What is the difference between an assisted living waiver and nursing home Medicaid?
If the case manager does not want to pay for a nursing home, what are the next steps?
Why do you need a supplemental insurance on a waiver? How is dental work done without it?
Why do many answers say LTC?
Thank you.
https://www.nysarctrustservices.org/nysarc-trusts/pooled-trusts/community-trust-ii
Our mother was transferred into SNF from ALF after she was admitted to the ER/hospital/rehab after a health crisis. Initially she was private pay until all her funds were gone. However, then her Federal pension income and Social Security put her over the monthly NJ Medicaid cutoff by about $65. NJ allows and required us to setup this Qualified Income Trust account so she would qualify for NJ Medicaid LTC. Per my quick GOOGLE search it sounds like NY state may have something similar for MIL to financially qualify for NY LTC Medicaid. She appears to already meet the medical qualifications.
In my opinion, those individuals in the AL business office are giving you all the run around - I've been there too. You need to work around them because they are your obstacle. Some of their actions are criminal regarding medications, and more.....
I'm going to leave with one very important piece of advice that might help the overwhelmed feelings.
When separating the actions (commonly called services provided)
-- moving MIL out of AL, helping MIL with care, ADL assistance, etc. --
with paying for who does the care
and
where the care takes place (commonly called room and board)
-- AL/MC/SNF --
it should help make sense of what steps to take to move forward. They can be addressed separately and indeed, MLTC requires that it be done this way.
Good luck.
How does he apply for LTC without their approval?
She has no money, we cashed out the 5000 in life insurance months ago for a creamation and pre-pay insulin for a year. In September, the year is up and we do not know how we will pay for the insulin, $60 does not cover it.
There are two different assessments for regular Medicaid LTC (MLTC). 1) Financial and 2) Medical. Meeting both of these is much more strict for MLTC than it is for community waivers. Guessing here, it seems MIL passes the medical but does not meet the financial. Only you and yours know this piece of information.
He made 4 phone calls today the assisted living, the care team the DHS worker and the congressman.
They have not applied for the LTC waiver, the community waiver pays for the assisted living not a LTC waiver. The LTC waiver needs to be approved by the care team who deny it. He is waiting for the congressman callback.
On another note, the doctor wanted to know why the medications were wrong. My husband requested a log and they refused. The doctor then requested the log, assisted living refused. The doctor called the police and APS over it so he had a visit with them today.
We are both overwhelmed with all of the information.
Also, we took her credit card away from her. Assisted Living said we needed to give it back. Do we?
Your husband should be applying for LTC Medicaid if MIL qualifies. Not the AL or the AoA. The LTC via standard Medicaid and the In-home/AL Care waiver she is currently on are two separate and unique programs. It would be MUCH EASIER if the care management team agreed with her moving to Medicaid LTC BUT it isn't mandatory for DH to have their agreement to apply. That is why it helps if MIL gets admitted to ER.
The must-answer question at this point is: Does your MIL qualify for LTC Medicaid? Medically it seems she meets the requirements but what about financially?
What is a clawback?
where in my experience this gets real in the weeds is when an individual goes from their old Medicare and secondary or gap insurance and then applies for and goes onto LTC Medicaid. LTC Medicaid really cannot be applied for until the individual is actually in a NH (or a MC or a AL that participates in LTC Medicaid waiver system) and considered a long term care resident. The application process is not quick; could take 2 months, could take 6. However until they have cleared and become eligible for LTC Medicaid, they are still on their old insurance.
AND this can become a clawback issue.
why? Well LTC Medicaid takes months to be approved BUT that approval is retroactive to the day the person applied. So if it was 6 months ago, then LTC Medicaid will go back to pay the facility for room&board to that date and also for care provided at the NH also billable to Medicaid to that backdate. Now once your old insurance finds out, they will not honor a double payment and will want Medicaid to pay and will clawback thier payment to any vendors who now could bill Medicaid for that coded care.
I had this happen with my late mom, was a real buttrash to deal with too. Mom had high coverage BCBS for federal retirees (FEHIB). It was her secondary to her Original Medicare and for high option FEHIB that Bcbs can be the primary if vendor participates in FEHIB program. She had basically no copay ever, beyond fortunate. Anyways mom goes into a Nh and applies from day 1 for LTC Medicaid. She gets approved at 5.5 months. She had PT at the NH who were not facility employees but outside contractors so did their own billing. Billed BCBS & paid. So once mom approved for LTC Medicaid she became a “dual” (on Medicare & Medicaid) and her old FEHIB was suspended as FEHIB BcBS won’t pay if there’s another that will and that’s Medicaid so BSBS stops. Anyways around 6-7 months later BCBS claws back thier payments to the PT. They needed to rebill to Medicaid as it’s the secondary health insurance. This also happened to my moms gerontologist and retina surgeon as she saw them both at the beginning of the month that she later in the month moved into the NH. The 2 MDs & 1 PT rebilled to Medicaid right away, I did not even know it had happened / that clawbacks get done, it was not an issue. But 2 PTs did not accept Medicaid (just wtf why a vendor seeing NH patients would not do Medicaid is beyond me…) and didn’t notice the $ clawback till abt mo 9 and the other a full year later. I moved my mom to a much better NH#2 at mo 10 in this drama. They billed mom personally to NH#1 address. When it finally surfaces & I become aware it’s beyond a year. Medicaid ain’t paying as its past time limit. Mom has no $ except for her $60 LTC Medicaid personal allowance. PT #1 was forgetabtit but the other was really pissed. I offered to repay over time but he wasn’t having it and just stayed mad and never billed us.
Had no idea clawbacks happened and that ever could be an issue. The PT I see told me that it’s actually common for PT as often the patient is there from an accident or incident that is a tort lawsuit (like auto accident) and once the settlement happens the responsibile party now has to pay and the initial insurance can possibly clawback its payments if they can to force the now responsible one to pay instead; so bc of this he really doesn’t see auto accident PT patients. I mention clawbacks bc this AL your Mil is in seems to be a hot mess for being organized and clueless on how Medicaid billing runs.
LTC Medicaid pays for skilled nursing care facility aka a NH. LTC Medicaid is dedicated funding from federal govt to the states ($ amt based on demographics) for SNF only but states can request for some of that dedicated $ for SNF / NH to go to elsewhere. So PACE type of day programs, IHHS, AL, MC, can - if a state chooses - be funded via a waiver. & for more fun! each waiver program has its own eligibility.
LTC Medicaid NH eligibility is pretty straightforward by & large for most states: “at need” financially so if individual a max $2k in nonexempt assets & under abt $2,200 a mo in income and all income less that modest personal needs allowance ($50-60 avg) goes to the NH as a copay; and medically “at need” for skilled nursing care. They become “duals” for health insurance so on Medicare & Medicaid; all thier room&board, drugs, daily care costs covered. Facilities who participate in LTC Medicaid cannot charge for extras like medication management; state does a LTC Medicaid prefixe day rate reimbursement. No $75 fee for scheduling a bath, or $500 for insulin shots. Really the only extra NH can bill a LTC Medicaid resident is in room phone, cable and beauty shoppe. LTC application is different than community based Medicaid application as community allow for a lot more money as they are expected to still have living costs, pay their health insurance, do drug copays, etc. and medically do not need to be skilled care.
I’ll bet that your MIL isn’t on LTC Medicaid or LTC Medicaid waiver but on community based Medicaid and some sort of emergency/ interim waiver to her community based Medicaid. AoA “Case management” is not set up to do SNF eligibility as they only do community Medicaid. And if the AL doesn’t not actually have LTC Medicaid beds, they too cannot do a LTC Medicaid application for your MIL. See if this is it.
The way you describe her conditions with insulin, unable to transfer, etc. she definitely has skilled care needs. She needs a NH.
Imo the easiest plan is for AL to call EMS to take her to a hospital ER / ED as something appears to be a “serious concern”, & she gets hospitalized (MediCARE) then discharged to a NH for rehab (MediCARE) and is determined not to be able to go back so she remains at the NH; files a LTC Medicaid application and now has a fat health chart that show “need”. Facilities do “ER dumps” on residents all the time…. although they won’t come out & admit it. It’s a way to legitimately move out a resident whose care or problems goes beyond what the place wants to deal with. Once at the ER or up in the hospital, the old place will refuse a return. It’s a legit move as not putting elder out on the curb but are in the safety and security of the hospital. Talk with the head RN at the place about this.
& really please do not allow yourself to be coerced to having her move in with you. Good luck
Mother in law fell May 27th, husband documents these things. We were at Costco when it happened. Since the care team said they could no longer pay for the necklace, she had to use Alexa to our phone. We called the facilty about her fall and we arrived within 30 minutes. She was still on the floor, we called an ambulance and had her taken in for x rays. The aides came in the room after the EMTs had her on the cart.
We asked that she go a nursing home then and the care team said no she doesn't need it and the facility told the hospital social worker she was fine to come back to the assisted living.
There is no nurse or doctor at the assisted living, just the aides. The administrator does not have a medical background just a business degree.
Is it possible to go around the care team to get the LTC?
Also, do we need to keep paying for her insurance since it is the community waiver.
Thank you.
There is always a supervisor and there is always an appeals process. That's what you need to find out.
Your congressperson may indeed be interested in social change, but dollars to donuts s/he has staff in her office that deal with elder affairs.
Please call.
What is the difference between an assisted living waiver and nursing home Medicaid?
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Each state has a different definition of how they apply Medicaid. Only MIL's case management can actually answer this for New York in detail. Someone from New York on this forum may have a better answer.
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If the case manager does not want to pay for a nursing home, what are the next steps?
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It depends on the processes in place for New York. You may be able to appeal through an appeal process. You may be able to write to your Congresspeople. You may be able to reapply. And you may be able to use an attorney. You may try to figure it out on your own using Google and forums. Each has benefits and drawbacks. None are absolutely guaranteed to work.
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Why do you need a supplemental insurance on a waiver? How is dental work done without it?
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There are four different types of Medicare. For simplicity!: Part A is hospital, Part B is doctors, Part C is supplemental (Medicare Advantage or MediGap) and Part D is drugs. Part A everyone on Medicare is covered. Part B there is a monthly fee -- usually taken directly from Social Security Direct Depost (SSDD)/Check. Part D also has a fee and it can be billed or taken directly from the SSDD/Check. If one pays for Part C, then the others three are rolled into Part C and it acts as all the others together. It also MAY include dental, vision and hearing which ARE NOT included in the others.
Basically, Part C IS like having any other insurance policy and indeed, is handled by companies that underwrite employer/employee insurance.
You give the dentist MIL's Part C membership card and they bill it like all other bills.
Think of it this way, Part C is like going to a sit-down location and ordering your meal off a menu. It comes that one way and it includes everything together on the plate. Parts A, B, and D are like ordering at a buffet. You can choose different meat, side, and drink based on your tastes that day and moment.
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Why do many answers say LTC?
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See my original post.
LTC is what people need that can't do ADLs but aren't yet dead or actively dying in an acute hospital situation. It encompasses everything from AL to in-home care to memory care to skilled nursing to family caregivers.
Medicare doesn't pay for LTC and Medicaid only pays for LTC for limited assets/income and only for places that provide skilled nursing. Private AL doesn't qualify for either.
Your MIL is in the wrong place.
Please clarify if any of these are wrong.
1) MIL was approved for in-home care using a Medicaid waiver.
2) MIL could no longer receive in-home care.
3) They placed her in AL in lieu of in-home care.
4) MIL hasn't been financially or medically re-evaluated to place in an LTC facility since the initial temporary placement in AL.
Has MIL ever been approved for Medicaid LTC in a facility according to NY policies?
Has she been recently seen by an independent doctor that has recorded her decline in ADLs?
Has your DH requested a re-evaluation or re-applied to Medicaid to place her in a different facility?
Is MIL's case management team at AoA completely separate from the department that reviews and handles the Medicaid application for LTC in a SNF?
I cannot speak for the New York policies and procedures. We bypassed the AoA/case management process and each state has its own methods when it comes to handling Medicaid. An attorney would be the best place to find out the requirements to get MIL the help she actually needs today and not what she got in the past.
IMO, only your case management team can answer if LTC and home waivers are covered under one process in NY or if MIL has to reapply for LTC now that there is no in-home care.
We thought the waiver was only for the in home care but it is not. It is the assisted living too. When she was home, they gave her a necklace for calls, aides, depend products and paid part B. Now, they pay the difference between share of cost and the charge. We pay everything else including part b.
That is the LTC question, why does waiver not cover a nursing home. I am in New York.
I am not sure what you are asking.
My congressman is more concerned about certain social changes than elders.
Ainorlando's last posts say that your MIL’s assessment should be a ‘medical assessment’. You say that it is done by “a care team of a nurse and social worker through the Area on Aging”. What links do these people have with MIL’s facility? You told us that this religious facility deals with COVID by saying that they are all ‘protected by God’ – and God hasn’t stopped hundreds of thousands of deaths. I would be very chary about accepting anything said by anyone who goes along with the facility management.
If the case manager is saying MIL doesn't qualify, DH needs to clarify with the case manager is this because of her medical needs or her financial situation. The two work independently of each other when Medicaid is involved. MIL MUST qualify 1) financially and 2) medically. Both are individual assessments and are two different processes to qualify. Once both are met, only then can she actually receive LTC assistance from Medicaid. And each state has a different way they determine these. Hence why the advice is heavy on talking to an attorney because the process for this is very time-consuming and complex.
Here is my suggestion.
Your DH needs to start with MIL's doctors and find out what level of care she needs.
Then DH needs to find a place where she can afford to live that gives that care level.
Then DH needs to find out how much that is going to cost monthly.
Then DH needs to find the way to pay for that care out of MIL's money or by going through the Medicaid process for MIL's state -- which is up to him to do.
And if he cannot or is not willing to do the work, he needs to hire a case manager to do the work for him.
Finally, your only part in this is to support your DH in how he accomplishes this but DO NOT try and "save" him from having to put in the work to get HIS MOTHER the help SHE NEEDS.
Oh, and one thing I must note, ALL of this can vary per LO/individual circumstances/people involved. So it is very fluid. Not only from day to day but from situation to situation. Take what helps from these posts and leave the rest.
So...like learning a new language, let's go back to the basics.
1) Everything for your loved one (LO) is based on how many activities of daily living (ADLs and iADLs) can the person do by themself.
This is from ONE US government website:
Activities of Daily Living (ADLs): Activities of daily living
are activities related to personal care. They include bathing or
showering, dressing, getting in and out of bed or a chair,
walking, using the toilet, and eating. If a sample person has
difficulty performing an activity by himself/herself and without
special equipment or does not perform the activity at all
because of health problems, the person is deemed to have a
limitation in that activity. The limitation may be temporary or
chronic at the time of the survey. Sample persons who are
administered a community interview answer health status and
functioning questions themselves, unless they are unable to do
so. A proxy, such as a nurse, always answers questions about
the sample person’s health status and functioning for long-term
care facility interviews.
2) The fewer ADLs LO can do by themself, the more help the LO needs. This is ranked by LO doctors and in the case of Medicaid, by the person doing the medical assessment. Social Workers (SW) and others, may or may not have the best knowledge to know what a LO can and cannot do for their daily situation.
3) Assisted living (AL) is for those that cannot do only one or two ADLs (for example, cook or drive). Once it goes beyond one or two, the person needs greater help -- as is the case with your MIL.
4) The more ADLs the person cannot do, the more care they need. Once LO reaches a certain point, they need help with many or ALL ADLs. The LO then requires Long Term Care (LTC).
5) LTC comes in basically three types: self-pay in a facility or Medicaid in a facility or family does the care. Medicaid only pays when the care is so necessary that it requires Skilled Nursing (SN). Skilled nursing is when a person cannot do many or ALL ADLs -- let alone the iADLs.
6) MediCARE only pays for critical and acute care -- that is hospital and rehab. MedicAID only pays for SN in a skilled nursing facility (SNF) for those with very limited assets and income. Nursing homes and some limited other types of homes are SNF. Straight AL is not considered SN.
7) A few select places do everything from AL up to and including SN. They are usually self-pay.
8) Most places do not take MedicAID clients if they can have more private/self-pay as the rules for MedicAID are complex and not as profitable.
Now with that, it sounds like MIL needs more help than AL but based on some opinions, not enough for SN. She is what I like to call the "lost stage". She is in between acute care and skilled nursing. During the lost stage is when we as loving, caring and helpful humans try and take them in and care for them. THAT is the big mistake we make with our hearts and the one that so many on here are trying to help you avoid. It is a worse nightmare for MOST (not all -- there are exceptions) of those that try that path.
As for the ACH and money issue, just like any other business, AL can require you to NOT pay by check. It sounds like that is what they are asking you to do. They want to be able to "pull" their money electronically. However, based on your posts, your more pressing questions are regarding MILs current needs. She needs a higher level of care than AL can provide.
The logistics of that higher level of care is where you start dealing with case managers, doctors, facility requirements, the way it gets paid, Medicare part A/B/C/D,continued
Is that why the "case manager" and not the doctor is evaluating the level of care she needs?
Your dh should be blowing up the phone of his congressperson's elder affairs office AND seeing a certified eldercare attorney to get his mother the care she NEEDS, which is skilled nursing care in a LTC facility.
The case manager is a care team of a nurse and social worker through the Area on Aging. They decide what the waiver will pay for. Her primary doctor said she needs a skilled care facility, the care team said they do not agree.
On another post, someone said she may not need the supplemental. The care team told my husband she does so we are responsible to pay it since he is POA.
Assisted Living is not meant for a person like your MIL who can't move unless she's physically moved by caregivers. Who needs insulin several times a day. Who needs a pull cord put into her hand in order to pull it. And who expects to have cleaning done on a daily basis (no managed care facility provides daily cleaning service, btw). Her dirty incontinence briefs should be removed from her bathroom daily, and it should be tidied as necessary, but a room cleaning/linen change/vacuum is done weekly. She is far too needy to be in AL in the first place, which the ALF should have told you before she was moved in. AL is meant for fairly independent seniors who need a minimal of help to function, who are there for socialization, 3 meals a day, and to see the doctor who comes in house to see them instead of having to schlep all over town, basically.
If your MIL is immobile and in need of insulin daily, I would think she is a prime candidate for LTC *long term care* in a Skilled Nursing Facility with no problems under Medicaid.
If you move your MIL into your home, things still won't be done 'perfectly' b/c in reality, with a needy elder requiring 24/7 care, there is no such thing as perfection. And, you yourself will be doing all the 24/7 caretaking so then, you will wish you had left her in the 'imperfect' care setting she was in which was better than you doing 24/7 caregiving which is STILL imperfect. Know when to let go. Figure out which battles to fight & which ones to let go of. Stop complaining and pointing out all the little imperfections you see in the ALF otherwise your DH will demand his mother be brought HOME for you to care for her there instead. See where I'm going with all of this?
Good luck.
They moving her pull string. Husband has went there twice since we came home due to her calls. Each time, the string is moved, she is stuck in her chair and Alexa is her only help. It is so sad.
If mom is not capable of doing anything for herself them she is not a candidate for assisted living. Living in assisted living means mom can do the majority of things to function in life herself. Clearly she doesn't and cant. I know if she cant clean someone else must be cooking for her too.
The point of a facility is so that she is not living in your house. Believe me if you think you are in MIL Hell now you will really understand what hell is like once she moves in.
Your husband and his siblings are playing semantical games with you.
This is the same man who sat there and said nothing when the we hate you song was sung at your kitchen table. After you cooked dinner for everyone. Remember that?