“Planning Ahead for Medical Assistance”: A Three-part Series (PART II: “Type of Facility Affects Eligibility for Medical Assistance”)

Medical Assistance (MA) is a maze of requirements and rules. Some of those requirements and rules have significant ramifications if not understood or planned out in advance. This three-part series is an effort to “daylight” some, but not all, of the most important requirements for which there must be advanced planning in order to avoid unpleasant surprises and unexpected outcomes. Elder Law attorneys often specialize in this area of practice. If you believe that your circumstances either now or in the future may include paying for long-term care using Medical Assistance, asking an Elder Law attorney can assist you in navigating this maze and preparing yourselves and your loved ones for the next steps.

(PART II: “Type of Facility Affects Eligibility for Medical Assistance”)

If you reside in a facility when you apply for MA, the type of facility will determine a number of things. The type of MA program and the funds available are just some of the most important reasons for understanding the difference in type of facility.

The difference between Assisted Living (AL) and Skilled Nursing Facilities (SNF) is an important distinction for many reasons, and not always clear by a facility’s title.  Assisted Living facilities often provide services that make them “feel like”  nursing homes to those who are unaware of the differences. Not understanding the distinction can create some unpleasant surprises for the MA applicant and his or her family.  If an individual needs to apply for MA, a number of issues depend on the type of facility in which the applicant resides  – most importantly, these two issues:

1)     MA for an individual in an AL facility will only pay for the Elderly Waiver (EW) program, which does not pay for room and board. Further, EW will not allow for payment of any retroactive benefits, if date of application for MA and the month of financial need don’t match up well.

MA for an individual in a SNF, on the other hand, is called MA-LTC (MA – Long Term Care) and will cover room and board.  Since AL facilities often charge in excess of $1500/month for “room and board,” the difference is clearly significant. * Be careful to apply for the right program and understand what that program will fund.

2)     An AL facility (and, in some cases, a “continuing care” facility) may impose a period of time a MA applicant must be able to pay privately for services (meaning, out of their own pocket) before they are eligible to remain in such a facility if MA-EW becomes necessary. This time period is commonly something like 1-3 years. Therefore, it’s important to understand both in what type of facility an individual resides and if there are any “private pay” requirements to allow an applicant for MA to remain there and avoid a surprise move to another facility.

If an AL facility does not impose a length of time for private pay requirement, they commonly set aside only a handful of “EW” beds/rooms for those residents on MA-EW.  Since a limited number of beds is usually accompanied by an inability to ensure availability of those beds, a MA-EW applicant has a good chance of needing to look for another place to live because there isn’t room at his/her current residence when he/she needs it.

These two issues alone can quickly undermine financial and residency plans and send family members and loved ones scrambling for solutions to the problems. Elder Law attorneys can be very helpful in the planning process by assisting individuals with understanding their choices and outcomes down the road, and avoiding these common misunderstandings while navigating the pressures of long-term care.

ALL READERS:   This blog is not, nor shall it be deemed to be, legal advice or counsel. This blog does not create an attorney-client relationship with any reader.  It is designed to encourage thoughtful consideration of important legal issues with the expectation that readers will seek professional advice from a licensed attorney.

bridget@decorolaw.com