We are often called upon to assist families with a loved
one facing imminent nursing home care. In some
instances, families may face the difficult situation of both
parents being ill and requiring additional care beyond
what can be provided in the home setting. For example,
one parent may require placement in an assisted living
facility or rest home, while a second parent may require
nursing home level care. In such a situation, long-term
care bills can quickly add up. Assisted living and rest
home facilities typically cost between $4,000 and $7,500
per month, while nursing home care ranges between
$9,000 and $11,000 per month.
Medicaid, also known as MassHealth, is the primary
source of funding for care in long term care nursing
facilities. To qualify for Medicaid for long term care, an
individual must establish financial eligibility. Assisted
living facilities and rest homes typically, with some
limited exceptions, require private payment and do not
accept Medicaid benefits.
As noted above, complex financial criteria must be met
before an individual can qualify for Medicaid benefits to
pay for their nursing home care. Currently, the financial
asset limit for a couple is $111,560, with $109,560 being
allotted to the community spouse residing outside of
the nursing home, and $2,000 being allocated to the
ill nursing home spouse. The amount allotted to the
community spouse is known as the community spousal
resource allowance.
When the community spouse is faced with
extraordinary medical expenses, he or she may appeal
to Medicaid for an increase in their community spouse
resource allowance. For example, Medicaid recognizes
the fee paid by a community spouse to an assisted
living facility or rest home as a medical expense that
would justify an increased community spouse resource
allowance. If granted, the increased community spouse
resource allowance enables the spouse in the assisted
living facility or rest home to retain a significant portion
of the couple’s assets in excess of $111,560 in order to
continue to pay for their care needs in the community.
The nursing home spouse’s care will be paid for by
Medicaid.
A recent case handled by the Special Needs and Elder
Law Practice Group demonstrates the value of seeking
legal advice when faced with the difficult emotional
and financial scenario of caused by caring for two ill
parents. In the case, both spouse’s care needs increased
beyond what could be provided for them in the home
setting. The husband was admitted to a rest home,
while the wife was admitted to a nursing home. Private
payment invoices for their care at both facilities totaled
approximately $18,000 per month. If the couple had
continued to pay privately for their care at each facility,
their assets would have been depleted within their life
expectancies. We submitted a Medicaid application
for the wife, requesting that the husband be allowed to
retain all of the spousal assets in excess of $109,560 to
pay his rest home fee.
Because appeals for an increased community spouse
resource allowance cannot be decided by a Medicaid
caseworker, the case was initially denied. On appeal
to the Medicaid board of hearings, we successfully
argued to the hearing officer that the community
spouse be allowed to retain all of the couple’s assets
due to his extraordinary medical expenses. The case
was approved, and the wife was granted Medicaid
eligibility. The community spouse is now able to utilize
the couple’s assets to continue to pay his care expenses,
while allowing his family flexibility to plan for future
placement and treatment options as his care needs
increase.
The world of Medicaid planning is complex, and
contains many traps for the unwary traveler. It is always
best to seek advice from competent counsel when
your loved one enters a long term care nursing facility,
assisted living facility, or rest home.
