Who Pays for Nursing Home Care While Medicaid is Pending?

Summary
Who pays for care while a nursing home resident while they have Medicaid Pending status, which happens when they are waiting the state’s determination of approval or denial of Nursing Home Medicaid benefits? Often, no one pays the nursing home during this time. Many nursing homes do not charge a resident during if they are Medicaid Pending, but the facility could legally charge. A nursing home, however, cannot evict a resident for not providing payment as long as their Medicaid application is pending. Even so, a nursing home facility might put pressure on a resident and their family to provide payment and threaten them with eviction.

Definition of Medicaid Pending

After an applicant has applied for Medicaid but before they have heard back from the state they have Medicaid Pending status. In other words, they have not yet been approved or denied Medicaid coverage. The length of the Medicaid Pending status depends on the applicant and the situation. Federal law gives Medicaid agencies 45 days to review and respond to Medicaid applications, or 90 days if the application also requires a disability determination. However, states are allowed extensions and it is very common for one’s Medicaid application to be pending for a longer period of time. More on Medicaid Pending.

Should Family Members Pay the Nursing Home While Medicaid is Pending

A nursing home might claim they need payment during the delay between Medicaid application and determination, and therefore, put pressure on a resident’s family to provide payment. It is not generally recommended that payment be made. While a nursing home might threaten eviction, they cannot evict a resident while they have a Medicaid Pending status. Furthermore, while a nursing home is required by law to provide reimbursement of costs paid after a resident has been approved for Medicaid, it can be extremely difficult for one to get their money back. It should also be mentioned that in some states, Medicaid will not pay for nursing home care for any month in which the nursing home bill was paid in full. Therefore, if any amount is paid, one should ensure it is less than the amount billed.

Share of Cost Should be Paid

Even though a nursing home cannot evict a resident who has a Medicaid application pending, it is recommended that they pay their estimated share of cost during Medicaid pending. Also called a patient liability, it is the amount a Medicaid-funded nursing home resident must pay to the nursing home towards their care costs each month. Once approved for Medicaid, a nursing home resident must give most of their income to the state – this is their share of cost. They are only permitted to keep a small amount of their monthly income for their personal needs. This is called a personal needs allowance, and ranges between $30/month and $200/month, depending on the state. There are other potential allowable deductions, such as health insurance premiums and an income allowance for a non-applicant spouse, which can lower one’s share of cost. One’s share of cost is calculated after Medicaid approval, but one can estimate the amount and pay it during Medicaid pending.

How is the Nursing Home Paid?

Once a resident has been approved for Nursing Home Medicaid, Medicaid will reimburse the nursing home for the expenses accrued while the beneficiary had Medicaid Pending status. Medicaid will reimburse the nursing home at the Medicaid pay rate (which is less than the private pay rate) minus a resident’s share of cost. As discussed above, it is often recommended that a resident pay their estimated share of cost during Medicaid pending. If not paid in advance, they will still owe a share of cost from the period their application was pending. If one is denied Medicaid eligibility, they will owe the nursing home the full cost at the private pay rate for the period their application was pending.

If Medicaid is Denied, Who Pays the Nursing Home

If one’s Medicaid application is denied, they can appeal Medicaid’s decision. The reason for denial and instructions for filing an appeal will be included on the denial notice. We recommend consulting with a professional like a Certified Medicaid Planner before filing an appeal. A nursing home cannot evict a resident during the appeal process. However, if the appeal is denied, or if a resident chooses not to appeal, they will owe all previous nursing home bills at the private pay rate and must pay the nursing home moving forward.