This must be an unusual question because I can't find suggestions anywhere. I'm hoping this forum can give me some ideas. My mother is in late stage dementia and has been in a nursing home for 3 years on Medicaid. According to the NH, in our state of CT, she gets to keep $60 a month from SSI and $90 a month from the VA. I find it a challenge to keep her bank account below the $1600 maximum so that she continues to qualify for Medicaid. A haircut in the facility costs a mere $20 and she definitely wouldn't enjoy or need a haircut every month. I buy her clothes, shoes, special toiletries, treats from time to time but $150 a month is alot to spend on these kind of items. I bought her flowers, seasonal decor gifts, cozy outfits and blanket, Alzheimer "toys". I'm at a loss of what else I can use this money on. My mother's dementia is at the point where she wouldn't enjoy leaving the facility so going out for lunch or ice cream is no longer a possibility. She already has a TV in her room that she doesn't watch. The nursing staff suggested a medical recliner for her room but seriously there is barely room for that and I know she wouldn't use it. She spends most of her days in her wheelchair in the community room. Recently I've had a massage therapist come in to give her a chair/hand massage which she enjoys. I will continue to do that but I need some ideas for more big ticket items so that I can get her account down to a balance that is easier to maintain under the limit. I know, its a ridiculous problem to have. Does anyone else have this problem? Does anyone have some ideas to spend money on for a late stage dementia resident of a nursing home?
K. Gabriel Heiser
A senior’s income and assets must fall below certain levels to qualify for Medicaid coverage of their stay in a skilled nursing facility. If their countable assets exceed $2,000, they will not qualify until the excess is spent down or converted to an asset that is not countable.
For income, the 2018 federal limit for eligible applicants is $2,250 per month. However, many states allow Medicaid applicants to spend down their income on medical expenses to get below the $2,250 limit and thus qualify. These states are known as “medically needy” or “spend-down” states. But what can an applicant do if they live in a state that has a hard income limit and doesn’t allow spend-down? Say their assets are below the eligibility limit, but their countable monthly income is $2,275. In this scenario, the senior has too much income to qualify for Medicaid, but they certainly do not have enough money to pay for a nursing home or other long-term care facility!
It was this very situation that led to the 1990 case of Miller v. Ibarra in Colorado. As a result of the decision in this case, those states that do not permit an income spend-down all offer Medicaid applicants the ability to set up a simple irrevocable trust to hold their excess income. Funds in this trust can be used to pay the Medicaid recipient a monthly personal needs allowance (approximately $60, but this varies by state) and, if applicable, pay their community spouse a minimum monthly maintenance needs allowance (MMMNA). From there, any funds that are left over are used to pay the Medicaid recipient’s nursing home bill. The difference will be covered by Medicaid, assuming the applicant otherwise qualifies. Such a trust is called a Miller Trust (after the court case mentioned above), but it can also be referred to as a Medicaid Income Trust, a (d)(4)(B), an Income-Only Trust, an Income Diversion Trust or a Qualified Income Trust (QIT).
Each state has different rules, but in “income-cap” or “categorically needy” states that don’t allow spend down, at least the excess over the income limit amount must be placed into the trust. The Medicaid applicant cannot be the trustee of this account since they are essentially giving up their rights to the money it contains. The trustee is typically a family member, and each month they use money from the trust to pay the Medicaid recipient’s share of cost (SOC), personal needs allowance, their spouse’s MMMNA, and other medical costs and premiums not covered by Medicaid and Medicare. Assuming some basic rules are followed regarding this process, excess income will not prevent an applicant from qualifying for Medicaid, unless their income is so high that it exceeds the amount that Medicaid would otherwise pay to the nursing home each month for their care.
Keep in mind that a Miller Trust can only be used to hold income going to the individual who is trying to qualify for Medicaid, and many states require this income to be direct deposited into the trust account. Applicants cannot put only portions of certain income sources into the account. For example, you cannot put part of your pension or social security check into the trust—it’s all or nothing. Assets and income sources that do not count towards eligibility limits should not be placed in this account either. This includes a community spouse’s income, VA benefits like Aid and Attendance and housebound pensions, income tax payments and some annuity payments.
Give her flowers every week or 2xs a week.
Anything that she can benefit from in anyway is exactly what you should do.
Can you hire a caregiver to come in and help her with interaction that she enjoys?
I think that you have good solutions already, you just need to keep them on a regular schedule.
Or maybe a visit from a therapy animal, if the facility allows that.
- fresh flowers delivered to her room;
- eatable bouquet;
- chocolate covered fruit;
- meals/treats delivered to her room (with delivery services like DoorDash you - - can have a whole meal or milkshake or smoothie delivered);
- manicure and pedicure;
- wash & set;
- digital photo frame with slideshow feature;
- photo book of family, landscapes, birds, animals, etc.
- if allowed a small refrigerator;
- Walmart/grocery delivery of fruit/cheese tray;
- my father enjoyed high qualify chocolates (Godiva has a subscription service to deliver a box each month);
- mouth rinses (for dry mouth or dental health); and,
- essential oils along with a diffuser.
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