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A nurse offers medical assistance to an older woman in a wheelchair.

One misfortune, such as a sudden disability or diagnosis, can change the financial outlook of a person or married couple in a drastic way. The typical reason for applying for Medical Assistance for Long-Term Care Services, a program that pays for an eligible applicant’s nursing facility or community-based healthcare services, often includes an unforeseen circumstance that precipitates a need for this level of care. Suddenly, a person’s (or couple’s) plans and visions he or she had for himself or herself have become completely untenable.

For families deciding what to do, it can feel like their world has been flipped upside down in a single moment. There are so many unanswered questions that were not ever a concern before: How will I pay for this? What will happen if I run out of money before being approved for services? Will my spouse have anything left to live on? Will I be left impoverished just for needing this service?

Single persons, couples, or families grappling with these issues—especially when time is of the essence—need answers to these questions quickly. One of the first issues that people considering a Medical Assistance application will face is whether they will apply for the general Long-Term Care program to stay at a skilled nursing facility/nursing home or whether to seek eligibility for a waiver program that allows the applicant to stay in-home or at least at an assisted living facility/care unit. Although both programs fall under the Medical Assistance umbrella, there are important distinctions between the programs that affect people’s choices.

Waiver-Based Medical Assistance vs. General Long-Term Care

Most people prefer to receive community-based services outside of a nursing home. When it becomes apparent that a person may need to apply for Medical Assistance, even eventually, that individual or both spouses often plan a move to an assisted living facility, where they will pay their own way as long as possible, often selling their home or condo to begin paying for services themselves. This may not be the best financial or legal decision available to them. This is because the currently owned home or rental property is often still the most cost-effective place to receive care.

Seeking a waiver-based Medical Assistance program pays for care services, not room and board. The assistance covers broad needs that help an applicant with their needs for daily life, including bathing and dressing, and even chores and cleaning services. However, when moving to an assisted living facility, the waiver program fails to cover the rent; that will be left to the personal funds of the waiver recipient or the recipient’s family. Many people go all-in intending to qualify for the waiver program, only to find that they will still be on the hook for rent at the facility they were desperate to live in and that they sold everything else to get to. This comes as an incredibly unwelcome surprise.

Sometimes, getting into an assisted living facility is difficult in its own right. Assisted living facilities typically require potential residents to prove that they can afford to live there for two years. And because of high demand for assisted living facilities (and difficulty staffing these facilities in recent years), facilities want to assess whether they are even equipped to meet a person’s care needs. It used to be commonplace that residents of assisted living who were able to initially finance their stay privately would always have continuity of care and a place to stay once waiver services were paying for them. That is not necessarily the case anymore. The facility may move a person who has recently gone on waiver services to a different room or claim that there is no space or ability to provide continued service at all.

By contrast, a general Long-Term Care application will entitle the applicant to room and board expenses being paid, but only if a nursing home level of service is required. Therefore, that application requires proof of need for skilled nursing care that is beyond the capabilities of an assisted living facility. As you can see, there are many issues to consider, and the best thing a person can do is consider them with an Elder Law Attorney who practices in this area.

A budget may be the first order of business. People often put a great deal of weight on the large assets that they own, focusing on things like homes, brokerage or retirement accounts, and the like. These funds are what people think of when having to pay for the large costs of care that have only been increasing astronomically in recent years. However, you can least afford to get tunnel vision when it comes to considering your every option. Sometimes, it is helpful to focus on income and expenses because that is what we live on. If one option appears to provide more stability from a financial perspective, that may be the best option going forward.

The discussions you will have with an Elder Law Attorney will be very forthright and will often require finding a way to budget with your utmost goals in mind. These are difficult discussions, but they have an aim and outcome in mind: getting the best, needs-specific care for a client or client’s family member while qualifying for the most appropriate program available.

Trust Henningson & Snoxell

Although it appears like there is no opportunity to plan, it makes sense to proceed thoughtfully. None of these goals can be reached without the knowledge necessary to make a roadmap to get there. Even when there seems to be no room to maneuver, one of our Elder Law Attorneys can make sure you take your next best step forward. Contact us today to get started.

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