Her total SSI is 1460.00 per month. She has the beginnings of dementia and is frail (uses walker).I work full time and my spouse is home but cannot take care of all of her needs. She has blue cross blue shield insurance and medicare, but that is it.
Btw the divisor is keyed to the daily reinbursement room & board paid by your states Medicaid LTC program. I think the average r&b paid is $ 177.00 a day. Some states are lower (like when mom was alive & in NH in TX was $ 155) and some states on the east coast have R&B close to $ 300. So a 50k transfer penalty will be over faster on the upper Atlantic than the same 50k in TX.
Really my take is that unless your elder is generationally wealthy, if they live long enough they will run flat out of $ as the cost$ of care are just horrendous, and family will run out of ability & kum-ba-ya so Medicaid will be applied for. Planning needs to be done with that in mind BUT getting once vibrant, independent elders to do this.....well thats a whole other issue!
Medicaid is also for people over 65 who have Medicare and may even have Medicare supplemental insurance but who cannot afford to pay for their basic care. (NOTE: Both the medical need for care and the cost of that care seems to be much easier to prove when people are already in long term care facilities. I don't know how it works when a person is being cared for at home by a family member. ASK! Your local Council on Aging and/or Medicaid office is where you must start.)
Even with income -- or "too much income" -- if people have exhausted their assets/savings and their expenses exceed their income, they may well be eligible for Medicaid. As other commentators have said, each state has its own rules for eligibility so you have to start there. PLEASE DON"T WAIT A MOMENT TO DO THIS! You can continue to explore other options such as in-home health care, which won't be provided by Medicaid unless and until she applies for and is deemed qualified, but there may be other sources of help. But the application process is not for the faint of heart and takes a good bit of time so do begin now, please!
For example, you will have to provide all her banking records, records on the sale or gift of real property, and sale or gift of vehicle or other especially valuable personal property for a "look back period" of five years prior to the date of application. And you will need to apply for a VA "pension" -- which only then may entitle her to "Aid and Attendance" —even if you also apply for Medicaid. Applying for the VA benefit is a LOT easier than applying for Medicaid but still takes some time. Only veterans who served during war time (not necessarily in combat but definitely during war) are eligible. You will need a copy of the veteran's DD-214 or "discharge papers" (which you can apply for on line or the local VA representative can assist you). If the person is in a nursing home, Medicaid takes almost all those monies from the VA as the individual's "share of costs" but if she's still at home or in your home, that could be a substantial help to you if she qualifies.
Medicaid is looking to see if there has been any "transfer of assets" or a gift, of virtually any size, during that five year period. Because Medicaid is funded by tax dollars it is intended to help only the truly indigent, not people who wish to give their money to their family and THEN apply for this assistance. So the state looks not at HOW the person spent their money (extravagance is not their concern) but ON WHOM the money was spent. Checks made out to family members need to be demonstrably for paying the expenses of the person applying for Medicaid. If a person has made a gift or gifts during the 5 year period prior to applying, this will result in a "penalty", the penalty is a disqualification period for a person who is otherwise eligible. The length of the disqualification period will depend on each state's rules regarding both the total amount of the gift(s) during the five year "look back" and the state's formula for calculating the penalty. As I understand it, each state uses a "divisor". For example, if the total gifts in the period were $20,000 and the state uses a divisor of $5,000 , the penalty/disqualification period would be four months, meaning the person seeking Medicaid would have to wait four months past when s/he would otherwise qualify for whatever monies Medicaid will provide.
Although the process is properly intended to protect taxpayers from the fraud of someone claiming they are impoverished when they have, in fact, given all their money to family or friends, it is also very difficult for those people who never thought they would "outlive their money". Who knows in 2012 that he'll suffer a stroke in 2014 and need long term care for the rest of his life at 3x the cost of his prior Assisted Living? Certainly not the Dad who stopped driving in 2011 and gave his car to his son at that time but will suffer a penalty for it in 2016 when he applies for Medicaid? Or that the $500 graduation gift to a grandchild in 2011 will come back to haunt him?
The cost of long term care is such that many people who never thought they would need public assistance may well need it. Our aging population needs to be educated many years BEFORE they need it -- without even knowing that they WILL need it -- in order to avoid these pitfalls. Not to mention in order to keep the records needed! Fortunately banks keep records for a long time, but how much easier (and cheaper) it is to start keeping them NOW just in case. And to start making legitimate but significant gifts (made with no intention to avoid having to pay for your own care in the future!) in a way that won't come back to bite you.
As my mother always said: "Getting old is not for sissies!"
Good luck to you; I'm sure your Mom will be found eligible for some assistance and I hope you and your family get this relief very soon!
MAC - Medicare & medicaid are very specific & different programs for populations who qualify. This site has a great articles on how they are similar but different.
In a nutshell: Medicare is a general entitlement that we all pay into via FICA during our working years and then from our SS once we retire along with general federal funding. Once 65, we enroll in medicare. BUT there are special disabilities (like end stage renal, or Lou Gehrig) who qualify for Medicare before 65. Medicare is primarily geared for coverage for short term events like hospitalization, payment to health professionals and Rx's. It does NOT cover LTC. It does cover hospice.
Medicaid is an "at need" entitlement. You can get Medicaid from birth to death if you are "at need" for a specific program & qualify for the program based on medical & financial criteria. Like children qualify for Medicaid and those healthy & happy teeth type of RVs you see in many communities are funded by Medicaid for preventive health programs for kids. Most in a NH are on both Medicare & Medicaid. Medicaid pays for the daily room & board cost of the NH stay as Medicare does not pay for R&B. What Medicaid pays for and the amount is determined by each state as Medicaid is administered by each state uniquely but within an overall federal guideline.
Eagle is spot on about contacting Office on Aging (aka Agency on Aging). AoA should have comprehensive info on what is available within yiur region. One issue with contacting the local senior center is that staff at the local center is going to be more about what you need to enroll in their specific program, which may or may not work for you or your elder. AoA has a wider net of information.
As an FYI (cause others have asked me via PM), I've never worked at a AoA but rather did health planning for a very big Council of Government & a lot was with the required Certificate of Need reviews for facility builds back in the 1980's.
It can all be quite confusing. I'd like to share my experience as to whats out there & why: Medicaid is an "at need" program - put in place in 1960's- that is administered by each state uniquely but within overall federal guidelines. The "at need" part is central because mom would have to be evaluated to be "at need" medically for whatever program she would be "at need" financially to be eligible for.
Medicaid for the elderly is primarily designed & written into law to cover care for those needing skilled nursing care level of services (a NH) & are impoverished with 2k in non exempt assets & within whatever her state has for the monthly income amount (this varies by state, when I applied for my mom it was $ 2100). For LTC will need to have MD orders for skilled needed and have a fat medical chart to back this up. Vast majority of NH admits are from a hospital discharge to NH for "rehab"; & rehab is a short term post hospitalization benefit paid by MediCARE; and then what happens is that the elder is too infirm to return home, stays at NH & applies for MediAID to pay for it. For NH medicaid, moms income (that $1460) has to be paid to NH as her SOC ( share of cost) less a smallish personal needs allowance. PNA varies by state from $ 35 -15 a mo. Your mom if she's at beginning stages of a dementia, & still basically good on her ADLs & no other chronic diseases to produce a fat medical chart showing need probably won't qualify for LTC in a NH.
Instead Mom would need to look to see what community based Medicaid programs your state has. By & large most states do not ever pay for IL and just a few pay for AL. Community based programs are done by funding waivers from the Medicaid budget. So since their waivers, they do not necessarily have stable long term funding so a lot of facilities or programs shy away from waiver participation. Wavier funding usually runs on 3 yr & 5 yr funding cycles so it's hard to start up & be profitable & show "success" in that time frame. Waivers can stop totally too.
Current trend for community based is PACE or other PACE type of daily social & health care at a large day program center staffed by professionals, Social workers, adult activity partners, & community volunteers, etc. PACE is viewed as being pretty cost efficient & cost effective. PACE partners with 501c3s to do this so state doesn't have employees (which imho states just love as employees are budget busters). There is one by us (Benson Center) that brings them in by the van load each day & their run by a division of catholic charities. If PACE is happening in your state, I'd contact them or visit a center.
Some states have IHHS - in home health services. CA has a very established IHSS program done county by county. Elder gets evaluated for care needs and family is then trained to provide care and paid by the state.
For community based, just what happens with their monthly income depends on your state. Since they are still living in the community, they need to keep some of their monthly income to enable them to live in the community (like they need to have $ for rent, utilities, food, meds, etc). Most community based seem to have some degree of copay to participate (maybe $ 25 a day/$500 mo).
Within all programs, they will be evaluated for need periodically. So if moms at home care needs goes above maybe 35 hrs a mo, at home will stop as she's at the tipping point for cost effectiveness & probably mom would be evaulated to be better off for her needs in NH. For PACE, they are expected to show up regularly and participate in some way. For elders who are very antisocial difficult or used to being all bossy pit bully, PACE will be challenging.
Now how to find out what's out there.......all states have Area on Aging. AoA compile & have info on aging services in their region. This site has a drop down list on AoA. AoA are within a Council of Government, which are regional planning entities, funded by Feds, govt and larger grant programs. Some AoA are huge and in freestanding buildings away from the COG (although still part of the COG). AoA is pretty under the radar for most. Often the only time folks are aware of AOA is when they sponsor health fairs. But staff meet 1on1 with families all the time. Most NH ombudsman programs are done by the AoA. It's your tax $$ at work, so use them.
One thing you can also do is schedule an appt for EOD to talk with moms doctor. You may need to private pay for this. So much of being "at need" requires medical documentation over time. You have to know what moms chart is looking like and if she is at all close to being "at need" medically for care. If not, then things need to happen to establish need. If mom is in a gerontology practice, this is pretty straightforward to be done. If mom sees a family medicine doc or general practice internal medicine guy, perhaps not so much & mom may need to switch MDs. Good luck!
The one answer is a bit misleading. Medicaid is not just for people under 65 who do not qualify for Medicare. The best answer to this is to ask your office on aging, as each state is different. For example, my state allows for a small amount of money in the bank. My mom has a very small amount in the bank. Her social security goes directly to the nursing home. She has Medicaid. So, again, each state (and circumstance) is different.
Each state is different. Call your Elder Care or Aging Service office. Also was your Father or Mother a Veteran during war time? There is help for veterans and also spouses of Veterans.
You would need to call your State Medicaid office as each State has their own rules, regulations and programs.
Now with Medicaid, depending on what programs your State has, maybe they could send out an Aide to help for a few hours each week. If your Mom needs 24/7 help, it might be time for a higher level of care, thus Medicaid would help pay for a continuing care facility if this is an open option for you.
Btw the divisor is keyed to the daily reinbursement room & board paid by your states Medicaid LTC program. I think the average r&b paid is $ 177.00 a day. Some states are lower (like when mom was alive & in NH in TX was $ 155) and some states on the east coast have R&B close to $ 300. So a 50k transfer penalty will be over faster on the upper Atlantic than the same 50k in TX.
Really my take is that unless your elder is generationally wealthy, if they live long enough they will run flat out of $ as the cost$ of care are just horrendous, and family will run out of ability & kum-ba-ya so Medicaid will be applied for. Planning needs to be done with that in mind BUT getting once vibrant, independent elders to do this.....well thats a whole other issue!
Even with income -- or "too much income" -- if people have exhausted their assets/savings and their expenses exceed their income, they may well be eligible for Medicaid. As other commentators have said, each state has its own rules for eligibility so you have to start there. PLEASE DON"T WAIT A MOMENT TO DO THIS! You can continue to explore other options such as in-home health care, which won't be provided by Medicaid unless and until she applies for and is deemed qualified, but there may be other sources of help. But the application process is not for the faint of heart and takes a good bit of time so do begin now, please!
For example, you will have to provide all her banking records, records on the sale or gift of real property, and sale or gift of vehicle or other especially valuable personal property for a "look back period" of five years prior to the date of application. And you will need to apply for a VA "pension" -- which only then may entitle her to "Aid and Attendance" —even if you also apply for Medicaid. Applying for the VA benefit is a LOT easier than applying for Medicaid but still takes some time. Only veterans who served during war time (not necessarily in combat but definitely during war) are eligible. You will need a copy of the veteran's DD-214 or "discharge papers" (which you can apply for on line or the local VA representative can assist you). If the person is in a nursing home, Medicaid takes almost all those monies from the VA as the individual's "share of costs" but if she's still at home or in your home, that could be a substantial help to you if she qualifies.
Medicaid is looking to see if there has been any "transfer of assets" or a gift, of virtually any size, during that five year period. Because Medicaid is funded by tax dollars it is intended to help only the truly indigent, not people who wish to give their money to their family and THEN apply for this assistance. So the state looks not at HOW the person spent their money (extravagance is not their concern) but ON WHOM the money was spent. Checks made out to family members need to be demonstrably for paying the expenses of the person applying for Medicaid. If a person has made a gift or gifts during the 5 year period prior to applying, this will result in a "penalty", the penalty is a disqualification period for a person who is otherwise eligible. The length of the disqualification period will depend on each state's rules regarding both the total amount of the gift(s) during the five year "look back" and the state's formula for calculating the penalty. As I understand it, each state uses a "divisor". For example, if the total gifts in the period were $20,000 and the state uses a divisor of $5,000 , the penalty/disqualification period would be four months, meaning the person seeking Medicaid would have to wait four months past when s/he would otherwise qualify for whatever monies Medicaid will provide.
Although the process is properly intended to protect taxpayers from the fraud of someone claiming they are impoverished when they have, in fact, given all their money to family or friends, it is also very difficult for those people who never thought they would "outlive their money". Who knows in 2012 that he'll suffer a stroke in 2014 and need long term care for the rest of his life at 3x the cost of his prior Assisted Living? Certainly not the Dad who stopped driving in 2011 and gave his car to his son at that time but will suffer a penalty for it in 2016 when he applies for Medicaid? Or that the $500 graduation gift to a grandchild in 2011 will come back to haunt him?
The cost of long term care is such that many people who never thought they would need public assistance may well need it. Our aging population needs to be educated many years BEFORE they need it -- without even knowing that they WILL need it -- in order to avoid these pitfalls. Not to mention in order to keep the records needed! Fortunately banks keep records for a long time, but how much easier (and cheaper) it is to start keeping them NOW just in case. And to start making legitimate but significant gifts (made with no intention to avoid having to pay for your own care in the future!) in a way that won't come back to bite you.
As my mother always said: "Getting old is not for sissies!"
Good luck to you; I'm sure your Mom will be found eligible for some assistance and I hope you and your family get this relief very soon!
In a nutshell:
Medicare is a general entitlement that we all pay into via FICA during our working years and then from our SS once we retire along with general federal funding. Once 65, we enroll in medicare. BUT there are special disabilities (like end stage renal, or Lou Gehrig) who qualify for Medicare before 65. Medicare is primarily geared for coverage for short term events like hospitalization, payment to health professionals and Rx's. It does NOT cover LTC. It does cover hospice.
Medicaid is an "at need" entitlement. You can get Medicaid from birth to death if you are "at need" for a specific program & qualify for the program based on medical & financial criteria. Like children qualify for Medicaid and those healthy & happy teeth type of RVs you see in many communities are funded by Medicaid for preventive health programs for kids. Most in a NH are on both Medicare & Medicaid. Medicaid pays for the daily room & board cost of the NH stay as Medicare does not pay for R&B. What Medicaid pays for and the amount is determined by each state as Medicaid is administered by each state uniquely but within an overall federal guideline.
Eagle is spot on about contacting Office on Aging (aka Agency on Aging). AoA should have comprehensive info on what is available within yiur region. One issue with contacting the local senior center is that staff at the local center is going to be more about what you need to enroll in their specific program, which may or may not work for you or your elder. AoA has a wider net of information.
As an FYI (cause others have asked me via PM), I've never worked at a AoA but rather did health planning for a very big Council of Government & a lot was with the required Certificate of Need reviews for facility builds back in the 1980's.
Medicaid for the elderly is primarily designed & written into law to cover care for those needing skilled nursing care level of services (a NH) & are impoverished with 2k in non exempt assets & within whatever her state has for the monthly income amount (this varies by state, when I applied for my mom it was $ 2100). For LTC will need to have MD orders for skilled needed and have a fat medical chart to back this up. Vast majority of NH admits are from a hospital discharge to NH for "rehab"; & rehab is a short term post hospitalization benefit paid by MediCARE; and then what happens is that the elder is too infirm to return home, stays at NH & applies for MediAID to pay for it. For NH medicaid, moms income (that $1460) has to be paid to NH as her SOC ( share of cost) less a smallish personal needs allowance. PNA varies by state from $ 35 -15 a mo. Your mom if she's at beginning stages of a dementia, & still basically good on her ADLs & no other chronic diseases to produce a fat medical chart showing need probably won't qualify for LTC in a NH.
Instead Mom would need to look to see what community based Medicaid programs your state has. By & large most states do not ever pay for IL and just a few pay for AL. Community based programs are done by funding waivers from the Medicaid budget. So since their waivers, they do not necessarily have stable long term funding so a lot of facilities or programs shy away from waiver participation. Wavier funding usually runs on 3 yr & 5 yr funding cycles so it's hard to start up & be profitable & show "success" in that time frame. Waivers can stop totally too.
Current trend for community based is PACE or other PACE type of daily social & health care at a large day program center staffed by professionals, Social workers, adult activity partners, & community volunteers, etc. PACE is viewed as being pretty cost efficient & cost effective. PACE partners with 501c3s to do this so state doesn't have employees (which imho states just love as employees are budget busters). There is one by us (Benson Center) that brings them in by the van load each day & their run by a division of catholic charities. If PACE is happening in your state, I'd contact them or visit a center.
Some states have IHHS - in home health services. CA has a very established IHSS program done county by county. Elder gets evaluated for care needs and family is then trained to provide care and paid by the state.
For community based, just what happens with their monthly income depends on your state. Since they are still living in the community, they need to keep some of their monthly income to enable them to live in the community (like they need to have $ for rent, utilities, food, meds, etc). Most community based seem to have some degree of copay to participate (maybe $ 25 a day/$500 mo).
Within all programs, they will be evaluated for need periodically. So if moms at home care needs goes above maybe 35 hrs a mo, at home will stop as she's at the tipping point for cost effectiveness & probably mom would be evaulated to be better off for her needs in NH. For PACE, they are expected to show up regularly and participate in some way. For elders who are very antisocial difficult or used to being all bossy pit bully, PACE will be challenging.
Now how to find out what's out there.......all states have Area on Aging. AoA compile & have info on aging services in their region. This site has a drop down list on AoA. AoA are within a Council of Government, which are regional planning entities, funded by Feds, govt and larger grant programs. Some AoA are huge and in freestanding buildings away from the COG (although still part of the COG). AoA is pretty under the radar for most. Often the only time folks are aware of AOA is when they sponsor health fairs. But staff meet 1on1 with families all the time. Most NH ombudsman programs are done by the AoA. It's your tax $$ at work, so use them.
One thing you can also do is schedule an appt for EOD to talk with moms doctor. You may need to private pay for this. So much of being "at need" requires medical documentation over time. You have to know what moms chart is looking like and if she is at all close to being "at need" medically for care. If not, then things need to happen to establish need. If mom is in a gerontology practice, this is pretty straightforward to be done. If mom sees a family medicine doc or general practice internal medicine guy, perhaps not so much & mom may need to switch MDs. Good luck!
Now with Medicaid, depending on what programs your State has, maybe they could send out an Aide to help for a few hours each week. If your Mom needs 24/7 help, it might be time for a higher level of care, thus Medicaid would help pay for a continuing care facility if this is an open option for you.