Medicaid was denied. Anything in particular I should write in my appeal to Medicaid?
My moms long term care Medicaid was denied because they say she doesn't meet the medical level of care to get nursing home care. Has anyone gone through the appeal process that could give me some advice? I'll explain my moms and my background a bit.
My mom is 68 years old with Multiple sclerosis. She cannot walk or stand. She needs assistance with all transfers, to toilet, bed and her mobility scooter. She is cognitively alert and can feed herself, but cannot prepare meals. She also needs someone to dress her and wash her and her hair. She broke her hip in February of 2015, before then she could transfer herself so I was able to help with meals and shopping and anything else really. Now that she cannot transfer herself she needs someone around always incase she needs to use the bathroom. She can hold both urine and fecal for 5-10 minutes, after then she goes in her pull-ups or pad and needs someone to change her.
We just moved to Tennessee and I was sure that she would be accepted for ltc Medicaid because she was without question in our last state. I guess Tennessee has harder rules. They write that she can receive 8 hours of help at home a day and she will need to use free help from friends or family members. I'm the only family around and I cannot take care of her for those other 16 hours of the day. I have three young children, 5 year old, 3 year old and 10 month old and my husband is going overseas for the next 9 months. My mom gets up 2-3 times every night. I cannot mentally or physically handle the demands of her plus my children.
Is there anything in particular I should write in my appeal to Medicaid? I don't know what we would do if she is denied it fully. :/
This was TX and the appeal had to be filed within a pretty tight window (I'm remembering it was 30 days) but the actual appeal hearing date was set for almost 4 months later. The request for appeal was a 1page form attached to the denial letter. Denial sent both to NH& to me. The documentation, MD orders, health history stuff not needed to get medicaid medical appeal hearing date.
For my mom, there was a snafu by the NH on including all of moms RXs and preNH admit lab reports in her NH chart. This is stuff the NH need to do, not me or family as we can't fill it in or access files. Now the medical director of the NH also had been moms gerontologist when she was in IL,(she went from IL to NH and bypassed the AL stage) so in theory her chart should have seamlessly went from his private practice office to her NH chart. When the NH did moms admit, they left these out.....I had to send a fax to his private practice office to request mom's RX & last 6 months of lab reports to be faxed to NH to the attn of the DON (director of nursing of the NH). The lab reports were mucho importante as it showed her verifiable need for skilled nursing care. The NH put all this into her chart plus they did a cardiology work up on mom (to get another co-mobidity in her health history) and sent all to state as an addendum. State reversed the denial . All was done & over even before the appeal hearing date.
I'd bet that either moms old health history was not included in her health chart at the new TN facility, so no documented need or orders for skilled nursing care &/OR mom scored too high for ADLs for TN skilled nursing care requirements. I'd ASAP schedule a meeting with the DON. Try to contact her old NH to see if they sent over a copy of her files before the DON meeting. If they didn't, you need to get these copied & sent ASAP. They can charge you a fee for this but it can't be excessive. It flat may be easier to request the copies and you ask family or friend to go pick it up, pay the copy fee & have them overnight it to you. I've found the DON is the power center for a NH, she is the goddess & ruler...the MD comes over a day or 2 and goes to see residents as per the DONs list of priorities.
Your mom needs to get her health history to clearly show "need". Sometimes this can be simple changes.....like switching from the Exelon pill to Exelon patch as patch requires more "skill" to apply...or switching a medication to one that has to be compounded on site as that requires more "skill". You as the DPOA MPOA have to be very proactive in requesting this staff be done; it's your responsibility to get the requests, copies, etc.
If mom still gets denied, yiur choices are stark.....yiu personally sign off on a contract to private pay or mom moves in with you OR let mom become a ward of the state of TN. Often the ward is done as since it's court ordered the guardian can push past any red tape & get mom a Medicaid bed somewhere. Having her become a ward actually could be a good thing as really dear you have your hands full with 3 kids plus a deployment.
I'd bet your local MS group has families who have gone through some of the issues you are facing. I'd see if there is a support group & join it.
Just a final thought...mom is able to show valid TN residency, right? Mom has TN ID & can show her SSDI & other banking with a TN address, right? & all this was done, recorded, changed before she applied for medicaid, right? Mom does not own a home or a car in her old state, right? if any of these are not ok, it could make her ineligible for TN Medicaid.
In the interim, I'd suggest you call the MS group in TN to find a local support group. There are going to be others who have had to find a NH for a family member and can give you all sorts of insight as to the nuances of TN Medicaid. It's not the usual elderly with mid stage dementia who broke a hip and now needs a NH situation which is kinda numero uno for the move to a NH. Your mom is still young.
Now about the residency, in theory I think all states have a 30 day rule, but I think you will find that mom will need to show that she is doing whatever to establish residency. If she continues to keep the old states ID to verify who she is, has her banking showing an address in old state, Medicare has the old address, then the state of TN could declare that she is not a resident. If mom has anything that a could be considered real property - land, home, car - anything that ties into tax assessor records, those will be considered non-exempt assets for the new state and their value take her over the Medicaid asset limit (2K).
It may end up being that mom will need to switch to a another facility that will take her as "medicaid pending" and more geared to a younger resident. Good luck and let us know what happens.
Your moms young so you have a long history ahead of you with this facility.
Again so happy for you. I'm sure there will be some issue but it sounds like its all going to work out.
Igloo, that is a fantastic idea to stay on the DONs good side! Those are good ideas you gave me, thank you :)
The DON sounds like we knows her stuff so medically this is all fabulous. But the billing thats all controlled by the owners or the corp HQ and outside of her intervention. Ok worst case scenario......after 2 mo or so, they send mom & you a 30 day notice in which mom or you have to come to some sort of binding contract with the Nh on moms past due bill OR the NH contact the court to get mom made an emergency ward of the state. So mom becomes a ward of the state of TN.
Actually this could be a good - no actually great - thing for you. Ward of the state is done all the time often for those who have family who cannot fulfill the duties of a DPOA or guardian. Usually it would be done cause worthless son went & spent moms $ from the sale of her hiuse so mom cannot be eligible for medicaid as mom has a huge transfer penalty. Thats not you.....You kinda have both hands full & then some with 3 kids & a deployment hubs. A state appointed guardian for her means they take over getting her care done & often they can part the Red Sea as the are essentially an arm of the state. I would asap ask if any of the folks in the MS support groups have family who are wards and ask for the contact info for their guardian. Family can request a guardian if they have expertise in something beneficial & the judge will be sensitive to this. MS has it own unique issues I would think.
Guardian does not need to be permanent either. Your mom is still competent so it could be she's a ward for finances only. So the guardian deals with health issues. Or you seek the guardian till hubs comes home permanently from deployment or military service.
I've been an executor now 3times and guardianships were also heard in probate court. I can recall temporary guardianship being placed for a lady who's only child was going off for duty (very emotional & he came in full uniform) & being lifted for a daughter who was finally finished with her chemo so now good to resume being a DPOA.
I'd guess that most of the time hearing turn mom over to ward of the state is viewed as a threat but it could be the solution if TN has a good open system for wards.