Nursing Home Social Services Reference/Flow of Care/Verifying Benefits and Finances

Benefits and Finances Most long term care residents are on Medicaid. Some rehabilitation (rehab) stays are paid at least initially by Medicare in part or whole. Knowing how to apply for Medicaid and Medicare will be important for serving residents and the facility. Eligibility for Benefits Long Term Care (LTC) Medicaid is the most common insurance payor in nursing homes (SNFs) and less common in Assisted Living Facilities (ALFs). The bill for a stay at a SNF can be more than $200 per day. This is $73,000 or more per year. Most older adults plan for this by getting Long Term Care Insurance or organizing their finances to be transferred early to their children or charities. This must happen more than five years prior to the application for Medicaid. Some states allow residents to put some money in an approved trust. This can also be used for monthly income over the limit for Medicaid and/or savings. Trusts come in a few different varieties in Colorado. There are personal needs trusts, disability trusts and other arrangements. An elder care lawyer would be helpful for the resident and their family to engage for these needs. In Colorado, there is legislation called the Spousal Impoverishment Act which contrary to its name allows one part of a couple to get Medicaid without causing the other partner to be put out of the couple's home and use up all of the their income or savings. In Colorado, the spouse at home can get a portion of the spouse's income to pay necessary bills and keep a car, the home and up to $120,000 of their savings. How LTC Medicaid Benefits are Applied LTC Medicaid is the payor of last resort. This means that the resident pays for everything that they are able to and then Medicaid pays the rest. Read this carefully For each month at the SNF, the resident pays for the first few days and or expenses. LTC Medicaid then pays for the rest of the month. For example, John the resident has SSA check that pays $2000 a month benefit. Let us also simplify and say the facility charges $200 a day for the semi-private room that John lives in. Let us also assume that there are no other incidental expenses. John's $2000 dollars each month pays for the first ten days of the month's charges for the room. LTC Medicaid then pays for the remaining days of the month (18 or 19 days in February, 20 or 21 for other months). This means that you should not discharge a patient in the middle of the month as their benefit check would have been all spent. During the coverage of any Medicaid program, other persons such as family cannot pay for or subsidize any medical care. Medicaid presumes if another entity will pay for such services, Medicaid is not needed. Again Medicaid is the payor of last resort. Resident income, gifts or other emoluments would be used first to pay for care and Medicaid would pay only the remainder. Another LTC Medicaid concern is the minimum stay. In Colorado, if the resident is using LTC Medicaid for the bill at the facility, the resident must stay at the facility for at least 30 days or Medicaid will not pay for any nursing home charges. Limitations for Eligibility LTC Medicaid is need based. meaning that only those who have insufficient income or other justifications are eligible for the benefit. States have different criteria, even counties within states may have different income criteria. This is generally expressed as some multiplier of the Federal Poverty Level. The Federal Poverty Level is set each year and can be found here: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines In addition, there is an asset limit of $2104.00. This asset limit is determined by adding all of the balances of bank accounts and the value of tangible assets that are not excluded. Excluded assets may be one car. This list of excluded assets is different for different forms of Medicaid and may be different for each state. There are other less common reasons for denying Medicaid. If in the five years prior to the application for Medicaid, the resident gave away a substantial sum of money to another person, or gave away a substantial asset Medicaid may be denied or a penalty levied. An elder care lawyer may be helpful in sorting these issues out. Exceptions for Government Windfalls An exception for these limitations is when a government has paid the resident for a claim in arrears that exceeds the asset limit. In this case, the resident is allow 90 days to spend this money. In other words, the asset limit is waived for the amount of the "windfall" for nine months. This must be spent on items purely for the benefit of the resident. It cannot be used on housing, meals, prescribed medications or medical care that would be paid for by LTC Medicaid. How Medicare Benefits Work for SNFs Medicare pays for two separate kinds of service that may involve a nursing home. The first is catastrophic care and rehabilitation and the second is hospice. Medicaid can be used with Medicare. Medicaid will pay for the Part B premium and copays as well as Part D costs if resident is on Part A. For Part C Medicare (which is private insurance) the rules may be different. Check with your state and county Medicaid office. For rehabilitation, Medicare does pay for up to 100 days of nursing home care. However, there are some details to be careful about. Medicare will pay substantially more for care than Medicaid does. This is because Medicare is paying for catastrophic care and rehabilitation. This is called skilled care versus standard nursing home care. Skilled care includes therapies such as occupational therapy, physical therapy, speech and language therapy and psychiatric treatment. Because this is rehab care, Medicare will stop paying anything when the resident plateaus or does not continue to improve. Medicare pays for first 20 days in full. There is no copay during this time. After 20 days, there will be a 20% copay. Because nursing homes are more than $200 a day, 20% can be a large amount for the resident. If resident is also on Medicaid, then Medicaid will pay this amount for the resident. For hospice, regimes of care are designed by a hospice agency. Bills for facility charges are paid through the agency. There are many things that can be obtained for the resident under hospice, especially goods and services that offer comfort for the resident. Medications will change, routines for the resident will change and social services and nurses will be cooperating with the hospice staff to provide care for the resident. A caution with hospice residents is that only items considered comfort measures will be paid. No "forward-looking" or "future-oriented" measures will be paid for. The hospice agency and their team will assist you in sorting this out. Some of the rationales for payment can be surprising. They include drug withdrawal and other discomforts related to a changed care regimen. Additional items that might be unusual will be paid chaplain attendance, music, art, massage and animal therapies.