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The Facility Said If I Pay for 2 Years then I’ll Get 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 it’s requirement  that residents private pay for a certain period before being considered for one of it’s Medicaid slots.  Carol heard something entirely different, that as long as she meets that 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 consumer is unfamiliar with them and the assisted living representative very often isn’t much more knowledgeable either.  There are strict income and asset requirements.  Assets must be spent down to less than $2000.  Income, however, can often be a permanent bar to New Jersey’s assisted living Medicaid program.  There is a strict income cap of $2130 per month – and that’s gross income.  If Carol’s mom has income that exceeds that cap, she will never be eligible for New Jersey Medicaid in an assisted living setting (although she could qualify for one of New Jersey’s nursing home Medicaid programs).

We also can’t forget about 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 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 someone 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, but 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.

Finally, the facility can’t guarantee that a Medicaid slot will be available at the exact time when Carol’s mom qualifies.  It has a limited number of slots and they could be filled when Carol’s mom is approved.  It is impossible to know years – or even months – in advance whether a slot will be open at precisely the “right time” for Carol.  It is a game of “musical chairs” of sorts.  When the music stops, -ie.  Medicaid is approved – will there be a “chair” available?  Impossible for anyone to say.

Carol’s approach is understandable.  She is trying to do what is best for her mom and she wants to know now that if the money runs out Mom can stay at the facility and transition to Medicaid.  As you can see, it isn’t that easy to do, but so many families are completely misinformed.

And in fairness to the facility, they usually don’t even have all the financial information yet to be able to say, for example, that Carol’s mom has too much income to qualify.  That’s because Carol simply asked a general question about Medicaid.  She is still “shopping”.  She hasn’t yet made a commitment “to buy”.   All she asked is “do you take Medicaid” and all the assisted living facility representative was saying is, “yes, we do accept Medicaid”, not that her mom will be guaranteed to get Medicaid.

When I explained this all to Carol she became confused.  “So, does that mean Mom can’t move to an assisted living facility?” she asks.  No, not necessarily.  It just means she has to understand when Medicaid is and isn’t part of the picture.  And if it isn’t, then she ought to know that now, as early as possible, so we can help her put together a long term care plan that will work.  For example, if Carol’s dad was a wartime veteran, then VA Aid and Attendance benefits, and not Medicaid, ought to be the focus at the assisted living facility.

By the end of our conversation Carol was beginning to understand what I was saying.  She was not asking the right questions of the right person.   I told her that, as elder law attorneys, we could put a plan in place to help guide her on how to get the best care for her mom at an affordable cost.  She was grateful that she found us now, before she spent all her mother’s money.  As I frequently tell our clients and prospects, “when you run out of money you run out of options”.