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What Happens When Medicaid Runs Out?

What Happens if Medicaid Runs Out?

The legal bases for a nursing home to legally discharge or transfer a resident are very limited in most states across the country. In fact, if Medicaid runs out, this is not a basis for a nursing home to remove a resident.

In some very limited cases, however, a nursing home does have the discretion to discharge or transfer a resident involuntarily. In those instances, there are certain requirements that a facility must meet and certain notifications that the nursing home must provide to the resident, the resident’s legal representatives, and the resident’s health care providers.

If you believe that your loved one’s nursing home has not complied with its legal requirements, then you must have an experienced nursing home lawyer on board in your case. A Duluth nursing home abuse lawyer can contact the nursing home and undertake an investigation, if necessary, to make sure they safeguard your loved one’s legal rights at all times. A nursing home lawyer can also represent you at any hearings that take place at the nursing home, before an administrative law judge, or in the state civil court system.

Types of Payments Made to a Nursing Home

It is no secret that care at a nursing home can be extremely expensive. Therefore, before placing a loved one in a particular nursing home, you want to make sure that you explore all of the available options.

Also, before signing any agreement with a nursing home, you want to make sure that you understand everything that you are signing. Before signing the agreement, you may negotiate some changes and negotiate certain terms of the contract. However, the nursing home does not have to accept or agree to your changes.

When it comes to paying for nursing home services, some individuals use private sources, such as family resources, private insurance, or the resident’s own financial resources. However, Medicare and Medicaid are also common payment methods that individuals use to pay for their care at a nursing home.

Medicare is an insurance program that is provided by the federal government. This program will pay for skilled nursing care in a facility. However, these payments will only last for a small amount of time. On the other hand, Medicaid is an insurance program provided by the government that aims to assist individuals who have a limited amount of income. When a potential nursing home resident is financially eligible, Medicaid will step in to pay for his or her care at the facility.

In some instances, a resident may enter a nursing home and use private or family financial resources to pay for his or her treatment and care while staying there. However, if these resources later run dry, the resident may be eligible to receive assistance through Medicaid. Although a great many nursing homes across the country will accept Medicaid payments, not all nursing homes and long-term care centers will accept them.

Reviewing a Nursing Home Admissions Agreement Thoroughly

Many elderly individuals must go to a nursing home after they suffered a fall or some other serious injury or illness. The elderly individual’s loved ones may be anxious to try and get the individual placed in a reputable nursing home as soon as possible.

However, before deciding on a nursing home, you should be sure to weigh all of your options and review the admissions agreement before signing it. In some cases, you may also want an experienced nursing home attorney to review the admissions agreement with you and, if necessary, suggest changes or modifications. You should also make sure that you have a signed copy of the document that you can keep for your records.

In terms of the law that applies to a nursing home admissions agreement, if the nursing home participates in Medicare or Medicaid, then both federal and state law will apply to the contract. However, if the nursing home does not accept payment through these federal programs, then only state law will apply to the initial agreement. It is also important to keep in mind that under federal law, nursing home residents have protections from discrimination or harassment based on the form of payment.

Preference by Nursing Homes Based on Payments

Nursing homes have the right to give preference to applicants who pay for their nursing home care privately, as opposed to those who are eligible for Medicaid services.

However, under federal law, a nursing home does not have the right to engage in any of the following:

  • Require that potential nursing home residents waive their Medicaid or Medicare rates at the time of admission
  • Require a nursing home resident to pay a nursing facility using his or her own private financial resources before he or she applies for Medicaid benefits
  • Require that the resident make a written or oral promise that he or she will not apply for Medicaid or Medicare benefits and/or that the resident is not eligible for these benefits

If nursing homes engage in these types of behaviors, they can face civil liability.

Medicaid Recipient Requirements at Nursing Homes

Residents of nursing homes who receive Medicaid assistance must use the majority of their income toward the care that they receive at the nursing home. Residents are, however, permitted to keep $50 that they receive in monthly income (or $100 for couples who are married), which they can use to pay for toiletries, clothing, personal grooming needs, and telephone calls.

Transferring a Resident Out of a Nursing Home in Limited Circumstances Only

Before transferring a resident out of a nursing home, or discharging a resident from a nursing home, a nursing home is required to look into all possible alternatives. In cases where a bona fide emergency exists, however, the situation may be different.

Moreover, a nursing home may legally discharge or transfer a resident, against the resident’s wishes, when any of the following is true:

  • The nursing facility does not have the proper staff or equipment that is necessary to meet the resident’s needs
  • It is necessary to discharge or transfer the resident to safeguard the resident’s well-being, and failing to discharge or transfer the resident has the potential to make other nursing home residents ill or become injured if the resident remains on the premises
  • The resident’s medical condition has improved to such an extent that he or she no longer needs the care that the nursing home provides
  • The resident uses his or her own financial resources to pay for treatment, and he or she has not paid the bill.

In cases in which a resident enters a nursing home as a private pay resident but later changes to Medicaid, this does not amount to a non-payment of charges. In cases in which the nursing home resident is eligible to receive Medicaid services, the nursing home will receive reimbursement from the federal government for a maximum period of three months before the nursing home resident applied to the facility.

Moreover, a nursing home may not enforce an admissions agreement that states that when a resident becomes Medicaid eligible, the facility will transfer or discharge the resident.

In situations when a nursing home resident is discharged or transferred from a nursing facility, and the situation is not an emergency, the resident has the right to receive written notification. This notification must also go to the nursing home resident’s doctor and legal representative within a period of 30 days before the discharge or transfer is supposed to take place.

The notification provided to these individuals must state all of the following:

  • The date on which the nursing home resident’s discharge or transfer is supposed to take place and become effective
  • The reason why the nursing home resident is being discharged or transferred
  • The name, telephone number, and address information for the long-term care ombudsman for the jurisdiction where the nursing home is located
  • Identification of the place where the nursing home resident is either being discharged or transferred
  • Information about how the resident may appeal the discharge or transfer with the long-term care ombudsman for the jurisdiction of the nursing home’s location

When a nursing home resident, or the nursing home resident’s family member, disagrees with the discharge or transfer to another nursing facility, the nursing home resident should request a hearing as soon as possible. By doing this, the nursing home resident will still receive care and services at the nursing facility while his or her appeal is pending. An experienced nursing home attorney may assist you with filing an appeal and representing you at a hearing.

Rights of Nursing Home Residents

All nursing home residents have various rights, and if a facility violates one or more of these rights, the nursing home resident, or the resident’s legal representative, may file a grievance or complaint to seek remedies available under various state laws.

Some of the most important rights guaranteed to nursing home residents include:

  • The right to take the necessary legal actions and measures to ensure that a nursing home resident receives the rights to which he or she is entitled, without fearing some form of retribution, retaliation, punishment, or harassment by nursing home staff members
  • The ability to have privacy within the resident’s nursing home room, such as the right to close the curtains and doors to the room
  • The right to have privacy when communicating with nursing home staff members and healthcare providers about medical and personal services
  • The right to not be the victim of neglect or abuse, including physical abuse and/or sexual abuse at the hands of other residents or nursing home staff members
  • The right to open mail sent to the resident without interference
  • The right to manage financial affairs for oneself
  • The right to safe, careful, and competent medical and nursing treatment at all times while residing at the nursing facility
  • The right to access medical records and other records stored at the nursing home
  • The ability to request to be discharged from the nursing home or transferred to a different nursing home facility
  • The ability to interact and communicate with individuals who are outside of the nursing home

Checking for how well your prospective nursing home enforces these rights to the elders is a good way to determine the type of care they provide… but to learn more about conditions that can increase the likelihood of elder abuse speak with our experienced nursing home abuse attorneys.

Filing a Grievance Against the Nursing Home

In certain instances, a nursing home resident may be eligible to file a grievance against the nursing home. Specifically, residents are allowed to make a written or oral complaint directly to an individual who works as an administrator for the nursing facility. Once a resident files a complaint—either formally or informally—the nursing home administrator must use his or her best efforts to try and bring about a resolution to the problem.

Personal Injury lawyer

David Brauns, Personal injury lawyer

In cases where there is a complex issue or problem, and a resolution is not possible within a period of several business days, the administrator must typically draft written communication to the complaining individual.

Once the nursing home resident receives and reviews the response, he or she may file a complaint (either orally or in writing) with the ombudsman for the state. If the complaint is still left unresolved, there may be a hearing on the disputed issue that takes place at the nursing facility. In addition to this nursing home hearing, a resident also has the option of filing a legal cause of action or administrative complaint and relying upon an administrative law judge to resolve the issue or issues in dispute.

After the administrative law judge makes his or her decision, there may be a right of further appeal in the court system, depending on the jurisdiction in which the nursing home is located.

An experienced Duluth nursing home abuse attorney in your area can explain all of your appeal rights to you in clear and easy-to-understand terms. If necessary, he or she can then assist you with filing an appeal in the proper place and with the proper individual.


Brauns Law, P.C.
3175 Satellite Boulevard, Bldg 600
Suite 330
Duluth, GA 30096
(404) 205-8614

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