When should I apply for chronic Medicaid for my mom?

Weisk, ahhh! PACE the new cute girl in town for health care cost containment!
I don’t know how your mom’s PACE runs, but in my city’s greater area there are 2. & for both, as it is for all the other PACE (maybe 5) in my State (LA), it is PACE staff that set determination, timeframe etc. for an enrollee to get all care and then possibly move into a higher level of care. Ours are run by healthcare facilities division of Catholic Charities & with professional staff for PACE which draw from staff at CCs congregate living facilities where more than a few residents come from to PACE. They in theory all* go into the format that is IF in PACE they are “duals” so MediCARE & Medicaid for health insurance billable costs PLUS community based Medicaid program for other more custodial / community type of billable costs.
HOWEVER they go under an entirely new # for insurance & only see healthcare providers at PACE or with a hospital or health science center affiliated with this PACE. So essentially a closed limited network for care once on PACE. PACE have should have affiliations with LTC facilities and LTACHs for when a participant needs more care than what the community based PACE day program can do.

PACE is the gatekeeper.

So “in theory” when day comes & are assessed “at need” for higher level of care beyond what community PACE can do, they seamlessly transfer into a NH. If this at all sounds like format of PACE she’s in, you imho need to ASAP schedule a care plan meeting to ask for a reset.

Why?? B/c you on your own as POA really cannot go just find her a NH & move her BECAUSE by her going on PACE - if it’s like ours - she no longer has unique Original MediCARE and unique low income Medicaid for her health insurance as she’s on PACE. She is now a new # for all insurance thru PACE and ALSO for any other costs done at the center her PACE bills to community based Medicaid. If you were to try this on your own, she would have to resign PACE then apply for another Medicaid as health insurance program and then do whatever needed to reassign her Medicare back to Original Medicare. And then do LTC Medicaid application for a skilled nursing care facility aka a NH as she’s no longer community based Medicaid. It’s not feasible, you’ll need PACE staff to whatever needed to keep her within their system & into a NH.

I know this is a lot to take in & confusing. PACE - to me - is really touted as easy peasy way to keep them home and worry free for costs with all health care completely co-ordinated and even with meals! activities! & transportation! provided. It can be but realistically only works when they have a big family with lots of womenfolk who totally can be in the home to help for free 24/7 for all nonPACE time; the fam totally do any & all whatever care and scut work to enable MeMaw to live in her home or in their families home till death. In your moms application & agreement with PACE, it’s there that PACE fully expect family to do all this, so if you signed off on her application you agreed to the fine print.

PACE is similar to how in-home hospice (another MediCARE benefit) requires a responsible family member there in the home pretty much all nonhospice time. Imho just flat not realistic for most of us.

Guessing yours is such that it’s both: she’s too ill AND you & maybe wf / sibling have your own lives & can’t be essentially 24/7 handmaidens. This is what you will have to clearly and emphatically get across to the care plan manager for her PACE and get them doing whatever to get your mom into one of a LTC facilities that works with this PACE and they get whatever detail from you for mom to go in a LTC Medicaid program “Pending” for her room&board custodial care costs at a NH. I’d suggest you clearly & FIRMLY tell PACE there is a deadline, like Jan 15th that you will be unavailable to be in the home for mom’s oversight.

more in part 2. Yeah maybe get an adult beverage….

Part 2. FWIW the one by us, seems to be somewhat reticent to get them off PACE & into a NH onto LTC Medicaid in a SNF/NH. As PACE controls “at need” assessment, have health chart with info used to determine “at need” medically for skilled, this could be an issue.

One cannot overlook the obvious…. that PACE is paid (primarily by Medicare but also by State Medicaid for both Medicaid as health insurance & community based Medicaid program) for elders participation/ enrollment. Once they leave and go into a NH, that $ stream leaves as LTC Medicaid program runs differently as to funding and how it’s required copay is done (more below). This is why I wrote that you have to be very CLEAR & FIRM that the situation at home with y’all doing care & oversight is no long longer feasible.

If you get push back, you do have the nuclear option:
you do ER/ED run where you call EMS, they take her to an ER & when discharge planner at the hospital calls you to come and get your mom, you - again clearly & firmly- say you cannot as it would be a unsafe discharge for her to return to your home as there is not the type of 24/7 oversight in your home needed for her (to have a safe and secure environment and do needed medication management). Make this your mantra if need be.
The ER / ED “dump” does happen. Like a NH will do this for a resident who is way past due on bills, maybe there’s a LTC Medicaid application issue and family has been noncompliant for communication or paying…. The NH finds an erstwhile reason to call EMS - like they appear to have had a TIA as these are real subjective in how they present - the EMS whisks them off to the ER and then the NH refuses to take them back. The hospital discharge planner has to find another NH placement or get family to “come and get your parent”.

Couple of things to note:
- in LTC Medicaid speak it’s “custodial care” not chronic care. Custodial for LTC Medicaid program will pay for room & board costs of being a resident “at need” medically & financially in a NH/SNF; or will pay custodial in a MC or AL if your State does waivers to shift dedicated fed/State LTC Medicaid $ from NH to instead go to a MC or AL.
Chronic tends to mean treatment for long standing disease, like diabetes or end stage renal disease, as billed to health insurance.
- LTC Medicaid will require your mom to do a SOC aka Share of Cost. Basically what happens is all income ea mo - like SSA- has to be paid to NH less smallish PNA personal needs allowance. PNA varies by State. Most $50 or $60. PNA kinda just enough for beauty / barber shoppe visits, maybe some clothing or toiletries. So if mom has any debt, CC, term life insurance premiums due, she will default unless you pay.
- LTC Medicaid is a different application. Just how it gets filed for those on PACE will be dependent on how the PACE runs. Is something you want to precisely find out about. If it is that mom needs to provide maybe 3 years of financial stuff to establish “at need” & impoverished, try to find out as it’s a narrow window to submit documentation for the LTC Medicaid application.
- PACE designed primarily as MediCARE paid for program; billed as health care paid for by health insurance. Federal $ as MediCARE. But as it’s health insurance, need to have a secondary health insurance which States push to be done by participants enrolling in Medicaid. Associated costs paid by being on community based Medicaid w maybe smallish income based copay

HOWEVER Medicaid requirement for PACE has been successfully challenged. Do NOT have to file Medicaid but can be MediCARE only with a copay, abt 3K a mo.

- LTC Medicaid & for some states, community based Medicaid as well, has a required attempt on recoup of costs paid via estate recovery. Done via MERP & after death. There will be letters sent to former POA on this.

Good luck & stay firm in your dealing with PACE!

She has only $1000 in a retirement account, no real estate, no life insurance, no CDs, a $5000 checking account and one $4000 savings account, no other property. She is well below the asset limit for our state (NY, which has a very high asset limit). Her monthly income is slightly over the state limit (about $30 over). She hasn't had any property transfers in the lookback period (home transfer to life estate was in 2015). She is a widow.

We already know she will very likely easily qualify for chronic Medicaid with some kind of modest spend down re the income. My question really was about WHEN it would be appropriate to apply for chronic Medicaid, given that she is still living at home. Do you wait until they actually have to go to a NH, or can you start the process earlier?

(Whatever the process entails- gathering documents ourselves, or having a lawyer do it. Just the time frame of WHEN you can start)

W72, Realistically PACE is her gatekeeper. As you very well know all her healthcare is tied into how this PACE functions. So you have to request assessment done to get her ok for higher level of care & then filed as a move to one of 2 NH affiliated w/ this PACE as now at-need for skilled.

Hopefully she clears assessment hurdle and easily done; moves into a NH. Then ya deal with the whatevers of her eligibility for LTC Medicaid. BUT if not, then you’ll have to go hard ball & tell them that you cannot do in home oversight required by PACE enrollment anymore and ask what needs to happen.

On “3K copay”, I’m sorry that was confusing…. 3K I posted about earlier was in reference to those PACE enrollees who wanted just Medicare & did not want to ever go onto Medicaid as secondary health insurance plus onto community Medicaid for incidental costs at PACE. What States do is charge a private pay rate if no Medicaid enrollment…. seems to average $3K mo.

However your mom will have a copay once she goes into a NH.
For those applying for LTC Medicaid program, they have to show “at need” both medically AND financially. Medically PACE should deal with this. Financially will be however State has income & asset maximum. You as POA have to provide documents on banking, property, etc. For income most have it pegged at $2742 mo & nonexempt assets 2K. If over 2742, they do a Miller Trust/QIT or pooled income or some other “parking” of excess income. Over 2K assets, do a spend down. May need to be done by elder law attorney….. really totally in the weeds for exactly how your State administers its LTC program. Someone at PACE knows what’s what.

But back to copay….. LTC Medicaid requires now living in NH elder to do a copay of almost all income to the NH. Called SOC / Share of Cost. Say mom gets $1800 SSA & pension of $790, total $2590 & her State allows her to keep $60 ea mo as PNA / personal needs allowance. Each month this mom has SOC of $2530 paid to NH. The 60 supposed to used for personal upkeep items not provided by NH…. so beauty shoppe, clothing replacement. Mom has zero $ to pay any costs on house still in her name. & for y’all it’s titled as a Life Estate / LE done in 2015, correct??

So now we get around house issues. LSS all costs on you to pay. For precise answers, you need to clearly speak with attorney experienced in how State does MERP aka estate recovery & how it views LEs for MERP. Some States approach recovery by doing attempted recoup on all property owned by elder at time of application. Even LEs as it’s still owned by her; does not transfer title till she’s dead. You are currently remainderman on her LE.

If MERP doesn’t exclude LE, she will have an after death bill of NH daily room & board charges & maybe also PACE community health charges, & have to be dealt with to get title transferred. As there is a disabled sibling living in the home, that could be a way to delay this happening. (If disabled was only heir, that is itself an exemption to MERP.) Really these are totally State specific issues that you need an experienced attorney to work with you on.

Elder & Family tend to be all gung ho on keeping the home. But once SOC becomes a reality, may not be feasible. It’s something to think about to make sure that whatever the case, once she goes into the Nh, you can pay all LE property costs and do this possibly for years and for a period of time after she dies too. It can be done but has costs and runs risk. Not really a DIY. You need an atty to go over options to ensure all as optimum as possible now and for after death.

also pay attention to prop taxes, if she moves into NH, tax assessor could lift her homestead exemptions completely. Might be quite the increase in taxes. Ask atty on if a way around this.

good luck & let us know how it goes, we do learn from each other!

Check Medicare a well. She probably already qualifies for skilled nursing facility through Medicare.

Weisk72: Retain an attorney.

Confer with an Elder Law Attorney. They may also be best able to not only answer your question but also can often help get Medicaid applications submitted correctly and expedited.

Welcome, Weisk!

Does mom have any assets (IRAs, retirement accounts, CDs, real estate aside from her primary residence)?

Is her monthly income (SS to pension, annuity payment) below her state's income level,,?

In most states, Medicaid only pays for LTC, which is assessed as medically necessary by a doctor. This means the person is pretty much immobile, bedridden or has a profound illness that requires a lot of daily medical care. So, besides qualifying financially, she also needs to be assessed as requiring LTC *unless* her state has different criteria and coverage.