Not eligible for Medicaid, but not enough money to private pay. What do we do?

Why do you think they are not eligible for Medicaid?

Community Medicaid and LTC Medicaid have different qualifying incomes.

If this is a couple, seeing an Elder Law attorney would be a good idea.

Usually, there is a way to spend down or to put assets in a pooled income trust.

Elder or estate attorney may be able to help you. Sometimes it's possible to put the income into a trust (fund) that makes them eligible for Medicaid assistance. It might be called Qualified Income Trust (QIT) or Miller Trust where you live. The money put into that trust is used each month to pay the NH and Medicaid pays the balance. If it is used in this manner, correctly, there would be no money left when the person passes away. If, for some reason, there is some money left after death, the State gets it as reimbursement for what Medicaid (State assistance) paid out.

Many people in your very situation use this method to bridge the gap on income and cost of NH. An atty would have to help you with it. And could also help with your Medicaid application.

As for all Medicaid programs, there is a certain amount of years they look back at bank accounts and other assets to see what happened to them. (Texas has 5 year look back period). So if mom gave her house to someone, that would be a penalty period. If she moved all savings accounts to someone, that would create penalty period. Get all paperwork together to show when she sold her house, price, where the money was put and how it was spent. Do the same for savings - statements to show how much was there 5 (or whatever for your state) years ago and how all the savings was spent down. If there are large payments, like gifting or personal payments to others, you will have to note what the payments were for. Gathering all this prior to meeting w/ atty will help a lot to speed things along.

So not eligible because too much income? In a State that do Miller Trusts, that tends to be what’s set up, assuming the income source is qualified to fit the criteria for a Miller. Usually it’s elder law attorney work but some state have forms to do it if the income source is something standard.

The states that don’t allow for Miller do something similar, could be called a pooled trust. Just what and how, would need to be elder law attorney familiar with how that runs for your State.

What happens is the new “trust” becomes the payee for the overage aka any amount over the max allowed as income each month for LTC Medicaid. So now their “income” becomes low enough to be ok for LTC Medicaid income max. The overage either gets paid separately to the Nh or goes to the State.

Out of curiosity, is this RRRB? They pay crazy high for those that make Railroad a lifelong career. Do another post if it is, ok.

Do some research and go visit qualified Medicare/Medicaid approved skilled nursing facilities (SNFs) in your area. Your State Agency on Aging, the local or your State Health Dept. generally has information re: SNF quality marks but so does CMS (US Centers for Medicaid and Medicare). US News and World Reports also posts annual ratings. Check them out and go see them, ask questions regarding staffing ratios, what percentage of staff and residents are fully vaccinated for COVID. Look at the COVID case numbers (cases/deaths). Ask to speak w/meet the unit RN and social worker (do you have a good feel for them). Are residents clean, well fed, are all the room and common areas clean. Check out the food and eating areas, ditto for any in-house services PT, OP, on and on. Ask who are their physicians "on staff" (many may be contract types) but you can check them out too; board certified, how long, experienced geriatric types. Speak with the Business Office leader as they can be VERY helpful with the how to qualify for Medicaid part.

PS: most of these facilities like it when someone comes in private pay (a sweetener to them) before qualifying for Medicaid.

You will have to spend down the total amount of assets your LO has to be well below your State's limit (often $2K, perhaps less/more depending on where you live). To do this (the facility business officer leader can work with you on this) you can write a check to the facility ($3.5K) or whatever amount to be well below the State Medicaid threshold. And then apply for Medicaid. Your LO would be "Medicaid pending."

Assuming your LO meets the "level of care" requirement for your State for Medicaid long term SNF coverage (check on this w/them as soon as you pick a facility); then as long as each month you write a check to the facility to maintain your LO's assets below the State threshold, you should be ok. Once Medicaid long term care coverage is approved (may take a few months), moving forward you will need to write the facility a check (pay on line if they have such an option) a monthly "cost of care contribution" amount which is your LO's monthly income (SSA/retirement) minus about $80-90 dollars. That is all incoming funds to you LO will moving forward go to the facility except for the minor amount one can keep for them in their bank account. That said, the total Medicaid threshold amount MUST be maintained so this might require you to write other checks to the facility if needed.

Best to get all the documents in order asap: access to tax filings, bank statements, and retirement account statements GOING BACK 5 years. This paperwork is required to apply for Medicaid long term SNF coverage. Best if you have on-line access to all your LO's accounts to monitor moving forward and to download more as time goes forward. Each year there is a Medicaid redetermination, and that requires more paperwork (taxes filed -- yes, you still need to file taxes for them -- income 1099 statements, etc.).

PS any fees to lawyers as well as fees to pre pay funeral expenses are an OK expenditure for Medicaid. As others have said, get with a licensed elder care attorney in the State where you LO lives (each State has different laws/rules). The attorney can also help prepare a durable power of attorney naming you to have control over things to handle this. As well as prepare an advanced directive naming you the "health agent" to make decisions if/when needed. Ditto for end of life documents (Will/Trust). Finally, the attorney should review any paperwork the SNF wants you to sign as there are "trick" questions in the document which is a legal contract. DO NOT SIGN or agree to be "financially responsible" yourself or to "take the person back" (sounds harsh, but puts the onus on the facility to find a safe discharge if necessary RATHER than you having to figure this out). All to say have the attorney review any/all documents before anyone signs. Good luck with this

My Mother had an income of about $4,000 a month from SS and the VA (my Dad being a POW). She lived in NYC which offers New York State Community Medicaid for home care…totally different than rules for a nursing home. I hired a geriatric social worker to help me. Lots of paperwork but so what. I had to “impoverish” her…she could only have about $15,000 I think. She never had much anyway. I had to set up a Pool Income Trust to send her income to each month. I put all charges on her Master Card and had to send the Trust all bills and receipts each month which they paid from the money in the Trust. She was allowed to keep $800 a month. This allowed her to qualify for Medicaid. I used the excess $800 she was allowed to keep to pay for help I hired on my own. Note: on death any money in the Trust is retained by the State. There were many months where the bills exceeded the money in the Trust for which we had to make up the difference.

It was like a full time job…but worth it. It allowed her to stay at home with my help and my brothers and her wonderful aides. She died at 103.
I know all states have different rules on Medicaid with New York offering great services as relates to in home care.

Don’t give up trying to get the help you need through Medicaid. There is also something called a Nursing Home Waiver Program in NY I started to look into for help…also a Medicaid program for in home care.

My short answer is speak with an Elder Law Attorney. An initial consult to share your situation and learn more about their services may be at no cost. The deep ocean of elder care is vast. The services of the Elder Law Attorney usually provides valuable information to help navigate the waters and not drown.

LTC Medicaid picks up the rest of the cost. LTC Medicaid is a different program than regular Medicaid, and the income limits are different. Each state has different procedure or rules for qualifying, but I guarantee you there is a way to get placement in the SNF in your state with part of the costs covered by LTC Medicaid. The person must medically need the SNF however. If its a dementia patient and no one is able to care for the dementia patient at home, that person can get placed as well.

Are you assuming this person won't qualify? Has this person actually applied and was rejected?

You can consult with a Medicaid Planner for their home state in order to know for sure, and to discuss strategies that might help them qualify if they don't.

I'd suggest finding an elder lawyer who can advise you on how to handle the monthly income so she can qualify for Medicaid (i.e. no assets above $2,000.00) There are elder lawyers who handle just these kinds of situations. I had to do something similar and we needed someone with very specific knowledge. I'd bet that there is a way to set something up. It would be worth the fee, as long as the SNF accepts Medicaid.

XenaJada: Retain an elder law attorney.