Summary
Who pays for care while a nursing home resident is awaiting Medicaid’s determination of approval or denial of nursing home benefits (“Medicaid-pending”)? Often, no one pays the nursing home during this time. Many nursing homes do not charge a resident during Medicaid pending, but they are able to do so. A nursing home, however, cannot evict a resident for not providing payment as long as their Medicaid application is pending. Even so, a nursing home facility might put pressure on a resident and their family to provide payment and threaten them with eviction.
Medicaid pending is when one has applied for Medicaid, but is awaiting their eligibility determination. In other words, they have not yet been approved or denied Medicaid coverage. The length of time during which one is in Medicaid pending status varies. Federal law gives Medicaid agencies 45 days to review one’s application and approve or deny their request for benefits. If a disability determination is required, this period is extended to 90 days. However, it is very common for one’s Medicaid application to be pending for a longer period for a variety of reasons, but commonly missing or incomplete documentation is the cause. More on Medicaid pending.
A nursing home might claim they need payment during the delay between Medicaid application and determination, and therefore, put pressure on a resident’s family to provide payment. It is not generally recommended that payment be made. While a nursing home might threaten eviction, they cannot evict a resident while they have a Medicaid application pending. Furthermore, while a nursing home is required by law to provide reimbursement of costs paid after a resident has been approved for Medicaid, it can be extremely difficult for one to get their money back. It should also be mentioned that in some states, Medicaid will not pay for nursing home care for any month in which the nursing home bill was paid in full. Therefore, if any amount is paid, one should ensure it is less than the amount billed.
Even though a nursing home cannot evict a resident who has a Medicaid application pending, it is recommended that they pay their estimated share of cost during Medicaid pending. Also called a patient liability, it is the amount a Medicaid-funded nursing home resident must pay to the nursing home towards their care costs each month. Once approved for Medicaid, a nursing home resident is only permitted to keep a small amount of their monthly income for their personal needs. This is called a personal needs allowance, and ranges between $30 / month and $200 / month, depending on the state. There are other potential allowable deductions, such as health insurance premiums and an income allowance for a non-applicant spouse, which can lower one’s share of cost. One’s share of cost is calculated after Medicaid approval, but one can estimate the amount and pay it during Medicaid pending.
Once a resident has been approved for Nursing Home Medicaid, Medicaid will pay a nursing home retroactively from the date the Medicaid application was filed. In other words, Medicaid will pay for the entire period that the resident’s Medicaid application was pending. Medicaid will reimburse the nursing home at the Medicaid pay rate (which is less than the private pay rate) minus a resident’s share of cost. As discussed above, it is often recommended that a resident pay their estimated share of cost during Medicaid pending. If not paid in advance, they will still owe a share of cost from the period their application was pending. If one is denied Medicaid eligibility, they will owe the nursing home the full cost at the private pay rate for the period their application was pending.
If one’s Medicaid application is denied, they can appeal Medicaid’s decision. The reason for denial and instructions for filing an appeal will be included on the denial notice. A nursing home cannot evict a resident during the appeal process. However, if the appeal is denied, or if a resident chooses not to appeal, they will owe all previous nursing home bills at the private pay rate and must pay the nursing home moving forward.
Medicaid eligibility is complicated, and the application process is full of potential pitfalls. Families should consider working with a Medicaid Planning professional when applying. These fee-based experts help people become eligible, while streamlining the application process and preserving assets for spouses and family members.
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