My mother is 90 and still lives in her home, with my unemployed adult brother living with her. Without going into too many details, I'll just say that for financial reasons my brother has been trying to keep her at home for as long as possible. She's had a few stints in a rehab after being hospitalized for illnesses (pneumonia) and they've been nice places, with good food and activities and even visiting entertainers. Each time I've gently suggested that she might be able to stay there one day, but she would start crying and getting upset, saying she has her own home and doesn't EVER want to go in a NH. I think she remembers the awful places my grandmother and great-grandmother were in the 1960s and 70s. She is a very stubborn woman and I've been dreading this NH issue for many years. It certainly hasn't helped having my brother side with her - it's been two against one. I am her DPOA, but do not have a medical POA; stupid, I know.
It's been a rough road the past few years and both my mother and brother, for their own personal reasons, have fought her going in a NH. It's now becoming apparent that we're nearing the end of the road for her staying at home and she will need to go in a NH soon. She is on a cocktail of meds that are keeping her fairly healthy for her age, but she has mild to middling dementia and worsening arthritis in her knees. There was an awful flareup of pain last week and an ambulance took her to the ER. They were unable to do much else but give her a painkiller injection and a lidocaine shot, along with a cortisone shot which didn't work. We didn't think she'd be able to get around the house too well when she got home (get on and off the toilet, etc) so we pretty much begged her doc to admit her, which he refused to do for an arthritic knee. We brought her home (with difficulty, after that painkiller), and she's been in pain but stable ever since. We have an appt with an orthopedic this week.
The helplessness we felt that night in the ER when told they us they wouldn't admit her was just awful. It was really obvious my brother wouldn't be able to handle taking care of her and I work and have my own family to care for. I asked to speak to a social worker about moving her to a NH that very night but was told since it was a Sunday night, there weren't any available. I think that night, coupled with my mother's increasing hygiene problems and dementia, has shown my brother that our mother can no longer live at home. I spoke to an elder lawyer a while back and the house will probably be transferred to my brother, as a "caretaker child". From that moment on, he'll own the house and be responsible for all the bills, which is the reason he's been fighting putting my mother in a NH for so long. Hiring an in-home caretaker is out of the question due to the cluttered condition of the home and other problems which I won't go into. We now have a home health aide coming in twice a week to bathe my mother and, while I'm thrilled that she's finally getting clean, it's been causing it's own kind of problems having someone come into the house.
I always thought my mother would move into a NH after another stint in the hospital and then rehab. I had hoped that it would be a natural progression. But it's obvious to me now that she'll probably need to go in one not due to illness but because of my and my brother's inability to care for her ourselves. My question to the message board is: how do I get her into a NH directly from her home? I can't imagine just loading her up into my car and driving her there; she would most likely throw herself out of the car. Is there a procedure? (I've already picked the NH). Also, does anyone have any advice on what we should do if (more like when) we're back in the ER with our mother and they won't admit her and there's no way she should be going home that night because we can't care for her? We're in NJ, by the way.
Thank you in advance for any advice or stories about your own experiences when moving a parent to NH directly from their home and how you got through it. I really appreciate your support.
Thank you,
Sue
MedicAID rules determined by each state & are state specific even though it is a federal & state program. Medicaid is needs-based. You are expected to spend your assets first and foremost before the state will pay. There are things you can do to reduce assets but these need to be done by someone qualified to do this that will pass your state's review. An certified elder law attorney is best.
For NH Medicaid eligibility, an individual must show that:
1) are 65+ (can be younger if qualified disability),
2) medical condition requires skilled level of nursing care,
3) monthly income at or below their states max (about 2K),
This is the “income test”– how much $ do you make. TX is $2,094.
4) all countable assets are at or below 2K
This is the “asset test” – how much $ do you own.
5) not gifted away anything of value during 5yr look-back period.
If you do, could be a “transfer penalty” when items are gifted. Penalty different for each state as it’s based on each state’s daily NH reimbursement rate. For Texas, it is $ 142.92 a day rate (2011).
Max look-back is 5 yrs. Most states require 3 – 6 mo. of financials with initial Medicaid application. Can require more financials if something pique’s interest. Financials are bank statements, social security and retirement statements, insurance policies, etc.
INCOME: If it is that every month they are over the states income limit BUT not enough to pay in full for the NH and qualifies for NH in every other way, then they can see an elder care attorney to do a "Miller Trust" or a "Qualified Income Trust". Say mom gets 1K from SS & 1,500K from retirement every mo. Income=$2,500. Basically $ 500 over ceiling for monthly income. No matter what is always is $500 over. So this excess $ 500 is what funds the trust and therefore mom’s income is now 2K and within the states income ceiling. The beneficiary of the trust is state's Medicaid program and upon death reverts to the state. Miller really has to be done by an attorney who does elder law as it needs to be flexible/adaptable and meet the criteria of each state's law on probate (death laws) & Medicaid rules.
ASSETS: All assets are counted, unless the assets fall within the short list of "noncountable" assets:
- personal possessions,
- a vehicle (some states have a limit on the value)
- their principal residence, provided it is in the same state in which the individual is applying & the house may be kept with no equity limit if the "community spouse" lives there; otherwise equity limit is 500K (750K in some). House does NOT need to be sold, is a "non countable" asset but elder will have no $ to pay for anything for house as all $ less a small personal allowance has to go to NH each mo.
- prepaid funeral(irrevocable, NCV, usually 10K max)
- small amount of life insurance (usually $1,500 & NCV)
All other assets (savings, stocks, whole life, rental property) are counted.Must “spend down” to get to their states max to qualify.
The financials are what most folks focus on. But remember that they also need to medically qualify for the need for skilled care for Medicaid.
This site has articles on Medicaid Medicare and how they are different. Also if you go back on this post to the beginning there are posts from myself & others with our experience in going thru the NH & Medicaid.
What you need to realize is MedicAID is a needs based program. So in order for your parent or anyone to participate and benefit from MedicAID you must be at-need. "At Need" basically mean they have +/- $2K each in assets and monthly income in order to qualify. But can have a home and a car (which are exempt assets). At-Need basically means they are poor and at poverty level. All their assets and income for 5 years prior to admission to a NH must have been used for them or their care (like private duty nurses or home health care agency) or their wholly owned property (like their home). If everybody could go and empty out our parents bank accounts and transfer all their property for zero to others today, and then apply for Medicaid tomorrow, the system could not pay for it and there would be no Medicaid program for anyone to be able to use.
If any assets or monthly income are transferred to you or others, then the state can impose a transfer penalty against the elder via their representative (this would be you as her DPOA) for the amount of funds based on the state's NH Medicaid reimbursement rate. The transfer penalty is a total cluster to deal with as it usually happens after the elder has been in the NH - perhaps for a few months - and then the state in it's require due diligence has found that mom transferred a car worth 20K and cashed in a 10K Treasury bill before she went into the NH. 30K transfer penalty. What will happen is that the state will send whomever is the residents family contact and the NH a letter that the elder is out of compliance with Medicaid and the $ amount and length of time. NH will require you come up with the $ and sign off a promissory note &/or hefty deposit or you get the dreaded 30 day notice (that they have to move and believe me no other NH will take them except by private pay contract with a deposit upfront). This is a total panic situation to be in and a terrible situation to place you parents in.
So in Texas, whose transfer penalty is about $ 145 a day, a 30K transfer would mean someone would have to private pay for 210 NH days. Each state's transfer rate is different. TX is a a low Medicaid reinbursment rate state.
Remember if and when you apply for Medicaid, you, as DPOA, basically sign off on an all-access pass to all your parents financial and legal. You have to provide for 3 - 12 months of their financial and asset and income information with Medicaid application. Which the NH usually vetts before they will even accept a resident as "Medicaid Pending". Many NH which have multiple homes have a regional admissions person who reviews whatever you provide before it even gets sent by the NH to the state program along with the NH's bill.
Property records are recorded by the local assessor and then folded into the state's data base, so moving property ownership will come out. Interest paid on savings or investments are available via IRS or state, etc. All their info is just keystrokes away and eventually it will be found out. If your state uses HMS for compliance, they will be able to find out to the penny every cent spent as HMS has a extremely good system via algorithms for compliance and recognizing patterns of fraud. HMS does compliance for Medicare (via CMS) & federal insurers.
For my mom, she was in IL before the NH, so her 6 months of bank statements (sent with Medicaid application) clearly showed where all her $ was going (to pay for IL) and showed a steady decrease in assets with nothing different or unusual. Even then, I had to go to her bank and have a bank officer do a detailed letter of all accounts, CD's etc. closed and where the assets went for 3 years prior. Fortunatly all closed went into her single checking account, so this was simple but took about 3 hours at the bank and I went prepared with my legal and all her account info. This letter was submitted with her initial application which ran over 100 pages of required documentation. Is it a total PIA? Yes, but every day I am grateful that the Medicare and Medicaid program exists as there is no way she or I could pay or provide the level of care that her NH provides for my mom, who has Lewy Body Dementia. Imho, if they live long enough (my mom is mid 90's) they will eventually run out of $$ and the caregiver will run out of ability (and humor) and thank goodness there is Medicaid for them available.
Actually I do sympathise. But what you, in return, need to recognise is that the dumping granny at the ER strategy is the last resort, often after years of her being turned away from other options because she's being looked after at home. Then her husband dies, or her child dies, or the caregiver breaks down in some other way...
Plus, you talk blithely about the children's having had years to plan their elders' care. HA! See if you can count the number of people on this very forum whose elders turn purple if anyone so much as breathes the word "plan." The children are not responsible for planning their care. The elders themselves are. They're the ones who've had the most advance notice and the authority to act. Why aren't you blaming them?
You see a similar dumping phenomenon with rescue animals, too. Most times the owners who abandon them are just callous irresponsible bastards. But sometimes there's going to be a heartbroken, grieving family in the background, whose circumstances mean they can't any longer take care of their beloved companion animal. Not don't want to, note. Can't.
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