Caregiving: Why is Medicaid So Difficult to Understand?

The Caring Generation® – Episode 175, September 6, 2023, Why is Medicaid So Difficult to Understand? If you are in a caregiving relationship you may be struggling with the financial aspects of a spouse’s or elderly parent’s care. Pamela D. Wilson, caregiving expert, offers an explanation of Medicaid benefits for home and community-based services (HCSB) and long-term care (LTC) placements.

Have a question?  Follow and connect with Pamela on her social media channels of Twitter, Linked In, Facebook, Instagram, and YouTube or complete the caregiver survey on her website.

Click on the round yellow play button below to listen to the caregiving podcast. To download the show so you can listen anywhere and share it with family, friends, and groups, click on the button (the fourth black button from the left) below that looks like a down arrow. Then, click the heart to go to Pamela’s Spreaker podcast page to like and follow the show. You can also add the podcast app to your cellphone on Apple, Google, and other favorite podcast sites.

Why is Medicaid so difficult to understand? If you are a family caregiver or a person who needs care, learning how to navigate the healthcare system can be a challenge. Medicaid and Medicare are different programs that operate under different constraints. Learn what healthcare providers rarely tell caregivers in this week’s episode of The Caring Generation.

Are Medicaid Nursing Homes Bad?

Watch More Videos About Caregiving and Aging on Pamela’s YouTube Channel  

Navigating the healthcare system can involve attending doctor appointments, going for tests or treatments, filling prescriptions, and managing health issues like high blood pressure, diabetes, kidney disease, arthritis, depression, cancer, or memory loss. Learning how to manage the healthcare issues of an aging parent can mean gaining an understanding of how Medicaid programs operate.

With age, everyone is likely to experience some type of health concern as the body begins to wear out. If you care for an aging parent or a spouse—or even yourself—you know that one accident that results in an injury, or experiencing an unexpected health event like a heart attack or even the flu can change life overnight.

A person healthy one day can be hospitalized the next. An aging parent can be independent one day, break a hip, and be in a nursing home for physical rehabilitation one week later.

While we never imagine that health changes will happen—they will. So, it’s important to consider how care can be accessed when elderly parents or a spouse need care and don’t have the money to pay for care.

Medicare vs. Medicaid

This brings up the topic of Medicare and Medicaid and the question of why is Medicaid so difficult to understand. Let’s start with Medicare which is health insurance for persons over age 65.

Not everyone automatically qualifies for Medicare. For example, qualifying requires 40 social security credits. Forty credits are about equal to 10 years of work. Jobs that do not pay into social security might include teachers, some railroad employees, or people who may have worked for the federal government. These types of positions have other retirement-saving programs.

Medicare is a replacement for private health insurance when a person retires and is age 65 or older. There are some other circumstances for Medicare like end-state renal disease but to keep this conversation simple we are limiting the discussion of Medicare and Medicaid to persons over age 65.

Medicare Does Not Pay for Day to Day-to-Day Eldercare

There is a lot of confusion about what Medicare pays for when a person is older. Let’s look at this from the opposite perspective and say what Medicare does not pay for. When your parents have health issues and they need non-medical types of care to live independently—Medicare does not pay for this type of assistance.

So technically, anything that you as a caregiver do for a loved one—assuming you are not a doctor or a nurse or any other type of healthcare professional—is NOT reimbursable by Medicare. This realization that Medicare does not pay for daily living assistance can come as quite a shock to the elderly and their children who are their caregivers.

In fact, Medicare is even going to the extent of providing training for family caregivers in some areas, like training to administer insulin, dialysis machines at home, and physical therapy so that family caregivers can do more and Medicare and do less. You may hear healthcare providers say that the home is the new hospital.

Over time, this will be true as families will be expected to bear more of the work of caring for aging loved ones. So, what does Medicare pay for?

Medical appointments, vaccinations, hospitalizations, and other types of medical care are reimbursed at an 80% rate. This means that your parents pay for the other 20% of care costs.

Now if you watch television, you will see advertising for other types of insurance like Kaiser, Humana, and United Healthcare which are Medicare Advantage plans. These plans work in place of traditional Medicare. Some offer other benefits depending on where you live.

All have “in-network” providers which means that you pay less if you see doctors at Kaiser Permanente locations go to Kaiser-affiliated hospitals etc. If you want to go out of the Kaiser system, your Kaiser insurance will not pay for out-of-network care. The same applies to Humana and United Healthcare providers.

Traditional Medicare operates under similar guidelines. Not all physicians have to accept Medicare. So, finding a physician who accepts Medicare can be a challenge.

Physicians can also accept Medicare and then decide to discontinue the benefit and patients have to find a new physician. Medicare is a federal program.

Medicaid Qualification

So, let’s move on to answer why is Medicaid so difficult to understand. This discussion about Medicaid is limited to persons over age 65 to minimize confusion about other Medicaid programs.

Medicaid is a combined federal and state-funded program. It is a program for low-income individuals and persons with disabilities.

Why is Medicaid so difficult to understand? In part, because Medicaid programs differ by state. So, for example, if you live in Colorado and a friend lives in Florida and you both qualify for Medicaid, you may not have access to the same programs.

Adult children often worry about how to pay for the care of income-strapped elderly parents. If your parent is low income and they have health problems they may be able to qualify for Medicaid.

The very important point is not to wait until the last minute to figure out how Medicaid works. By seeking information about why is Medicaid so difficult to understand you will be ahead in planning for the care of aging parents.

What most caregivers do not know is that the processing time for a Medicaid application can be one month to a year. Depending on where you live, there also may be wait lists for Medicaid services. Do your homework. Call your county office of health and human services to find out the requirements for filing for Medicaid.

HCBS, LTC, LTSS

What does Medicaid pay for? Again, this varies by state. Which is why Medicaid is so difficult to understand.

Generally, for older adults, Medicaid pays for Home and Community-Based Services also referred to as HCBS, and long-term care referred to as LTS or long-term care (LTC) services and supports (LTSS). There are other programs, but again we are keeping this discussion narrow to make Medicaid a little easier to understand.

If mom and dad live at home and they are low income—again defined by your state Medicaid office—if they require assistance with activities of daily living or have early memory loss they might qualify for in-home care assistance.

This type of assistance would include help with what are called Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). These are activities like bathing, dressing, managing toileting or incontinence, and helping with safe transfers like getting out of bed, or standing from a chair if a person is experiencing physical weakness or has balance issues.

In-home caregivers provided by Medicaid can also aid with laundry and meal preparation, they can remind parents to take their medications, do a little light housekeeping, and so on.

Are Medicaid Caregivers Trustworthy?

Another commonly asked question, is are these caregivers trained, reliable, and trustworthy? My response is just as with any business – the qualifications of the employees vary as does the interest in the position.

To be perfectly honest you may have to work with an agency and go through a couple of caregivers until you find one that is a good match. You also may have to go through one or more agencies.

Due to COVID and problems with staffing, retaining home care workers is a significant challenge. In some states, the Medicaid program will pay family members to be a caregiver.

Should I Give Up a Job to Care for An Aging Parent?

In these situations, it is important to take a very serious look at this trade-off that may appear ideal. But if you are giving up employment, an income, and your independence, how long will you agree to do this and how difficult will it be to become re-employed?

If you are giving up employment, consider the value of benefits you are giving up. This may include your ability to save for your retirement and live your life.

Many caregivers jump in and do not think about the trade-offs and the effects on their lives, family relationships, friends, income, and independence. So, before you consider giving up a job to have Medicare pay you to care for an aging parent, give this very serious consideration.

There is also a long list of things that may not be considered until a loved one needs to apply for Medicaid. Here are a few.

• As a caregiver never co-mingle funds or bank accounts that might give the appearance that you are the one spending your parent’s money.
• Do not pay their bills or buy things for them and then reimburse yourself. Medicaid will question these activities.
• There is a 5 year look back on all applications to check and see if assets like money or property were given away so that a person can qualify sooner.

Let me share an example from my time as a care manager. A client gave her granddaughter $60,000 for her wedding. A year later the woman became ill and was denied Medicaid benefits because that $60,000 could have been used to pay for her care.

The Cost of Care

I hear and receive written comments from adult children who express concern about Medicaid taking their parent’s money. Most of these children want their parent’s money for an inheritance.

Think about this if you need a car and you pay for the car. You pay cash or you take out a loan and you pay the loan back. If you want to buy groceries; you must pay for the groceries.

Why is there an expectation that private health insurance or government programs for Medicare or Medicaid are cost-free? When it comes to Medicaid there are a lot of different opinions.

There are people who need Medicaid, appreciate the assistance, and benefit from the services offered. Just the opposite, there are elders who refuse to go on Medicaid because they do not want a handout.

Then, as we discussed, there are adult children who are waiting for an inheritance and who are angry that, if assets exist Medicaid should be reimbursed for services provided to aging parents.

On this topic, in the case of Medicaid, there is something called “estate recovery” which means that some states will place a lien on property and recover the money after a person passes away. Like buying a car this is no different than taking out a loan and then paying it back.

If you have parents, they earned money that can pay for their care. If you are an adult, I recommend that you work and save money so that you have money to pay for your care when you are older.  If you plan ahead, you won’t have to rely on Medicaid to take care of you.

Changes Related to Aging

Retirement is not the dream that everyone hopes for. Your income—in most cases—decreases.

Health expenses increase due to the having more health problems. If you were not attentive to your health when you were younger through exercise, a good diet, stress management, and other aspects of well-being your health will show the results when you are older.

This is not to say that a perfectly healthy person cannot die tomorrow. It happens. During retirement, the cost of everything continues to go up while your income remains stable.

These are not factors that anyone considers until they see a loved one struggling to pay their rent, buy groceries, or pay for medical costs. Utilities, property taxes, HOA payments, groceries, gasoline, homeowners, and car insurance. These rates increase every year.

Plan and Take Control of Your Life

So back to the topic of giving up a job to be paid by Medicaid to care for a loved one. Think about the short and long-term effects of giving up income that you cannot get back.

While caregivers may feel guilty about not caring for a loved one, a hard fact of life is that we’re all going to die of something someday. These are the difficult emotional challenges of life.

Watching a loved one’s health decline is heartbreaking. Being the person who is sick all the time is no joy. Nor is being the person diagnosed with cancer whose family pressures him or her to have chemotherapy or radiation without really understanding how this might affect the quality of life.

If you want to have choices, plan early. Be clear about the care you want or don’t want so that your children—who are your caregivers—don’t take over your life and make all of the decisions for you while they are waiting to inherit your money.

If you want choices you have to create the choices for yourself. Create your medical and power of attorney documents and appoint someone you trust even if this person is not one of your children or even your spouse. Create your living will and a will.

Why is Medicaid So Difficult to Understand?

Let’s look at three common questions from caregivers about Medicaid.

1 – Do Nursing Homes Dislike Medicaid?

Another question that caregivers ask is—why are Medicaid beds in nursing homes limited. Or put the way the caregiver asked the question, why do nursing homes not like Medicaid patients?

Here is the information you may not know. Federal and state government funds pay for Medicaid services.

Nursing homes and some assisted living communities that accept Medicaid are paid a flat daily rate. This rate can be just below the break-even amount of the per day costs for the individual.

If you owned a business, would you want to lose money or break even on every client that you serviced? How would you remain in business? How would you pay your staff or yourself?

This loss of money means that nursing homes have difficulty paying operating expenditures. This challenge can translate to staffing difficulties and having a poor reputation for care. When resident populations become unbalanced with more Medicaid patients, the nursing homes can close because they can’t pay their operating costs.

The government does not own these nursing homes, private companies, non-profit organizations, or investor groups own the nursing homes. There is nothing wrong with wanting to be a business that earns a profit.

How would you like to go to work every day and instead of getting a paycheck, you paid the company you worked for $10 a day? That is the reality of Medicaid.

2 – How Long Does It Take for Medicaid to Approve an Application?

The answer to Medicaid approval timelines is that approvals depend on the accuracy of the application and the backlog in each state. I have had applications approved in 8 weeks and some in 12 months.

A couple of recommendations:

• If you hand deliver your application, make sure to get a date and time-stamped copy of the cover page and the name of the person to whom you delivered the application.
• If you submit the application online, make sure you receive a reference number and a confirmation of receipt. Applications become lost all the time or they say that you never delivered the application.
• Keep an entire copy of the application in case it becomes lost so that you won’t have to recreate the paperwork.
• Be the squeaky wheel. Call every week to find out about the status of the application. This allows you to make sure it exists and someone is working on it.
• Don’t wait until the last minute to apply because approvals can take months and there can be wait lists to receive services or be accepted into programs.

3 – Is the Care in Nursing Homes Bad?

Question three from caregivers is —our mother complained of pain. The nursing home did nothing. Mother ended up dying in our opinion because the nursing home did not do their job. What can we do?

The answer to this question is twofold.

• First, research the Affordable Care Act Section 3025 called “Rehospitalization”. Hospitals are penalized if a patient is in the hospital and goes to a nursing home for care and if this person returns to the hospital within 30 days.

If you have a parent who broke a hip, for example, most hospitals and nursing homes that they refer business to have agreements that the nursing home will do everything in their power NOT to send this older adult back to the hospital. If elderly patients return to the same nursing home within 30 days of being discharged, the hospital can be financially penalized.

Let’s say that you are a family member who becomes very active in the care of your parent. Even though mom or dad is sick the nursing home may refuse to send your parent to the hospital.

My recommendation is to let the staff at the nursing home that you will call 911 if they don’t. Now if you do this and there really is not a serious need the nursing home can refuse to accept your parent back into their care. So this can be a tricky situation.

Reasons Hospitals Refuse to  Admit the Elderly

Here is an example of what can happen in this type of situation. Years ago, a client of mine was in a nursing home, and based on my experience, I suspected that she had pneumonia. She was sent to the emergency room turned right around and sent her back to the nursing home saying nothing was wrong.

The probable reason– admitting an elderly person with pneumonia who might be discharged and returned to the hospital can result in a financial penalty. Another consideration might be that an elderly person with pneumonia might need an intensive care bed which may be limited.

Hospital staff would rather treat young people who have a better chance of recovery in the intensive care ward versus an older person. So, on Day 1, my client was sent to the ER and returned to the nursing home.

In the meantime, my staff and I called the doctors on call to ask them to visit to prescribe antibiotics or to treat the suspected pneumonia. But because the hospital said nothing was wrong, they refused.

On day 2, my client is much worse. She is coughing and wheezing. There is yellow mucus coming out of her nose and throat. The nursing home staff called 911. The paramedics took her to the same emergency room who again refused to accept her and returned her to the nursing home.

There were more calls to the doctors on call for assistance. They did nothing. On Day 3 911 was called again. My client was sent to another hospital. She was diagnosed with advanced pneumonia and died two days later.

This is an example of an experienced care management team with legal responsibility who under the worst of circumstances could not convince the healthcare system to treat an elderly woman.

Bias Against Care for the Elderly

So if you are a family member know that these situations can and will happen and you may do everything you can but your loved one still may die. Many health systems see anyone over age 65 as disposable. They also group elderly people together as having the same concerns.

So a healthy 65-year-old may be treated the same as a person who is 65 with Alzheimer’s’. The truth is that many healthcare staff are biased against care for the elderly. There are research studies about age bias.

Second, my advice is regardless of your age or the age of your parents.

• Take care of your health.
• Save for your retirement so that you can have choices about your care.
• Become an advocate for yourself so that you get the care you want from the healthcare system.
• Don’t accept no if you believe you need care fight for yourself because no one will. Insurance companies are quick to deny claims knowing that patients won’t fight for their care.

Being elderly and getting necessary care can be a fight. This fight can mean becoming involved in state healthcare initiatives and legislation. This means getting involved in politics which fewer people want to do.

Politicians pass legislation that has unintended consequences for consumers and patients. Taxpayer money is wasted on duplicate programs across multiple agencies each wanting to protect their funding. Government overreach presents an ongoing risk for patient care and patient choice.

Politicians’ votes follow the money. This money comes from the healthcare lobby, healthcare systems, and other companies who want to protect their interests.

The choices of patients and consumers will continue to be drowned out until their voices become louder than politicians and healthcare system providers who view patients as data and revenue instead of people. 

 

 

Looking For Help Caring for Elderly Parents? Find the Information, Including Step-by-Step Processes, in Pamela’s Online Program.

©2023 Pamela D. Wilson All Rights Reserved