What to do when money is running out for assisted living, and due to income has been denied Medicaid assistance?

tink - This is going to be long, get a drink………..

1. what I'd suggest is that over the weekend you all carefully go over what seems to be the sticking point in the lady's not qualifying, you will need to look at both issues for Medicaid - medical & financial qualifiers.

2. Realize that for Medicaid, in most states, AL is not covered. Now some states do a "diversion" program to pay for AL. But my experience is that they are few & far between and most AL do NOT participate in diversion as it financially is not worth it OR the list for the # of diversion beds is tiny and comes from those in the AL who have been there fully on private pay for 2 or more years. If her AL isn't on Medicaid diversion, you need to find another place. So you need to get her into a NH. Now at 97, she should have enough medical issues to qualify for "skilled nursing care" needed.

This is mucho importante for Medicaid medical review. If she is one of those, who are still totally good on her ADL's, Medicaid approval for medical may not happen. If you think this could be an issue, you need to get the lady to become a patient of an MD who is also the medical director of a NH. Believe me, they will know how to build the file to show the need for skilled nursing care. I moved my mom from IL to NH - totally bypassed the AL stage too. It took about 4 -5 months of every 4 - 6 weeks of MD visits to get mom to needing skilled nursing. The visit she had a 10% weight loss and a bad H&H lab report, the MD wrote the orders for skilled. Moved her from her IL apt to NH right about 5 weeks later too.

My experience with mom's IL was that the the AL & NH admissions were never ever going to find her OK for NH. It was a tiered facility that went from IL to AL to NH and with a full hospice wing. I thought it would be great as mom could age out at the place and move along the system. No way, their opinion was "she was good for AL only and AL is totally private pay and really it's just a bit more than she is now paying in IL". So I started looking at NH's for her. All the NH have a medical director and they have private practices too.

Sometimes it's just a simple change, like moving them from taking Exelon pill to a Exelon patch which requires "skill" to do; or compounding a medication that just taking a pill if they have swallowing issues. Understand?

3. About Medicaid financial. You need to find out what the exactly # is for your state's Medicaid asset maximum & income maximum. Like for TX it's 2K assets; $ 2,163 for monthly income. If she has any nonexempt assets (a whole life insurance policy with any cash value, savings, other investments) over 2K, you have to cash them in and spend them down on her care or her needs. You just have to sit and carefully go through her stuff to see where she stands financially.

You will have to find and look at the past maybe 3 years of banking; find her last SS awards letter (this comes out in Dec) and awards letter for any other money she gets. All this will be needed to figure out, if she is over the Medicaid limit.

Look for any other things that could be out there: insurance policies, property ownership. You want to find out all assets she has, if any.

Now for the monthly income, if she is over whatever the amount allowed, she probably can do a Miller Trust. This is all legal and since it's legal, the AL, NH or the Medicaid caseworker cannot mention it, as they cannot give legal advice.

How Miller works is pretty simple: say mom lives in TX & has $ 800 SS a mo, and gets $ 1K in her late hubby's federal retirement and she also gets $ 500 a month in her state employee retirement. Mom gets $ 2,300 a month income. Not enough to pay for NH and over the Medicaid amount of $ 2,163.00. She is over by a tiny $ 137.00. But if all the income is a guaranteed type, then she can do a Miller trust for the excess $ 137.00. How Miller needs to read & be done has to be done by an elder lawyer who knows how to structure all this to be OK for your state laws and Medicaid program. There was someone from FL who did this for their mom and it ran about $ 800 to set up and it was a total pay out type of Miller. By total payout, it means that each month the NH got all the mom's money so nothing left to deal with after the lady died; now other states may actually set up a Miller as a real trust that builds each month by the excess and has to be dealt with by probate after death.
Miller needs good experienced legal to set up, definitely not a DIY project.

4. About possibly moving her to TX, bad idea. Medicaid since it's a state program will require that they are a resident of the state. At this point in time, since she is already needing care, going through the hoops of moving and establishing new residency is probably just too difficult. She would have to get new bank accounts, etc and at 97 it will just be oh so difficult. Probably take months to get her to become a resident and all private pay till that happened. Sounds like her daughter would not easily be able to deal with this too.

will continue on another post.

Have you consulted an elder care attorney about this?

Yes, unfortunately, there's not anything they can do for the family at this point.

Hmmmm, I'm no expert on Medicaid, but it's my understanding they don't deny nursing home costs based on income . . . they simply confiscate the income and make up the difference when all assets have been spent down.

Maybe she hasn't been "prescribed" nursing home care....? There has to be a skilled need, I believe.

Something doesn't make sense. More information?

5. So the elder lawyer said there is nothing they can do? why? was it such that family did not have the $ to pay for the attorney? or just what? There are always options that good legal can suggest.

6. Current facility, yes they can turn her out for non-payment. Now they won't kick her to the curb but it can be ugly.

ALthough there are safeguards on all this, most of them are in effect for those who are having their stay paid for by Medicaid or Medicare. If they are private pay, then however the contract reads is what can be done. What is likely to happen is that they will bill family for the care. If family does not pay, then they will file suit for recovery for payments due from whomever signed mom into the facility.

If the elder signed themselves in, then there isn't much that can be done financially. But most IL, AL & NH will have someone within the family sign off on an responsibility agreement within the housing contract. Whomever did that will be billed. Will they turn it over to debt collection? Kinda depends on the amount and what is allowed in your state for judgements.

If family just won't come to terms with the facility, what seems to happen is that the state is contacted, the elder is made an emergency ward of the state and then moved to a facility who will take them & the state payment allowed for wards of the state. At my mom's NH#1, this happened for a lady who's son had sold his mom's house; kept the funds and so her Medicaid application was denied as she was ineligible and had a transfer penalty. She got moved to a NH in another county who was super low on occupancy and needed residents. As she was a ward of the state, the son or other family was not told of the move or where she was. Son came to NH (he was on the floor when I was visiting my mom), all upset, cops called, ugly, ugly. But totally avoidable had he dealt with it appropriately. This is pretty extreme and totally not what you want to have happen. Cannot imagine how traumatic for the little lady too. usually family moves the person back home till they deal with the transfer penalty period.

7. Is there anything that is a transfer penalty that is keeping her from qualifying for Medicaid? If so, what? Some transfers you can adjust (auto's); other transfers you flat just cannot get around (gifting a home).
Let us know what you find out. We all learn from each other. Good luck.

The main issue is she has too much income a month from pension and social security coming in that will repeatedly continue to have her denied, basically she has a few hundred short of $3K coming in. Her children have been told to spend down to $1.5K which is what is the qualifying amount the state requires. But, even when it's spent down there will still be too much to qualify due to her income which isn't enough to cover assisted living and other necessities like diapers and medication.

In agreement with igloo about moving her to TX, not only will it require putting a 97 year old on a plane, but a 97 year old who could potentially have a complete and total mental melt down in flight that could end up causing the pilot to divert to remove her from the plane (son and daughter would both fly with her). In addition just getting through the airport could be extremely traumatizing. And getting her in and out of bathrooms and dealing with adult diapers and the whole 9 yards just wouldn't be good for anyone involved. But, ultimately she would be living in her daughters house with her and her husband. Daughter already has a pretty busy social life, and don't think she's prepared to have to give that up. Were also dealing with a 97 year old who is ridiculously healthy other than ailments such as incontinence, high blood pressure, mild parkinsons, mild dementia, legs and feet that swell, and acid reflux could live to be 105.

The attorney her son had spoken with had said that had they of hooked up with her when she still had a significant amount of money in savings, they'd be able to use the loop holes in the system to hide the cash and had her put on medicaid. But now that she's down to the wire money wise theres not much they can do to help.

As far as qualifying for a nursing home, she's not that bad off in terms of medical problems, seen as very healthy for her age. So, unless she falls and breaks a hip or has a stroke that ends up advancing the dementia where she can't independently do things on her own, other than bathing none will take her. Nor is any Dr going to say that she should be in one.

It was her son that put her in there as husband and wife couldn't look after her anymore, he doesn't have any money he can contribute to help pay. Living pay check to pay check like the majority of the USA is these days.

Sorry this post is a bit scatterbrained, I myself as much as the family is a bit overwhelmed and frustrated.

tink - she should be able to do a Miller trust to deal with excess income. Read my #3 in the earlier post on Miller. Millers are done for Medicaid all the time.

Did the attorney actually say "hide the cash" & use the word "loopholes" ? If so that is totally illegal and the penalties are pretty strict on doing this. Hide & loopholes imply fraud and illegality. I would be surprised if the attorney actually said this, probably more like you all just waited too long to be able to have any options but to just spend-down all her assets. Was he a NAELA listed attorney?
Medicaid planning is about doing long term planning for everybody's eventual aging. Nothing illegal. Perhaps clever & perhaps creative but totally legal.

I'm going to take a guess in this, but are there transfer penalty issues out there on the ladies application? Can she provide 5 years worth of financials without any transfer or gifting showing up? You mention living paycheck to paycheck, so did they take any funds from mom or did mom pay for things for them? If so that is a whole other issues as to why she will be ineligible for Medicaid.

My Elder Law attorney said to put all of her assets into an Irrevocable Trust. Her Income would then be given to Medicare as a sort of "payment" for a nursing home. They won't pay for Assisted Living, only a nursing home for as long as needed with her income all going to Medicare.