Getting smart: nursing home + insurance edition

June 9, 2018 10:07 AM

My grandfather is having some health issues (currently in the hospital). He's likely to be discharged soon and released to nursing home/rehab care for at least a bit, if not long-term. We're trying to figure out the best way to go about all of this - he's got medicare, VA benefits, and also long-term care insurance. Which should we tap into first (understanding I don't have the full background on his long-term care insurance coverage yet)? How do these all work together? (In Indiana, if that makes a difference) Would appreciate any good resources for helping us make smart decisions in all of this. We've already spoken to the social worker at the hospital. Thanks!
posted by RunRunRunRun to Health & Fitness (5 answers total)

For the initial rehab part, I would guess that will go through Medicare, like it did for my father. He's a disabled veteran, and so gets veterans' disability payments, but we didn't use anything from that for rehab.

Medicare gives you a certain number of covered rehab days per year/after a qualifying life event, and then after going through rehab, if you meet the criteria for progress, they discharge you. This can happen as soon as a week in, depending on the level of progress they assess is possible to be made. It's important to be engaged during this process and make sure to advocate for as much rehab as possible, as this is the starting point in terms of their ability level when they leave the facility. Depending on the amount of assistance necessary with activities of daily living, the discharge may need to be to a long-term care facility such as a nursing home or assisted living facility. You can appeal the discharge on his behalf to your state's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) if you don't think he's ready to leave or hasn't made the progress suggested.

When it gets to the point of someone needing to become a resident of a long-term care facility, that's when ability to pay—and thus things like any veterans' pension benefits he might be entitled to, long-term care insurance, or occupying a Medicare bed in a facility come in. The last would only come into play if he doesn't have long-term care insurance, veterans' pension benefits, or sufficient assets to pay privately.

Since he has long-term care insurance, that would likely be the means of payment for long-term nursing or assistive care after discharge from rehab. The other potential means of payment are a lot more invasive in terms of their financial disclosure and documentation requirements and for us were only fallback options to investigate if absolutely needed.

For your family, this is the point at which you should probably ask the social workers at the hospital for a list of rehab, nursing, and assisted living facilities to investigate in your area, considering carefully his level of functioning, potential to recover ability to perform activities of daily living through rehab, proximity to family caregivers, etc. The social workers generally can't make a specific facility recommendation, but you should look up and/or contract local organizations that do provide such evaluations and recommendations for seniors. Look very carefully at reviews online. Visit any facility he might be discharged to and ask many, many questions. Visit any facility you're considering for long-term care and do the same. (These might be the same facilities, depending on what services are offered, but note that a facility's rehab and long-term care can greatly differ in terms of quality, often due to financial reasons. Rehab has a very straightforward pathway to the facility being paid and/or reimbursed for costs via Medicare, so often a facility might have great rehab but depressingly bleak spaces and options for long-term care.) Take notes and discuss as a family, but ideally schedule visits with as many family stakeholders as possible.

Also, if he doesn't have a spouse (or possibly even if he does, depending on their status), determine who in the family has power of attorney and/or needs to get it, and what estate planning documents might exist in that regard. We did not have that documentation at the time my divorced father went into the hospital, then rehab, then assisted living, but we had incomplete unapproved documents that we had to go through the process of having my father approve, then sign with the attorney, witnesses, and a notary present, so others could legally make care decisions and sign things on his behalf. There are different powers of attorney; at first, my father only delegated durable power of attorney (durable meaning the power persists after incapacitation or death) and made a family member a co-trustee of a trust that all accounts were then titled into, so they could handle financial matters and contracts on his behalf. Later, when he was ruled mentally incapacitated, the medical power of attorney kicked in, so they could make medical decisions on his behalf. It's also important to determine and document your loved one's DNR or full code status, which every facility will probably ask you about a million times (with good reason).

So those are a few initial thoughts! Hopefully someone can chime in with links to resources for all these types of things, and mention any exceptions to the process I went through in Missouri, that are more specific to your area. I'm sorry your family is going through this and I hope he can get the care he needs!
posted by limeonaire at 10:49 AM on June 9, 2018 [3 favorites]

When we got to this point with my mother-in-law, asking around + googling + talking to the social worker at the facility led us to an eldercare advisor -- a person whose job it is to know all the ins and outs of all of these things, plus all the local facilities. We did have to pay that person a fee -- which was somewhat expensive. Maybe around $600 if I remember correctly. I do remember thinking "Is this worth it?" and the resounding answer was YES.

This woman knew *exactly* what benefits were available, and more importantly, how to work the system. She was able to reduce my MIL's benefits in one category by something like $12, which then put her in a different financial category which meant other benefits were coverered at a higher rate -- which ended up saving us literally tens of thousands of dollars over the last two years of my MIL's life.

She knew how to use the various levels of the system -- what was Medicare and what was Social Security and what was (fill in the blanks -- I don't even know all the various parts).

This advisor also knew the local nursing homes and rehab facilities very well -- which ones were good or bad, which ones best matched our needs.

My MIL had a good death -- I think about this often -- and the craziest part of this is that so much of it was due to this eldercare advisor's skill. In the end, she was in an excellent facility which was totally unfancy and was covered by Medicare and was staffed with absolute angels.
posted by BlahLaLa at 12:03 PM on June 9, 2018 [2 favorites]

Medicare pays for the first 100 days of nursing home care following an acute care admission, if it is classed as an admission and if it lasts at least three days. The first 20 days are subject to no copay. The next 80 days have a $167.50 per day copayment.

Seconding Blahlala's recommendation for a paid advisor. Lawyers who specialize in elder law issues can advise and assist on payment issues if longer care is needed. This page leads to a listing.
posted by yclipse at 12:21 PM on June 9, 2018 [2 favorites]

Oh right, also, when you're looking at nursing homes, you can request to read through their logbook of quality of care complaints and how those were resolved, then ask any questions that come to mind. My brother and I did this and it was very edifying to get a sense of what a particular facility's strengths and weaknesses might be. Medicare's Nursing Home Compare provides some similar info and is worth going through for any facilities you consider. I remember being a bit disenchanted by how many facilities have routine violations of basic food and fire safety.
posted by limeonaire at 6:48 PM on June 9, 2018

So if your grandfather is having some health issues, and is likely to be discharged soon to a nursing home/rehab center (skilled nursing facility) limeonaire pretty much summarizes what to expect with one error. For long term care, or what is called custodial care in skilled nursing facilities, once skilled services are discharged, the payer source will be Medicaid once all other payer sources are exhausted, not Medicare - Medicare ONLY pays for skilled services.

Since you indicated that your grandfather may have veterans benefits and a long-term-care insurance policy there are a couple of other options in the near-term. VA benefits unfortunately are somewhat limited to what is called Aid and Attendance which would provide some assistance for placement in a board and care or assisted living setting. The big caveat here is Aid and Attendance is often for lower income veterans. That is to say, Aid and Attendance has a means test.

The best option near term is going to be to investigate the long-term-care insurance policy for what coverage it provides. Those policies can be very helpful however, they may be time-limited. They may also only pay for any portion of the total cost of long-term care defined as custodial care. Once long-term care insurance policies funds are exhausted then your grandfather might be facing private pay, out-of-pocket costs for long-term-care or custodial care with Medicaid (Medi-Cal in California) as the payer of last resort.

If he's married, there is an additional option, at least in California, I'm not sure about other states, called Medi-Cal (Medicaid) Long Term care. This would allow for his spouse to retain fairly significant resources and still be eligible for Medi-Cal (Medicaid). In California this is called the Community Resource Allowance (CSRA) and it increases every year according to the consumer price index. The current 2018 CSRA is $123,600. This would include liquid savings/assets and additional countable resources up to the limit. Additionally the California law allows the community spouse to retain a maximum monthly maintenance needs allowance of $3090 (2018). The whole idea behind this program was to make sure that the community spouse was not left impoverished by requiring a total spend down of all resources before the patient becoming eligible.

A great overview can be found at the website of the California Advocates for Nursing Home Reform, then look under Free Community Resources, and then Medi-Cal. For other states, especially with the changes under the Trump administration, it's hard to determine what regulations might be. You'll have to look at each particular state's program criteria.

You mentioned Indiana, so refer to this for an overview or this official Indiana government site for more information... It seems to be similar to the California Program, when and if the time comes when all other resources are exhausted.

Good luck...
posted by WinstonJulia at 4:07 AM on June 10, 2018 [1 favorite]