Can nursing homes evict Medicaid patients?

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mr_scaramanga
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Can nursing homes evict Medicaid patients?

Post by mr_scaramanga »

I usually don't like to just quote articles from newspapers for the purposes of discussion, but this Nytimes piece really disturbed me. It's somewhat personally relevant because I have an elderly relative who is childless and I think is going to be in need of long term nursing care in the not too distant future (I am their closest remaining relative.) They have had a series of medical problems requiring hospitalization and I think pretty soon a doctor is going to recommend they move to a nursing home. They have almost no assets, so I assume they would qualify for Medicaid quickly.

I had understood that Medicare will pay for 100 days of care when coming from a hospital while being an inpatient for some number of threshold days. If your finances are such that you qualify for Medicaid, I had understood that the nursing home could not evict you when you qualify for Medicaid.

However, this Nytimes article : As Nursing Homes Chase Lucrative Patients, Quality of Care Is Said to Lag, really disturbed me.

Link: http://www.nytimes.com/2015/04/15/busin ... o-lag.html

Here is the relevant section of the article:
The shifting landscape, some say, marginalizes poor long-term residents with extensive medical needs. “This focus on Medicare, Medicare, Medicare has pushed out people in the custodial care world,” said Anthony Chicotel, a staff lawyer at California Advocates for Nursing Home Reform, who says he fields calls at least once a week from residents who are being evicted because their Medicare coverage, which lasts 100 days, is expiring and the residents will transition to lower-paying Medicaid insurance. “They’re being pushed out, and they don’t have anywhere to go, really, that can take care of them.
Has anyone experienced this happening? For example, have you had a parent or relative be evicted from a nursing home when they qualify for Medicaid? I was under the assumption someone could not be evicted from a nursing home if they were a resident when they became eligible for Medicaid.
Last edited by mr_scaramanga on Tue Apr 14, 2015 2:51 pm, edited 3 times in total.
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nisiprius
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Re: Can nursing homes evict Medicaid patients?

Post by nisiprius »

I'm not an expert, but I think two different things are being mixed up. There's "rehab" and there is "long-term-care." Both kinds may be provided by a "nursing home" but they are different things.

Where I live, some "rehab" facilities are connected with a hospital, with no long-term nursing home attached, and are connected with a nursing homes... sometimes there is a triple deal, a single facility that provides assisted living, rehab, and long-term nursing home care.

Anyway, MediCARE pays for "rehab," which is predicated on the assumption that you are going to recover and go home.

MediCAID pays for long-term-care, which makes no such assumption.

"Evict" seems like a loaded word here. When the hospital says you have to leave, nobody says that the hospital has "evicted" you.
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skepticalobserver
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Re: Can nursing homes evict Medicaid patients?

Post by skepticalobserver »

Are you saying that once a nursing home Medicare patient exhausts the Medicare allowance, qualifies for Medicaid and willing to apply for Medicaid, that the patient can be evicted from the nursing facility? This is absolutely contrary to my understanding of federal nursing home regulations. There has, however, been controversy over those situations where a Medicare patient, who is placed in nursing facility after a hospital stay for "rehabilitation," and that after the Medicare allowance was exhausted the nursing facility coincidentally determined that the patient's rehabilitation had "plateaued" (the condition for which he received rehabilitation would not improve) and the facility uses that as a reason to run him out of the facility. Under federal regulations, and at least one court decision, the "rehabilitative plateau" criterion alone can not be the basis for removal from a facility if the patient qualifies, and is willing to apply for, Medicaid.
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mr_scaramanga
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Re: Can nursing homes evict Medicaid patients?

Post by mr_scaramanga »

skepticalobserver wrote:Are you saying that once a nursing home Medicare patient exhausts the Medicare allowance, qualifies for Medicaid and willing to apply for Medicaid, that the patient can be evicted from the nursing facility? This is absolutely contrary to my understanding of federal nursing home regulations. There has, however, been controversy over those situations where a Medicare patient, who is placed in nursing facility after a hospital stay for "rehabilitation," and that after the Medicare allowance was exhausted the nursing facility coincidentally determined that the patient's rehabilitation had "plateaued" (the condition for which he received rehabilitation would not improve) and the facility uses that as a reason to run him out of the facility. Under federal regulations, and at least one court decision, the "rehabilitative plateau" criterion alone can not be the basis for removal from a facility if the patient qualifies, and is willing to apply for, Medicaid.
I was referring to the situation where once a Medicare patient exhaust their allowance and then qualifies for Medicaid. Like you, I understood that federal regs did not allow an eviction in these circumstances. However, the article seems to imply this is being done. This is why I find this article somewhat confusing.
Penguin
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Re: Can nursing homes evict Medicaid patients?

Post by Penguin »

Eviction because of transition from Medicare to Medicaid seems to be illegal in California.
Article 3. Administration - California Welfare and Institutions Code Section 14124.7

Legal Research Home > California Laws > Welfare and Institutions Code > Article 3. Administration - California Welfare and Institutions Code Section 14124.7

14124.7. (a) No long-term health care facility participating as a
provider under the Medi-Cal program shall seek to evict out of the
facility or, effective January 1, 2002, transfer within the facility,
any resident as a result of the resident changing his or her manner
of purchasing the services from private payment or Medicare to
Medi-Cal, except that a facility may transfer a resident from a
private room to a semiprivate room if the resident changes to
Medi-Cal payment status. This section also applies to residents who
have made a timely and good faith application for Medi-Cal benefits
and for whom an eligibility determination has not yet been made.
(b) This section does not apply to any resident of a skilled
nursing facility or intermediate care facility, receiving respite
care services, as defined in Section 1418.1 of the Health and Safety
Code, unless it is already being provided through a Medicaid waiver
program pursuant to Section 1396n of Title 42 of the United States
Code, or is already allowed as a covered service by the Medi-Cal
program.
(c) Nothing in this section shall limit a facility's ability to
transfer a resident within a facility, as provided by law, because of
a change in a resident's health care needs or if the bed retention
would result in there being no available Medicare-designated beds
within a facility.
(d) This section shall be implemented only to the extent it does
not conflict with federal law.
Jon
Mitchell777
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Re: Can nursing homes evict Medicaid patients?

Post by Mitchell777 »

It's been a year or two since I spoke to an attorney about this but this is my recollection. If you are a rehab patient they do not have to keep you as a nursing resident. In fact all three facilities I spoke to wanted a certain amount of private pay months (it was years actually, not months) before accepting you. Then, only if they accept Medicaid and some do not, they will keep you under Medicaid after your private pay runs out. I think this may vary by state somewhat. It semed to be about how many open beds there were locally, if a facility accepts Medicaid, how much private pay you have vs others.
skepticalobserver
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Re: Can nursing homes evict Medicaid patients?

Post by skepticalobserver »

This may be a trend that the regulators are tolerating because of business/political pressure. Perhaps the regs have been reinterpreted? Whatever the case, my experience has been that LTC administrators are pretty tough cookies when it comes to the bottom line. Some will shade the truth and out right lie about Medicare/Medicaid rights. Most disturbing are attempts by LTC administrators to get relatives of LTC patients to provide financial guarantees. Many unwittingly do so not understanding that the estates of the patients are, and should be, 100% financially responsible.
Crow Hunter
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Re: Can nursing homes evict Medicaid patients?

Post by Crow Hunter »

Mitchell777 wrote:It's been a year or two since I spoke to an attorney about this but this is my recollection. If you are a rehab patient they do not have to keep you as a nursing resident. In fact all three facilities I spoke to wanted a certain amount of private pay months (it was years actually, not months) before accepting you. Then, only if they accept Medicaid and some do not, they will keep you under Medicaid after your private pay runs out. I think this may vary by state somewhat. It semed to be about how many open beds there were locally, if a facility accepts Medicaid, how much private pay you have vs others.
This was similar to my experience.

My Mother qualified for a stay in an assisted living facility after she had a PEG tube procedure. The facility that she transitioned to was for rehab only. It was NOT a "traditional" nursing home. She was there for physical therapy and to learn to use her PEG tube before going home. I stayed there with her for a while and a physical therapist came by 2x per day to do exercises and walking.

All the patients that I saw while I was there were recovering from some injury/surgery.

They specifically discussed the fact during the enrollment that if she did wind up needing further assisted living/nursing home care beyond the Medicare recovery allowance it would have to be at a different facility as their facility was only for rehabilitation not long term care and they weren't equipped for that.

Actually, that was the specific and only reason my Mother agreed to go. She absolutely did not want to be in a nursing home but she was okay with being in a physical rehabilitation facility.
NotWhoYouThink
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Re: Can nursing homes evict Medicaid patients?

Post by NotWhoYouThink »

Also note that just because you run out of days on your Medicare coverage, that doesn't mean that you qualify for Medicaid, and that some of the 100 Medicare days are only partially covered, depending on the existence and coverage of a Medigap policy. OP mentioned his/her relative had no other family, so no spouse. That would mean that most of her assets would have to be spent down before she would qualify for Medicaid. Maybe that has already happened, but it's something you should look out for. If you think this may be a long term need, it's not too early to start looking around for places that would be suitable.
vested1
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Re: Can nursing homes evict Medicaid patients?

Post by vested1 »

We went through this in California last year, due to the mutually agreed upon decision to place my MIL in a skilled nursing facility due to her deteriorated condition. You need to make sure that the facility accepts Medi-caid, and most do not. The shell game they play is looking at the available assets and then determining whether there are available beds. Hint: ask them if they have available beds before asking anything else. Although this can't be proven I'm pretty sure if the assets were meager the beds would be unavailable. We were lucky in that my MIL's facility is clean, has a good reputation, and is the best within 50 miles yet only a few miles from our home.

The cost is approximately $8,500 a month until her assets run out, and she's been there about a year now, you do the math. If/when she runs out of assets we have been assured that she will not be evicted and that her care will remain the same, as it should since at that time she will have paid around $500,000. It really is a racket, and if she didn't absolutely need to be there we would prefer to have her live with us, but she has steadfastly refused. We don't care about an inheritance but we are definitely in the minority.

Most facilites that we would even consider refused to accept her because of the possibility of her running out of assets. One said they would be happy to take her but that she would have to leave when her assets ran out. We asked another about transitioning to Medi-caid if her assets ran out and they told us if she was accepted they would not evict her, but would call us back with bed availability. It was no surprise when they called and told us no beds were available, (Refer to hint above). Others that would have accepted her were no better than reeking warehouses.

She's 92 and very frail but could easily last another 10 years in my opinion. Without getting political it seems a shame that our country makes growing old and running out of money a personal rather than a social problem. Some would say that statement is a contradiction considering that my MIL will likely transition to Medi-caid after a few more years. That would be true if all facilities accepted Medi-caid. Unfortunately it is usually the ones with lower standards of care that accept Medi-caid, although the cost is pretty much the same as those who don't.

I personally consider it immoral to charge such exorbitant rates for the amount of effort expended. Are social programs to blame for the higher cost to those who have remaining assets? Perhaps, but that doesn't change the helplessness or the angst she feels over seeing her life savings being drained at such an alarming rate, or change her attitude over her commitment to help those in need.
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DrippingSprings
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Re: Can nursing homes evict Medicaid patients?

Post by DrippingSprings »

A few relevant points.

It takes time to apply for Medicaid and be approved. And certain standards with respect to income and assets must be met. So, after the initial 100 days, when a patient goes from part A to part B Medicare, they might not have any funding at all for a continued stay. This can be a big problem; discharge planning has to start before the patient is even admitted to a long term care facility.

Medicaid has a lower reimbursement rate; facilities generally will limit the number of Medicaid beds they have. They might not take Medicaid at all.

Now, in an ideal world, long term care facilities would take everybody for as long as necessary, but like any other business, they have to set certain limits in order to remain financially viable.
Bruin
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Re: Can nursing homes evict Medicaid patients?

Post by Bruin »

There is no requirement that a facility participate in the Medicaid program. If a person has both Medicare and Medicaid, is being covered by Medicare at a facility that does not accept Medicaid, when their Medicare coverage is over they will likely need to leave the facility. While it practically may or may not be an eviction for transitioning to Medicaid, legally what could be happening is their Medicare coverage is over, they have no insurance that the nursing home accepts therefore are considered private, and would be evicted for non-payment of their private bill. It would be quite obvious they would not be able to afford a private bill as they qualified for Medicaid.

If one is at a facility that accepts Medicaid, they could not be evicted solely for transitioning to Medicaid, however, there are several reasons one could be appropriately "evicted":
- That person does not need nursing home services, a lower level of care would be more appropriate (Assisted Living or Home Health).
- That person is a danger to themselves or others.
- When qualifying for Medicaid, there is cost sharing amount the person owes for their care like a co-payment. Failure to pay the cost sharing amount would be legal grounds for eviction.
- Not sure if this is still possible but in the past nursing homes used to have specific beds that were certified for Medicare use only, and should ones Medicare coverage be over and no other beds were available in the facility that MAY be grounds for a transfer.


There are of course specialized facilities, like inpatient rehab facilities that really aren't nursing homes and can't care for residents long term, much like a hospital.
Mitchell777
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Re: Can nursing homes evict Medicaid patients?

Post by Mitchell777 »

Interesting article and i've seen many of those things. The one thing I saw that was not mentioned, and this is only my experience, has to do with current nursing home private pay patients. Although when you go to a rehab facility, from home, it is fairly easy to get the facility to work with the insurer (Medicare or Medicare Advantage) to get a week or three of additional rehab, it is not so easy when you are a current nursing resident of that same facility. When you are a current resident, and you go to the hospital and return, you are no longer on private pay but on your insurer's dime. You are probably in your same room. In my experience the facility will now cut you off from therapy much more quickly. They want you back on private pay which is much higher for the same room. The reason given is you are not making progress. I will not get into the Jimmo settlement, but the last time I tried to get more therapy for my family member I went through 2 appeals. You can never actually speak with the insurer's doctors making the decision. Finally I was told the 3rd appeal was to a admin law judge and the lead time on that was in excess of 400 days (that is no misprint). Just my experience.
Bill M
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Re: Can nursing homes evict Medicaid patients?

Post by Bill M »

Some experience with this with my grandmother in the 1980s and 1990s. When she first entered the nursing home, there was a financial qualification test she needed to pass, i.e. sufficient assets to pay for some number of years of care. And there were restrictions on wealth transfer (no surprise). Nice room in the front. When the funds ran out, the quality of the care took a noticeable hit, and she was moved to the back of the facility; she had essentially bought that room in the back. The experience convinced my parents to move into a continuing care retirement community when they retired. The experience convicned me that LTCi is worthwhile.
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Re: Can nursing homes evict Medicaid patients?

Post by dhodson »

Unfortunately you really can't get much from this article. I imagine people commonly think they are getting "kicked out" after rehab if the family really wants the person to stay in a nursing home. The rules on this are pretty clear and I doubt there is widespread breaking of the rules given the government is the group that will go after you if you break the rules.
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Re: Can nursing homes evict Medicaid patients?

Post by Mitchell777 »

dhodson wrote:Unfortunately you really can't get much from this article. I imagine people commonly think they are getting "kicked out" after rehab if the family really wants the person to stay in a nursing home. The rules on this are pretty clear and I doubt there is widespread breaking of the rules given the government is the group that will go after you if you break the rules.
This is a topic I'm trying to learn more about. Could you elaborate on the rules that would require the rehab facility to keep you on as a nursing home patient if you were not a nursing home patient at that facility prior to requiring rehab?
dhodson
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Re: Can nursing homes evict Medicaid patients?

Post by dhodson »

They don't have to keep you. I imagine some families think they do or they think of the rehab as a "nursing home" or don't realize that part of the building is rehab and you aren't guaranteed a switch to the other.

The big problem is that people want a free lunch. Either people need to pay for nursing home care or they need to pay more in taxes so the gov't does it for them.
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DrippingSprings
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Re: Can nursing homes evict Medicaid patients?

Post by DrippingSprings »

Mitchell777 wrote:Interesting article and i've seen many of those things. The one thing I saw that was not mentioned, and this is only my experience, has to do with current nursing home private pay patients. Although when you go to a rehab facility, from home, it is fairly easy to get the facility to work with the insurer (Medicare or Medicare Advantage) to get a week or three of additional rehab, it is not so easy when you are a current nursing resident of that same facility. When you are a current resident, and you go to the hospital and return, you are no longer on private pay but on your insurer's dime. You are probably in your same room. In my experience the facility will now cut you off from therapy much more quickly. They want you back on private pay which is much higher for the same room. The reason given is you are not making progress. I will not get into the Jimmo settlement, but the last time I tried to get more therapy for my family member I went through 2 appeals. You can never actually speak with the insurer's doctors making the decision. Finally I was told the 3rd appeal was to a admin law judge and the lead time on that was in excess of 400 days (that is no misprint). Just my experience.
It can in fact be true that a patient is not making progress. It is the therapy staff that makes that determination. Once a patient plateaus, they are commonly placed on restorative care, which is performed by an aide. If their status changes over time, new orders for therapy are then appropriate. Insurance companies do not pay for maintenance therapy.

I doubt that a long term care (LTC) facility would actively attempt to block a patient from receiving therapy if the patient needed it. I have never heard of such a situation. Therapy generates more revenue for the facility.

On the other hand there are insurance companies who make determinations to refuse payment for therapy when therapy is clearly indicated. I have encountered that situation several/many times. And that is not limited to LTC; we encounter it in outpatient and acute care settings as well.
Mitchell777
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Re: Can nursing homes evict Medicaid patients?

Post by Mitchell777 »

You obviously are in this field and I agree with much of what you said. Of course it is possible a patient is not making progress. However when one is very old that progress can be very slow. The physician, who works only with nursing home patients has told me they are not providing nearly enough time to show progress but that is one situation. My disagreement is in the therapy bringing revenue. Of course it does, but in my case the private pay ends when the 100 days begins (they cannot bill you twice for the same room you already had prior to entering the hospital). At that time they make money on the therapy but lose a lot on the payment for room and board (vs the private pay at ~ $10,500 per month i write check for). I believe the delta is in the $4K per month range as I recall (insurance or govt pay vs private pay)
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DrippingSprings
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Re: Can nursing homes evict Medicaid patients?

Post by DrippingSprings »

Reimbursement to a SNF (Skilled Nursing Facility -- nursing home) under Medicare Part A (the 100 days that you refer to) can vary greatly depending on the amount of therapy minutes a patient receives. The more minutes provided, the higher is the reimbursement rate. As a result, the SNF has a financial incentive to provide therapy time. The reimbursement can easily exceed your private pay rate of $10,500 per month.


So, why would a SNF stop providing therapy services? If after a reasonable time period has passed, a patient does not show ongoing progress, Medicare will deny the claim. This can be done retrospectively even after a claim has been paid. There are, for example, what are called rack audits. An independent auditor comes in and reviews all the Medicare claims made. The auditor is paid for every claim they deny. So, the auditor has a financial incentive too deny claims. The denials can be appealed. A lot of man hours get invested in the appeal, and they take time to resolve. Failure to demonstrate progress when there are no mitigating circumstances documented other than age almost guarantees the claim will remain denied. But the services were already provided, and so the SNF is out a lot of money.
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