There are some very important differences in the Medicaid regulations and coverage for nursing home vs. ALF Medicaid. ALF Medicaid is a community based “waiver” program. It is not part of the basic Medicaid coverage that all states must agree to provide when they accept federal funds. Rather, this is additional coverage that they can choose to offer or not.
So, what do I mean when I say that ALF Medicaid is not retroactive but nursing home Medicaid is? Let’s say I apply for Medicaid on June 15 and I want Medicaid to start paying for my care on June 1. I must meet all the eligibility requirements as of May 31 in order to be eligible for coverage on June 1. However, it may take 6 months or longer for the State to review my application and approve it.
If my application is not approved until December and I am in a nursing home applying for “nursing home Medicaid” then the approval will be retroactive to June 1. I can even seek coverage back another 3 months to March, again, if I have met all financial and other eligibility requirements as of February 28.
On the other hand, if I am applying for “ALF Medicaid” and same scenario above, my application is approved in December, I will not get coverage back to June or March because there is no retroactivity. This can obviously lead to gaps in coverage in an ALF between the time my money runs out and I can’t pay the private pay rate and the time my application is approved, leaving large unpaid bills.
I recently explained this to a client’s family as we are readying an ALF Medicaid application. She called me a few days later to say that the facility told her that there is “gap coverage” for this time frame. I have been through this many times before. Clients call to tell me they were told something about Medicaid that is very different from what I told them. It happens because Medicaid regulations and “the system” are very complex and confusing. Usually this is caused by one of two things. Either the clients misinterpreted something they were told or the person who they spoke with is misinformed.
In this case, the client’s family misinterpreted what they were told. Next week I’ll share with you where the disconnect occurred.