Nursing Home Admissions are Complex
Question: Two years after my divorce, I moved in with my mother because her health was failing. My father had died several years before. Now, four years later, after suffering a series of strokes and relatively long hospitalizations and rehabilitation, the doctors tell me that unless I quit my job or bring private paid people into the home to care for her, I should begin looking for a long-term care facility for my mother to which she can be discharged. Realizing that her assets would not last long and that her income of $765 per month was insufficient to pay for her care, I began seeking out a Medicaid nursing facility. And was I ever shocked at the admission process and the complications involved. I was told different stories by each facility about the Medicaid qualification process and was presented with what I consider to be very oppressive contracts that include provisions that I be financially responsible for my mother's care. The hospital discharge personnel are nice, but have been very little help. Exactly what are the admission rules, and how will I know the best thing to do?
Answer: Unfortunately, the nursing home admission process is anything but easy. Because there are no centralized filing procedures, those who need a nursing home bed must visit a number of facilities, get and complete applications, and be placed on a waiting list for a bed. This process can be very frustrating, especially when a family member is in a hospital and their Medicare days are running out. Frequently the family is caught between a hospital demanding the patient be removed and the nursing homes saying no beds are available. This is particularly true where the individual will be a Medicaid resident.
According to the Nursing Home Reform Act of 1987, Medicare or Medicaid certified facilities must 1) not require residents or potential residents to waive their rights to benefits under the Medicare or Medicaid program; 2) not require oral or written assurances that potential residents are not eligible for or will not apply for benefits under the Medicare or Medicaid programs; 3) provide oral and written information about how to apply for Medicaid and Medicare benefits, how to use such benefits, and how to obtain a refund for previous payments covered by benefits; 4) not require a third-party guarantee of payment as a condition of admission, to expedite admission, or as a condition of continued stay in the facility; and 5) in the case of a Medicaid recipient, not charge any amount in excess of that required to be paid under the state Medicaid plan as a precondition of admitting or expediting the admission of the individual to the facility or as a requirement for the individual's continued stay in the facility.
While in most cases discrimination by a Medicare or Medicaid certified facility against Medicaid-eligible residents is prohibited, the admission process is an exception to that rule. Since October 1, 1990, the NHRA requires Medicare and Medicaid certified facilities to establish and maintain identical policies and procedures regarding transfer, discharge, and the provision of services for all residents, regardless of source of payment. Unfortunately, nothing in the Act expressly prohibits unfair admission practices based on source of payment. Only a handful of states expressly prohibit such discrimination, without which Medicaid-eligible individuals can be refused admission or placed on Medicaid-only waiting lists even though beds are available. This allows the facility to save the beds for private pay or Medicare residents.
Since the admission procedure is so important and complex, we strongly suggest that you seek the assistance of a private geriatric care manager who can interface with the hospital discharge planner and help you find a suitable facility for your mother. We also suggest that you contact an experienced elder law attorney in your area who can review the admission documents to make sure that the agreement does not restrict or alter your mother's rights that are granted by federal law. In no event should you sign any admission agreement that contains any payment guarantee requirement by you.
SoloFact: Many of our readers are confused about what it takes for elderly family members to qualify for Medicaid-sponsored long-term care in nursing facilities. As a result, elderly family members are admitted into the facility as private pay patients, spend all of their assets, and then find out that they still do not qualify for Medicaid assistance. For this reason, a review of the basics seems in order - with the caveat that "the basics" vary from state to state.
Although most think that the only criterion is financial, nothing is farther from fact. Generally speaking, in order to qualify for Medicaid-sponsored long-term care services, a person must meet both financial and medical eligibility requirements. After a screening process, there is a written evaluation of the applicant's needs. Then a recommendation is made about the most appropriate place where care can be provided to meet the individual's assessed needs.
Bottom Line: Before an individual is admitted to a nursing facility and before money is spent for long-term care, it is a good idea to get an evaluation by a geriatric care manager or other expert to determine the probability of the individual medically qualifying for Medicaid in the future.
