The Biggest Misconception about Assisted Living Facilities and Medicaid (Part 2)

                Last week we were discussing Carol, her mom and a very common disconnect we see when families speak with assisted living facilities.  The facility explained its requirement that residents must private pay for a certain period before being considered for one of its Medicaid slots.  Carol, however, heard something entirely different.  She heard what was said to mean that as long as she meets the private pay requirement, Mom will get New Jersey Medicaid.

                It’s easy to see why this happens.  First of all, the Medicaid rules are quite complicated.  The average person is unfamiliar with the rules and regulations of Medicaid and very often the assisted living representative isn’t much more knowledgeable either.  There are strict income and asset requirements.  Assets must be spent down to less than $2000.  Income is viewed by another set of rules.  Medicaid has a strict income cap of $2250 of gross income.  For applicants who exceed that cap a Qualified Income Trust must be used but the rules are very technical and it is easy to be tripped up and lose Medicaid eligibility for failing to follow those rules.  That, however, isn’t the biggest misconception about assisted living Medicaid.

                We have to look at the medical requirement.  Although Mom is in an assisted living facility, she must establish that she needs nursing home level care, not assisted living level care, to qualify for Medicaid.  Nobody can say for sure in 2 or 3 years whether she’ll meet that test and it isn’t up to Carol or the facility to decide.  Medicaid makes that determination after sending out a Medicaid nurse to examine her.  Keep in mind that if Carol’s mom is in a nursing home it is difficult to argue that she doesn’t need nursing home level care.

                The same can’t be said when she is living in an assisted living facility.  Most people there do not need nursing home level care, at least when they first move in.  They gradually need increased care so that at some point they will meet the medically needy test, however, if that does not happen before the funds are spent down then Medicaid eligibility won’t be reached.

                So is that it?  Well no, it is possible that Carol’s mom meets the medical test and the facility’s private pay requirement and still won’t get Medicaid.  Next week I’ll explain why.