My mother needs care but her "care plan" is conflicted.

Dtellie asked...

My mother fell a few months ago, was hospitalized, then entered a rehab. After a few months they said her "care plan" doesn't indicate she needs skilled nursing and wanted to place her in an adult home but adult homes don't handle people who are on oxygen 24/7 (emphysema) plus she has macular degeneration and can barely see and can't read at all. So I fought them and even had the ombudsman go to a care plan meeting. The rehab center said they have an opening in one of their nursing homes for her and I took it.

She has been there 3 weeks and now I get a letter that says that her care plan hasn't changed and they will stop billing Medicare. I already applied for Medicaid and it was just approved.

My mom can 'feel' her way to dress and eat but can't prepare foods, can't see to take the medication the proper way so I don't understand why they didn't score her for skilled nursing. She has a history of blackouts and major depression. So my question is...can a nursing home (who is medicaid approved) make her leave because a care plan doesn't indicate she needs skilled nursing? Will Medicaid pay for her care in a nursing home even though the PRI (patient review instrument) done by the rehab indicates she is not nursing home material? I am worried they will kick her out on the streets and I can't take care of her in my home for many reasons including a disabled husband and son already living with me.

Expert Answer

Kay Paggi, GCM, LPC, CGC, MA, is in private practice as a geriatric care manager and is on the advisory board for the Emeritus Program at Richland College. She has worked with seniors for nearly 20 years as a licensed professional counselor, certified gerontological counselor, and certified geriatric care manager.

In spite of all the recent publicity, many caregivers are surprised to learn that Medicare does not pay for long term care, no matter what the circumstances or the diagnosis. This is the reason the nursing home and the rehab facilities cannot continue to bill Medicare for your mother's care. Medicare will cover a certain number of days with a maximum of 100 days. Your mother has exceeded that limit and so is no longer eligible for Medicare.

That brings up the question of Medicaid. Medicaid is a joint venture of the federal and state governments. The specifics of who is eligible for Medicaid vary from state to state. Medicaid was created to pay for care for people who are indigent, who need care and cannot pay for it. Apparently your mother meets the criteria for Medicaid in her state because you said she has been approved. She should be able to stay in the facility where she has been approved as long as she needs care. My understanding is that it is illegal to discharge a patient from a care setting if they have no other place to live. Your state ombudsman will be able to speak to this issue better than I.

A person who cannot see well enough to manage their medications or prepare a meal but is otherwise healthy is better suited to an assisted living community. Assisted living provides assistance with the tasks of daily living but not skilled nursing care. Some states have such communities that accept Medicaid reimbursement. Ask her Area Agency on Aging if her state has these communities, and then find out how to qualify.

If there are no such communities locally or there are no openings, she should be able to stay where she is now.