• Skip to primary navigation
  • Skip to main content

OSRAA

Oregon Senior Referral Agency Association Raising Industry Standards since 2004

  • HOME
  • REPORT VACANCY
  • CONSUMERS
  • MEMBERS
  • PARTNERS
  • LIBRARY
  • EVENTS
  • CONTACT US

Adult Care Homes

How to avoid Medicaid spend down stress: One family’s experience

How to avoid Medicaid spend down stress: One family’s experience

June 19, 2019 By Sande George Leave a Comment

elderly woman with caregiver

Medicaid spend down takes pre-planning and knowledge. Get 13 insights about choosing a care home when planning a Medicaid spend down.

Avoid the stress this family experienced.

A Medicaid spend down plan – you think you’re doing it right

A family friend called. Four years ago, she and her siblings found an adult care home for their aging mother. They agonized over making the right decision until they found one that seemed like a perfect match. The peer group, location, and care level fit their mom's needs.

The oldest son, Jeff, handled mom’s finances. She had money in the bank from the sale of her home and property. Mom was physically healthy but pleasantly confused. He knew she’d out-live her assets and would need Medicaid to pay for her care in the future. To qualify for Medicaid, she had to spend all her money on care and medical costs first until it was almost gone.

Jeff asked all the right questions and was honest with the provider about how much money his mom had.

The care provider assured them that when their mother ran out of money, he would accept Medicaid. The owner didn’t have a Medicaid contract at the time but said he’d be willing to sign one when the time came.

My friend’s family is large so every day someone visited mom in her beautiful new home. They enjoyed the birthday parties and outings the caregivers hosted for the residents. Families were always welcomed. The caregivers treated their mom with love and kindness.
My friend and her siblings sighed with relief, grateful for the care their mom received.

Jeff thought the monthly rate of $7500 was high but worth it. And besides, he believed mom could stay in the home on Medicaid. The owner had verbally promised.

Mom spent down. It's time to apply for Medicaid.

care provider says no to Medicaid

Now, after living in the home for 3 ½ years, Jeff told the owner he was applying for Medicaid soon. Mom was running out of money. They had spent $315,000. Only $25,000 was left in mom’s account. He reminded the owner that he'd promised to open a Medicaid contract.

Right away the owner began making excuses. He said the timing was bad for him. He wanted to open a second care home and couldn’t afford a Medicaid resident. He didn’t want to hassle with the extra Medicaid oversight and paperwork.

At one point, the owner hinted he’d consider a Medicaid contract if the family paid the difference. (Medicaid reimbursement is much lower than private pay open market rates).

My friend and her family panicked. They started searching online about what to do. They talked to friends, social workers, and the visiting nurse. Could they enforce the verbal Medicaid spend down agreement with the provider? If they could, should they? Would the providers become angry and treat mom poorly? How could they find a new home on such short notice? Were there any nice homes that would take Medicaid right away?

Jeff called a family meeting to discuss the situation. His brother yelled about the deceiving, cheating owner. His sisters cried. They worried about how to tell mom that she was moving. How would she react to a new home? Would another move cause more memory loss? 

Get help choosing a care home that takes Medicaid

I recommended they call a registered local referral agent for help.

The referral agent understood all their concerns. She reassured them that there were available options. In fact, within a few days she had homes for them to visit.

All the care homes she referred were pleasant and clean. Perhaps a little more modest than mom’s current home. But the providers were friendly and had good references. Most importantly, they already had a Medicaid contract. So a short Medicaid spend down wouldn’t be an issue.

The good news! - my friend’s mom transitioned to her new place without any problems. She’s even made friends with another resident on her first day. Her family is grateful for that.

But they wonder how this stressful situation could have been avoided. How could the Medicaid spend down planning work better? They don’t want other families to go through this stress. 

What is Medicaid and how do you qualify?

Doctor writes Medicaid
  • Medicaid is a Federal and State program for low income elders who need care. One must qualify and meet the criteria for both income and care levels.
  • When an elder qualifies, then Medicaid pays for housing, care, supplies, and medical costs.
  • Find OSRAA Medicaid & Elder Care Resources Here

Read more:   Oregon Medicaid Eligibility: 2019

How do you plan for Medicaid?

Medicaid takes a lot of pre-planning - the devil is in the details. Don’t find yourself disqualified, with no money, and needing care. Work with a Medicaid case worker at the Department of Human Services.

It’s also recommended you work with an elder law attorney to properly spend down. 

Read more about Medicaid spend down planning: NW Estate Law

Do all care homes accept Medicaid?

  • Homes are not required to contract with the State in accepting Medicaid. They must disclose if they have a contract or not
  • If a home has a Medicaid contract, they cannot ask a current resident to move out when the resident qualifies for Medicaid.
  • Conversely, if a home has a Medicaid contract, they are not obligated to accept new residents already on Medicaid. Also, if someone will qualify within a few months, a home may deny admission.
  • Do the math. Be clear about how much money your loved one has before they’ll need Medicaid. Be honest with prospective providers.
  • Never rely on a verbal promise for Medicaid spend down. Get it in writing. Make it part of the written contract.
  • Some families purposely choose a private pay only care home for spend down. They think these facilities are “better” and want an upscale setting for as long as possible. These families anticipate another move.
  • If you choose this plan, keep in mind that your options will be limited. Providers who accept Medicaid need private pay funds for as long as possible. Medicaid reimbursement is much lower than market rate.

How to choose a care home when planning a Medicaid spend down?

  • If you think you’ll need Medicaid in the future, select a home that has a current Medicaid contract. Or at least has had a contract in the past. Some homes really do honor their word. They open a Medicaid contract for long-term residents who need it. (get it in writing)
  • Never agree to “making up the difference” between private pay market rate and the Medicaid reimbursement. This is illegal Medicaid fraud. If a provider suggests it, file a complaint with DHS.  Read more about filing complaints with Oregon DHS
  • Check with your referral agent about any past complaints or negative experiences with a care home. One benefit of working with a referral agent is their experience and all the networking they do. Word gets around when providers make “false promises”.
  • Situations do change. Some care homes have cancelled their Medicaid contracts with the State. They decided to accept private pay residents only. All the residents on Medicaid had to move out of the home. This doesn’t happen often but it’s something to be aware of.

What you can do when a provider makes false promises:

In a situation like my friend's, filing a formal complaint with the State won’t have much effect. There’s nothing a licensor can do about verbal agreements.

But you can file a complaint with OSRAA.  Here's our Contact Us page

If you have a negative experience with a provider making false promises, we want to know. Our members will be cautious in referring that home. Especially to someone needing future Medicaid.

Finding the right care home for a loved one is stressful enough. Avoid the type of situation my friend and her family faced. Follow the advice above. Work with a registered OSRAA referral agent member.

Find an OSRAA member Referral Agent:  Member Directory

Did you find this article helpful?

Let us know in the comments below. 

You might also like this article and companion video:

Medicare vs Medicaid

There's a lot of confusion about Medicare and Medicaid. In this article we explain the differences between the two. Find out who qualifies for each program, what services are covered, and the qualifying steps needed to get started.  

Filed Under: Adult Care Homes, Blog, Finances, Local Referral Agencies

What is Adult Care Home Part 2

What is Adult Care Home Part 2

November 9, 2017 By Sande George 2 Comments

Adult Care Homes: The Relational, Non-Institutional Option.

This is Part 2 of What is an Adult Care Home? It covers the pros and cons of care homes for older adults needing care. You'll better understand the setting and the kind of care provided. And you'll gain insight into the resident profiles best suited to adult care homes. But first...

play

Meet Carolyn and her dad, Bill

Carolyn’s dad, Bill, had a stroke and couldn’t live alone anymore. At first, Carolyn thought about bringing him home to live with her. But she soon realized how difficult caring for her dad would be. She didn’t have the physical strength to help with his transfers. Her bathroom wasn’t accessible. And, she'd have to quit her job.  Bill needed someone nearby around the clock.

Confronting expectations

Carolyn felt bad. She felt she was letting her dad down. When Carolyn was young, her frail grandmother came to live with the family. Her parents made sure grandma’s last years were surrounded by family. Carolyn’s dad always said that’s what he wanted someday if needed. Carolyn felt she wasn’t living up to the family’s expectations.

Guilt, guilt, and more guilt

Carolyn was racked with guilt. She stressed over thoughts of her dad living in a nursing home permanently. He hated it there during his rehab stay. Bill complained non-stop about the noise and food. Carolyn spent hours researching ways to remodel her home, find home care workers, and estimating costs. She wanted to meet Bill’s expectations, get the best care for him, and use his finances wisely.

The social worker at the rehab nursing home recommended Carolyn consider an adult care home for Bill. She referred her to a referral agency. 

Bill fits the profile

Carolyn met with a referral agency to discuss care, preferences, and finances. They also agreed an Adult Care Home would best meet Bill's personality and care needs.

Here's what they told Carolyn...

In Adult Care Homes the caregivers live in the home with the residents - just like in a family situation. There aren’t shift workers coming in and out. The same caregivers care for Bill every day. They would get to know him and they way he likes things done. They learn to anticipate his needs and can respond quickly. Even with unscheduled care.

Bill isn’t interested in bingo, bunco, and billiards. He prefers quiet conversations in small groups, reading his books or watching his programs. He likes sitting on the deck and watching others work the garden. It reminds him of his gardening days.

Bill’s health care needs are significant but stable and predictable – his caregivers can manage his medical care. He’s confused at times because of the stroke but he’s not up at night or wandering.

The referral agency introduced Carolyn to several care homes nearby. She liked them all but felt especially comfortable with one home. She asked the caregivers to go meet Bill at the rehab center. Bill liked them too and agreed to “try it out.”

After a few months in the home, Bill has developed close relationships with his caregivers. He's made friends with the other four residents in the home and their families. 

Relief

Carolyn feels relieved having her dad close-by, receiving competent, heartfelt care. She can stop by and visit him often. She takes him on outings or brings him to her house for family occasions.

The funny thing is, Bill doesn’t usually want to stay at Carolyn’s house for long visits. He wants to “get back home,” he says.

THINGS YOU SHOULD CONSIDER

​
If you’re considering an adult care home for someone you love, here are some things to consider.

Medical & Health Considerations

  • Anyone moving to an adult care home must be medically stable; with blood pressure, pulse, temperature, and respiration in normal ranges for at least 72 hours. 
  • Infections must have been treated with antibiotics.
  • Wounds should be dressed and follow up medical care scheduled.
  • Diabetics must have blood sugars under control and predictable.

Because care homes have a higher staff to resident ratio they can usually manage more complex medication management regimes. Also, staff can meet frequent “hands-on,” unscheduled care demands better than a larger facility.

Social & Activity Programs

  • Adult Care Homes are best suited for people who don’t want to participate in lots of group activities.
  • Care homes are smaller and quieter settings - active "social butterflies" are usually unsuited.
  • A larger community with a robust activity program may be a better choice.

Supervision

  • Care homes are a smaller environment.
  • People needing close supervision are usually served well.
  • People who aren't safe behind closed doors for at least two hours, should consider an adult care home.
  • The trade-off for closer supervision is smaller personal space: a bedroom versus an apartment in a larger community.
  • People who aren't safe behind closed doors for at least two hours, should consider an adult care home.The trade-off for closer supervision is smaller personal space: a bedroom versus an apartment in a larger community.

Night Care & Behaviors

  • Care homes Care homes must have a caregiver on premises at all times.
  • Care homes are family-style and caregivers need to sleep at night.
  • They respond to infrequent calls for help.
  • They will often provide room check once during the night.
  • Most homes can’t provide awake staff for frequent unscheduled night care. 
  • Some homes can manage frequent night care because there’s more than one caregiver and they take turns staying awake. Most can not.


If your loved one absolutely needs frequent night-time assistance, be prepared for extra charges or consider a different type of care setting. 

  • Residents with behaviors may not be a good fit for the smaller care home environment.
  • Behaviors include: acting out, combativeness, exit seeking, and severe social behaviors.

Each situation should be evaluated on an individual basis. Contact a senior referral agent for help.

Adult Care Home "House Rules"

  • Each home sets their own house rules regarding outside smoking areas, accepting resident pets and visiting hours.
  • Most homes ask families to avoid visiting at meal times. Residents tend to focus on visitors and not their meal.
  • Maintaining respect for all residents’ privacy is important.
  • Older people tend to retire earlier so late visits should be avoided.

If your loved one has a pet they can’t part with, finding a care home will be challenging because most homes don’t accept resident pets. Most larger communities like assisted living do allow pets.

If you have an odd work schedule, a large extended family who frequently get-together or want to visit your loved one late into the evening, be sure to discuss these with the provider. Larger communities usually don’t have visiting hours. 

In Conclusion

Adult care homes are the solution for a non-institutional, relational, family-style environment for care. Making sure a loved one receives personal and medical care in a home-like setting gives family’s peace of mind. It’s the next best option to bringing your loved one home to live with you.

Referral agencies have previewed and pre-qualified the care homes in your neighborhood. Call an OSRAA member today for help.

Filed Under: Adult Care Homes, Long Term Care, Senior Housing Tagged With: adult care home, adult foster home

What Is An Adult Care Home? – Part 1

What Is An Adult Care Home? – Part 1

October 7, 2017 By Sande George 6 Comments

Adult Care Homes, also called Adult Foster Homes, [ACH or AFH] are single family residences offering care to senior adults. They provide a home-like care setting.

Care homes are usually located in residential neighborhoods and look like any other family home. The difference is that the home is licensed to care for older adults who are not family relatives.

A Little History of Adult Care Homes

Historically, our frail elderly lived with family, friends, and neighbors – often with several generations under one roof. Housing and care arrangements were informal.

After WWII, nursing homes, formerly “poor houses”, began providing care to the very poor, frail and disabled within a community.

In the 1960’s, significant government oversight and regulation of nursing homes was set. Laws enforced compliance with safety codes. The government began funding care through Medicare and Medicaid. Nursing homes became a highly regulated industry and care became institutional.

Nursing homes became institutional

During the 70’s and 80’s, the informal care provided by families and neighbors shifted. Because care homes provided less institutional care than nursing homes, they became more prevalent. Care home became a direct competition to nursing homes and so an industry was established.

Government regulation, oversight, and supervision expanded too.  Adult care homes today are regulated almost as much as nursing homes.

Care homes are limited in how many elders can live in the home. In Oregon, the limit is five residents.

A resident is an elder who’s not directly related to the provider. Limiting the number of residents helps maintain the home-like, family atmosphere of care homes.

Care providers live in the home and give personal help and medical care to their elderly residents. Residents can never be left unattended – a caregiver must be in the home at all times. Adult care homes provide closer supervision because of the smaller environment. Caregivers can respond quicker to resident needs.

In comparison, larger facilities have a higher ratio of residents to caregivers; each caregiver has more residents they’re directly responsible for.

Adult Care Home Licensing and Inspections

Each care home has one primary business owner and operator. Owners are liable and responsible for compliance with all rules and regulations. Some homes are operated by registered nurses or other medical professionals, but it’s not required.

Owners are not required to live in the home or always be present. They may even own more than one home. But owners must be available by phone in case of emergency.

Owners may employ qualified caregivers and resident managers – who are required to live in the home.

Again, the state wants care homes to maintain a home-like environment which means limited shift workers. When caregivers or care providers live on premises there’s a greater sense of bonding and family atmosphere. 

The State licenses both the home and the owner

  • Homes must meet structural and safety requirements.
  • Care providers must meet certain standards such as documented caregiving experience, pass criminal background checks, complete basic training and pass an exam in English. Yearly continuing education is required to maintain a care provider’s license.

Adult Care Home Licensing and Inspections

All homes are inspected and licensed by the Department of Human Services on a yearly basis. The inspection is unannounced and conducted by a licensor or other assigned State/County employee.

Inspections include: 

  • a review of all resident records,
  • medication administration logs,
  •  physician orders,
  • written care plans,
  • change of condition notes,
  • contracts, etc

In addition, the inspector will ensure the home’s structural safety compliance, medications are locked, hazardous materials properly stored, water temperature is correct, and much more.

The licensor may even conduct a fire drill. In Oregon, caregivers must demonstrate they’re able to vacate all residents within 3 minutes in event of a fire.

Adult Care Home Custom Construction

Homes vary in size, aesthetics, and amenities. Homes may offer private or shared bedrooms. Private bedrooms may have a private en-suite half-bath. In older, converted homes, the bathrooms are often shared. A separate shower room is standard and used for scheduled bathing.

In the last decade, newly constructed custom-built care homes have changed the ACH market. These homes have all the latest innovations: roll-in showers, call systems, security systems, private bedrooms with private bathrooms and aesthetic features.

The larger, new construction and amenities meet the higher expectations of today’s consumer.

However, homes with all the latest and greatest amenities don’t necessarily provide better care. They may, in fact, reduce the “family factor”.

Basics Services Provided in Care Homes

  • Homes must provide room and board as part of the month to month rent.
  •  Base rent is comparable to assisted living and residential care rates.
  • Care and personal services are an additional monthly rate and can increase as care needs increase.
  • The maximum amount of care a home provides depends on their personal limits and their licensing level set by the State.

Types of Payment Accepted in Adult Care Homes

Medicare does not pay for adult care homes.

Payment for the monthly charges in an Adult Care Home are: private pay, long-term care insurance, and possibly supplemental Veteran’s benefits (Veteran benefits are not enough to cover 100% of rent + care).

Some homes accept Medicaid. (a State & Federal low-income assistance program – see article and video, Medicare vs Medicaid)

Important Note! Understand Medicaid

  • Understand Medicaid when considering an adult care home.
  • Owners can choose to maintain a contract with the State and accept Medicaid reimbursement.
  • The State sets the reimbursement rate. It’s much lower than the open market rate. 
  •  Family can not "supplement" to make up the difference between Private pay market rate and the Medicaid reimbursement rate. It's illegal and considered Medicaid fraud.

If a care home has a Medicaid contract,  they are not obligated to accept new residents currently on Medicaid.

Homes often have a contract so that their long-term clients, who run out of private money, can continue living in their home. 

Read the contract regarding Medicaid carefully. Contact an OSRAA agent for help.

Summary

Adult Care Homes offer a viable alternative to the larger assisted living and nursing home facilities. Is a care home the right option for you or a loved one? The same reasons making a care home the right choice for one person can be the same reasons it's the wrong choice for another.

Call an OSRAA member if you’re considering an adult care home for yourself or a loved one. Get expert guidance, information, and peace of mind.

Members Directory

See Part 2 about the Pros and Cons of Adult Care Homes:
“What Is An Adult Care Home? Part 2”

 You’ll gain insight about specifics of care provided and the personality of residents best suited to care homes.

Filed Under: Adult Care Homes, Long Term Care, Senior Housing Tagged With: housing

Copyright © 2021 OSRAA