This is my second essay on caregiving, first published on another website on April 16, 2012.

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“We don’t accept cash.”

She must have misunderstood me.  When I offered to pay cash, she must have thought I was about to reach into my pocket, like some character from Mad Men, pull out a fat money clip, and begin peeling off hundred dollar bills until I got what I wanted.

“What I meant was,” I said, anxious to reassure her, “I could write you a check for the difference.”

“We wouldn’t know what to charge.”

“Well,” I continued, still not fully appreciating what I was up against, “I could put up a big deposit, and you could refund whatever you don’t use.  Or I could just give you my credit card.”

“We don’t accept cash.”

Maybe I should start at the beginning.  A little more than a year ago, my mother had to go to the hospital.  After she was there for about a week, she was still not well enough to go home, but neither was she sick enough to stay in the hospital.  So, a social worker stopped by my mother’s room to help me select a skilled nursing facility.  A skilled nursing facility provides care or therapy for people who have been released from a hospital, but are not ready to go home.  Medicare will pay most of it for 20 days, after which there is a co-payment for about 100 days.

The social worker suggested three such facilities, and I picked the one closest to where I lived. What I did not realize at the time was that a temporary stay at a skilled nursing facility is an opportunity to try out a nursing home.  In other words, the typical nursing home, providing long-term care, is often combined with a skilled nursing facility, providing temporary care.  In many cases, the rooms are the same:  someone who goes into a skilled nursing facility for therapy, but then undergoes a serious decline in health, requiring long-term care, will not even have to change rooms.

Medicare, of course, does not pay for long-term care.  I knew that if my mother should have to stay in a nursing home, she would soon run out of money, at which time I would have to get her on Medicaid.  When I happened to mention this to the woman in charge of admissions, she informed me that they did not accept Medicaid.  As I had naively supposed that all nursing homes accept Medicaid, this came as a surprise.  Moreover, I realized that an opportunity had been lost.  I had inadvertently selected a skilled nursing facility that would not be suitable for my mother, financially speaking, should she ever need long-term care.  Had I selected one that does take Medicaid, then from my mother’s temporary stay there, I would have known whether to bring her back when she needed to stay somewhere permanently. With this in mind, if you want to find out which nursing homes in your area accept Medicaid and which do not, I recommend medicare.gov.

After about a month, my mother was released, and she returned to her apartment.  As it was close to my apartment, and as I was retired, I was able to spend a lot of time over at her place attending to her various needs, like shopping, cooking, and cleaning.  But after a few months, she had to go to the hospital again.  As before, she needed to be released to a skilled nursing facility, and this time I selected one that would accept Medicaid, especially since it appeared that this time she might have to stay for good.

However, the admissions coordinator informed me that GEHA (Government Employees Health Association), the insurance my mother had in addition to Medicare, was not a supplemental policy, but rather a secondary one, a distinction I have yet to fully grasp.  The practical consequence was that GEHA would not pay for the portion that Medicare did not cover.  “I’m sorry,” she said, “but we will not be able to admit your mother.”

I had already been through this with the previous nursing home, but in that instance, I was simply told that I would be responsible for paying the difference.  All I could figure was that the woman I was now talking to must be used to dealing with poor people, who cannot afford to pay anything out of pocket.  “Oh, that’s no problem,” I assured her, “we can pay cash for whatever Medicare does not cover.”

“We don’t accept cash.”

And thus began the surreal conversation with which this story opened.  I called the social worker at the hospital.  She offered to call the nursing home herself.  Ten minutes later, she called me back to tell me that the situation was exactly as I had described it.  I selected another nursing home.  In this case, the woman in charge of admissions did not even bring up the subject of payment.   After my mother was released from that place, I received a bill and paid it.

Hopefully, the cash-refusing nursing home is just an anomaly.  But it is something to be on guard against, in case it turns out to be the beginning of a trend.  In particular, in selecting a supplemental insurance policy, it might be a good idea to find out how much it covers of skilled nursing care.

There is one more thing you need to know about skilled nursing facilities.  A lot of nursing homes have waiting lists.  If you are hoping to get your mother into a nursing home, it may take months to get her admitted.  And I am not just talking about the really nice nursing homes for rich people, the ones that do not accept Medicaid, like the first place my mother stayed in. I once took a tour of a nursing home that looked like a cheap hotel where they rent rooms by the hour.  And they had a waiting list!  But if your mother enters a nursing home directly from the hospital, by way of the skilled nursing unit, she will move to the front of the line.  In fact, once she has a room there, they are unlikely to ask her to leave, should it turn out that she needs long-term care.

Officially, everyone is treated equally.  It is whispered, however, that when it comes to waiting lists, preference is often given to those who can pay privately for a while.  The reimbursement from Medicaid is not generous.  A Medicaid bed is better than an empty bed, but not that much better.  With too many Medicaid beds, a nursing home may end up having to close its doors.  It needs a certain proportion of the more remunerative private-pay beds in order to cover its costs.  Therefore, a prospective applicant who can pay privately for many months is more desirable than one who needs to get on Medicaid right away.  So, if you need to put your mother in a nursing home, and she can pay privately for a while, you should casually mention this fact when talking to the person in charge of admissions.

Now that I think about it, it might not be a bad idea to have one of those Mad Men money clips after all.