If Medicaid pays so much for its nursing homes why does it give more support to private facilities?

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My Dad stays in a Medicaid financed nursing home, so it does not cost him anything beyond his SS money ($800). The facility is very shabby, understaffed, not very clean and you would, in one word, describe it as "cheap". Cheap? Not really. For a resident who pays out of pocket the price would be $8,000 a month. However, for this price I could place my Dad in a nice clean lovely private facility with the highest level of comfort and care. I cannot afford $8,000 place, but I might be up to paying $4,000 if Medicaid would contribute the rest. I don't understand why they don't. Everyone would win, am I correct? There is a program called Medicaid Waiver that covers some part (not sure if it's really 50%) of the price of the staying in private nursing homes. However, when I recently tried to apply for this program and move my Dad to a private facility it turned out that there is a waiting list, and, anyway, Medicaid only allows a few spots in the facility to be taken by people on a Medicaid Waiver program. What am I missing? Why Medicaid prefers to pay $8,000 for my Dad's very meager and, honestly, almost below the dignity living instead of saving at least half of this sum and allowing him to live in comfort?

Answers 1 to 9 of 9
Top Answer
I think you are confused about what Medicaid decides and what the facilities decide.

Medicaid pays a set amount in a given area. They don't decide how much the nursing home charges -- they just require that if the facility accepts Medicaid the facility can't charge more than the Medicaid-approved amount (for Medicaid payments -- they can charge what they like for self-pay residents).

I assure you, Medicaid is NOT paying $8,000 for your dad's care. Let us say the set amount they pay in your area is $3,000. The NH is not allowed to charge more than $3,000 for your dad's care. The really nice place down the road will also get $3,000 from Medicaid, and cannot charge any more than that. If you ran that nice place, might you want to limit the number of Medicaid residents you accepted? It is NOT Medicaid that sets the number of patients they will pay for in a facility. The facility does. Many do not accept ANY Medicaid patients. Those that do have to abide by the Medicaid rules.

Wouldn't it be nice if the Medicaid payments came a little closer to meeting the self-pay rate at facilities? More facilities would be willing to take in more Medicaid patients. The facilities control whether/how many they accept for the Medicaid amount.

I think you are a bit confused about the waiver program as well. That covers in-home care, and in some places assisted living. It "waives" the requirement that the person be treated in a nursing home only. Nursing homes are not paid for from the "waiver" funds.

I can understand your frustration! But the things you are complaining about are not under Medicaid's control.
Jennigibins- Thankyou for explaining the waiver. Now it makes sense to me. It can be so confusing.
Confusing? You get the prize for understatement of the day!
I think the whole system is a mess. We purchased mom's wheelchair for less than half of what the Medicare approved place was charging for the exact same chair...but you can't get reimbursed if you don't go to their place. Why would they not be happy that you shopped around and saved us, the tax payers money? We found this true with multiple things. Frustrating!
I never heard of a place making u buy from them. I have heard they help with purchasing equipment from Medicare and supplimentals but not requiring you to purchase from them.
Medicare (Medicaid?) doesn't purchase wheelchairs for their insured. They rent them. After Medicare has rented one for you for many months -- and more than paid the full price -- the vendor will tell Medicare (or Medicare will tell them, I'm not sure how that works) that no more payments are needed, and that you may keep the wheelchair.

Some people only need a chair for a few months, while they are recovering from an accident, for example. Other people only need it a few months because they become bedbound or die. You need to verify that it is still needed every month. Perhaps this arrangement saves Medicare money in the long run, I don't know. But the vendor agrees to handle this paperwork. And of course they have to take the chairs back from those who only need them a few months.

So you can probably find a chair at at lower cost from a vendor who simply sells the chair and doesn't have to handle any paperwork or take back chairs. But why would you? Why not go with the program your insurer has set up?
You can probably find lots of medical devices for free by calling local social services. Every town in my area has closets full of supplies
I was told by my Long Term Care Provider that many more than not (they do not advertise this) public and privately owned assisted living facilities with specialized care, multiple levels of care,  as well as memory care do have a few Medicaid beds or shared rooms set aside based on availability for this purpose. The issue is that a person has to play detective and ask the right person at each facility to get the correct answers. 
Thank you, jeannegibbs.
Yes, I am confused (and yes, this is an understatement :) , but your answer did help me to understand a thing or two.
The nice private place, I'm admitting my Dad to, calls itself "adult foster care". I guess this name is a little trick that lets their tenants to apply for Medicaid Waiver? Still, out of 6 people living there, no more than 2 are allowed to have this Waiver. I guess Medicaid has a little trick against "adult foster care" little tricks?

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