My Dad is in long term care and on hospice. I am his guardian and am learning as I go along. I missed his Medicaid redetermination deadline after he was only on it for 5 months. I quickly sent in paperwork and documents because we have a 90 day grace period to submit but his coverage was dropped due to the lateness. I’m so scared. I call them often and the first few told me it was processing but then I was told I was missing something and 2weeks later I was told it was the wrong application. I actually had some one tell me it was denied due to being over income limit which can’t be the case because nothing has changed about his income. Then the next person couldn’t tell and that it was processing. His nursing home has been harassing me. I’m terrified! I can’t sleep or eat. Would they actually kick a man in hospice out until the decision comes through?
Most enter the NH as a post hospitalization patient discharged for rehab within a NH/SNF. Using health insurance policy benefits for rehab stay. He’s on MediCARE and on 1. Original Medicare and a gap/secondary/supplemental health insurance (like BCBS, Humana, or Medicaid as health insurance which is different than LTCMedicaid but interwoven) or 2. He left OGMedicare and gone into a Medicare Advantage Plan. So what was he on for health insurance & what has been his benefits? when did rehab precisely end? Once rehab ends, if he stays he segueways from a rehab patient (on insurance) to a custodial care resident. Custodial is paid either by private pay, LTC insurance or LTC Medicaid if low enough in income and assets with no “gifting” issues based on a 5 year review.
NH can kinda tell what’s going on in rehab and so usually start the LTC Medicaid filing process, so that it dovetails. But he or you as his POA have to provide all the various info as to his assets and income that his States LTC Medicaid wants. What happens is initial application filed & he is given initial “Medicaid Pending” status. “Pending” can b pretty automatic. While Pending he should be paying NH all his mo income less a smallish Personal Needs Allowance. He does a Share of Cost. Most States PNA $50-$75. Pending tends to be a 3 mo process while State finishing more deep up to 5 yr review of assets & income. Can go longer. 6 mo kinda max.
Redetermination is - in my understanding- different than recertification. Recertification is annual process. That it’s being done at only 6 months in, to me, is happening bc there is an issue with something found in 5 year review of income and assets. Something seems amiss. Go over all correspondence btw State & your Dad/you/NH to see what’s what and then contact Medicaid to what they precisely need.
As an example, let’s say Marie, age 88, on OGMedicare & “gap” BCBS, falls in her apt, breaks a hip, EMS takes her to ED/ER. Hospitalization & surgery, discharged after 1 wk to a NH w/rehab unit. In rehab 5 weeks. MediCARE pays 100% 20/21 days & @ 50% remaining 5 weeks. BCBS pays her other 50%. NH happy as Health Insurance rehab benefits pays abt double+ what LTC Medicaid would. BUT Health Insurance rehab benefit ENDS once discharged at 5 weeks. Marie cannot go back to her apt so stays at the NH. Marie has 10K in the bank & $2500 a mo in SS and no other resources. She pays NH 1 mo then files for LTC Medicaid. All done @ the NH. Status is “Pending”. Her State does what most do for LTC which is max 2K assets & $2980 a mo income. She is under so Pending seems ok. Then caseworker review via State data files, it shows her home sold under FMV 4 years ago. Tax assessor had house @ 290K but sold for 50K in 2022 & buyer has same maiden name as Marie. Pending suspended till redetermination completed. POA unaware of house sale deets back in 2022. Marie / her POA cannot show house value to realistically have been 50K. Buyer was a niece & has no responsibility to-now in 2026- pay Marie higher value or title house back to her Aunt. Marie gifted 240K in assets. Her State LtC Medicaid pays NH $285 day. Marie has 842 days asset transfer penalty that started the date she file for LTC Medicaid. Ineligible 2+ years!
Stuff like this happens. Often POA unaware. Important you asap find out precisely what is missing or questionable in dad’s past. Hopefully, something simple. NH is nervous as they know could be stuck w/6 mo partially unpaid bill on a resident on hospice. fwiw they will find a legit way to have him leave if you do not personally take financial responsibility.
Hospice is a MediCARE Part A benefit. Whether he stayed on Original Medicare or went to a Medicare Advantage, hospice is paid by Part A. Fwiw the Advantage Plans step back when hospice is involved and the hospice billing is paid by Original MediCARE even if they continue to be on an Advantage Plan for other billable to health insurance costs. Yeah, it’s convoluted but tends to be all behind the scenes for billing that’s done.
The important part is MediCARE pays the hospice agency NOT the NH. So his bill for his custodial care stay at the NH is still owed….. if he ends up be ok for LTC Medicaid, then the State pays whatever negotiated day rate to the NH starting the date he became a custodial care resident and filed for LTC Medicaid and he pays his Share of Cost of all his income less his PNA every month to the NH; …… but if he is redetermined to be ineligible for LTC Medicaid, then his custodial care bills are owed to the NH at whatever rate they set (private pay rate or lower LTC Medicaid rate or something else), starting the date he went off of rehab.
His hospice bill - either way - is paid by Medicare to the hospice agency as it’s a Part A Medicare as health insurance benefit.
The anxiety was beyond belief, even with a lawyer navigating this because even though my lawyer did his job he was not reachable if I had questions which only added to my anxiety.
My suggestion would be to find yourself a good Medicaid expert that knows the ropes and can navigate this. Most of these people worked at Medicaid and know who to call. It is money well spent if you can afford that. Here is a link to find someone near you: https://cmpboard.org/locate-a-cmp/
If it is any solace, my father's situation eventually was resolved. Your's will also. Take care of yourself, you will get through this.
Was Dad on any type of Medicaid before entering the NH? Because if he was, the LTC paperwork is probably different than the health insurance or even in home help.
I agree, you need to talk to the financial office. Someone there should understand Medicaid. Your Dad should also have a caseworker with Medicaid.
Medicaid redetermination paperwork, IME, is time sensitive. I am given a date to get to get it back to the office which is about a month. In my State that 90 days refers to having the initial application completed in 90 days from date of application. This gives you time to spend down any money they have, get info needed together and if not already placed, find a facility to place them. If not done within that 90 days, you start over.
Request a meeting with the nursing-home administrator or business-office manager, not just whoever is calling about the unpaid balance. Tell them:
“His Medicaid redetermination/reinstatement is pending. I need you to document his account as Medicaid pending and work with me to resolve the eligibility issue.”
If the facility actually threatens an involuntary discharge while Medicaid is pending, that's the point where you should contact the state Long-Term Care Ombudsman immediately. CMS's guidance on this particular issue is unusually clear.
If Dad's Medicaid eligibility determination is actually pending, a Medicaid-certified nursing home cannot simply discharge him for nonpayment while Medicaid is deciding his eligibility. CMS specifically addresses this situation in its nursing-home regulations and guidance.
That said, stop relying on repeated telephone conversations with different Medicaid workers. You've already been told several contradictory things—processing, missing information, wrong application, over income, etc. You need to establish in writing exactly what the status of his case is, what was submitted, what (if anything) is missing, and whether his case is being treated as a late renewal/reconsideration or as a new application.
Keep copies of absolutely everything you submit and proof of when it was submitted. As his guardian, I'd also ask the nursing home's business office/social worker to help you straighten this out. Medicaid-certified nursing homes routinely deal with residents whose Medicaid applications are pending.
If his income and assets truly haven't changed and he qualified only five months ago, an alleged “over-income” denial deserves investigation. There may be an administrative/documentation problem rather than an actual change in eligibility.
And don't let the nursing home intimidate you into personally agreeing to pay his bill. You are his guardian; that doesn't make his nursing-home debt your personal debt. His funds are used according to the Medicaid rules, but don't sign anything accepting personal financial responsibility.
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