Does Medicaid pay for the remainder of balance after your monthly checks?

Sassy, as others have aptly posted lots of red flags flying on this NH. Office manager 100% wrong if expect you or your mom to pay any “gap”. Mom only required to do income based copay less her personal needs allowance.

What exactly a NH is paid for LTC Medicaid room & board rate is dependent on how your State administers its program. Seems to avg abt $190 day as some So. states pay low. A custodial care resident on LTC Medicaid is only responsible for a copay of their monthly income(s)(SSA income or a pension or an annuity) less your States Personal Needs Allowance ($30-$140) & less a waiver due to a dependency (like community spouse) if that exists. So a widow in TX with SSA $2050 has NH copay $1990 as TX has $60 PNA. No extra charges for basic room & board type of services & NH have to provide for snack available throughout the day. But NH can bill for cable, in room phone, field trips, beauty shoppe.

When I looked at NH in TX, many had cable & in room local phone “included” but on further examination NH were billing $60 for this & paid via the PNA$ by becoming SSA representative payee. NH really pushed their being rep payee. & a couple said it had to be done this way, which isn’t accurate. Now it can be easier for families. But you as POA do not have to do this & if you ever need to move your elder to a new NH, changing rep payee from NH1 to another will be a beast to do.

But I digress, If you also have other issues with the facility, I’d move her & do it via a “lateral transfer of care”.

I did this for my mom. Bit of a ballet. So need to plan it out. If still under “Medicaid Pending” status, imho, you should wait till she clears LTC Medicaid application totally and you get her eligibility letter with her exact copay info. Why? Well this NH still has to get details to the State to get that application done and can be petty and foot dragg if they want to. So wait to get her 100% approved and be 100% ok & current on her copay & billing. But keep her PNA $ - personal needs allowance- to a minimum or none at all. And do NOT let NH#1 become her representative payee for SSA or any other income. Ya need to be able to control her income & how her copay done in my experience.

Now if already LTC Medicaid approved, then with that letter you can go & shop around for a new NH. For my mom I went to one that had its medical director with my moms old gerontology group and they put mom on their wait list, which came up pretty quickly. I did initial paperwork which included a request to send over an assessment duo. RN & SW visited mom bedside and call me from there to tell me all ok for mom meeting the level of care at their NH capabilities. I went over later that day to sign off transfer. Did actual transfer first of the mo after mom got her 2 incomes. Paid ea NH prorated % to the penny for that new mo from moms checking account. Zero $ in her PNA at NH #1. & I had started to move stuff out ahead of time so day of move, really just mom, a tote bag, her purse and a train case. VERY! IMPORTANT! new NH told me I had to, HAD TO, get all of her medications from the nurses stations. This would be something I would never have thought about. These are done in 60/90/120 day blister packs hanging on racks. MediCARE will NOT pay for duplicates so if you don’t get these, you will have to pay for the refills. Could be serious $$$$$. The charge RN was fairly hostile on this but I was ready with ziplocks and Sharpie to put the meds in. Other than that, on retrospect, fairly organized easy and got her to NH#2 mid morning. I set the room up late afternoon before. As lateral transfer, with an assessment, it’s all good for LTC Medicaid. NH can see the LTC Medicaid recipient history so you do want to make sure always current on the required copay.

If NH hasn’t been clear on the PNA…. like how the account is available, not sent statements, has billed items on it; or not even explained it at all, I’d move her if u have options available.

It gets a little more complicated when a spouse applies for nursing home assistance from Medicaid and the well spouse remains in the home and retains his/her own income to live on. Preparations must be made for the division of assets before applying for Medicaid for the other spouse. In states that are community property states, you will have to consider ALL income and all assets in order to avoid leaving the home spouse destitute! I suggest consulting a lawyer ahead of time

She is wrong. Family pays nothing when Medicaid is involved. Do not sign anything that makes u responsible. Always sign as POA if u have it. This is Moms debt not urs. Like I said she hands over her monthly income and Medicaid pays what the NH has contracted for. I would call Medicaid and run this by them. This clerk is giving out wrong info or the NH is taking advantage of recipients families. It needs to be reported. Yes, I would keep looking.

Joann29
im not worried about the % of anything. What I’m worried about is that she told me after the the checks were taken and Medicaid paid a “certain percentage”, that I would be responsible to pay even more. That’s the only thing I was worried about. After talking to several other places & making phone calls, this appears to be something this NH tells several patient family’s.

Really, why are you worried about the % rates. When on Medicaid, Moms monthly income goes to her care. If NH offers Medicaid, then they cannot bill for any extra. They except what Medicaid pays them. Mom pays her share and Medicaid pays theirs and that is what the facility has to except. They cannot bill family or recipient for any extras. Mom is receiving Medicaid. Everyone knows she is spent down to nothing. There is no reason for them to expect more than they are receiving. If the NH is having a problem with Medicaid, thats between them and Medicaid. If Mom is giving them her SS and any pension she is receiving and she is 2k or under in assets, she is doing her share. She owes them nothing more. If the NH is trying to bill Mom more, report it to her caseworker.

Your Mom probably has Medicaid for Health. Medicare pays first Medicaid picks up the balance. You will never see a statement from Medicaid because they just pay and if they didn't the provider would suffer the loss because they excepted Medicaids terms and conditions when they contracted with them.

Thank You for the replies. I thought that was how it was supposed to be.
this is a Nursing Home not assisted living.
but I will be pulling my family member out of there. I’m not impressed with them. I’ve been lied to more than once about their rates. Everybody tells me something different in there. Thank You

I have to agree with IsThis. Medicaid does not pay the balance. My Moms NH bill when she private paid was 9300. When she went on Medicaid she gave the NH her 1700 a month and Medicaid paid about $2000. So the NH got about 3700 a month for Mom. Like anything else, these facilities contract with Medicaid and except a lower amount than if private paying. My Mom still had her house when she passed and Medicaid put a lien on it. Mom was on Medicaid July, August and till the 23rd of Sept. The lien was just short of 6k.

I have worked with government agencies and not one of them paid full price. They negotiated a contract with the companies I worked for and that is what they paid.

Is this a Nursing Home or is it Assisted Living or a Group Home?

This NH sounds really unscrupulous and like they are NOT being completely honest. I would recommend getting a second opinion from a different facility and if you choose this one, have an attorney read and approve the contract. If you don't, you could be unpleasantly surprised.

Both of your questions about information this facility has provided throws up waving red flags. Please protect yourself and your loved one.

Newbie, not to contradict you but, Medicaid has set rates that are far below the self pay rate.

The facility does get all of the monthly income, less PNA but, they contract with and accept the predetermined rate that Medicaid pays.

If Medicaid paid the self pay rate balance, every facility would offer all their beds to Medicaid.

Medicaid does not pay a fixed percentage of LTC costs. The recipient is expected to pay almost all of their monthly income to the facility and then Medicaid pays the balance. The recipient is allowed to keep a small amount from their monthly income as a "personal needs" allowance (PNA). The amount of this personal needs allowance varies depending on the state, since Medicaid is a state-administered program. The Federal minimum is $30/month but in most states it's higher. This table is useful in comparing each state's asset and income limits for Medicaid and the amount of the PNA. https://gotltci.com/2023/01/what-your-state-lets-you-keep/

To illustrate, let's say a person has $2,000/month in social security. The personal needs allowance in the state is $40. The facility's monthly charge is $8,000. The person would pay $1,960/month to the facility, keep $40/month for their PNA, and Medicaid would pay the balance owed to the facility, $8,000-1,960 = $6,040.

Medicaid pays the balance of the bill after the person on Medicaid pays as much as he can through his monthly checks. To say it another way, all of your monthly income goes to the nursing home except a small amount , around $60, for personal needs like haircuts, and Medicaid pays the rest of the bill.