who had around $ 600 a mo. For both, they were coming from an at home living situation to a NH. Mom was in IL & MIL was in a senior housing apt. So not an admit to rehab at a NH ( so coming in with Medicare paying the rehab benefit). The NH's I toured we're positively giddy to take my mom with her $ 1,800 a mo income. For MIL not so much based on what my BIL /SIL said.

Why?....well Medicaid takes anywhere from a couple of months to almost a year to process an application. My moms took almost 6 mos to get medicaid approval. MIL moved into NH but within 4 mos went into the hospital and then into a freestanding hospice where she died within a couple of weeks. MIL died before her NH medicaid application was approved & it was approved over a year later after her death.

During the application process, the state medicaid pays zero -nothing -nada BUT the resident has to pay their SOC every month while they are " Medicaid pending". So my moms NH got $ 1740 a mo from mom. But for MIL around $ 500. A lot of residents die within the first 6 mos too. So the NH can end up not ever getting paid if Medicaid doesn't get processed & get approved. The elder is dead and really there usually no estate to go after. Most families aren't going to continue to dog the Medicaid application to get it approved (like my BIL/SIL did) once their elder dies. So the NH is flat out of ever getting fully paid.

That's why imho a potential resident with a high SOC makes admissions giddy. & why they will do a not-by-the-rules preference for higher SOC elder.
It's all about the $$$$$$$....always.

I can answer the medicaid question. When you're on medicaid in long-term care, medicaid pays a set amount to the facility per month. Additionally, the facility gets the resident's social security check, pension, and required distributions from their 401k. They call this the resident's "share of cost" and it is usually sent directly to the nursing home from social security. Everyone's share of cost will be different. It makes a difference because this is extra money the facility is entitled to. So if one person's ss is $1500 and another person's is $500, the facility will want the person who gets 1500, because they'll be getting a "copay" that's $1000 more per month.

That's a great quesetion, Trevor. We'll throw out an answer and ask the community to help make it right(er). -- There is a difference between what Medicaid pays/guarantees as payment including social security, pension, etc and what a facility can charge private payers. They make more off those who can afford to pay more out of pocket. But many/most, depending on the state, have a Medicaid fallback so that if/when a resident runs out of money, the resident will not then have to leave. But if a bed is empty, no money is being made on that bed, so it's better to have a Medicaid transfer than wait for a full paying customer.

Thanks for some helpful answers. There are some conflicting comments, though. If Medicaid covers the cost between patient Social Security / pension, what dofference does it make how much patient income is?

Admissions people at the NH Mom wants to go to couldn't be nicer. They say that she WILL get in but can't guarantee when. I don't want to get her hopes up if this is not so but there really is no way that I can know.

Why does she want to transfer? Not really a care issue but the facilities are a lot better at the other place and it is a more convenient location.

On Medicaid, your Mom has a caseworker assigned through Medicaid. That person works for her....not the gov't...not the NH. Get in touch with that person and arrange a meeting to discuss your Mom's concerns and why she wants to move. The caseworker knows all the facilities in the area that accept Medicaid and she/he could do the research into who has a bed. Yes, nicer facilities often do take Medicaid pts, but they only set aside a certain number of beds for Medicaid, since those do not bring in full payment to the facility. So there might be a need for Mom to be on a waiting list for a bed. She could have her name on a list at multiple other places, such that, whomever had a bed first would call her or you or the Medicaid caseworker. It takes a while though, because, typically, there will also be in facility residents, who are private pay, also on a waiting list for a Medicaid bed....and they would be first choice. But remember, these are mostly elderly folks, and the reality is that people in nursing homes are dying constantly, thus creating openings and movement. I would start by getting to know Mom's Medicaid caseworker. They can solve MANY problems!

You first have to get the Medicaid bed availability/eligibility. Why does mom want to move from this NH?

Sunnygirl is right about speaking with family in the parking lot. Reviews are kinda a crap-shoot as if folks are happy they don't post a review. Older facilities are always going to get lower ratings. My MIL's old NH in New Orleans was fabulous but always hit with deficiencies in reporting as buildings were 1880's.

I moved my mom from NH#1 to NH#2 at around month 10 of her first year in a NH and on Medicaid. It was pretty straightforward…I got a couple of other NH names from my mom's gerontology group (their staff were part time medical directors at NH), visit 3 and found 1 that seemed a better fit (great activities director, long time staff, good DON, & lots of residents were advanced elderly/over 95).I filled out a request for evaluation & NH2 sent over an RN and CNA to visit mom at NH1 to evaluate her to see if they could provide the level of care mom needed. They called me from her room & said all was good. Next day I went & did the paperwork at new NH. Mom moved the next month.From the time of the RN visit to mom's move in was maybe 10 days. The new NH had 6 open beds as they just finished up a wing renovation and mom was a pretty easy care resident so I do think all this factored into her moving with a bit of a time lag. If your in an area which open beds is an issue you may not have as much latitude in this.

Medicaid allows them to move from facility to facility without any issues. No 30 day notice needed. I faxed the notice of move to administrator 7 business days in advance. Old NH cannot bill you for empty bed under Medicaid rules. BUT I'd advise you to plan out as to the date of the move to make the SOC / co-pay more manageable. As you know they have to do their SOC every month at the beginning of the month. So if you move them out say the 15th of the month. Mom will not have the SOC to pay the new NH that is due for the rest of the month. The old NH will have to return the SOC for the days not there….but this could take days, weeks or months. If this is a crappy NH for billing (my mom's first NH was horrendous for accounting), it's going to be a total cluster to deal with. What I did was move mom right after the beginning of the month and paid old NH for the few days there & to the penny and paid new NH for the rest of the month. Everybody got the co-payment required by Medicaid. If mom has a personal needs allowance at the old NH, you want to make sure you get this cashed out too. And don;t do it last minute.

The new NH told me to make sure that I got all of mom's medications. This is kinda critically important as most often Medicare & Medicaid pay for meds in larger 90/120 day blister pack or a large container. THese are usually in a bag or locked closet at the nurses station. The M&M's will NOT pay for a whole second set of medications. This could be frightfully expensive to have to pay. You need to get RX's. I took a box of pint size ziplocs & a Sharpie marker to put mom's meds into just in case & glad I did. The nursing staff was quite ugly on doing this & dumped her Remeron out on the counter but I wasn't leaving without mom's meds.

New NH let me go and set up mom;s room (TV, photos, curtains) the day before. See if you can do that as it will make things go easier. I did have to have her there before lunch to meet with social worker who took her to her lunch table with her name card already done.

Oh as to why...NH1 was pretty dramatically different over time from the one 1 toured initially when looking for facilities for mom. She moved from her IL to the NH as a Medicaid Pending resident. Took 6 mos to clear Medicaid btw. Issues with #1 were both in nursing but also administrative. Nursing was whenever they was any problem that required a bit more work, they would send mom (& other residents) to the ER. For mom it happened 3 times and seemed to be just flat excessive as the issues weren't ER needing imho. Personally I think the NH did this in that often the resident would get admitted and then discharged after 3 days so the NH took them back and it would be on the Medicare rehab benefit so much much higher pay than the lower room & board reimbursement rate paid by Medicaid. This going to the ER would also cascade into billing issues from everything from outside costs on ambulance to aide to go to ER with her; plus all those hospital Medicare costs. Plus the confusion to mom (but she was a pretty tough old bird). Also the old administrator left and place went through 3 different ones and did not replace the MSW who also left with old administrator. It wasn't a snake pit but just rudderless. I got a strong Stark Law issues vibe as lots of family owned ancillary services to this NH as well.

Along time ago I had a friend who landed in a nursing home, and she actually transferred to another one. I'm not sure how the process went, but all I know is that she was successful. She was in another nursing home in a neighboring town, and she apparently wanted to be more local with people she knew. I think my friend may have very well been on Medicaid as well. Transferring between nursing homes is definitely possible

I would also examine if the high rating place really is better. I'm not familiar with how that works, but who does the ratings? What factors do they consider? I would ensure that the new place really is better and will provide your mom a better experience.

I know that my cousin is much happier at a facility that is not as upscale as the first place she entered. I suppose if the person does not have dementia, and I don't believe your mom does, the upscale furniture and appliances might mean more to her. My cousin could care less about fancy stuff and it's just the people who make her happy. I'd make sure this new place really lives up to the rating score.

I even visited places and sat in the parking lot and waited for family members to come out. I would ask them about their impressions. I think that most are candid.

The way that Medicaid reimbursement was explained to me, the amount of pension or Social Security should not be a factor. Medicaid allows a certain amount of money per day to pay for nursing home costs. If that amount is $200 per day or $6,000 per month, Medicaid would then subtract the amount of SS and pension income (while allowing for the personal needs allowance, usually around $80 per month), and pay the difference to the care facility. The SS and pension dollars become the Share of Cost, and Medicaid pays the rest. The "Medicaid bed" is a factor because Medicaid in general pays far less than the private pay rate at the facility. The facility must limit the number of Medicaid beds in order to keep the cash flow positive. As Sunnygirl wrote, Medicaid beds are generally the least expensive. This is usually a shared room in a nursing home and the smallest living space in assisted living. In a local assisted living facility there are two bedroom apartments, one bedroom apartments, studio apartments and rooms. Medicaid reimbursement is the same regardless of the size of the accommodation. As a result, only the rooms are eligible for Medicaid placement, and since there are only four of them in the facility, there is a waiting list.

We certainly cannot blame you for attempting to transfer to a better NH. We're in the same process and finding the same problems regarding bed availability. The top rated homes in our area typically ask for a year or more of private pay before accepting a new patient but do have Medicaid bed wait lists. Unfortunately, Medicaid transfers in are not as advantaged as those who can pay privately or through LTC insurance first, and those who can pay out of pocket are taken over Medicaid transfers. In the event there is no one available to move into a bed who can pay for it, it seems that for most homes, that is the point at which a "Medicaid" bed is offered.

There can be double hurtles. For instance, the best home in our area is part of a larger community care system in which there is continuity of care from none to NH/Hospice. Older adults "buy in" and become residents in which they are simply renting senior housing. If they decline, they are guaranteed placement in the next level if that level of care as required. So, those beds go first. Then those who can buy in with their own money go to those left. Finally, if there is no one else who can pay waiting, whatever bed that remains goes to the next Medicaid transfer in line.

That's tough Christine. That must have hurt to be turned down by the Memory Care while the other private pay was accepted. I will note that when my cousin was accepted into Memory Care, they had spaces available for women, but not men. Maybe, that was the difference.

I did not have experience with a nursing home, but assisted living. The way it was explained, was that the long term care facility has to accept what the state or Medicaid pays to them on behalf of the resident. So, if the facility accepts Medicaid, they can't refuse you admission.

So, maybe, the beds they are describing are SHARED rooms. I think that if they only have single rooms that are private pay, then they are waiting to get a SHARED room to open up. I'd ask if that is what they mean.

I have read that in some states the family may pay extra and supplement for the Private room, even if the resident is on Medicaid.

I suppose it depends on the state, but I know people in nursing homes that move around to different ones. I think the Medicaid case worker and facility know how to handle all of that. I would confirm that the new place has everything they need in hand, so that when the opening arrives, it involves a phone call to get her transported. I might then call once every two weeks to check on the opening.

Pamstegma, I'm baffled by your response. Do you know Trevor's mother? Or are you in possession of a crystal ball? Do tell...

Trevor, I speak for NY. It may or may not be the same in a different state. All (99% of) nursing homes accept medicaid payments. When we're talking about long term care, at $12,000 a month, eventually even the private pay resident runs out of money and has to go on medicaid.

I do find that nursing homes can descriminate financially, not accept someone, and use "lack of beds" as a cover up excuse.

What they care about is not so much that the person is on medicaid, but the "share of cost" amount they will receive. In other words, the amount of social security, pension, and 401k distributions the medicaid resident must now pony up as their medicaid copay.

If the nursing home application includes a request for detailed financial information, that may not be a good sign. If the application asks for only medical information, that may be a better sign. I speak from experience. The only nursing home that accepted my mother was the one that didn't know how much social security she was bringing in.

I had an experience when I was looking for nursing homes where I arrived just minutes before another family. We both needed a bed in the dementia unit. I was blown off when I mentioned medicaid. I was told there were no beds. The other family (within earshot) was told the same thing, then asked about finances. When they mentioned private pay and railroad pension, the admissions person began explaining the process to them and making arrangements, right in front of me.

As I followed up for the next few months, I was told by 2 nursing homes that my mom was "medically accepted," but unfortunately, there were no beds.

And technically, there's no such thing as a "medicaid bed."

One hinge is the availability of a bed.
Additionally, I'd visit with the Social Services people who administer Medicaid in your county of NH. I would never depend upon "only" what the nursing homes tell you.
I trust her current nh and the prospective one are in the same state?
Grace + Peace,
Bob

If mom is not happy where she is, she will not be happy in another place. You will move her and then she will complain and say she wants to return to the first place or go somewhere else. This is classic manipulative behavior; her goal is to gain control over you.