Betty was concerned and unsure about what to do next.  Betty's husband Ted, age 81, suffered his third stroke within the last two years and then he was hospitalized for a week.  Ted was discharged to a nursing home for skilled rehab, but due to the effects of the stroke along with his dementia, he did not participate in rehab.  At a care conference, the nursing home staff said Ted's Medicare coverage would end in 3 days and they recommend that Ted needed 24 hour custodial care.  This was no surprise to Betty.  After all, Ted needed help getting up and walking and could no longer dress himself.  Two years ago, Betty hired a home caregiver to assist her with Ted's care at their home, 8 hours a day, 7 days a week.  Ted's doctor had been telling Betty he needed 24-hour care for a long time and should not be left alone at home, so Betty rarely left their home in Rochester Hills anymore.  Now it seemed like the time had finally come that Betty could no long meet Ted's needs at home and she would have to consider moving him into the nursing home.

The nursing home staff said their private pay rate was $230 per day or Ted could qualify for Medicaid.  At $230 per day, Betty did not know how she would pay a nursing home bill of $6,900 per month for very long.  She had already spent down so much of their savings on Ted's home care, but Betty was worried about the quality of care Ted would receive if he was in a “Medicaid nursing home.”

When I met with Betty for an initial consultation for long-term care planning, I was not surprised to hear this.  As an elder care lawyer, many of my clients express this concern to me about the quality of care in a “Medicaid nursing home.”   People are surprised to learn that there are not that many Medicaid nursing homes.  For instance, Oakland County has 40 skilled nursing facilities, which provide a range of care from short-term rehabilitation to long-term custodial care and only one of these facilities is strictly a Medicaid facility.  There are 4 facilities that only accept Medicare as a payment source.  These facilities are geared more toward short-term physical therapy and rehabilitation services, so they are not concerned about having these patients convert to long-term care nursing home residents.

Since Medicare only pays for up to 100 days of rehab in a nursing home, that is why there are only 4 facilities in Oakland County who only accept Medicare.  Since there are such a small amount of people who only need care for a short period of time, the other 35 facilities serve both the short-term and long-term care population, and usually in the same room, not a “Medicaid wing” of the facility.

These other 35 nursing homes in Oakland County have what we call “dual-certified beds.”  By dual-certified beds, I mean that the facility is licensed to accept either Medicare or Medicaid as a payment source for the person occupying a particular bed.  The term is a somewhat inaccurate in that the facility can also accept payments from the resident at the facility's private pay rate, so there are really three potential payment sources for most nursing homes:  Medicare, Medicaid, and private pay.

My experience has been that once a resident converts from Medicare to Medicaid in a dual-certified facility, the quality of care does not change.  With most facilities having semi-private rooms, or two-people in a room, dual-certified means one person in one of the beds might be receiving Medicare benefits while their roommate might be receiving Medicaid.  The same care staff will be attending to both of them in the same room.  The nurses who are working there have no idea who is receiving Medicaid is opposed to who is paying out of pocket.

In fact, Medicaid dollars are really the nursing home's “bread and butter.”  Betty asks me what I mean by that.  With the average monthly nursing home costing $7,032 in Michigan, few seniors can afford to pay at the private pay rate for very long without exhausting their savings.  That is why about 70% of people in a Michigan nursing home have Medicaid as their payment source.  The nursing homes rely on these residents to stay in business and, in order to keep their licenses, they must provide good care to them.  After all, if a nursing home bed is vacant, the facility receives no payment, so they have to keep their census, or number of residents up.  With the cost being so high and so many people needing long-term care in a facility, not short-term care, nursing homes expect most of their residents to have Medicaid as the payment source and do not provide a lower quality of care to this group, which are their main customers.

Betty is relieved to hear this and says it makes the decision to move Ted to the nursing home easier.  I assist Betty with some estate planning and her Medicaid application.  After the application is approved 60 days later, I have another meeting with Betty to review some follow-up matters.  I ask Betty how Ted's care has been in the last 2 months since he has been Medicaid pending.  Betty smiles and says Ted's care has been just fine.  He remained in the same room after his Medicare days ended and she has not noticed any problems since they converted to Medicaid.