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Medicare/Medicaid Planning: Why to consult an attorney before your parent is placed in a nursing home

Thursday, February 16th, 2012 by

We recently have been helping a family try to untangle a mess created by the lack of planning. The matriarch of the family (“Mom”) became ill and was hospitalized. Her condition was very serious, so the decision was made to place her in hospice care after the hospitalization. However, she recovered and then was transferred to a nursing home. During this trying process, her children were besieged with requests, such as “you must complete this Medicaid application immediately”, “sign this”, “sign here”…Finally, it all became overwhelming and they sought my advice.

As we often say, what you don’t know can hurt you. When Mom was placed in the nursing home, the family learned that Medicare would not pay any of the bill. This is because Medicare pays nursing home bills only under very limited circumstances. In order for payments to be made to a nursing home, Medicare rules require that the patient be admitted directly from a hospital stay of three (3) days or more and be undergoing some type of rehabilitation designed to improve the patient’s condition. If this criteria is met, then Medicare pays one hundred percent (100%) of the first twenty (20) days stay in the nursing home, and eighty percent (80%) of the next eighty (80) days’ stay. This can provide a family with some cushion of time within which to make plans to apply for Medicaid assistance, if necessary.

In our situation, because the family was unaware of this rule, they agreed to place Mom in hospice care first rather than the nursing home. Had they been aware of the rule, they would have been able to request that Mom be placed directly into the nursing home and that hospice perform its services there. Not knowing this fact, and without having consulted an attorney previously for advice, the family was required to pay several thousand dollars in expenses that it otherwise could have avoided.

The next mistake our clients made was succumbing to the pressures from the nursing home to “hurry up and complete your Medicaid application”. The family applied for Medicaid when Mom was ineligible to receive this assistance. Although Medicare is an entitlement to persons over the age of sixty-five (65) who are enrolled, Medicaid is need-based assistance, which is available only to impoverished citizens who meet Medicaid eligibility criteria. This criteria includes having no more than $2,000 in non-exempt assets and a limited amount of monthly income. In our family’s situation, Mom’s assets were limited, but slightly over the eligibility limits when the application was completed. By applying to Medicaid too soon, the family was forced to pay $6,700.00 out of pocket for the first month’s nursing home stay while taking the necessary steps to comply with Medicaid regulations and revising their application to reflect those steps.

Had Mom or her family planned for this eventuality ahead of time, the attorneys’ fees spent on such planning would have been far less than the out of pocket costs actually incurred. Plus, the family would have had peace of mind knowing how to orchestrate an orderly transition into the nursing home and would have avoided the stress and upset of being rushed into making decisions which were not in their best interests.

Our goal as elder law attorneys is to help as many people as possible avoid the Mom situation. If you or anyone you know may be dealing with Medicare or Medicaid in the near future, we would be happy to assist you with your planning needs.


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