What can we do if mom won’t apply for Medicaid and she has no money to pay for her care?

"But my main question was 'what recourse do we have if mom will not apply for Medicaid but doesn't have the funds to private pay for more than 20 days?'"

They will pressure the family to take her in or discharge her to her house if they believe her to be safe. If the current facility doesn't take Medicaid, she will be evicted and the state will begin the process of guardianship and place her in a Medicaid-pending facility.  You should meet with the social worker at the care facility ASAP to discuss all of this.  You have more choices NOW before this occurs.

Just lost my post and hate rewriting.
Briefly Mom should stay where she is on Medicaid. Talk to the social Worker and contact Adult protective services. Sis may have been painting a rosy picture on her caregiving capabilities.
Your sister will not be permitted to continue living in the house once medicaid is involved.
Do not start paying for anything, the state of the house no longer matters to medicaid it will just be sold off as a fixer.

If there was ever a time to be "the bossy older sister", this is it, Optimist!

Your sister sounds overwhelmed and possibly depressed.

Somewhere around 40% of all caregivers die before the folks they are caring for do. It sounds like you love your sister and would hate to see her dug further into this hole that mom is insisting on digging.

There comes a point in our lives where we have to not care about not being popular any more. It happened to me twice; once when I told mom I could no longer respond on a daily basis to her "emergencies" and leave work and family to "rescue" her and that she needed facility care; and once, at the end of mom's life when my brother and SIL were resisting hospice care for my actively dying in pain mother. I'm a VERY conflict averse person, but in both cases, I saw that damage was being done to my mother and needed to be set right and how anyone else felt about me be d@mned.

This sounds to me like one of those times.

Go to the SW at the rehab and say "sending my mother home will be an unsafe discharge. Her home is a wreck; someone, maybe APS needs to go look at it and tell me that you don't consider the lack of (fill in the blanks) to be a health hazard to my mother in her present condition. I don't think mom will survive the 24-48 hours that it will take to send out home health, so please get someone out there to inspect it BEFORE she gets sent home."

Emphasize "unsafe discharge". Say you are notifying your lawyer and that you want it in writing on facility letterhead that they have seen the home that they are sending your mother back to. For good measure, you might call the hospital that your mom was discharged from; there are Medicare penalties when patients are readmitted for the same diagnosis within 30 days. The HOSPITAL has a vested interest in mom NOT coming back to them so soon.

Mom should no longer be "driving the bus". If sis can't stand up to her and say "nonsense mom, of course you have to apply for Medicaid; do you have $25. per hour to pay for home health?", then she's not doing your mother any favors.

Why does mom think she doesn't qualify?

Since there is so much uncertainty, perhaps a visit to an Elder Care Attorney (who helps plan the spend-down before Medicaid) would be appropriate. His/her fees is part of the spend-down. With an appropriate plan, you can make sure that there are no regrets later.

Who has Medical and financial POA? If you you can apply. The rehab can evaluate Mom for LTC. They can help u with forms. Medicaid will put a lean against the house at time of death. I would suggest selling the house unless sister is willing to pay the taxes, utilities and upkeep. Mom cannot pay for these things once she is on Medicaid. You will need to look into your sister being able to live there.

BarbBrooklyn-thank you all. Sister says she 'needs help' getting the house in order for someone to come look at it to see if it is safe and appropriate for home health aide but really doesn't think mom will be good back at home. I have tried for years to have her move the clutter, repair the hole in the kitchen sink pipe, etc., all to no avail; was hoping to avoid a time like this when sister is embarrassed at the mess in the house but doesn't have the forethought or skill to keep the home reasonably cleaned all these months. I don't think I would suggest my sister waste a moment trying to do anything to the house in preparation of that visit; it would take her a long time to do anything meaningful and I'm sure the experts can observe through the clutter what needs to be done.  She's embarrassed but as I have been reminded of on this site before, the experts have seen EVERYTHING so just invite them in to get the ball rolling as to next step.  Otherwise, increasing inability to do anything substantial and meaningful for mom.

Mom thinks I'm poking my nose where it doesn't belong when I told her (and offered to pay) to fix a broken window in the basement. There is so much delayed maintenance of the house, it is heartbreaking to me. I grew up in that house. Part of me wants to sit back and watch out how this will play out as I am getting pushback from both my mom and my sister, and my middle sister is so self-absorbed with her own life (she is on third marriage with no children) that she can't bear to lift her finger to help when my sister is so overwhelmed. Someone once said, 'Failing to plan is planning to fail'. Oh so true.

optimist1, when your Mom mentions that she wants to go home, you need to figure out if Mom means the current house that she owns, or if she means her own childhood home. It is not unusual for an elder to say they want to go home to their childhood home where life was simpler and fun.

I am curious about the "home health aide" that will come in to take care of your Mom. Is that something that Medicaid said they would do? If yes, that is great that your Mom's State would have that program as many States do not. As for a visiting nurse, they usually stay 15 minutes or so, just long enough to check vitals.

Am I reading this right, the sister who takes care of Mom also has a full time job? Oh my gosh, no wonder she drags her feet on getting things done around the house. She is running on fumes, being physically and emotionally drained. I vote that Mom does not come home, but reside in a continuing care facility using Medicaid for her care.

As for the house, if Mom is accepted by Medicaid, sell the house ASAP. As others had mentioned someone would need to pay for the mortgage, home owners insurance, the utilities, etc. out of their own pocket. If the house is sold when Mom finally goes into a nursing home, then there is a relief not worrying about the house... but all the equity in the house must go for Mom's care.

Let us know what is decided. Keep us up-to-date.

For those on this thread, please try to read Opti’s post from last month, it’s enlightening especially the answers from Doriannne (her “home is the representation of self” analogy is beautifully written).

Opti - well quite a bit has happened in the past month, hasn’t it! Well at least you didn’t get APS involved as mom got hospitalized...... I totally understand how conflicted you are right now as when our son was a hs senior (a jr in college now) I was dealing with my moms NH, Medicaid, home plus college visits and applications (omg frickin’ “Common application”), FAFSA, plus you have a girl so it’s more time & $$ especially if she’s wanting to go Greek and at a school like Ole Miss that is very socially & dorm decor competitive. Please try to make your family - your hubs & kids - your priority OR at least try to make it seem that way, lol.

That being said, here’s my thoughts: considering that mom is bedfast, diabetic with early dementia, & was living in a hoarding level house with decades of non maintenance, realistically she needs to stay in the NH. Your sister - the 42 yr old who has been living with mom - needs be told by you that if Sissy moves mom out of the NH & back home it will be very very difficult to get mom back into a NH again as Mom will be viewed as non-compliant for care & facilities will find a way to not accept her as a resident. If sissy moves her back, it’s Sissy & mom at the house forever & you cannot fund their codependency. If mom refuses to file for Medicaid and Dpoa Sissy won’t do it as they are oh so dysfunctional codependent, what can happen is that the facility will contact APS and APS will ask the court for mom to be made a temporary ward of the state. Court appoints an outside guardian from a list of vetted local guardians. It’s not ideal but if Sissy just won’t deal that what’s likely needed to have mom stay in the Nh to get the level of care she needs. I’d speak with the SW at the NH to let them know you’ve heard this is an option and you’d be ok with it. Although you could yourself file for guardianship I’d be concerned that as your not local & also not in state that the judge would not appoint you as they tend to want guardian within their purview; also guardianship filing has cost, seems to run 7k-10k as you need an atty & all this is your cost to do & pay for whether or not you are successful in getting guardianship. Honey that’s college application, visits & tuition & dorm $$. FAFSA in how they calculate “parental contribution” doesn’t give an ants butt or factor in your spending on mom/sissy/mom’s house. Mom is not your legal dependent and on last years IRS 1040. Fafsa is all about your 1040. There’s going to be major drama at home if you find daughter is short on college costs, your fafsa has you as totally able to afford the tuition and you & hubs have to get a private loan for her college costs. Parental loans for thier kids college isn’t low interest unless your low income yourselves, plus it’s new debt on you. Daughter can get a Stafford but unless she’s living at home and going the JC route, the Stafford won’t cut it alone. Freshman year Stafford $4500. Even if she’s scholarship, there’s still all sorts of costs. I have a dear friend who’s daughter is a Terry scholar (TX) and Terry supposedly covers all costs..... well so far this freshman Fall they needed an additional 5k for costs, fees, stuff that just isn’t covered.

What does NH do when non-payment happens? My experience was that the NH sends both to the resident and whomever in family who they have on file as contact a “30 Day Notice”. The Notice basically states that within 30 days resident or family must sign off on a legally binding private pay contract or the NH will seek redress. The Notice is cc’d to local APS and whomever is Ombudsmen for NH, if they’ve filed for Medicaid the state Medicaid program is cc’d as well. If nothing happens then APS is asked to review the situation and usually APS files for emergency guardianship hearing.

Guardian takes over & they can place mom’s house up for sale so that mom will have a way to pay for the NH and spend down till poor at which time guardian files for Medicaid. Sissy will have to move as she doesn’t own the home. Sissy needs to let it sink in that if state takes over mom’s situation & if that happens sissy need to live at the house isn’t the guardians or the states problem. 
BUT If she as mom dpoa files for Medicaid for mom, she will keep some degree of control on what happens with the house. Even if it means she stops paying taxes, insurance and house falls into disrepair even worse, Sissy can still live there as Medicaid views it as an exempt asset of mom’s till mom dies. Now mom will have no $ to pay property costs as Medicaid requires a copay or SOC (share of costs) of moms SS $ and all other monthly income to the NH. So sissy on her own to pay house costs. If you feel the need to help, you could pay some of the utilities directly for Sissy so she doesn’t freeze & has running water. Sissy’s 42, she in theory can get a job as no more in home caregiver for mom. 

Opti, a ? for you, in your thread last month, you mentioned mom’s hefty credit card debt. If the CC spending was for Sissy and Medicaid discovers this, it could trigger a transfer penalty inquiry by Medicaid. Perchance has mom been writing checks to Sissy to give Sissy spending money as well?? There’s no personal care contract between them, so if mom’s been doing this, it too will trigger a transfer penalty inquiry. Medicaid can do a 5 yr look back on mom’s finances. If there’s been gifting going on, or you suspect that it has, please please do NOT ever sign off by your own signature on any mom related documents/ paperwork cause if you do and mom is deemed ineligible for Medicaid, the Nh and whatever vendors who were expecting to be paid by medicaid will bill you instead. NH at 5k -15k a mo..... that’s like a full semesters dorm costs. Please make sure your funds are first & foremost for your own nuclear family. Mom & Sissy must be secondary imho.

I’d bet your other sister- who has washed her hands on the situation- has herself gone through all this with mom in the past and had to totally remove herself from them for her own sanity. Help as you can but don’t put yourself at risk. It will be hard but you can do it and start 2018 afresh.

Opti - also regarding the “we buy ugly” sales, my experience is that they offer the land value of the home to maybe 20/30% above land value. If you look at the tax assessor bill (well at least ours are this way) it’s made up of a figure that’s the land value AND the improvements value added together for assessed value. Improvements means the house & outbuildings. The “uglies” tend to heavily discount improvements value.

If this property has all sorts of issues it may not be the assessed value as those are based on recent sales of comparable houses of same sq foot and type (like 2 bedroom 2 baths under 1800 sq ft). Mom’s house could be way way less value. If neighborhood has all sorts of Reno’s or tear downs it’s going to be off. But you’d have to get it appraised to have it legally (good enough for court) at less value. If lots of issues you may want to get it inspected first and then the inspector report is given to appraiser to use within their report. For my moms house I also got a residential engineering report as foundation & watershed issues - this was kinda hard to get as not many do lower value residential, took months to schedule in. Her home came in significantly under assessor value & entered in probate as such, judge signed off so it’s legally the appraised value & not the tax assessor value.

Give some though if there could be any issues, liens, etc that could be lurking about as title company will find it. The uglies seem to want you to use the title company they select. To me there’s a whiff of collusion about this approach. I’m of the use a Realtor with a local MLS type of firm school of thought on buying/selling a house as it’s not simple; paperwork has to be done & recorded correctly. Buyer & seller split the 6% Realtor commission unless the house is in an hot market area where theres really no inventory (this is what it’s like in parts of New Orleans where I am) so the seller can pretty well make the buyer pay all costs including commission. 

Optimist1 - the suggestion to sell the house is because while Medicaid won't pursue the house until after your mom's death - your mom will not have enough money to pay the taxes, insurance, utilities, and upkeep on the house. Most of her money (less about $60-$100 per month for personal items) will go to the nursing home as her Share of Cost. Medicaid will pay the rest. Who is going to pay all of the expenses on the house when your mom cannot?