Nursing Home Searches

A large part of my job includes helping families find a nursing home for their loved ones.  Families often find caring for their loved ones to be too much physically and financially, and they end up looking to the solution of last resort.  Many spouses and children promise their aging loved one that they will never put them in a "home."  Sometimes, though, the reality of caregiving makes that promise impossible to keep. (Why people resort to nursing homes and the lack of viable community options are different topics to be covered later.)

When talking about nursing homes, I usually start the conversation with the basics: there are two ways to get into a nursing home.  The first, and most preferred method, is to be admitted to a nursing home for rehab after a qualifying 3-day hospital stay.  This is what triggers Medicare to pay the bill (for up to 100 days of rehab).  The other way to be admitted to a nursing home is from home or an assisted living community for long-term care.  Long-term care, unlike rehab care, is not paid for by Medicare and must be subsidized by private funds, VA benefits, long-term care insurance, and/or Medicaid. 

At this point my families are usually still with me.  "Okay, well Mom is not in the hospital, so we just need to find a long-term care bed."  And this is where the conversation gets difficult.  Finding a long-term care bed is difficult.  And it is difficult because of money.  Nursing homes receive two types of revenue: room and board payment for long-term care residents and rehab payments for short-term rehab residents.  The difference between these two revenue streams is not small; the results of a 2009 national survey showed that the average reimbursement per resident per day for rehab was $441.44 and only $171.50 for long-term care residents (assuming the payor-source is Medicaid, which it is for 70% of long-term care residents in nursing homes).  Nursing homes have an incentive to favor short-term rehab residents over long-term care residents, and often the motivation is not only profit but organizational viability.  The nursing home industry reports that for each long-term care resident, the nursing home loses an average of $19.55 per resident per day. That's a (-14.0%) shortfall.  So, how do nursing homes stay afloat?  Luckily, the average profit for short-term rehab residents is 18.1%, which helps balance out the long-term care losses.  For the families that are looking for a long-term care bed at a nursing home, this is bad news.

Most families seem to believe that once they make the painful decision to move their loved one to a nursing home, they will find the best facility closest to their home and schedule an appointment for the move.  We can go over tools to do the search, things to look for, questions to ask (see www.ahrq.gov for some great guides); but most families will likely have to settle for less than their ideal nursing home. The very best of the nursing homes are able to attract short-term rehab residents and turn down long-term care residents.  Finding a long-term care bed seems to come down to who is desperate enough to take the long-term care payment over $0 for an empty bed.  Furthermore, the decision to take a long-term care resident over an empty bed is made on a daily basis, so there is no planning ahead or scheduling the move.  Families must respond immediately to a bed offer and make the move within 1-2 days.  That part is also hard for families.  Moving into a nursing home is not like moving into an apartment or even an assisted living community.  I'm not sure what else in life it is like.  These issues continue to affect residents after admission, too.  Consider a resident who may be well enough to go home or go to an assisted living facility from a nursing home.  The resident will be taking a risk by giving up their nursing home bed.  If their move is not successful and they need to return to a nursing home, will they be able to get back in that nursing home? Will they be able to find any nursing home that will offer them a bed?  These questions must be taken into account when considering leaving a nursing home.

The decision to move a loved one to a nursing home is often painful for families.  Like adding salt to a wound, the nursing homes families get to chose from are often not their first choices, and families have to make painful compromises on either location or quality.  I feel for families facing this situation, and I do my best to empower them with information to hopefully lessen the sting of reality and to reassure them they are doing the best they can.

Reference: http://www.mcknights.com/medicaid-outlook-bleak-for-providers-in-2012-report-finds/article/219572/

MAGI and Medicaid: How one may change the other

"The Patient Protection and Affordable Care Act” creates a new eligibility category in Medicaid, which will expand access to health care for millions of low-income Americans. For the first time, Medicaid will extend eligibility to all individuals who have income up to 133 percent of the Federal Poverty Level (FPL).  As part of this, states were going to start using a new calculation for income based on the Internal Revenue Code of 1986.  This income test uses a calculation called Modified Adjusted Gross Income, or MAGI, which allows all Social Security benefits to be left out of the calculation.  So, starting on January 1, 2014, all SSDI recipients as well as SS retirement beneficiaries would be able to apply for Medicaid and would be eligible (from an income perspective) if their MAGI (which excludes SS payments) fell at or below 133% of FPL (or $14,484 for a single person in 2011).  So, let me do the math, if a person makes $2,300 in monthly income, and $1,200 of that is from SS retirement payments, and $1,100 is from pension payments, that person (with an annual income of $27,600) could qualify for Medicaid because only $13,200 is counted as income for Medicaid qualification purposes.  (Now, I'm sure there will still be asset limits that will affect Medicaid eligibility, and most people will not meet those asset limits.)

In response to this new change, US Congressman Diane Black (TN-R) proposed HR 2576 to address MAGI.  Her bill would change the IRS code from 1986 so that MAGI would include all Social Security Benefits.  If her bill is adopted (and it passed the house 262-157 on October 27th), then my person in the example above would not be eligible for Medicaid.  Rep. Black assumes that this use of MAGI was an unintended consequence of the ACA that should be fixed (see her post http://black.house.gov/press-release/black-medicaid-bill-passes-house-bipartisan-vote), but I am not so sure. I have listened to both the supporters and the critics, and I am not sure how I feel about it.  This change may result in the denial 500,000 possible Medicaid recipients.  Would these people be better off with Medicaid? Would we all be better off if they had Medicaid (see http://www.cbo.gov/ftpdocs/124xx/doc12484/hr2576.pdf)?  If those 500,000 end up not receiving Medicaid, does that mean they will not be able to afford any health insurance?  And if they have no health insurance (or have to pay a significant portion of their income to health care), will we all be hit harder with higher premiums and increases in healthcare as their medical bills will likely go unpaid?  I suppose if they all did get Medicaid we'd all be paying higher taxes or higher fees for government services.  The assumption seems to be that these individuals would not be eligible for Medicaid but would be eligible to purchase "affordable" health insurance from the health insurance exchanges. I am not so sure those insurance plans will be "affordable."  In regards to HR 2575, my US Rep, Hank Johnson, voted "nay" on October 27th. The Senate will consider HR 674 (HR 2576 was attached to HR 674, and that is another issue altogether) on Monday, November 7, 2011. I suppose we shall see, and I am still not sure where I stand on this issue.

More COLA? How the new increase affects other benefits.

On October 19, 2011, the Social Security Administration announced that there will be a 3.6% cost-of-living adjustment (COLA) for 2012.  This is big news since this is the first adjustment since 2009.  Starting in January, beneficiaries will see an increase in their retirement checks or social security insurance (SSI) checks.  SSI checks from 2009-2011 maxed out at $674/month; in 2012, those checks will be as big as $698/month.  This brings an SSI recipient's annual income up to $8,386.75 from $8,095.32.  The average SS retirement beneficiary will receive an additional $39/month due to this increase (that is an additional $467/year).

The max benefit amount the SSA sets for SSI is used to determine the income qualifications for other benefits.  For instance, in Georgia, a nursing home resident must have less than $2,022/month in income to qualify for Medicaid (or use a Qualified Income Trust to qualify).  That $2,022 amount is three times the SSI max benefit (so, 674 x 3 = 2022).  With the new change, the income cap will be $2,094/month (that is, 698 x 3 = 2094). So, starting in 2012, nursing home residents that receive less that $2,094/month in income may qualify for Medicaid (if they also meet asset requirements).  This is just one example of the benefits that will be effected by this change in COLA.  Veteran benefits, requirements for community programs and others will be effected, too. Social workers and public benefits specialists will have to quickly get up to speed on the new requirements once they go into effect.  We have become familiar with the old numbers since they were good for 3 years, and now we'll have to change our cheat sheets and databases!