My sister-in-law has Multiple Sclerosis. It has affected her brain, so she cannot take care of herself. Over the past year she has declined substantially and we need to have her move from the assisted living home she is now in to a skilled nursing facility. She is totally incontinent. Doesn't know what day it is. Can't bathe or dress herself. She is very hostile and aggressive to staff and patients. It is so bad now that the man who manages her home wants to kick her out.

She has Medicaid Star+Plus Home and Community Based Services. Does anyone understand the process that we have to do to get her coverage for the skilled nursing care?

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Seth - ok so the glitch is her paid via Medicaid medical insurance coverage & they (United) are being nonresponsive. Its not just items needed to be dealt with for AL staff but also for her health care providers that are contracted through the United MCO she is with. The AL is / should be getting daily fixed rate room&board reimbursement from the state Medicaid waiver program she’s on BUT her medical care is under control of United. I bet if you had an off the record talk with manager of AL, he will tell you that dealing with UHC is a nightmare & always foot dragging. If she’s been there since she was younger, like in her early 40’s, & there a long time, they probably are cutting her lots of slack but it’s just gotten finally untenable.

imo the issue for facilities is the sea change that now TX Medicaid by & large requires enrollees to be with a negotiated insurance co. TX Star Plus has it that medical care must be within a MCO - Managed Care Organization. TX Medicaid is still paying for her care BUT provider(s) has to be within those affiliated with the MCO. Why? Cause Medicaid has preneogtiated rates for care and where/how care done & the various insurers are vying for enrollees as get base rate per enrollee. The bigger players in TX are Superior & Molina and imo they are who I would try to get her into a facility that uses them as their MCO as they understand more targeted insurance coverage. United imo kinda wants to be everything for everybody from MediCARE advantage plans, Medicaid MCO, gap plans, plus regular individual & group/ corporate coverage.
Your SIL needs a highly individualized MS disability care plan.
Shes not the usual 85 yr old Grannie with dementia entering a NH.

Also Phone calls are fine but I’d do a fax & a certified letter with the return registered receipt card from USPS to United stating this needs to be a priority case review with SNF placement for her immediate health, safety & security.

My mom was on TX LTC NH Medicaid before the MCO switch and her last year was when it started to creep into place. The old system was MD medical director billed Medicare &/or TX DADS Medicaid and got paid. Often MD had thier own smaller individual or group practice & medical director of other NHs. It’s been hard for smaller facilities as their established go-to MD is not a participating provider for any MCOs. Some docs just can’t go with some MCOs as not hospitals or clinics their on privileges with or MCO reinbursement too low. NH have closed especially more rural ones. Your situation is even more difficult as she’s not in a NH but AL & AL doesn’t have to have the required skilled nursing care system (& drugs) that a NH will have.

If your in SA, it’s like 1.5M now, right? Big big city, there's going to be MS support groups & they will know what places are better for dealing with LTC care for MS patients. AAOA likely knows of meetups. Also please talk with the sons about if moving her out of FtBend can be agree on. Move to be more outside of Hurricane evacuation zone. Really trust me, you do not want to deal with a disaster related placement on her. Good luck & let us know what happens.
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I’m going to approach this from a different angle.... so you posted she has MS & in an AL, if so she’s on one of many TX Medicaid waivers.
Is she under 65? If so that’s a different waiver than over 65.
How her care can be paid will be imo very interdependent on her age. If she’s under 65, she’s “disability” eligibility & funding. If over 65 it’s elder w/disabilities eligibility & funding.

But my first ? Is ... do you want to keep her over in Ft. Bend? or move closer to you, to Bexar Co? I’d make that be the first decision to happen.

To me, if she’s on the youngish side and so your likely to be dpoa for eons, I’d try to get her to have a lateral move now to SA or a nearby county and have it as an AL lateral move but into a facility that is “tiered”, so has a wing or building that are AL and also those that are skilled nursing care. So in this plan she moves into AL bed and within couple of months moves over to a SNF bed in the NH LTC part. If she has assets, there might need to be a spend down done promptly while shes still in a AL waiver bed so she gets impoverished before or at the jump to SNF NH bed.

Whatever the case or county, I’d suggest you contact the Area Agency on Aging to find out what facility might be set up for MS residents and accept Medicaid both waivers & LTC. The AoA (or AAoA) are part of your council of governments. They - COGs - are regional planning & funding flow bodies; all states have COGs. It’s your tax $ at work. For TX, you’ll be dealing either with HGAC AAOA as they do the outlying counties like Ft. Bend; OR Harris County AoA if actually resident & facility in Htown city Harris county limits. For SA, either it’s Bexar Co AoA if in the city or Alamo Area Agency if your in surrounding counties. The office in SA for both is in Tesoro bldg where IRS office is. For HGAC, each co has satellite offices but HQ in Htown (on Timmons) & the main Ft Bend office is in Rosenberg & a smaller one over by the Schlumberger HQ.

Personally I’d try to move her. There’s gonna be another Hurricane evacuation drama. (We went thru Katrina & mil NH moved en masse into TX). You might want to ask where she is now what their Hurricane plan is. Lots of facilities have agreements in place with facilities in SA or the crescent of counties N of 1604 up to Austin as it’s a manageable -in theory - evacuation drive. LOL. Get the names of those facilities and call them to see if they have an open bed for her to lateral move into, then drive over for a looking-Lou.

AoA website should have seminars & workshops for family to help figure out the mice maze that is Medicaid. Go to them. Call to speak with disability staffer. If she is younger & under 65, to me this is key, mucho importante, as it will be different medicaid $. Most Medicaid LTC is all about kids dealing with their 85 yr old parent & trying to get them into a NH. For disability & younger, regs & eligibility will be similar but different. Good luck.
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sethsgrammy Feb 2020
Wow!!! Thank you so much for taking the time to write all of this. I truly appreciate it. We moved her from Corpus Christi to the Houston area (Sugar Land) because that's where her adult sons live. They wanted her there. However, I'm the one who holds the POA. Today I talked with Texas Health and Human Services and was told that she already has what is needed to get the skilled nursing care. However, United Healthcare carries her Medicaid plan under the Star Plus Waiver. So it is now my understanding that UHC is the one who needs to move on this. THHS told me to make them understand that it is an emergency placement. I've called both Friday and yesterday with no return call from UHC because our case manager is PTO. So I called again today and spoke with the escalation department. Just hoping that they'll return my call tomorrow with information. Thanks again for caring enough to write all of this. This is some really good information!
Tthink about finding a NH that will accept her and ask them to assist with the transfer and applying for Long Term Care Medicaid. It sounds as though she is now on a Medicaid Waiver. The SW at either facility should be able to help you.
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Call her Medicaid case worker and tell him/her that the AL is saying they can no longer have her there. So u now need to place her in LTC.
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