Back Medical Bills of Medicaid Nursing Home Residents

When there are outstanding Medical bills from before a nursing home resident was approved for Medicaid, it can be a bigger problem than when you put your car in gear and instead of moving it just sounds like a grunge band with defective amplifiers.  The problem of back medical bills often happens through no fault of the nursing home resident or the resident’s family.

For example, let’s say that Edina Monsoon has been in a nursing home for 12 months at $9,000 per month.  Her income is $2,100 per month from Social Security and pension.  Her savings were used up eight months ago and her daughter, Saffron, applied for Medicaid.  Unfortunately, Edina had demutualization stock worth $5,000 associated with a small life insurance policy that Saffron did not know about.  The stock was discovered about two months into the application process and it took two additional months to get the stock sold.  She lost four months of Medicaid eligibility and consequently owes the nursing facility more than $25,000 that she has no way to pay.  Edina’s Patient Pay Amount, the portion of her care that Medicaid will not pay, eats up nearly all of her income.

The outstanding bill is more the nursing facility’s problem than Edina’s.  She does not have the money to pay it and there will not be any money in her estate when she dies, so a lawsuit against her would be pointless.  However, the facility may sue Saffron, claiming that she was negligent in not finding the insurance company stock.

There are also “parental support” laws, in some states, making sons and daughters liable for indigent  parents’ care.  Some people would get pleasure out of having to pay a parent’s nursing home bill, just as some people get pleasure out of chopping a hole in the ice on a frozen lake and jumping in.  Most other people would consider it in their interest to find ways to get as much as possible of the bills covered by the government program established for that purpose – especially when the outstanding bill is about 10 times the cost of a new transmission.

There are two ways that some of the bills may be covered: First, if Edina is hospitalized for at least three days, she may have a period of Medicare eligibility with no Patient Pay Amount (PPA).  Secondly, the Medicaid regulations may allow an offset to the PPA for pre-eligibility medical expenses (PEME).

A patient who is covered by Medicare may be eligible for up to 100 days of “skilled care” following an inpatient hospital stay that included three midnights.  If the patient has supplemental insurance that covers the skilled care deductible, the period on Medicare may be at no cost to the patient.  Since the PPA only applies when there are care costs, Edina’s income could be applied to the outstanding bills for earlier care.  If she has 100 days covered by Medicare and her medigap policy, the $6,000 she would otherwise pay for current care can be used to reduce the outstanding bill from before Medicaid was approved.  To get the maximum benefit from the period of skilled care, demand that rehabilitation be continued for the full 100 days available under Medicare rules.

In some states, the Patient Pay Amount for current care may also be offset by pre-eligibility medical expenses.  The period of allowable PEME varies from three to six months.  Don’t ask why the PEME offset for a federal health program varies from state to state – it just does.

Having the Patient Pay Amount offset by PEME may require persistent demands addressed to the facility billing department or the Medicaid agency, itself.  The procedure varies from state to state or even from county to county.  In some areas, the facility billing department can offset the PEME directly against the PPA.  In other areas, the facility must submit a request to the Medicaid agency.  In still other areas, no one at the facility or at the local Medicaid office will have a clue about PEME offsets, no matter whether you ask in English, Croatian, Farsi or Klingon.  In those areas, an Elder Law attorney may be able to educate the bureaucrats.

If the facility’s billing department does not know how to submit PEME for PPA offset, the resident’s agent or attorney may be able to effect submission of the necessary paperwork.  Usually, this only requires a letter accompanied by copies of the billing statements.  The challenge is finding the name and address of the proper person at the Medicaid agency.

Old medical bills is only one of the financial, social and care problems that plague nursing home residents.  An experienced Elder Law attorney can help solve many problems that may not seem “legal” in nature.  In Pennsylvania or Michigan, Garrison LawHouse PC will provide valuable advice and assistance.  For a personalized referral to an understanding and skilled Elder Law attorney in other states, please call:


John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
©2013 John B. Payne, Attorney

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