Don’t Forget About Medicaid’s Medical Test – Part 4

In my post last week, I explained the risk of residing in an assisted living facility (ALF), running out of money but being too healthy to meet Medicaid’s medical test.  If the applicant is still only paying the basic room and board cost and not for any care when the money runs out, a Medicaid application will fail for failure to show the need for long term care.

On the other hand, some cases are not that clear cut.  One such case resulted in our filing a Medicaid application.  The client sold her home and used the proceeds to pay for care in an ALF for 4+ years.  Her family reached out to us within months of the funds running out.  Her care was above the base level but she was not exactly cooperative in the decisions to provide for her needs.  She insisted that she was fine and didn’t need the care she was receiving.  Furthermore, because she still had her mental capabilities, she was able to clearly communicate with the Medicaid nurse conducting the evaluation.  

It was a close call but we filed the Medicaid application.  We were able to satisfy all the financial requirements, however, the application was denied because Medicaid determined that she did not meet the medical test.  While I was not present for the evaluation, upon reading the nurse’s detailed notes it appeared that the nurse, at least in part, relied on statements made by the resident that did not support her medical need for care.  That’s all Medicaid needed to hear.  They denied the application.

When that happened, the ALF continued to bill the resident at their private pay rate.  While income from Social Security and pension was about $5500 per month, it was short of the private pay rate by a few thousand dollars a month.  The ALF refused to waive the additional fee and authorized its attorney to send an eviction notice.  

I explained to the family that until some medical event occurrs such as a hospitalization, refiling the Medicaid application would only net the same denial based on the same medical facts.  Something needs to change medically.  I also explained that, while the facility could pursue eviction proceedings, it could not force them to take in the family member.  Apart from another facility willing to take her, there was no suitable living arrangement in a home setting that could provide a safe environment.

So, what was the final outcome?  The family was, not without some difficulty, lucky to be able to find another ALF at a lower monthly cost so that the gap between the private pay rate and the resident’s income was more manageable for the family to pay the difference until such time as we are confident that a successful Medicaid application can be filed.