Medicaid is a comprehensive health care program that covers a wide range of people who require nursing facility medical care and meet certain financial eligibility guidelines. Medicaid is an imperative resource for seniors, covering more than 65 percent of all nursing home care. Nursing care currently costs approximately $100,000 a year. Most individuals that require long-term skilled nursing care must eventually utilize this program. With close to inevitable dependence, it is of the utmost importance to know what common mistakes to avoid.
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First: Know when you need help. The reality is that most people don’t ever plan to go to a nursing home. It’s often the default are setting for those with chronic long-term illnesses what cannot be treated from home or in a personal care facility. Medicare covers up to a maximum of 100 days and often times, even less, so costs add up quick at roughly $8,000 a month. Seek immediate advice to discover your options before Medicare coverage ends.
Second: Recognize potential problems. As a taxpayer-funded program, the government ensures an exhaustive financial review process before covering the bill for your costly care. Known as “verification,” this process requires a detailed review of five years of all of your investments, bank accounts, real estate transactions and transfers (i.e. “gifts”). If you will have problems providing this information or, worse off, gifts that may have occurred during this “look back” period, plan to deal with them as soon as possible. The County Assistance Office will eventually discover these problems which could lead to delays or even denial of coverage.
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Third: Communicate. A decision of either eligibility or denial can take several months to be produced. During this time period, the nursing home is waiting to be reimbursed. Typically, the resident is only covering a small portion of the actual monthly costs (called the “patient pay amount”) and the nursing home is taking on the risk of the application being denied. For this reason it is necessary to keep an open line of communication between the resident (or her representative) and the nursing home and the County Assistance Office. Periodically inform these parties of the progress and status of the application.
Fourth: Don’t delay appeals. Many applications are denied at first. Whether it is the result of incomplete verification or gifts that are not exempt from penalty, it is imperative to appeal in a timely manner to maintain the retroactive coverage requested in the initial application. Applicants have a 30-day window to appeal. In some cases the applicant may simply need to provide additional information, however, in more complex cases, there may be a legal issue that needs to be submitted for a “fair hearing” in front of an Administrative Law Judge to resolve the matter.
Finally: Consider seeking experienced legal advice. The stakes are the highest and applicants and appeals can take several months to resolve. For example, if the unpaid nursing home balance is $8,000 a month an appeal is denied after six months, the nursing home will expect to paid $48,000 from the applicant. If the applicant is unable to pay, the nursing home may pursue collection from the adult children of the nursing home resident (Filial Responsibility). Nursing facilities are a business and must be paid for their services.
Medicaid coverage for long-term care services is a highly complex blend of federal, state and local laws, rules and customs. Our hope is that all seniors plan ahead for the contingency of needing long-term facility care. If faced with an immediate need for such care, families should protect the health and safety of a loved one and seek the counsel of an Elder Law Attorney.
The Elder Care Firm is dedicated to helping seniors, veterans and their families navigate the long-term care maze. Contact Elder Law Attorney Christopher Berry to ensure your loved one continues to live with peace and dignity.