Mom in an Assisted Living, what happens in Texas when her money runs out?

Don't use emotions to deal with the upcoming situation, if possible. My mother has been in Assisted Living and now the Memory Care annex since 2014 and will be running out of money in about 18 months. Her facility is ONLY private pay & will not accept Medicaid at all. So..........I will be applying for Medicaid in about 14 months, providing she's still alive, and get her into a Skilled Nursing Facility (Long Term Care) that we like, where she stayed for rehab in May, private paying for a few months until Medicaid kicks in. That's what you need to do too. Don't panic. Don't consider this sad and scary...............consider yourself fortunate to be living in the United States where Medicaid IS available and Long Term Care CAN be an option, otherwise WE would be taking our folks in our homes! Now THAT, to me, would be sad and scary, since my mother is wheelchair bound, incontinent, suffers from dementia and about 10 other health related issues that I'd NEVER be able to handle myself!!

Be well. Take the bull by the horns by putting one foot in front of the other and plodding through. You can do this!! Stay in touch here for lots of support, we're all in the same boat!

I’m going to approach this somewhat differently..... there's oodles of emphasis on the $$ aspects BUT Medicaid also has a medical side equally important. As a first step, I’d suggest you get your mom evaluated, aka a “needs assessment” done. This to see IF she’s at point of verifiably needing skilled nursing care in a NH; or still good for AL or needs MC. AL she is in now hopefully knows someone who can do this, if the AL does not do them routinely. It likely will be an RN & SW duet.

Why? The report will let you know what type of placement & if TX Medicaid AL waiver might be feasible OR if she’s going to instead apply for TX LTC NH Medicaid.

TX does have waivers for AL & in home care. Since 2015-16 TX has it going thru Medicaid Star + Plus waiver system & it now uses MCO (managed care organization) system. TX DADS website has lots of info on Star + Plus. MCO requirement imo is challenging for those outside of bigger cities. For example, if most doctor, PTs etc in your co. aren’t in network for MCOs for McClellan, there isn’t many facilities locally that participate in waiver. You may have to look beyond McClellan. Yeah it’s confusing. I’d suggest you contact Area on Aging for your region - Heart of Texas AoA 254-292-1800. AoAs are part of your COG - council of governments, which are regional planning bodies & grant holders for programs in your area. I bet 4 staffers for Aging, & 1 will be a benefits specialist- thats who you want to talk with once you know moms assessment imo. They will know what facilities available.

Background: Prior to ‘15, TX did CBA (Community based alternative) model that paid for AL.... CBA was limited in beds available. Imo not there wasn’t impoverished elders qualifing for AL but rather AL by & large could easily fill beds w/private pay & not need to deal w/reporting requirements & uncertainty waiver funding (3-5 yr budget cycle). Most AL did not do CBA. My mom moved into TX IL in a “tiered” community (IL, to AL, to NH & had a hospice wing) & It actually had AL CBA beds, which was a big reason why chosen. Reality was a handful out of AL 100+ beds actually on CBA waiver & these had long “interest lists” (Medicaid speak for waiting list). I assumed she would move from IL into AL & onto Medicaid once she started having issues. Wrong! List w/dz++ already in AL ahead of her. Instead I had her established “need” for SNF NH & moved her into a free standing NH. Lots of families did this & NH Medicaid beds were 95% filled most areas. State SNF costs seriously big, even with TX being a low room & board reimbursement rate. State decided in ‘14-15-16 to prioritize moving current NH residents out & into AL waiver or in-home community attendant Waiver. Didn’t affect my mom as she was bedfast & on hospice by then. But some families actually had to move elder to AL or back home if not showing SNF “need”. State waiver also geared for care via MCO. Superior & Molina Health do a lot of the MCOs. If your mom is inflexible on who her docs, etc. are, & old MD not with MCO for AL in her area, going MCO may be difficult for her to adjust to.
Assessment is now imo super important & imo you need to know exactly where she is for “need” so you know what Medicaid program to put your effort into trying to get her into. Good luck.

She’ll have to apply for Medicaid. You should probably speak to the l facility she is in now and see if they a)take Medicaid and b)require her to self-pay for a certain amount of time before she can stay there on Medicaid. It’s tricky because some facilities require you to self-pay for up to 2 years and some medicaid programs require you to self pay for 1-2 years. I believe Texas uses a waiver program for assisted living and there may also be a waitlist for waivers. So it would be a good idea to start planning now.

I thought assisted living was all private pay? Only Medicaid nursing homes accept Medicaid?

Sounds like she is self pay now, if so and she is getting close to running out of money, now is the time to apply for Medicaid. I would TT the Social worker at the home, they can provide you with the necessary information to handle this situation. Don't panic, this can be worked out.

Also on “when $ runs out” situation, to me, the biggest factor will be IF the current AL accepts TX Medicaid Star + Plus AL waiver & has waiver open beds available. If they do, it probably gives you a couple of months to transition & do the Medicaid application.

But if the AL does not participate in Medicaid at all, you need to look at her admissions contract as to how they handle delinquent accounts. Eventually they will do a “30 Day Notice” that she has to move out. The 30 day will have it CC’d to whatever probono legal clinic in your area. For Austin-SA zone, that’s Rio Grande Legal Aid. Your kinda further up 35, so maybe it’s a DFW pro bono legal aid group.

Will the AL kick mom to the curb???.... not really as it’s beyond bad PR. But what’s likely is that the AL will find a reason or two to call EMS & mom goes off via EMS to the ER.... and then the AL will refuse to take her back. I’ve know this to happen and the reason was that the resident appears to have had a TIA (transient ischemic attack) & is non-ambulatory and not cognitive... it’s all stuff that very subjective. But the monkey is now not the old AL responsibility.

The monkey is now moved to be a problem for the discharge planner at the hospital. The discharge planner will seek you out & hound you take her to your home or find an AL for her unless she actually gets a 3+ day hospitalization & has a post hospitalization rehab discharge done. For those, they go to a SNF that has a rehab unit. And rehab is covered by Medicare for 100% for first 20/21 days & then up to 100 days at 80%.
This can be a way to get her into a NH. She’ll have a fat health chart that shows “need“ & MediCARE is paying first 20/21 (so NH is happy) & gives you time to get her applied for LTC Medicaid as a Medicaid Pending resident. She eventually transitions from Medicare patient to Medicaid resident. Comprende? Nationwide this is how most folks enter a NH.

Realize that Residents in AL do not have the safeguards or legal requirements for appropriate level of care transfer that a resident in a skilled nursing care facility (a NH) has. If she’s in AL, she’s viewed as basically good on her ADLs & might need some assistance. Often family want to keep the elder in AL way way past their ability to do their ADLs as AL is way cheaper than NH. Its yet another reason why an accurate “needs assessment” is super important.