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Old 04-10-2015, 02:30 PM   #21
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Originally Posted by ERhoosier View Post
Sadly, I cannot agree- at least in the states I've lived and/or had NH contacts via relative & friends.
First- Many NH's are not accepting Medicaid, and folks can be forced out of their NH when their $$ runs out and Medicaid takes over. Feds try to put a positive spin on this by saying... "In many cases it is not necessary to transfer to another nursing home when payment source changes to Medicaid NF."
Nursing Facilities (NF) | Medicaid.gov
They could have phrased the situation differently and said in many cases it IS necessary to transfer when changing to Medicaid. Sure some NH will let a resident stay after switch to Medicaid, but seems that fewer are doing so with each passing year.
Second- There can be significant differences in the care actually received by Medicaid vs insured/self-paying patients. Note the list of services NOT covered by Medicaid. Some very important therapies (PT, OT, ST, etc.) are not covered by Medicaid. As in no $$ no service. Another noncovered "service" that I've seen with relatives/friends is the "specially prepared food", which can be a notable step up from the "generally prepared" NH fare. How does a NH resident on Medicaid pay for any of these "extras" after spending down most all their assets to meet eligibility

Fact is that there are many very valid reasons to get LT care insurance &/or set aside personal assets for one's potential NH care. Medicaid is a basic (often VERY basic) safety net, not a long term financial plan.
As a self-pay patient you could afford extras, since you would not qualify for Medicaid due to having too many assets. Most patients come in as self-pay or self-insured to start off. Once they have "spent-down" to under Medicaid limits Medicaid takes over.

So the question is - are the uncovered services in a nursing home, that you pay for, worth the hundreds of thousands of dollars needed to pay for them? I think I would eat slop if I knew hundreds of thousands would be going to my heirs (with a proper estate plan) as a result.
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Old 04-10-2015, 03:06 PM   #22
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Originally Posted by jim584672 View Post
You say a "Medicaid nursing home" as if there are scores of non-Medicaid nursing around. This is simply not true. Almost all nursing homes accept Medicaid. If you want to pay the bill yourself fine, but you will get the same care as someone on Medicaid.
I will take issue with this.

I think this varies quite a bit. I've done a lot of talking to facility directors at nursing home facilities in 3 states in trying to come up with a plan for my FIL (who has since passed) and now for my MIL. One of the questions I ask when I'm asking questions about pricing, staff levels, what is included, and availability, is "do you accept medicaid".

I would put the figure at about 50/50. This is for the San Diego area, the Lexington area, and the Philadelphia area. (All have family nearby so are possible areas.) Several that took medicaid, eventually, required that you show you would be able to pay full freight for at least 2 years before accepting you as a client... they wouldn't kick you out when you ran out of money and went on medicaid - but they didn't want the lower medicaid rate from the get-go.

For the ones that said they didn't take medicaid at all I asked what happens when a long term resident runs out of money... the answer was variations of "we contact the family and if that doesn't work, we find a facility that takes medicaid and arrange a transfer." In other words - they turf the resident from what has become their home.

One facility we've looked at closely is a continuing care community. They charge a higher monthly rent up front but the rent/cost doesn't go up as you move from independent to assisted to nursing. They do not take medicaid at all. They do a full financial analysis of your assets before accepting you as a resident. It's very nice (I know a few residents there in independent apartments). I can see the attraction if you have a pension that will cover most or all of the high monthly rate.
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Old 04-10-2015, 04:33 PM   #23
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Question - I imagine that nursing homes, like mortgages lenders, get a full view of one's finances. What prevents them from setting the price at a level that tries to extract as much as possible, without being too obvious, before one dies? Does one customer know what another customer is charged for room, board and specific services?
If I were shopping for a nursing home I'd do it in the opposite order. You tell me what it will cost to stay here and if I choose your place, I will furnish proof that I have the means to pay the bill.

Someone mentioned that most nursing homes take Medicaid plus non-Medicaid patients, which is true, but my aspiration, if I decide I don't want to live on my own, is to move into a continuing care community. This is an Erickson community. You don't like the one you're in, our your kids moved to AZ and took the grandkids with them? That's OK- you can move to the one in AZ. One near me sends out a newsletter and I still remember the article about a group of ladies in their 90s working on a prairie grass restoration project, with help from other residents who were building bird houses in the workshop.

I'm guessing they don't take a lot of Medicaid residents.
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Old 04-10-2015, 05:07 PM   #24
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Originally Posted by Tadpole View Post
Question - I imagine that nursing homes, like mortgages lenders, get a full view of one's finances. What prevents them from setting the price at a level that tries to extract as much as possible, without being too obvious, before one dies? Does one customer know what another customer is charged for room, board and specific services?
With both parents the prices were published up front. Obviously there were add ons that also had prices listed.

If everyone isn't suffering from severe dementia many talk about prices, food quality, lack of ice cream with birthday cake. Many with severe dementia will join in too, it's hard to tell if they really understand.
It'd be tough to hide any major differences, but this years "Better call Saul" made a point about overcharges to SRs. in a home.

Someone already said how cruel dementia is, so sad.
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Old 04-10-2015, 05:49 PM   #25
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When my mom was in the memory care assisted living place (last year and a half of her life), I noticed that nearly everyone there was so engrossed in their own private world that they didn't seem to even notice what anyone else was doing.

It was a pretty nice place ($5,500 a month in 2010, fairly low cost part of the country). Staff was professional and caring (I visited at least twice a week).

So my observation (N=1) is that the folks in these places are not as stressed by the environment as the rest of us are. My mom, for example, never had any complaints about it -- she enjoyed the attention and the opportunity to interact (as much as she could) with others. Actually an improvement (from her perspective) from her former abode in a retirement community where everyone had their own apartment and mostly hibernated there.

Just another thought that might be comforting.
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Old 04-10-2015, 06:13 PM   #26
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Originally Posted by MichaelB View Post
From the same article


Keeping in minds that the nursing home means the patient requires continuing medical care. Dementia patients can live in Assisted Living, which costs much less.
I think you meant to say "Some dementia patients can live in Assisted Living which costs much less."

Others require constant supervision, even more that many nursing home residents with medical needs.
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Old 04-10-2015, 06:38 PM   #27
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You say a "Medicaid nursing home" as if there are scores of non-Medicaid nursing around. This is simply not true. Almost all nursing homes accept Medicaid. If you want to pay the bill yourself fine, but you will get the same care as someone on Medicaid.
You're missing the difference between homes that don't accept Medicaid period, homes that allow clients who run out of private funds to remain on Medicaid and homes that accept Medicaid clients from the start.

I have recent experience NH shopping in the NE Illinois (Chicago and collar counties) area. We found that a lot of NH's here do not accept Medicaid clients who cannot private pay for some significant amount of time (frequently looking for two years). They do accept private pay clients who might outlive their personal resources and eventually switch to Medicaid, but don't accept Medicaid patients from the get-go. Some don't accept Medicaid at all, even if you start private pay. Some accept clients who are Medicaid from the get-go and those NH's tend to be near 100% Medicaid clents. NH's who accept Medicaid folks from the get-go tended to be, uh, crappy.

My MIL could private pay for more than a year. Additionally, she started out with the 100 day Medicare coverage allowance, so close to two years total. Her only ongoing income is SS, which the NH receives. The home we finally got her into reviewed her finances, her health and us. This home has Medicaid clients (MIL is now one) but keeps all Medicaid beds filled with folks who started as private pay. No Medicaid folks admitted off the street. So far, we're happy with this place. MIL has needed a significant amount of medical care and their staff seems very good.

We looked at 3 homes which accepted Medicaid patients from the get-go and did not like them. We're in Illinois where NH's struggle to receive Medicaid reimbursement from our financially destitute state. If you live in a more prosperous state, things might be different.
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Old 04-13-2015, 12:56 AM   #28
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The above is pretty much true in my experience as a geriatric psychiatrist regarding patients starting out private pay and switching to Medicaid.

Most private pay patients or their families do not pay for physical therapies and rehab out of pocket. It is quite rare. Medicare has changed the rules in the past year or so about who can have "restorative" care, meaning instead of stopping therapy when the patient plateaus, Medicare will now pay for a certain amount of rehab to keep the patient at their current level of functioning and help them not deteriorate further. So more and more patients are getting restorative care and many more patients are getting to walk periodically by therapy aides who brace them with a strap contraption.

Very few people in nursing homes have straight Medicaid without having Medicare Part A and B, although there are some. Part B I think pays for the restorative treatments.

In the many homes I have worked in there is no different day-to-day treatment given to the private pay vs. Medicaid long-term stay patients. A strictly Medicaid home however might have a larger percentage of psychiatrically or developmentally disabled patients who aged out of various group homes or just got too sick for them.

When I consulted to assisted living centers the locked dementia units cost almost as much as a nursing home and none were covered by insurance at that time. The advantage was that these units were small, well-staffed, the residents had a lot of non-stimulating activities and were pretty well taken care of.

Given the ongoing restrictions Medicare, Medicaid and the various states are placing on the use of psychotropic medications, be prepared for a lot more agitated, violent people and incidents in the coming years. It is truly awful what these regulations are doing to my profession and I am glad I mostly retired last week and will be completely done with w*rk by year end. I can no longer reasonably and judiciously medicate patients with compassion and help alleviate their suffering. After 33 years of being licensed to practice medicine I am appalled that "they" think they know so much more than I do about my chosen specialty and have legislated it so narrowly. My hands are literally tied.

Enough of this, off the soapbox for tonight.


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Old 04-13-2015, 05:53 AM   #29
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My mother had a case of dementia. It got so bad at the end that she had to be watched 24/7 for her own safety and those around her. I had no choice but to out her in a home. She had no real assets so Medicaid paid the huge bills.

The dementia units are filled with people who are out of their minds, literally. Horrible places where no one cares. Such a horrible situation for all involved.
MIL "bolted" out the front door yesterday for the first time. Fortunately, we saw her.
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Old 04-13-2015, 05:56 AM   #30
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Thanks for mentioning this. I've been holding back thus far. This is true. My mother finally decided to go into a nursing home. Private. Decent. More than decent, in fact. Not in the Mitt Romney Class but most here really aren't contemplating THAT level of care and balloons every day. She was completely spent down. They are collecting her SS and a small pension she has. The rest from DAY #1 was paid for by Medicaid. The end.

The moral of the story is, if you want to feel comfortable in this, try to privately find at least one or two years. Probably doable by most here. That will get you into almost any nursing home barring the tippy-top tier. IF you live past that and run out of beans Medicaid will cover it and you won't get "demoted" or wheeled out to the parking lot.

It's a pretty useless time of life to worry about spending money anyway. If there is a spouse involved, THAT will require some planning. Get divorced now.
Great advice, and funny too
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Old 04-13-2015, 06:02 AM   #31
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Originally Posted by braumeister View Post
When my mom was in the memory care assisted living place (last year and a half of her life), I noticed that nearly everyone there was so engrossed in their own private world that they didn't seem to even notice what anyone else was doing.

It was a pretty nice place ($5,500 a month in 2010, fairly low cost part of the country). Staff was professional and caring (I visited at least twice a week).

So my observation (N=1) is that the folks in these places are not as stressed by the environment as the rest of us are. My mom, for example, never had any complaints about it -- she enjoyed the attention and the opportunity to interact (as much as she could) with others. Actually an improvement (from her perspective) from her former abode in a retirement community where everyone had their own apartment and mostly hibernated there.

Just another thought that might be comforting.
Great points, thanks. My great aunt is in place like this, and she thinks she works there as a nurse. completely happy
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