Don’t Forget About Medicaid’s Medical Test – Part 3
In my blog post last week, I explained the risk of not satisfying Medicaid’s medical test when residing in an assisted living facility (ALF) as opposed to a nursing home. Assisted living residents do not typically need nursing home level care when they first enter a facility. While this may be expected to occur over time, it is not guaranteed that it will happen by the time they run out of money.
As I explained last week , families are often confused by the discussion about Medicaid during the admissions process. “Private pay for 2 years – or in some cases 3 years – and we will agree to make a Medicaid slot available”, the ALF says, “provided that a slot is available.” They understand that to mean that as long as they meet the financial obligation, Medicaid will follow. But, what if it doesn’t follow?
Over the years, we have had many an instance in which we speak to families considering a move to an ALF who may not have enough funds to cover the cost before Medicaid eligibility. In some cases, the potential resident doesn’t have enough funds to even meet the 2 or 3 year private pay requirement. In that case the families tell me they are prepared to pay the difference. In other cases, the potential resident may have enough to meet the ALF’s private pay requirement but not much more than that.
Obviously no one has a crystal ball to be able to predict the future. If the potential resident has no current need for assistance with any of the activities of daily living, it is impossible to say for sure that he/she will need it in 2 or 3 years when the money runs out. Families need to be prepared to pay for much longer than that. When we put actual numbers on what the additional cost could be – in the hundreds of thousands of dollars – the stark reality hits and some families realize that a move to an ALF is not the right financial fit.
Sometimes, however, we are not consulted at the time a facility move is made. These families reach out to us when they are within months of running out of funds and needing to apply for Medicaid. We must make a quick determination whether to file a Medicaid application or not. Because the application process is time consuming, we do not want to file applications in cases that will lead to obvious denials.
Because not all ALF residents need the same level of care, facilities generally have a base level cost and then additional services are either bundled or offered on an “a la carte” basis for an additional cost. If a resident is about to run out of money but is only paying the base level room and board fee, but not for any assistance with ADLs, he or she will be denied Medicaid benefits. When Medicaid conducts its medical evaluation, it will conclude that if the resident is not paying for and receiving assistance, that is evidence that there is no need for assistance with the ADLs. Hard to argue with that.
Other cases are not so clear cut. I’ll talk about that next week.