When my paternal grandmother fell and had to be hospitalized and then discharged to a nursing home for rehab, I learned quickly what is and is not covered by Medicare and Medicaid. For starters, Medicare requires that a patient spend three midnights in the hospital before being admitted to a skilled nursing facility. My grandmother fell one morning before 6:30. Her injuries from the fall were significant enough to merit keeping her long enough for the "qualifying hospital stay." The information at www.medicare.gov states "This is at least three days." Ask any nurse or physician... they will tell you that technically it is "three midnights." There is a difference, so be sure you discuss this with your physician and medical staff. With the push to get people in and out of hospitals, some doctors may be reluctant to keep the patient this long, so be prepared to play hardball.
Once the patient is admitted to a skilled nursing facility following a qualifying hospital stay, Medicare will pay for up to 100 days of rehab if deemed necessary by a physician and nursing home therapists and case workers. Once this time period is exhausted, the patient may either be discharged or remain in the nursing home at his/her expense - or covered by Medicaid if certain qualifications are met.
Medicare.gov states that "Medicaid is a State and Federal program that will pay most nursing home costs for people with limited income and assets. Eligibility varies by State. Check your State's requirements to learn if you are eligible. Medicaid will pay only for nursing home care provided in a facility certified by the government to provide service to Medicaid recipients."
In my grandmother's case, should she have needed to stay beyond 100 days, Medicaid would have paid for her care by garnishing her monthly Social Security check, less a set amount for personal extras (somewhere around $25) such as clothing, hair care, vending machines, and specialty items. There are rules and regulations, and many of these are explained at www.elderlawanswers.com (see Medicaid Rules under ElderLaw101). One of these rules states that "In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets." This includes checking and savings accounts and cash. We got into trouble on this one, because my grandmother misunderstood and believed she could have $2300 in assets. When she fell and had to enter the nursing home, her checkbook showed a balance of $2117 plus change. Loopholes in Medicare coverage and other "red tape" resulted in a bill for three days of nursing home care - to the tune of $150 per day. We are very careful now to make sure she never has more than $2000 in her checking account or "countable" assets. This is one of the first things you will be asked to present at the nursing home - a current bank statement and/or your checkbook registry.
Also be prepared to show:
* proof of any life insurance policies and a prepaid funeral plan (even though they do not count toward this limit)
* a complete list of all prescription drugs purchased for as much as the past six months
* information on all checking/savings accounts, as well as any CDs and bonds the patient owns
* vehicular title and proof of insurance
Personal assets that count toward the $2000 limit for Medicaid benefits do not include personal possessions such as a prepaid funeral plan and small life insurance policies, clothing, furniture, jewelry and other items, and one motor vehicle. Thanks to the Deficit Reduction Act of 2005 (DRA), a person's home is no longer in danger to the extent it was prior to this time. Check with your local Medicaid office for exact qualifications and restrictions, but this relatively new legislation is a real blessing to those who face a nursing home stay and are worried about losing their home.
Think you'll transfer your assets to a relative to qualify for Medicaid and avoid having to pay for nursing home care? Think again! Then read the ElderLaw section on "The Transfer Penalty" to see how this really works. As stated in this section, "...for transfers made prior to enactment of the DRA on February 8, 2006, state Medicaid officials will look only at transfers made within the 36 months prior to the Medicaid application (or 60 months if the transfer was made to or from certain kinds of trusts). But for transfers made after passage of the DRA the so-called lookback period for all transfers is 60 months." In other words, if you are transferring your assets to your children tomorrow, don't plan on going to the nursing home for more than five years, or you'll be paying some hefty penalties. There are a few exceptions to the DRA, and these are explained on this page, also.
My maternal grandparents both spent their last years in a nursing home. During this time, my grandmother inherited $10,000 from an aunt. Because of this "windfall," she ceased to receive Medicaid coverage until the inheritance had been depleted to cover her nursing home care - at the rate of about $3000 per month. Once the money had been spent, her Medicaid coverage resumed. She was not allowed to legally transfer this inheritance - or even to refuse it. There were limits on how much she could give to others, such as birthday gifts for her children and grandchildren. I'm sure her aunt felt she was being generous, but this inheritance turned out to be nothing more than a source of irritation and inconvenience. I do not recall if my mother had to reapply for the Medicaid benefits, but I feel quite certain there was some hefty paper work involved, as always.
The Medicaid program is truly a blessing to many, like my maternal grandmother, who worked hard all of her life at several jobs to make ends meet. Her monthly Social Security benefit barely covers her living expenses. She has been admitted to a nursing home on three separate occasions for rehab, and each time the therapy was successful and resulted in a return to her own home, where she has managed quite well for the most part. Had the therapy not worked well enough for her to be discharged, she would not have been unable to afford to stay in the nursing home and receive needed care. In light of this consideration, the massive amount of paper work required for admission and the careful attention to the details of the Medicaid rules and regulations all seems worth the effort.
Medicaid is complicated - and was most likely made more so by those who attempted to abuse the program. But for those who truly need the coverage, Medicaid is the only means to secure nursing home care. In this regard, learning about Medicaid coverage and regulations takes on a new meaning.
Resources:
www.elderlawanswers.com
www.medicare.gov