Anne Hurley, a former Maryland Legal Aid attorney, says regulations on safe and secure patient discharges from nursing homes are vague and difficult to enforce. Vonda Wagner's case, Hurley said, is an example of a long-standing problem in nursing home oversight. (Capital News Service photo by Amanda Eisenberg)
COLLEGE PARK, Md. (Oct. 5, 2016)—A common event that can force someone out of a nursing home involves disputes over money, particularly the finer details of two government health insurance programs for the elderly, Medicare and Medicaid.
This difference between the two, consumer advocates say, can give nursing home operators an incentive to discharge patients when the more generous Medicare benefit expires.
In a nutshell, Medicare, which primarily serves people 65 and older, offers a more generous benefit but it lasts just 100 days for skilled nursing care.
Nationally, Medicare pays about $13,809 a month for such care—far more than the average Maryland Medicaid reimbursement rate of $7,404. When Medicare's nursing home benefit runs out, patients either pay out of their own funds or turn to Medicaid, the state-administered program designed for lower-income people.
But navigating the complex application process is so time consuming that patients are often forced to leave the nursing homes while awaiting approval.
Nursing home operators and consumer advocates both agree on at least one point: The Medicaid system is overly cumbersome and too slow to provide benefits.This problem illustrates the regulatory and economic complexities of the nation's long-term care system.
"The Medicaid process itself is broken. It is difficult," said Mark Yost, chief operating officer for NMS Healthcare, which operates five nursing homes in Maryland. Typically, a patient applies for Medicaid at "their sickest moment …. You're catching the family at the worst possible moment, and unfortunately you've got to get that process rolling quickly."
The disparity in Medicare and Medicaid payments is an issue Maryland Legal Aid attorneys cite in discharge complaints from nursing homes, and they note NMS is among the most active nursing homes in the state discharging patients. A Capital News Service analysis of Centers for Medicare & Medicaid Services data shows NMS discharges 65 percent of nursing home patients, greater than the state average discharge rate of 57 percent.
Alice Hedt, former Maryland Long Term Care Ombudsman, part of the Maryland Department of Aging, said the state's process is "extremely slow, and the process needs to be expedited."
"In Maryland, getting a person transitioned from Medicare to Medicaid can be a very lengthy process, and it needs to be started very early in the time that the person goes into the nursing home," Hedt said.
Time is of the essence: The average wait time for a patient to be approved for Medicaid's long-term care ranged from 52 to 63 days, according a report by the Department of Health and Mental Hygiene from July to November 2015. That processing time comes as Medicare only provides 100 days worth of coverage for nursing home stays.
Isabella Firth, president of LifeSpan Network, the country's largest trade group for senior care providers, called the state's Medicaid application process "woefully inadequate," citing long delays in informing facilities whether residents are qualified for Medicaid.
People "fall through the cracks …They languish," Firth said. "I think it creates a fair amount of anxiety and risk for operators and I think it creates anxiety for the customers too. … You're dealing with somebody who is in a very fragile state. The last thing you need to worry about is paying for it."
Facilities waiting for Medicaid responses continue to care for patients but "they're kind of in the dark," she said, as they are unsure if the program will cover the resident's care or whether they will be unable to cover their costs.
Firth pointed to NMS Healthcare as an organization that is particularly frustrated by these delays, as they work with people who have "very complicated needs."
The Medicaid system is a federally funded long-term care program, geared for low-income people and administered jointly by the federal and state governments. Medicaid covers long-term nursing home care and other benefits not covered by Medicare.
Patients can generally tap Medicare's "skilled nursing" benefit to finance 100 days of care in a nursing home if they receive specific nursing services as spelled out in the law. After 100 days, the patient is expected to finance all costs through private pay or insurance or to apply for Medicaid.
But once a patient's Medicare benefits run out, then it is up to the facility to assist the patient in applying for Medicaid long-term care, said Anne Hurley, former project director for The Long Term Care Assistance Project at Maryland Legal Aid.
"That process is very onerous," Hurley said.
People applying for medical long-term care benefits have to complete a 17-page form and provide verification for any income and benefits as well as assets or property they own. For example, a person applying for Medicaid has to spell out financial details over the past five years to prove whether they transferred a house or other assets at below market value or made large gifts. Asset transfers 60 months prior to the Medicaid application process could be subject to penalties, for example.
The Department of Human Resources reviews applications that don't include all necessary verification and requests—from the applicant or applicant's family or guardian—the additional documents needed for verification, said Shannon McMahon, deputy secretary for Health Care Financing at the Department of Health and Mental Hygiene.
Single residents might qualify for Medicaid if they make less than about $16,394, whereas a two-family household might qualify if they make less than about $22,108, according to the Medicaid Planning Administration in the state's Department of Health and Mental Hygiene.
Some applicants might have to work with an attorney to "spend down," a process to legally use non-exempt assets so that they can qualify for Medicaid.
Medicaid patients provide nursing homes with a steady, fixed source of income. Yet this comes at a price, as these patients can require a higher level of care. NMS, for example, has a business model that involves accepting patients with more serious conditions and will admit patients who "are not financially qualified… as long as there's some initial payer source," Yost said.
Most discharges are because of "financial issues," Yost said. He explained a process in which, if a patient hasn't qualified for Medicaid—perhaps because the patient's application is still in process or "a patient's not cooperating and telling you what [resources are] out there"—and cannot pay otherwise, NMS will discharge the patient.
Capital News Service reporters Joe Antoshak and Darcy Costello contributed to this story.