Medicaid (referred to as Medical Assistance in Pennsylvania) is a comprehensive health care program that covers a wide variety of people who need nursing facility medical care and meet certain financial eligibility guidelines.
For seniors, Medicaid is a very important resource covering more than 65 percent of all nursing home care. As you've read in our previous columns, nursing care currently costs approximately $100,000 a year. Therefore, most people who require long-term skilled nursing care eventually must deal with this program. Therefore, the stakes are high and it is important to know what common mistakes to avoid.
First: Know when you need help. Most people don't plan to go to a nursing home. It's typically the default care setting for those who have chronic long-term illnesses that cannot be treated at home or in a personal care facility. Medicare covers only up to a maximum of 100 days and many times less, so at roughly $8,000 a month, the arrears add up quickly once insurance coverage ends. Get advice immediately on your options before Medicare coverage ends.
Second: Recognize potential problems. Medicaid is a taxpayer-funded program and before the government is going to foot the bill for your expensive care, there will be an exhaustive financial review process. This process, called "verification," will involve a detailed review of five years of all of your investments, bank accounts, real estate transactions and transfers (i.e. "gifts"). If you are aware of problems providing this information or, worse yet, gifts that may have occurred during this "look back" period, plan to deal with them immediately. These problems will eventually be discovered by the County Assistance Office (trust us, they will) and could lead to delays or denial of coverage.
Third: Communicate. The Medicaid application process can take several months to produce a decision of eligibility (or denial). During this time period, the nursing home is waiting to be reimbursed. Generally, the resident is only paying a small portion of the actual costs monthly (called the "patient pay amount") and the nursing home is bearing the risk of a denial of the application. Therefore, it is important to keep the lines of communication open between the resident (or her representative) and the nursing home and the County Assistance Office. These parties should be made aware periodically of the progress and status of the application.
Fourth: Don't delay appeals. For one reason or another, many applications are denied at first. This could be a result of incomplete verification or gifts that are not exempt from penalty. Regardless of the reason for the denial, it is crucial to appeal in a timely manner to maintain the retroactive coverage requested in the initial application. Applicants have a 30-day right to appeal. At this point, the applicant may simply need to provide additional information. However, in more complex cases, there may be a legal issue that needs to be submitted for a "fair hearing" in front of an Administrative Law Judge to resolve the matter. Either way, if you do not timely file the appeal, you will not even have the chance to fix things.
Finally: Consider seeking experienced legal advice. As stated previously, the stakes are high and applications and appeals can take several months to resolve. For example, if the unpaid nursing home balance is $8,000 a month and an appeal is denied after six months, the nursing home will expect to be paid the arrears of $48,000 from the applicant. If the applicant does not have the funds to pay, the nursing home may pursue collection from the adult children of the nursing home resident (see our previous column on PA Act 43 -- Filial Responsibility). While all parties involved desire a smooth transition to Medicaid covered care, nursing facilities are a business and must be paid for their services. (So, if things don't go right with the application, the nursing home resident's children may be seeking legal counsel anyway -- and not under the best circumstances.)
Medicaid coverage for long-term care services is an extremely complex blend of federal, state and local laws, rules and customs. While our hope is that all seniors plan ahead for the contingency of needing long-term facility care, when faced with an immediate need for such care, families should not gamble with not only the health and safety of a loved one, but with the financial consequences as well.
Julian Gray and Frank Petrich are both certified elder law attorneys with over 55 years of combined elder law experience who practice in the Pittsburgh area at Gray Elder Law. Send questions for consideration in this column to firstname.lastname@example.org, and visit their website at www.grayelderlaw.com