My 94-year-old mother has dementia and lives with me. Would Medicare pay for her to have skilled nursing care?

My mom is 94 also, and slipping farther all the time. I had a chat with the doctor a few weeks ago, he said that her treatments will eventually do no good, I took her to an appointment last week and he ordered hospice for her. In our county we do not have separate facilities for hospice, it goes through the local hospital and it involves home care. It is entirely paid for by medicare if it is doctor ordered, even the medications and an oxygen converter. I have been concerned for some time about someone to moniter her medical condition, this will go a long way.

Medicare only covers a certain number of hours, even for Hospice.
I was told 4 hours per day 5 days per week. Additional hours are paid for privately or, you need to apply for Medicaid.

Services provided for someone with Dementia are not considered skilled. There are criteria related to disease process and functional ability that require a skilled RN. Your Mom could be evaluated by a Long Term Home Health Care Program. There may also be Dementia Programs in your community that could advise you,.

GKerg - I'm assuming that you & your DH want to have mom move into a LTC/NH
rather than continue to live with you all which would be the case for hospice (home care - which Medicare totally covers)? And that you need to find a way to pay for LTC /NH? And have her admitted as medically necessary for LTC/NH? My comments are based on that.This is going to be a bit long...........

Yes you are correct in Medicare only pays for LTC for a small # of days (25- 28? days?) if they were admitted to the hospital prior for at least 3 full days. The ER or being in an out patient stay part of the hospital doesn't count as a hospital admission. Medicare site has details. After that LTC in a facility/NH are either private pay, LTC insurance or Medicaid. 65% of NH residents are on Medicaid.
If they live long enough, they will run out of $$.

For Medicaid all the regulations are state specific even though it is a federal program. Most states have the max monthly total asset of 2K. The exact amount and how the assets are looked at are unique to each state. BUt whatever assets are over the ceiling you need to start to “spend down”.

“Spend down” – means get assets (excluding homestead & car) under the state’s Medicaid asset ceiling. They can buy funeral and burial policy, life insurance (irrevocable NCV). Glasses, dental care (spotty on Medicaid), hearing aids, walkers. If they have a home, prepay for utilities, cable, insurance, repairs. No $ gifted to others. Everything must be for their care or their homestead property. Medicaid look back is 5 years. The state can go thru 5 years of bank records & also require receipts to any item that pique’s their interest.

Now is your problem she bought a whole life insurance policy that now has a cash value? You can get it changed to a term life policy - there may be a significant penalty to do this. You need to contact either the agent/broker who sold it or consumer relations for the insurance company to find out what your options are. The state may want to be the beneficary of it if the policy is large and she applies for Medicaid.

Or you could cash out the whole life policy. Again there will be a penalty BUT you will have money to buy prepaid funeral and burial plans (make sure these are no cash value and are irrevocable - the funeral home will know what's what); you can then also buy her a small term life policy (about 1,000 - 1,500) that you can then use for funeral/burial incidentals. At her age it will probably cost the face value of the policy but it will keep some money after death to use and out of the state's hands. She could buy a car as that is a non-countable asset for Medicaid but you need to keep it within whatever your state's specific guideline for value.

You have to spend the rest of the money on her care and needs.

Whatever you decide to do keep in mind that all these issues are sticky, you'll need to hire an experienced lawyer to help. To begin your search for the best lawyer for the job, contact the local bar association and ask whether it has a lawyer referral service that includes those who specialize in elder law or conservatorships. You can also contact the National Academy of Elder Law Attorneys for a referral to its members in your area.

I'm a firm believer in having an elder care attorney take care of all this. It will not be expensive as most is done by the paralegals. You do want to go in prepared with what the information is for the documents (e.g. insurance policy #, with the info on all the births, deaths & prior marriages) as well as valid ID for the elder. If the decisions have been already made, this should all simple, straightforward paperwork. Should take 1 - 2 hrs for intake & then 1 hr a couple of days later for the signatures to be done and paperwork return.

If mom has assets, then all this should be paid from her assets. This also is important if you ever get challenged. If you pay for all, and you benefit, then other family could go to court to find it a coerced document.

Other than the whole life policy are her other assets under 2K a month (like her SS check and any retirement she get's for her working life or her husband's)?
If it's above 2K and will always be above 2K (like her SS is 1,000 a month and she has a federal retirement/annuity of 1,200 month, so she is always 200 over the asset limit), a good elder care attorney can have her do a Miller Trust. This way she can financially qualify for Medicaid to pay for LTC/NH.

For Medicaid they do need to qualify for BOTH financially and medically. The financial you deal with. The medical is something that the NH and you will have to work together on. yes hbarnard is totally right in that dementia alone does not qualify for skilled nursing in a LTC/NH.

For the Medicaid "medically necessity" to be admitted to the NH, she will need to have medical issues that she cannot do on her own that require "skilled" nursing. Sometimes it can be as simple as changing the medication, for example alot of them are on a pill like Aricept which doesn't require skill to give or to take. BUT if they were to change her med to the Exelon patch, that requires "skill" to administer as a daily evaluation of the site needs to be made and rotated. Another would be instead of giving a med in a pill form, it may get changed to having to be crushed and mixed into a special food supplement, which requires "skill" to do.

For the healthy elderly in addition to dementia, they will need another chronic disease that needs "skilled". The doc can indicate coronary heart disease and prescribe 81 mg of aspirin. Which is another skilled nursing need. If she has diabetes or any cancers that will meet the need for skilled nursing.

What is your mom's MD like? Is she seeing a gerontologist? If you can get her to be seen by one that would be great and tell them what the situation is. What can be really super useful is to have you mom seen as a private patient by whomever is the medical director of a LTC/NH that you want her to move to. This will help for getting the medical paperwork for Medicaid done in a somewhat more timely manner to get her qualified when she get's admitted to the LTC/NH.

Back to the life insurance issue, the state's DHHS will want a copy of the policy if she is applying for Medicaid.So whatever you do needs to be able to be looked at. For us, with my mom we had a problem with her $1,000 face value term life insurance! It was old, from the 60’s, when policies were 20 – 30 pages, so you had to read through it for the word "term". The Medicaid worker doesn’t have time for level of detail so couldn’t check whole or term but could check information not provided. So I get a letter requesting this info asap/48 hrs. I got a stockbroker, who holds a TX insurance license, to do a letter that the policy was term and faxed it to HHS. My point is, the Medicaid application is being scrutinized. Good luck.

Dementia is a long road, my mom lived to 100 so the idea that she is near death because of her age may not be there. If you are not ready for hospice...then her income will decide her fate. The state care called medicaid will pay for a care giver and you as the daughter will receive $. But U will have to take a week of classes to understand basic care and be certified to be paid by medicaid. Talk to a state social worker and see where you stand. Blessings francy

Dementia is a long road, my mom lived to 100 so the idea that she is near death because of her age may not be there. If you are not ready for hospice...then her income will decide her fate. The state care called medicaid will pay for a care giver and you as the daughter will receive $. But U will have to take a week of classes to understand basic care and be certified to be paid by medicaid. Talk to a state social worker and see where you stand. Blessings francy

Wow 100 years old, how long did she have dementia? How long are they bedridden, I have heard up to 4 years like that and it scares me. I think that jkerg is going to have to pay for the funeral and sacrafice all monies to the nursing home, thats the only way. Its got to be so hard to do, I cannot even imagine :(

DT, can I ask what Hospice does for you? My Mom qualified last year but they said they could only come and bathe her maybe 2 hours, once a week at anytime, not morning. I bathe Mom mornings as she wakes up soaked so Hopsice was no good for me. My Mom doesnt want to get UP at all now and it sometimes wont walk even with asistance, its getting tough so transfer her, like dead weight.
I wonder whats next, what a horrible disease, I just wish she could see and understand tv or the green grass and flower but she doesnt.
luvmom

Igloo: so right about having the right doctor evaluate your parent for any gov. program. You really need someone who has expertise in these evaluations...his/her regular doctor may not know what the program requires and how to evaluate for it. In fact, I always prepare a sheet that outlines all Mom's medical issues and mobility challenges to give to the doctor (they cannot observe your parent as you do). It was good advice to contact the hospice company and ask who they use. They can also give you great advice about services. Also, not all hospice companies are alike. Some are great - others are only concerned about how much they can bill. Each state has their own way of interpreting the rules.

Luvmom: Many times patients are referred to the hospice that the doctor or hospital recommends...not always reliable. Ask around for a referral, then talk to the directors before you commit. Ask specifically what they offer, how many days, equipment, etc. In our state you can have up to 3 days of personal care and a nurse as needed (even a PT). Ask them who there most experienced aide is and request that person (the aide has a lot of clout in getting additional services.) The focus is on comfort care, not "cure." They will provide equipment (such as a hospital bed) if needed and other medical items such as guaze, pads/diapers, etc. As the patients' needs grow, they can assist in whatever they need. Also, that your hospice would not come in the morning is ridiculous...try another company. You are going to need a lot of help if your Mom is becoming bedridden and cannot transfer. You need professionals who know how to lift properly, etc. or it will take a toll on your health.
Good luck and please take care of yourself. There are so many good people out there who can help....don't take it all on your shoulders....Lilli