It arrives as a plain letter, or as a bill that no longer matches the last one. Sometimes it is a rate increase for next year. Sometimes it is far worse: the amount doubled overnight and nobody warned you.
Before you argue, work out which of four things actually happened. They have completely different answers, and families lose months arguing the wrong one.
1. What kind of increase is this?
a) The Medicare cliff. If she went in after a hospital stay on the Medicare skilled nursing benefit, days 1 to 20 are covered in full and from day 21 a daily coinsurance kicks in — a few hundred dollars a day. Coverage ends entirely at 100 days, and often much sooner, when the facility decides she is no longer "improving". This is not a rate increase. It is the benefit working exactly as designed, and it catches nearly everyone.
Two things to know here: the "improvement standard" is not the law — under the Jimmo settlement, skilled care must be covered to *maintain* function, not only to improve it. And when the facility issues a notice ending Medicare coverage, you have the right to a fast appeal to the Quality Improvement Organization named on the notice. The deadline is short — usually by noon the day before coverage ends — so read the notice the day it arrives.
b) A level-of-care change. Her needs increased, so the facility moved her to a higher care tier. Ask for the assessment that justified it and compare it against the MDS. If the level changed but nothing in her care visibly changed, that is a fair question to put in writing.
c) An annual private-pay increase. Legitimate in principle. Your leverage is the admission agreement: it should say how much notice is required before a rate change. Ask for your copy — you are entitled to it — and check the notice clause against what actually happened.
d) The money ran out and Medicaid has not started. The most common and most frightening version. Handle it as an application problem, not a billing dispute — see below.
2. What the facility may not do
Federal law protects nursing home residents in ways most families never hear about.
- A facility may not require a family member to personally guarantee payment as a condition of admission. This is prohibited by the Nursing Home Reform Act. If you were asked to sign as "responsible party" and are now being pursued personally, get that paperwork reviewed — signing to manage her funds is not the same as promising to pay from your own.
- A facility that accepts Medicaid may not require a period of private pay first. "Two years private, then we will take Medicaid" is not a lawful condition of admission.
- A Medicaid resident may not be charged more than the Medicaid rate, apart from her assessed share of cost. Extra "top-up" charges to the family are not permitted.
- She cannot be discharged for non-payment while a Medicaid application is pending. Transfer and discharge grounds are narrow, require written notice, and are appealable to the state.
- Charges must be disclosed in advance, including what is covered and what is billed separately.
3. Three questions that change the outcome
Send them by email, so the answers exist in writing.
- "Please send an itemised statement showing what changed and the effective date." Vague new totals stop being vague once itemised.
- "Which clause of the admission agreement authorises this change, and what notice does it require?"
- "What is her current payer status, and what would her share of cost be under Medicaid?" This one reframes the whole conversation — most facilities would far rather help you file than lose a bed to an unpaid bill.
4. Medicaid is the real answer more often than people think
Families burn through savings because they assume they will not qualify. Three points worth knowing:
- Medicaid can pay retroactively, generally up to three months before the application month in most states, so a late application is not necessarily a lost one.
- The spouse at home is protected. Spousal impoverishment rules leave the community spouse a protected share of income and assets. The house is usually not counted while a spouse lives there.
- The five-year look-back penalises gifts and transfers, not spending. Paying legitimate care bills is not a transfer.
Applications get denied on paperwork more often than on eligibility.
5. If the answer is unsatisfactory
In order, in writing at every step
- The administrator and the business office, with dates and the itemised statement.
- The facility grievance process — every nursing home must have a grievance official and must respond.
- The Long-Term Care Ombudsman for your state. Free, independent, on the resident's side, and often the single most effective call you can make.
- The state survey agency, which licenses the facility, and the state Medicaid agency for eligibility and share-of-cost disputes.
- The state attorney general or consumer protection office for unlawful third-party guarantees.
6. When the number is simply not payable
Sometimes the increase is lawful, correctly noticed, and still out of reach. That is not a fight to win; it is a decision to make. Facilities differ enormously in price for similar care, and a resident whose funding source is about to change is exactly the resident worth relocating *before* an emergency discharge notice arrives.
Run both tracks at once — the Medicaid application on one side, alternatives on the other.
Curalune Care Help ($89) puts together, usually within 24 business hours, a shortlist of 3 to 5 facilities matched to her area and care needs — with contacts, current rates to confirm, and the questions to ask about what the quoted price actually includes.
*General information, not legal or financial advice. Rates, coverage and availability are always confirmed by the facilities and the responsible agencies.*