A Failure To Act

Medicaid is a health insurance program for needy individuals; however, unlike most health insurance programs, some programs of Medicaid will pay for long-term care costs, such as care in a nursing home.  Medicaid is a cooperative program between the federal and state governments.

Each state must voluntarily chose to participate in the Medicaid program.  Every one of the fifty states has voluntarily chosen to participate in the Medicaid program, including New Jersey.  When a state participates in the Medicaid program, the federal government contributes 50% or more of the cost of the program.

There are various programs of Medicaid in New Jersey.  The two main groups of Medicaid programs are community Medicaid programs and institutional Medicaid programs.  A community Medicaid program provides a traditional health insurance policy for needy individuals.  An institutional Medicaid program provides traditional health insurance and assists with the costs of long-term care services, such as nursing home care.

A state can also chose to expand its institutional Medicaid programs to pay for long-term care services at home or in an assisted living residence.  When a state voluntarily chooses to expand its institutional Medicaid program to pay for care at home or in an assisted living residence, the state is said to have implemented a “waiver program.”

New Jersey has several waiver programs that provide care to needy individuals at home or in an assisted living residence.  If an applicant for Medicaid benefits qualifies for a waiver program, he can receive long-term care services at home (such as a home health aide) or in an assisted living residence.

Currently, New Jersey’s waiver programs have an income cap on eligibility.  What this means is, if an applicant who has applied for a waiver service has income that exceeds a certain level, he cannot qualify for waiver services, no matter what assets he owns.

Currently, the income cap in New Jersey is $2,163 per month in gross income.  If an applicant’s gross income exceeds $2,163 per month, even by one penny, he will not qualify for waiver services even if he owns no assets at all and needs the services that the Medicaid waiver program provides.

In October 2012, the New Jersey Medicaid department received permission from the federal Medicaid department to expand New Jersey’s Medicaid program to cover those individuals whose income exceeds the $2,163 per month income cap.  To date, the State has failed to implement the new program.

The state was going to implement the new program in January 2013, then in July 2013, then in January 2014, then in July 2014.  At a recent meeting with the individual in charge of implementing New Jersey’s new Medicaid program, I learned that a July 2014 implementation date probably will not happen.

New Jersey is expanding its Medicaid program to cover individuals whose income exceeds the income cap because a decision of the United States Supreme Court known as the Olmstead decision and because the Americans with Disabilities Act compel the various states to provide care to disabled individuals in settings that are the least restrictive.  In other words, if a disabled (or elderly) individual could be living at home instead of in a nursing home, then the Medicaid program should assist him with living at home, not forcing him to live in a nursing home.

New Jersey’s new Medicaid waiver program has some admirable ambitions.  New Jersey’s failure to implement this program nearly eighteen months after they received approval of the program from the federal government is far less admirable.

Getting Mom into a Home

There are few people who want to live in a nursing home.  In fact, I have never met any person who wants to live in a nursing home when faced with the actual prospect of living in one.

With that said, there comes a time when people do have to live in a nursing home.  Some people’s care needs are so high that there family cannot care for them at home or they cannot receive the necessary care in an assisted living residence.

Many people seem to equate a family member’s residing in a nursing home with some sort of failure.  As if mom’s living in a nursing home means that the family failed to provide the care that could have kept her at home.  This simply is not the case.  In fact, failing to provide mom with the care she needs at home could be far more detrimental to her than living in a nursing home.

With that said, not all nursing homes are alike.  Some nursing homes are much nicer than others.  In order to obtain a fairly accurate ranking of nursing homes in your area, I recommend that you visit the Medicare website, www.Medicare.gov.

This site provides a ranking of nursing homes in a given area based on several criteria.  I have found the rankings on this site to be fairly in line with my general thoughts on a given nursing home.

I would also recommend that you personally visit nursing homes in your area to get a feel for the home.  You should arrive at the home unscheduled and request a tour.  You do not want to give the home the opportunity to stage your experience.

Once you have found a nursing home that you like, the question that may arise is, How do we get mom into this nursing home given her assets and income?  A nursing home can cost anywhere from $8,500 to $12,000 a month.  The better homes are in the $10,000 to $12,000 range.  Obviously, that is a lot of money on a yearly basis, and few people have sufficient assets to pay for that care for an extended period of time.

Most people enter a nursing home after being discharged from a hospital.  They enter the home for rehabilitation purposes.  Most of these patients/residents only expect to reside in the nursing home for several days to several months, and most will, in fact, only reside there for that length of time.

On the other hand, there are those nursing home residents who simply do not rehabilitated sufficiently to return home.  For these residents, the nursing home may become their permanently home.

Every week, I meet with clients who tell me that mom is in a rehabilitation center and they would like to get her into a nursing home.  When I tell them that mom is already in a nursing home, they often become incredulous, almost refusing to believe that the rehabilitation center is a nursing home.  I assure them that it is.

More importantly, once the nursing home has accepted mom as a rehabilitation patient/resident, the home, in most instances, cannot discharge mom if mom is desirous of becoming a long-term resident; this is true even if mom is going to qualify for Medicaid benefits immediately.

The nursing home may tell the family that they do not have a Medicaid bed or that there is a waiting list, but the fact of the matter is, mom is already in a bed in the facility and in almost every nursing home in New Jersey, every bed is dual certified for Medicare (which pays for rehab) and Medicaid.  So, the reality is, mom is already in a Medicaid bed.

This can be very helpful to a family that is feeling pressured by the facility and would prefer that mom stay put.