Is there a website or something that shows exactly what Medicaid benefits my mother is receiving, in North Carolina?
I want to understand what is being provided from both Medicaid and Medicare so I can see the big financial picture.
My mother is in a nursing home/LTF. Her Social Security goes directly to the facility, and her healthcare/room & board is supplemented by Medicaid. Is there a web site or something that shows what Medicaid is paying for and how much?
I have emailed the DSS caseworker three times with no response. If I need to make an appointment and go there in person, that's fine, but she hasn't even emailed me back to tell me that.
Mother owes a debt to the the LTF for the time she was there before Medicaid kicked in (between end of Rehab and Medicaid taking over). I do get monthly statements from the LTF, but it's hard to make any sense of them. For a while I was also giving the LTF her VA survivor's pension (her deceased husband was in the Navy), but the VA is about to cut that off (b/c they don't allow the pension if one is on Medicaid, which I was aware of), so I am keeping that in the bank account till I know that I won't have to pay it back.
This whole Medicaid/LTF thing has been entirely opaque. I have little idea how much and how the money is spent. I can see through the insurance company portal what her Medicare Advantage plan has covered but that's it. How can I be rep payee/VA fiduciary without this information? (I am also POA, but that's moot to the Feds.)
Thoughts and advice appreciated, thanks.
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Make an appointment with an elder law attorney in your area.
This is a hard job and you will need some expert help if you choose to continue it.
You may instead choose to give control over grandmother to state and a state court appointed fiduciary so that you can get on with your life. Many people do not feel up to being POA, Trustee, etc. It is a difficult job and there are legal consequences when it is done wrong.
See an attorney for options and advice would be my advice and I sure wish you luck. I did POA and Trustee of Trust for my brother. The first year my anxiety was through the roof. Very tough learning experience. Very best of luck out to you.
Which funds would that be, that would pay for a lawyer?
If she doesn't, sit with her and sign her up for it online
There is a place where you can designate someone as you Representative Payee.
Medicaid for those in LTF are usually 2 programs: as health Insurance that is combined with Medicare in some way AND then as custodial care paid under LTC Medicaid program for those “at need” medically & financially. Medically = needs skilled nursing care & financially = impoverished.
Medicaid for health insurance- as far as I’m aware - does not do “summary of benefits” (what CMS sends out for Original Medicare or what your moms Medicare Advantage Plan sends out) for costs they paid & to whom & any balance owed statements that is sent to the person enrolled. If I had to guess why, it probably is that as Medicaid as health insurance is the “payor of last resort”, & as such there is no further billing that a person on Medicaid is responsible for or the vendor is entitled to. If Medicaid as health insurance pays a participant vendor $9.87 for a service, it is what it is. It’s payor of last resort. No balance due. No bill. Paperwork wise this makes sense for the State as it would be waaaay way to too cumbersome.
fwiw most in a NH are “duals” for health insurance, so on Medicare & Medicaid. And what a lot of States do is have them instead of being on Medicare as 1 part (so CMS pays) and Medicaid as the other (so State health insurance program pays), State places them onto a MCO (managed care organization) provider & insurance payment system that then runs under single # & billing. ((Molina Healthcare is big insurer for these nationwide)). If NC doesn’t do this and your mom’s Advantage Plan will actually pay for her NH health insurance billable stuff, that’s imo unusual as Advantage usually requires in-network & NH staff are outside of their network. Now Advantage usually will pay rehab associated stuff as it’s technically post hospitalization related billing.
So that’s the health insurance aspects. HOWEVER for room & board part, it’s a different Medicaid program that pays for her custodial cost aka her room & board. It’s LTC Medicaid and you / mom did an application to establish she’s basically impoverished & NH did their part to show she needs skilled care. As mom was in rehab, she had a nice fat file so easy peasy for medical. For LTC Medicaid, each State has their own fixed daily R&B reimbursement day rate. Most lower $200 range. Find out what NC R&B is, then add up # of days of her LTC stay, multiply it by the day rate, it will give you a rough estimate of what her LTC tally is as of that exact date. BUT Every day it increases & State can change $ amount too re: could be additional custodial paid (this happened in some states for Covid). It’s a moving target.
Why nobody at the NH seems to care about this $ figure, it’s that it doesn’t matter to the NH as long as mom does her copay and they get the State fixed rate every day she’s alive. Mom made the NH her representative payee for her SSA, so her required Share of Cost / SOC is assured. Billing at the NH has no need to bother keeping the day rate tally mom is building; its not their concern, they only are abt getting the required SOC. It’s only till after she dies that the LTC Medicaid R&B balance matters….. as only after death does Estate Recovery (MERP) enter the conversation as State is required to attempt a recovery of all custodial care aka the R&B $ paid via LTC Medicaid from the now deceased. Dealing with MERP will fall on whomever was POA & future executor.
More part 2.
The SOC paid, doesn’t really enter the picture. It’s $ that goes to the NH directly and not really factored into State tally. It’s viewed as a “gap”. My mom had 2 mo income sources & almost at her States LTC max…. & when looking at NH that would take her as Medicaid Pending, it was oh so obvious that the NHs were excited over her income as it was waaaay higher than most. In theory NH are not supposed to show bias in who they accept as a LTC Medicaid resident but if you have two 95 yr old ladies & 1 has $2K income & the other $900, ya choose the 2K.
But I digress, so mom was on VA aide & attendance pension? If so as you know it will stop. VA tends to move glacially in resetting the $ and doing their recoup. So fabulous that you are having $ stay in her bank account. As VA will do a clawback. But mom will switch to a $90 a month personal needs allowance (PNA) paid to her from the VA. All should reset for themonth she filed the LTC Medicaid application.
Now heres where it can get sticky and billing at the Nh should know what exactly happens for NC. Each state LTC Medicaid program allow the custodial care resident in the NH to have a small amount of $ to retain from their monthly income for an income based PNA. Most States do $50 or $60 mo. The southern States tend 2 go lower, like yours - NC - has it at the federally required minimum of a whopping $30. ((My State, Louisiana is a big $38!)). Just how a State will look upon her $90 PNA from the VA will vary. This is what you imo want billing to let you know about: will mom get to keep both? the VA 90 plus NC 30?? Or will NC be petty & cancel it’s 30 and mom only gets the VA 90?
Up to each State to determine this as each runs it’s Medicaid programs uniquely. Like for TX they get to keep both State set $60 PNA plus VA $90, so $150 a mo to use. PNA is excluded from any SOC. Is never owed to the NH, it’s moms $ and you as her POA keep track of it and spends it as needed for items not supplied by NH/LTC Medicaid. It can stay in her old bank account if that works best for your situation.
You do however need to be mindful to never ever let the sum of all her money exceed $2,000. So if mom kept her old bank account and it has $1500 and this account gets her VA $90 direct deposit and mom also has a PNA in house trust account at the NH (like to pay for beauty shoppe), the two COMBINED should never ever go over 2K total.
Why? Because LTC Medicaid does annual renewals & bank statements will have to be submitted. Just how in depth the renewals end up being again! depends on how NC runs its LTC Medicaid program. So all that info you got together for her initial application ya gotta keep somewhere easy to find and then add whatever important financial and medical that comes in during the year as they too may be needed to be submitted for the renewal. Like in Jan of Feb of 2024 if she gets a 1099, that’s the type of item that will be included in her 2024 renewal next Fall. If her bank statements always show it ending above 2K and she also has a PNA with couple of hundred, she will have to reestablish “at need” financially again. So keep it all under 2k so this never ever could be an issue.
I didn’t know renewals done, had up everything submitted for the application into bins & into storage. More recent stuff scattered. It was a long long stressful weekend to do its questionnaire & get documents needed to be faxed / certified mailing asap. Totally prepared for the next one.
I believe NC will not allow her to keep the $30 PNA, but will allow her to keep the $90 from the VA. So that will cover out of formulary prescriptions, which Medicaid also doesn't seem to pay as I keep getting a bill. Her dual plan insurance also provides a monthly spending benefit that I can use to buy her snacks and some personal care items they don't provide like, baby powder/corn starch, really? Can't use the benefit for copays or prescriptions, but if she had a utility bill it could be used for that. I wonder if I can use it to pay for her cell phone?
Thanks for the info about keeping her assets below $2k, good to know. Pains me that if you have $2k you are classified as capable of paying. The private pay rate at her place is $10k/month.
AFAIK, the NH doesn't have a separate trust for my mother. For instance, for hair cuts I have to drop off a check or cash for the hairstylist, who is a third party and not an employee. They don't just add that to her bill.
Yes, the VA sent me a bunch of forms to fill out to prove that I didn't need to pay them back the pension received back to 2021. That freaked me out, lemme tell ya. All of that money went to the previous assisted living facility, and then the nursing home after she moved in there. I was using it to help pay back her debt to the NH until I got that letter. Sent in the forms, but haven't heard anything from them. I notified the NH that I wouldn't be writing any more checks from the VA account until I hear back whether the VA wants it back or not. I don't know where it'll come from, and it was spent appropriately. You can't get blood from a stone, or whatever that cliche is...
Part of my wanting to know this information is that the NH is not paying a premium they need to be paying, and I know her Medicaid patient liability has been lowered accommodate the premium. It's for a service called 360 Care that brings in dental, aural, podiatry and vision care, all the providers and machinery etc. so residents don't have to leave the building. The business office is disorganized and they haven't been paying, but since her SSA all goes to them, it's up to them to pay out of her money. If I understand that correctly.
In weak defense of the NH business office, there is one person doing all of it (94 beds), as well as fielding emails for the whole place. For instance, every time I ask the social worker if I can email her directly about something, she says to email the business office. But the business office just forwards the email to the appropriate party. The business office needs another person, if you ask me. It's a lot for one person. The whole NH is a little wonky imho. They got a new Administrator and she seemed horrified that I introduced myself to her. They have also had 3 social workers and 3 Medical Directors since my mom became a resident in January 2023. The current medical director is not part of her insurance network. I keep asking if he's going to join. She can't use the local medical facilities because they are all the same local medical system, which he is not part of. As an example, she would need to be transported 30 miles for a mammogram.
Seems like teamwork is not part of the corporate culture. I'm wondering if I need to find her another place, frankly. For my own peace of mind. Like, one that has a web portal so I can log in and see what's going on and not bother anyone. The business office doesn't answer my emails or calls anymore...
part 2 coming...
- establishing at the time of LTC application filing, that no assets were gifted or transferred within the 5 / 3 yr lookback. If your mom gets approved, that means no asset transfer issues.
BUT
- after she dies, the State or it’s outside contractor has to attempt a recovery of all costs LTC Medicaid paid for her. It’s via MERP or MERS. A Notice of Intent and questionnaire along with $ amt supposedly owed is what tends to get sent out to whomever State had on file as point of contact. LSS from beyond the grave there’s stuff to deal with. FUN!
Yes on finding out if NH has a personal needs allowance type of in-house trust account for her. Usually if elder made NH representative payee for SSA income, NH gets entire check and then deducts whatever State has as its PNA $ amount; & it goes into the in-house trust acct. In theory, NH should send POA a statement every 90 on it along with paltry interest. ((My mom 1st NH didn’t but 2nd & eons better NH did.))
No “on looking into LTF that take Medicare”. It’s only MedicAID, specifically LTC Medicaid program that pays for custodial costs at a facility. MediCARE does NOT; MediCARE is health insurance and pays only costs billable for health insurance benefits under Medicare. Like hospice, hospitalization, rehab, some physicians & therapist costs. Usually those in a NH are on 3 programs: 1. LTC Medicaid which pays room&board custodial; then are “duals” for health insurance under 2. Medicare and 3. Medicaid. If really low income States have special category programs to cover the gap. I bet that Care 360 is this type. Fwiw some states do entirely away with “duals” and put them under a single new # under a MCO managed care organization for health insurance. If you want to move her, it’s move her to another NH that accepts LTC Medicaid w/an open bed and assesses that they (the new NH) can provide the level of care required. It will not be simple; can be done but not straightforward & easy.
- “on line portal”. Good luck on that! Medicaid on line seems to be done for the nonLTC Medicaid programs, like Medicaid expansion, CHIP & WIC programs, low income Medicaid as health insurance. I know 3 who have done LTC renewals this year and all were sent snail mail packets with questionnaires & requesting documentation to be mailed or faxed back.
- “turn financial over to State”, LOL! personally I don’t see this happening unless you 100 % resign as POA and any involvement with your mom forever as you resign and petition to have mom become a Ward of the State of NC and the court appointed guardian for her then takes over all control & decisions. Like can move mom to another NH without your input. As long as you’re POA this stuff is all on you.
- “respond to my NH queries”. NH staff can only do so much. They are in many ways just another vendor trying to get paid by whichever Medicaid programs & by MediCARE in a timely manner. And for your mom, also getting paid by SSA as mom made them her rep payee.
fwiw that mom has done this will be a stumbling block to move her easily to another NH. Rep payee will have to changed by mom, as SSA does not recognize POA and could be 2 cycles; so likely old NH will have to refund however they do refunds; but the new NH will have to be paid accordingly as of date of move. You’ll have to cover the gap.