Hello....Mom has been in a nursing home for two months after a hospital stay. From what I understand, the nursing home will take her social security (her only income) except for $50/month and she is applying for Medicaid to pay the Medicare co-pay. Medicaid hasn't been approved yet, but we decided to take her home. My questions are (1) will Medicaid still pay the nursing home retroactively and (2) will we start receiving Medicaid for home-care and if so, will we continue receiving the $50 per month from social security?
- Your mom entered NH as post hospitalization discharge to NH for rehab. As it’s post hospitalization rehabilitation, it’s MediCARE Benefit. BUT is time & progress limited on Medicare A part coverage. Usually rehab lasts 20/21 days as 3 week kinda standard rehab period. MediCARE pays basically 100% of costs for 20/21 days. If she should be determined to need more rehab & “progressing” enough for Medicare rules, Medicare can continue paying her rehab up to 100 days, but, at 80%. 20% difference will need to be paid in some way. If she has secondary insurance, like BCBS, they usually pay the 20%. If she’s on Medicare “gap”, they pay if gap policy has that coverage. If she’s on Medicare Advantage plan, it’s gonna be dicier as usually NH rehab facilities are not “in network” for Advantage plans, so she will be private pay for 20% set at Medicare rates (which is higher than what Medicaid pays).
- if she’s applied for & submitted a LTC Medicaid application, she’s transitioned from rehab patient to skilled nursing care resident. She’s
now considered to be Medicaid Pending & facility billing her stay to the state at your states Medicaid daily room & board rate. Avg rate abt $190 day. While Pending, state is reviewing paperwork needed to determine if she is “at need” both medically & financially for LTC Medicaid; & LTC Medicaid rules for copay or SOC (share of cost) as to her monthly income are in force. Which is why her SS has to be paid to NH. The $50 mo is her PNA, personal needs allowance, & that’s it for her for extra $ once LTC Medicaid involved. Medicaid takes time to review so Pending status can go on a bit. My mom’s was not quite 6 mos.
SOC must be paid. If mom has bills, debts, house, car, whatever.... all costs on those either she defaults on OR family pays.
If she signed off for NH to become SS rep payee, she has transferred that power to them. Did she do this? Getting it moved back will imho NOT be simple. Gonna mean mom has to go in person to SS office to do.... if she’s not competent & cognitive to do, expect you having to do rep payee & cancellation hurdles.
If she leaves NH before approval, you have to continue process to have her approved as that’s only way NH will be paid retroactively by Medicaid for her days there. If she exits & drops dealing w/LTC Medicaid application, NH will seek to have bill paid by her, you or whomever else they can find & may bill at higher private pay rate than negotiated Medicaid rate. Whether morphs into problem depends on who & how admissions application done & how Litigious NH is. You do have copies of each page of her admissions agreement, right?
If she leaves, She needs to have a discharge report done. Getting it with outstanding bill could be sticky. If she leaves AMA (against medical advice), can become an issue in getting future insurance coverage if the diagnosis codes repeat & last time was AMA.
- LTC NH medicaid different than community based Medicaid (living at home or w/family). Mom likely to do somewhat different application. Whether or not your state has inhome support services totally up to how your state spends Medicaid waiver $. Most don’t do 1-on-1 in home care, or have at limited amount. State evaluates care needed. But will not likely ever be 24/7 unless your in NYS or other super costly state.
If your state does PACE, she may need to be evaluated for it before any other care happens. So PACE center 2-4 days wk & all care via PACE. NonPACE time is on family to do or she uses her SS income to pay for caregiving. Community Medicaid usually allows to keep SS$.
Try to get billing to break down M&Ms billing to date to see where costs are now. It may be easier to just pay NH days if just a few, move home & stop LTC application & do community application
I love this site....you guys/gals are the best....I'm feeling a lot better with a little knowledge under my belt.....
please try to this week clearly find out IF your mom signed off to have the NH become her representative payee for her SS income. Your posts kinda read that this is what has happened.
For NH - in my experience - getting this done is standard operating procedure as it ensures the facility gets paid first & foremost. It totally removes the possibility that spouse or family could forget or ignore paying the SOC to the NH each month. The sign off to SS could easily have been a sheet in the admissions packet that your mom or dpoa signed off on.
Once stuff like this gets processed in the SSA system, changing it back will not be simple. Every place we dealt with for my mom or MIL, all heavily implied or outright lied that changing SS payee was needed. It also gets touted “makes it all so much easier for families”, yeah that might be true. But really imo all about capturing their income & also keeps them tied to the facility. As I wrote, getting this changed back may involve needing your mom going in person to a SS office to switch it back as SSA does not recognize DPOA for anything SS.
I moved my mom from NH#1 to NH#2 within her first year. 1st NH was beyond dysfunctional for billing both at the NH & their corporate office in another city. As mom kept her SS & retirement $ all going direct deposit to her checking acct, the month she moved NH’s, I was able to write a check for her copay to old NH to the penny for her days there & also write the new NH#2 for those days there. If the NH had been her rep payee for her $, NH would beyond likely have footdragged returning any $ overage or Personal Needs Allowance trust fund $ till beyond forever. NH#1 incompetent, like they submitted bills for my mom for months after she moved out and filed refill RXs after she moved out as well. Hopefully your moms place isn’t a clusterF for management, but really try to clearly find out if they are now your mom’s SS payee and set into action changing that if you go with the plan to move her.
there’s 2 hospital runs?
So was timeline.... mom at home, falls & goes to ER then hospitalization then to NH for rehab then falls at NH so back to hospital then returns to NH? Docs don’t have a exact diagnosis, but there’s balance, Dementia issues. She was not “progressing” in rehab so discharged day 21.
if this is it, this is way WAY more complicated than going home & perhaps paying for 5 weeks of room & board in a NH bed after a hip replacement & successful rehab & now pretty good on their ADLs so going home can possibly work.
was 2nd hospital run NOT hospitalization but “observation” status?
Like at hospital maybe 60 hrs then back to NH?
The second time back to NH wasn’t under rehab was it?
If it’s all this, imo the NH is pushing Medicaid cause it’s gonna cover the stay at the NH past that first 21 days AND will also pay the time she was at hospital under observation AND days in NH after the second hospital run. Observational isn’t covered under original Medicare Part A. Part A is hospitalized not observation. She’d need a seriously good secondary insurance for observation coverage. Ditto for Advantage & gap plans. Does she have other insurance? Do they pay the copay for hospitalization, pay at all on observation or rehab days?
Observational stay could be quite a $$$ sum. Folks are often gobsmacked by having this to pay.
I’d try to get both the NH & the hospital bills to see what they are looking like before you move her out of the NH. She may be best off staying in the Nh till she clears LTC Medicaid.... Medicaid pays whatever Medicare didn’t and retroactively. I bet that why NH is pushing Medicaid.
On another note, if she’s fallen that much, I’d imagine she’s likely to fall again. If she moves in with you, will family be able to do 24/7 oversight of her? If all of you work, who is gonna be on site each day with her? I doubt state is going to provide 24/7 caregiver, when she can continue her care 24/7 in a skilled nursing care facility.
NH are expensive but realize it’s not just paying for bed costs, there’s nursing staff plus a slew of various health care professionals (PT, OTspeech Therapist, etc) on-site, on-call plus dietary, activities, transportation. Your mom may actually need a 2 person bathing team with her in a Geri chair going into a roll-in shower if she’s a big time fall risk. I’d really suggest you ask for a care plan meeting with staff and your siblings before you blithely take her to your home.
Each state has its own Community Medicaid program; eligibility and what these programs pay for (often they are called PACE programs) differs widely.
In some states, Community Medicaid will pay for full time in-home care. In others, they will only pay for a small numbers of hours.
This link may provide some good information:
https://www.payingforseniorcare.com/medicaid-waivers/pa-department-of-aging-waiver.html
You need to contact your local Medicaid office to find out what the Community Medicaid program will cover.
Not sure how it works when Medicaid is needed for a rehab stay only. I can't see them asking for her SS check for something like that. Were u told she may need 24/7 care and transferred to LTC? Because then they would require her to use her SS and any pension for her care. Medicaid pays the remainder. A Personal Needs Account would be set up and $50 a month put into it from her SS check. If Mom has a house, she can keep it but there will be no money for bills and upkeep. So, unless a family member pays the bills, the house would need to be sold and the money used for her care.
I think u may want to talk to the finance dept again. I think there maybe some confusion. Mom still has another month under Medicare for rehab. The money put out by Medicaid at this point should not be that much. Now if she is there over the 100 days Medicare pays for, then that is a different thing.
My one question would be why has Mom been in for 60 days.
But apparently the family has decided to bring mom home with in-home services; the question is, what will Pennsylvania Medicaid pay for in this scenario.