Managed Long Term Care for Medicaid

After some back and forth with Fidelis, they scheduled a nurse to come visit my mother and assess her need for home care. I made a trip out to meet her. The nurse was very nice (despite discussing the fact of my mother's dimension in front of her) but seemed to suggest that I would have to sign over all the money my mother was depositing to the Pooled Income Trust to them. I explained that if she did this she would not be able to pay her bills and remain in her home. We went back and forth for a while until I realized she didn't really understand how it worked. This has been something I've notice throughout this process and I'm not saying this to deprecate any of the workers. It is a very complicated system and everyone knows what they need to know. Nobody knows how the other piece of the puzzle works. This is probably another reason people use Eldercare Attorneys. It's their job to negotiate this system. Returning to the nurses assessment, she finally explained that they could offer 8 hours/day of home care. I explained I already had 8 hours/day of home care. She was very understanding and recommended I shop around to see if I could do better. I was very disappointed but immediately contacted two other companies and had nurse evaluations scheduled. Today I met with Centerlight. They nurse was very nice and straightforward and after asking as a number of very detailed questions and stated they could offer 16 hours/ week. She was very apologetic about this and recommended we continue shopping around. It should be noted that both nurses, unofficially, acknowledged my mother's need for 24/7 care, but both were bound by a very rigid system which uses ADLs to determine home care need. The nurse from Centerlight, explained that another client who required assistance with everything received minimal home care. I have an appointment with Guildnet in about 10 days and play to schedule one with Elderserve.
If it turns out Medicaid Long Term Care only offers 8 hours/day of home care it might mean Medicaid doesn't make sense at this time, and I will have to try again when my mother's condition has deteriorated further.
I used this guide for Long Island Managed Long Term Care companies to help me choose which companies I contacted: http://www.health.ny.gov/health_care/managed_care/mltc/consumer_guides/long_island/

Applying for Medicaid

After establish a pooled income trust and seeing that my mother's assets (those not in a trust), were now within the Medicaid requirements, I began the application process. I consider myself a fairly intelligent and capable person. I have a Masters Degree. I've run my own business for close to 15 years. I manage my own finances and my mothers. I'm familiar with negotiating paperwork and I'm excellent at multi-tasking. The Medicaid application was daunting but I was determined. Over a period of about 2 months I put together the laundry list of documentation requested on the application. I'm also working, in school, have a child, and manage my mother's life as well, so time is limited. I sent the thick packet, with cover letter, to Medicaid via certified mail. I felt I had gone above and beyond, including copies of the trust and other information that wasn't required but might help clarify the entire financial picture. About a week letter I got a response from Medicaid saying that I was missing numerous items and had until the end of the week to send the missing information or the case would be closed and I'd have to start from scratch. I called the worker, whose name was listed on the form, and pleaded my case, explaining it wasn't enough time to gather the missing documents. The Medicaid worker was very nice and gave me another week. I sent another packet, thicker than the first, via certified mail. After more back and forth I ended up sending two more envelopes to Medicaid and my mother was approved with a "spend down". This was when I learned that Long Term Care Insurance reimbursement was counted as income. They added $3400 / month for this reimbursement. At this point I have followed up and explained that they only reimburse up to $100/day so it is impossible to be reimbursed more than that. They calculated this number based on reimbursements I had received the prior month. Because it is based on time sheets, and there is a delay in reimbursement, one month might be less and another more. I'm hoping they will bring this number down to $3000. Initially I was shocked that they considered this income but now I've adjusted and am trying to find a way to handle this. I've learned that, sadly, many people actually cancel their policies in order to qualify for Medicaid. I could deposit his money into the Pooled Income Trust although it would be tricky because reimbursements come in piece meal during the month. The problem is I can't pay the independent aides I hired with the Trust. The Trust will only pay an agency. Agencies charge about $25 an hour (often paying the aides $10 or less/hour) so if I did switch to an agency I'd be getting 4 hours for the same $100 instead of 8, and very likely losing the trusted aides I hired because I doubt they'd be willing to take that cut to their income.
The idea was that Medicaid would eventually pay for the home care and not just 8 hours but what my mother really needed 24/7. This was my idea anyway. Medicaid explained that I'd have to sign on with a managed long term care company who would handle the home care. There are over a dozen of these companies covering Nassau county so I checked some ratings on the Medicaid site and called the number.

Using an Eldercare Attorney

I was referred to an Eldercare Attorney from a friend of a friend of my mothers. I had no idea about any of this so I appreciated the referral and contacted the attorney for a consultation. It was $450 for the consult which would be used towards any fees if the attorney was hired. After meeting the attorney I felt I could trust him. He was very warm and seemed to know his stuff. I was glad to get the help. The service ended up costing about $5500 for a package that included putting my mother's home into a trust to protect it, putting some assets into this same trust, setting up a will, power of attorney and some other items. If you have a home and need home care or go to a nursing home, you could very well end up losing your home to pay for the cost of the care. Although Medicaid will allow you to live in your home, when you die they will put a lien on the home to recover the cost of care. If you want to leave your home to your loved ones putting it in a trust is a good idea. As for your other assets, Medicaid in New York allows you to keep about $14,000 in cash. If you have additional funds you will have to spend those funds first before they start covering your services. You are only permitted to make a certain amount to qualify for Medicaid. It's $809/month in New York. Anything over that in monthly income has to be "spent down". This means that if you make $1000/month, you can give Medicaid $191 and they you can get services. You can also setup what is called a Pooled Income Trust. You can deposit excess income into the trust every month. You cannot get this money back but the Trust can pay certain bills. They will pay most expenses related to your residence and they can also pay for home care but they will only pay to an agency. I had hired my aides independently and the trust will not reimburse independent home care providers. To establish a Pooled Income Trust I had to pay the attorney another $3500. Like applying for Medicaid there is a lot of paperwork involved.
Although I initially liked the attorney I was very disappointed when they very clearly erred when calculating the amount I had to deposit into the Trust. I knew it was monthly earnings - $809. It's not complicated math but somehow they disregarded some of her earnings. I informed them of the error and they corrected it. About a week later I had to use the funds from one of my mother's investment to pay for home repairs (her roof needed to be replaced). This meant closing a fund and losing the monthly earnings it provided. I knew this would mean the amount deposited to the Trust would have to be adjusted. I contacted the attorney thinking it would be a simple matter of subtracting that amount from the total. They informed me that, although they had just calculated the correct amount a week earlier, it would be necessary for me to come in for a $450 consultation if they were to adjust the total amount. I was upset and declined their offer. I later learned that Long Term Care Insurance reimbursement is also considered income by Medicaid standards. They did not warm me about this or calculate this piece into the total. This means that if you are reimbursed $100/day for home care by a long term insurance play you are "earning" approximately $3000/month. This is money you will be required to "spend down".
The attorney also explained they can apply to Medicaid. This service would be another $5500. I declined and decided I'd try to do this on my own. I was disappointed to lose faith in an attorney I hoped to build a lasting relationship with. Now I'm once again on my own.

Long Term Care Insurance

My mother has Long Term Care insurance that she purchased through John Hancock over 17 years ago. She paid a couple of thousand dollars a year for this policy which provides up to $100 of home care per day. If you use $100/day it will last for 3 years. In order for it to be activated I had to file a claim with John Hancock, prove medical need and finally a nurse was sent to assess her. The nurse was very sympathetic and felt my mother should have 24/7 home care and so the policy was activated. First it was necessary to get all home care attendants approved by John Hancock. I did this and went through a number of people before finding two I felt comfortable with. I learned that $100/day pays for 8 hours at $12.50/hour. Before John Hancock would begin paying the policy it was necessary to get through a 100 day "elimination" period. This is standard, from what I know. This means I had to show I was paying out of pocket for 100 days before they began reimbursing me. You don't have to pay $100. You can pay less but you can't really hire people for 1 hour a day. I chose to hire people for 4 hours/day for about $50/day. 100 days never seemed so long. The insurance company requires time sheets be sent in showing what the aides are actually doing and they must be signed by both the aide and a representative or policy owner before being sent in. I did this for 100 days and now they are reimbursing me up to $100/day. It's been very helpful but 8 hours/day does not seem adequate at this stage. Usually 5-20 minutes after the aides leave my mother calls me because she is alone in the house and no longer remembers that anyone was there....so she is alone and feels like she has been alone for a very long time. She has not context to judge her aloneness. She is also pretty helpless as she cannot really cook a meal without someone. The knobs for the burners have been removed to avoid her forgetting to turn the burners off. She nibbles on fruits and food that has been prepared earlier in the day. I have to leave cash for the aides so that they can shop. I had tried having my mother manage her cash for a long time but she would keep on losing it or finding cash I hid and then losing that. This system works better.
One option for dealing with this "income" being added to your spend down is having the long term insurance company paying the money directly to another agency. John Hancock can do this but it is not clear how this would work with a Manager Long Term Care Insurance Company and if they could pay directly to another insurance company.

Background

My mother is 82 years old. She has dementia. You can probably call it Alzheimer's but that is not something that people generally diagnose until after someone has died. At the present moment she is OK in the moment but cannot remember things that happened a minute earlier. Parts of her history have disappeared from her memory or are significantly distorted. She can walk on her own but she is a bit wobbly and has very poor stamina. When we leave the house she is always someone's hand or arm. If she didn't she would be in danger of falling. She is able to feed herself, manage her toileting, wash herself, get out of bed or from a seated position by herself (although she will ask for help getting up if someone is around...it's difficult for her). I mention these things because they are the major factor in how you are assessed for homecare. There are six basic ADLs (Activities of Daily Living): eating, bathing, dressing, toileting, transferring and continence. Despite my mother's memory impairment she can manage her ADLs. She also has a history of a quadruple bypass, breast cancer and has diabetes. She cannot remember she has these issues, to take her medications, to eat regular meals (she eats when she feels like it), to wash herself, to change her clothes, but she can physically do these things. 

She has lived alone in her house since my father died over 20 years ago. I worry that she might fall or wander off or burn the house down. 

About this blog

The purpose of this blog is to serve as an aide for those who are in the process of applying or contemplating applying for Medicaid Long Term Care either for themselves or a loved one.
A disclaimer about any information I provide....I'm not a professional. I'm simply sharing my experience and my opinions and feelings about my experience dealing with this process. I recommend you consult the Medicaid site (http://www.medicaid.gov/) and / or an elder care attorney before undergoing the process independently. It is also important to realize I'm in New York and my mother resides in Nassau county and Medicaid rules vary by state and county. I hope you will be able benefit by some of things I have learned.