My mother in law is in a nursing home in New York. She is in good physical health but has moderate Alzheimers. We want to bring her to our home for Thanksgiving - we live in another state, so we would need to take her out of the facility for a least a week, as it is a significant drive. However, when my husband called to confirm everything was OK for picking her up, they said that she cannot leave for more than three days. They said any longer and Medicaid will stop paying for her care because they will assume someone else is able to care for her instead of her being in a nursing home. Is this right?? It doesn't seem correct to me. I did some research and found that NY Medicaid will pay for up to ten days per 12 months of therapeutic leave. But it's unclear to me whether a nursing home has the right instate a policy rescinding beds after a certain period of time. Does anyone know anything about this?
I have been battling in my state and had reason to research New York for comparisons. New York has one of the best 'Congress intended' Medicaid programs.
Each state has choices in many of the benefit provided, but there are many federally mandated benefits.
My state tried to tell me that a person needing one-on-one attendant care, a person in her space, dedicated only to her, can not receive that in a facility, because facilities historically do not provide that by contract.
The physicians and advocates have all been convinced of that, so they never challenge. I challenged. It is called 'Directed Care' and it is paid for by Medicaid. The facility can not provide such staff so they need to pay attendants from a home care agency to fill the 24/7 and bill Medicaid.
Your case management entity needs to research and comply with federal rules. They probably are applying the rule that time away for 'hospitilization' is not covered. That makes sense because that would cause double billing, but would not be for 'therapeutic leave' with family
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it took just a couple moments to find this for New York.
The google terms are New York Medicaid 'therapeutic leave' and 'bedhold' or 'reserved bed'.
----"Each Medicaid eligible resident who is occupying a nursing facility bed for which the Medicaid program is then paying reimbursement shall be entitled to take up to 10 days of therapeutic leave in any calendar year from any such bed, without the facility’s suffering any loss of reimbursement during the period of leave ". ---
----"Reserved bed days are reimbursed at ninety-five percent• (95%) of the Medicaid rate otherwise payable to the facility for services provided on behalf of the resident. Reserved bed days for non-hospitalization (therapeutic)• leaves of absence outlined in a recipient's medically acceptable therapeutic or rehabilitative plan of care are limited to ten (10) days in a twelve month period".---
You might consider moving her to your state. We did that by applying to the other state months in advance.
She stayed with us frequently before moving into the nursing home, so we're pretty prepared for all the things that go along with her being here (having the gate set up at the top of the stairs for nighttime, alarms on the doors in case she wanders, etc.). At this point, we're exploring bringing her down to a facility closer to us so that we and her other son can visit more frequently (she's in NY because one of her sons is there and that's where she lived for most of her life, but he works long hours and can't get there to see her as often as he would like whereas if she were down here, we could see her every day).
Like paying for skilled nursing care in a facility (a NH) is dedicated federal funding, so states have to pay for NH care but states can set criteria for eligibility (medical and financial) and determine the daily room & board reinbursement paid daily to facilities within federal guidelines. But AL is waiver funding, so states can determine if AL will be covered at all. Most states do not cover AL payments under Medicaid or limit the type of AL funding.
Another example is the personal needs allowance (the $ a Medicaid NH resident can keep each month for themselves) some states have this high - like Minnesota at $ 105.00 a mo - but other states have it lower at $ 35 - $ 50 a mo. My mom PNA in TX was $ 60 a mo. Some states are much more socially aware with & to their citizens so decide to spend $ on programs while other states do not.
Ellery - Personally to me trying to point out to your states Medicaid what NYS or MN does is a waste of energy as your states budget & social awareness is what determines what's what. That energy imo is better directed to state Legislature & those that sit on Health & LTCare committee.
Ellery - Out of curiosity, just how were you able to get your family member - who I assume was a legal resident of another state- to get approved for Medicaid in your state in advance?
I have discovered that institutions that are nationwide do not know or apply the state differences unless challenged.
Based on the quoted statute, I believe, in this case, it is the unknowing decision of the facility. If they were to just bill as usual, recognizing the 10 day limit, there would be no denial from Medicaid. Since the person is with family, there is no other billing.
I have won several appeals on this and the facilities are in question because by not following the guidelines, the encounter and utilization data was skewed for many cases, for many years. It is shown that the entities, lowest in the hierarchy, the home care agencies and facilities, are in the habit of making eligibility decisions. The systems never see the encounter for learning.
We applied months in advance of our move. There was no reason, no statute not to do so We had a move to address. Eligibilty does not begin until state residence is established, but at least all the required eligibility documentation was completed.
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