Medicaid Pending in Nursing Home

The Institutional Medicaid program (also known as Nursing Home Medicaid) is confusing; a senior can’t apply for Medicaid until he’s been admitted into a nursing home or other medical facility, yet he generally won’t be admitted into a nursing home until he has a payment source in place. The Medicaid application can be submitted while the senior is in the hospital, but since most hospital stays are less than a week it’s doubtful that the Medicaid will be approved in time to send the senior to a nursing home. Because the senior must be physically located in a nursing home or hospital in order to be eligible, any application submitted beforehand will be denied.

Seniors who have applied for Medicaid and are awaiting a decision are considered to be “pending Medicaid.” Anyone can place an application for Medicaid and there’s no assurance that they’re eligible until the application is approved. Because of this, many nursing homes won’t accept a senior without the Medicaid in place, or will require some type of guarantee that they’ll be paid in the event that the Medicaid is denied. This is because once the patient has been admitted, he can’t be discharged due to his lack of ability to pay. They can ask the family for a deposit and might even try to intimidate them into paying after the fact – but the reality is that the nursing home is stuck with the senior if there’s no safe discharge plan. This is why nursing homes usually screen seniors carefully before they’re admitted.

There are several ways to get a senior admitted while he’s pending Medicaid, one of which is to be admitted under the Medicare benefit for rehabilitation services and immediately place an application for Medicaid. Depending upon the state in which the senior lives, a Medicaid application can take anywhere from a couple of weeks to 90 days or more to be approved. If the application is submitted when the senior first arrives in the facility, there’s a chance that the Medicaid will be approved before the Medicare services are completed. If it hasn’t been approved by that time, the nursing home may ask for payment – but as long as the family didn’t personally guarantee the placement they’re under no obligation to pay out of their pockets. This is why nursing homes try to get families to sign the paperwork as the responsible party - the nursing home can’t discharge the senior if he can’t live alone yet doesn’t have a payment source in place. If the nursing home is able to charge the family during this time period there’s no lapse in payment.

If the senior has enough money to pay privately for a few months, he can place the Medicaid application at the time that he’s admitted to the nursing home. By the time that he runs out of money, the Medicaid might start paying for the senior’s room & board. This works as long as the senior has enough money to pay out of pocket – but if he runs out of money before the Medicaid is approved, the nursing home will want to get paid. It’s important that the family not sign any forms accepting financial responsibility for the senior – otherwise they’ll be responsible for paying the senior’s bill until the Medicaid is approved.

If the senior doesn’t have the ability to pay privately for awhile, it’s possible for the senior to find a nursing home that will accept the senior without a guarantee of payment and apply for Medicaid once they’re admitted. Later on, they can transfer to the nursing home of their choice. The less desirable nursing homes can’t be as choosy when it comes to accepting seniors.   A potential source for a guarantee is the senior’s family. Some nursing homes will allow the family to pay a deposit of several thousand dollars to the nursing home; if and when the Medicaid is approved the nursing home will refund the family’s money. Other nursing homes require that the senior’s bill be paid in full every month, with the promise of a refund when the Medicaid is approved. This seems extreme, but unfortunately (sometimes) it’s the only way to get a senior admitted into a nursing home.

The nursing home can’t legally charge the senior/family for the same time period that Medicaid pays. I have seen some nursing homes keep the private-pay monies and start billing Medicaid after those funds have been depleted, because the private-pay rate is usually higher than Medicaid. If the nursing home promises to give a refund, it’s important to get that in writing. A refusal to refund private pay monies when a senior has been approved for Medicaid can be considered fraud, but it’s difficult to prove – and you’d have to hire an attorney to represent you in this matter.

Some states, counties, hospitals or other private agencies will assess the senior’s ability to pay for the placement, and will have a guarantee process of their own. They generally have their own application process and require the same verifications that Medicaid requires. This is because they are guaranteeing that they’ll pay for the senior’s room and board forever if the Medicaid application is denied for any reason that is included in the application packet. Usually any agency that is willing to guarantee an Institutional Medicaid application has already put the senior’s finances through a rigorous eligibility process and is fairly sure that the senior’s Medicaid will be approved. The guarantee is approved based on the information that they were given, and if additional information is later discovered, the guarantee is rescinded. A guarantee can be a useful tool to get a senior into a nursing home – if you can find an agency to issue a guarantee. Agencies that offer guarantees are rare, but they do exist – in order to find out if there’s an agency in your area that will guarantee placement, call your Area Agency on Aging. Any nursing home can also provide this information if you ask.

Some hospitals will place an application for Medicaid in order to make the senior easier to discharge (and also to help cover the senior’s hospital bill), which somewhat expedites the application process. The hospital might even guarantee the senior’s nursing home placement. Some insurance plans will pay the nursing home for a month or two in order to get hard-to-place seniors out of the hospital. For the most part, hospitals and insurance companies rarely guarantee the senior’s payment.

If a veteran’s hospital is trying to discharge a senior to a nursing home, it’s possible that the VA will pay for a couple of months’ placement while the Medicaid application is in the process of being approved. Like other guarantees, this doesn’t happen often – and the senior will only be sent to a nursing home that already has a contract with the VA.

It’s possible to complete a Medicaid application on your own, although in larger cities many hospitals and nursing homes help with the process. There are private companies that submit Medicaid applications, as well as Elder Law attorneys who specialize in Medicaid planning issues. If you have any doubts as to the senior’s eligibility for Medicaid, it’s best to hire an attorney from the beginning rather than to have to hire one later to handle an appeal.