Health Care
MedicareMedicaidNursing Homes
Medicare
Barbara Gilchrist, J.D., Ph.D., is a Professor at St. Louis University School of Law, Clinical Law Program, and a Founder of this publication.
Editor's Note: The information in this booklet on Medicare is designed to give a brief description of this program, what the benefits are and how one qualifies. This information is current as of January 2009, but is subject to change at any time. For more detailed information call the Social Security Administration Office. What Is Medicare?
Medicare is a health insurance program administered by the Centers for Medical Services (CMS) (formerly HCFA). It is designed to help meet the hospital and other medical costs of senior citizens (age 65 or older) and some disabled persons under 65.
PART A - Medicare Hospital Insurance To be
eligible for Part A (hospital insurance), you must be:
1. 65 or older and qualify for Social Security benefits; or
2. Disabled and have received Social Security disability benefits for two years; or
3. Receive dialysis or need a kidney transplant because of permanent kidney failure.
Persons with 0-29 quarters for Social Security purposes may receive Part A coverage by paying a premium of $443. Persons not entitled to Social Security or Railroad Retirement, but who have at least 30 quarters, may pay a premium of $244.
Part A covers some of the costs of a hospital stay, as well as care in a skilled nursing facility or in one’s home (by a home health care agency) after leaving the hospital. Part A also covers Hospice Care. Doctor services are not covered by Part A.
PART B - Supplemental Medical Insurance Part B covers some doctor and outpatient services, medical supplies, and some preventive services.
Eligibility for Part B (supplemental medical insurance) is the same as for Part A, but a monthly premium of $96.40 must be paid. (Premiums change annually when Social Security benefits rise; higher premiums are charged to individuals with income in excess of $85,000 and couples with income in excess of $170,000.) The Part B premium will automatically be taken out of your monthly Social Security check unless you ask not to be in the program. It is important to note that if one delays in signing up after becoming eligible to enroll, the monthly premium will increase each year of the delay.
PART C – Medicare Advantage
Medicare Advantage (formerly Medicare + Choice) refers to private managed care health plans for Medicare recipients that have been available since 1997 in some geographic areas. These plans may take the form of HMOs, PPOs, or fee-for service. All of them restrict the patient’s choice of healthcare provider.
Medicare Advantage plans provide all the same benefits as Medicare, but are also similar to Medigap policies in that they offer a range of supplemental benefits to cover out-ofpocket costs such as deductibles and co-insurance. These plans also include coverage for those Medicare beneficiaries who exhaust their hospital inpatient benefits. Some plans offer coverage for other benefits not covered by Medicare such as routine eye exams, annual physicals, hearing exams, eyeglasses, or hearing aids. Prescription drug costs will no longer be covered under these plans unless enrollees also sign up for Medicare Part D. Many of these plans require an additional premium.
PART D – Prescription Drug Benefit Part D is the newest benefit and the most complicated in terms of choosing the best plan. Medicare beneficiaries may enroll either with a stand-alone prescription drug plan or a Medicare Advantage plan that offers prescription drug benefits. Monthly premiums are estimated to be $27.93, but will vary between plans. Which medications are covered will also vary between plans. Low income persons will be eligible for Part D without paying a premium or by paying a sliding scale premium depending upon income and assets.
Enrolling and Switching Plans The initial enrollment period for Medicare Part A and B begin 3 months prior to the person’s 65th birthday and lasts 7 months. Enrollment in Part D occurs between November 15 and December 31 . There is an annual general enrollment period from January 1 to March 31 when you can switch plans – from regular Medicare to a Medicare Advantage plan or visa versa or from one Medicare Advantage plan to another. These changes take effect July 1 of that calendar year. It is also possible to make one change at any time during the year. This application must be received by the 10th of one month to take effect the following month.
Services and Supplies Covered by Medicare The following hospital services are covered by Part A, if the costs are considered reasonable and the services are necessary: bed and board; nursing and related services; use of hospital facilities; natural and synthetic drugs, supplies, appliances and equipment normally furnished by the hospital; operating and recovery room costs; and other diagnostic or therapeutic items or services normally furnished by the hospital, including rehabilitative services.
The following skilled nursing home services are covered by Part A on a limited basis: nursing care; bed and board; physical, occupational, respiratory and speech therapy; medical social services; drugs and other health services generally provided by a skilled nursing facility. Medicare does not pay for custodial care.
All hospice services are covered under Part A, but the patient pays 5% of the cost and must forgo all other benefits— except for physician services and treatment of conditions not related to the terminal illness.
Part B of Medicare covers the following services and items: physician services; hospital outpatient services and supplies furnished as incidental to physician services (such as diagnostic x-ray tests and x-ray, radium and radioisotope therapy); and other medical and health services (including surgical dressings, splints, and casts; rental or purchase of durable medical equipment; ambulance services and prosthetic devices).
Some prevention and screening services have been added to Part B. Flu and pneumonia shots, mammograms, certain cancer screenings, glaucoma screening, 2 annual foot exams and nutrition therapy for diabetics are all covered under Part B. Occupational therapy and speech therapy may also be covered for persons with Alzheimer’s disease.
Medicare covers the rental or purchase of durable medical equipment (DME) used in a patient’s home under Part B. A physician must prescribe the equipment. DMEs include hospital beds, wheelchairs, hemodialysis equipment, oxygen tents, crutches, canes, and many others. Before purchasing or renting, the beneficiary should find out whether the supplier is approved by Medicare. If a recipient enters a nursing home, any DMEs provided by Medicare will not be covered. Therefore, it will be necessary for the patient to return these items or pay for them as out-of-pocket expenses.
Both Part A and Part B of Medicare pay for a limited amount of home health care administered by a public or private home health care agency. Home health services covered include: part-time skilled nursing care, physical therapy and speech therapy. Medicare can also pay for occupational therapy, part-time services of home health aides, medical social services, and medical supplies and equipment provided by the agency if skilled nursing care, speech or physical therapy is necessary.
Part B supplemental medical insurance helps pay for medically necessary physician and related medical services no matter where they are received, whether at home, in the doctor's office, a clinic, a nursing home or hospital. Related services include medically necessary supplies such as wheelchairs and hospital beds, as well as outpatient services such as laboratory tests and X-rays. Physical and occupational therapy, mental health services, and mammograms are also covered.
What Medicare Pays and What You Pay No private health insurance program pays for all of the costs for a visit with the doctor or a stay in the hospital. Medicare, although a public program, is no different. Both Parts A and B have initial "deductibles" that the patient must pay before Medicare pays anything. Both parts also have "coinsurance" payments, which go into effect after Medicare has paid all costs up to a certain limit. When that limit is reached, the patient must pay a certain amount of the remaining costs. Medigap policies and Medicare Advantage plans can be effective ways to handle those costs not covered by Medicare.
The Medicare program measures the use of services under Part A (hospital insurance) through benefit periods—also called spells of illness. The first benefit period begins the first time you enter a hospital after the insurance goes into effect. A new benefit period begins when you enter the hospital again, so long as it is at least 60 days after the last discharge from a hospital or other facility providing skilled nursing or rehabilitation services. There is no limit to the number of spells of illness (benefit periods) you can have.
Part A provides up to 90 days of hospital care for each spell of illness. However, there is a deductible charged at the beginning of the hospital stay and co-insurance after 60 days, both of which are the patient’s responsibility. Recipients also have 60 lifetime “reserve days,” but they are not renewable for the next spell of illness. The hospital deductible is $1068 for each spell of illness. If you are in the hospital for more than 60 days, the co-insurance amount is $267 per day. After 90 days of hospitalization, if you choose to use reserve days, the co-insurance amount is $534 per day. Medicare pays the remainder of all covered expenses.
Part A also provides up to 100 days of care in a skilled nursing facility (SNF) per spell of illness, but the patient must be admitted within 30 days after leaving the hospital and have been in the hospital for three consecutive days prior to entering the SNF. In order to be covered, the care in the SNF must be for the condition for which the patient received care in the hospital or for a condition that emerged while the patient is receiving care in the SNF following hospital care. The condition must also be one that requires daily skilled nursing or skilled rehabilitation services that cannot practically be provided anywhere except a SNF.
Medicare pays all covered expenses for the first 20 days. For days 21 -100, there is a daily co-insurance of $133.50. Medicare also pays for home health care visits if skilled nursing care or rehabilitation that can be provided in the home is required.
Part B, the supplemental medical insurance part of the Medicare program, has a basic payment rule for all charges for covered medical expenses. There is a $135 deductible for all approved charges in each calendar year. Medicare then pays 80% of all additional approved charges for covered medical expenses. The patient is responsible for the remaining 20% of the costs of all covered medical expenses over that amount. If there are charges that are not approved by Medicare, these will be the patient’s responsibility, unless that physician has agreed to accept assignment. This means that the physician has agreed to only charge the amount approved by Medicare.
Part D, the prescription drug benefit, will have an annual deductible of $295 and co-payments that vary depending upon the total annual drug costs above the initial $295 For costs between $295 and $2,700, the co-pay is 25% (up to $601.25). Costs over $2,700, but less than $6153.15 are entirely the responsibility of the enrollee. Costs in excess of $6153.15 will have a co-pay of 5% or $2.40 for a generic drug and $6 for a brand name drug.
Part D Out-of-Pocket Example:
| Deductible |
$ 295.00 |
| Initial Coverage ($2700-295) x 25% |
601.25
|
| Coverage gap ($6153-2700) x 100% |
3453.75 |
|
________
$4350.00 |
Medically Reasonable and Necessary Charges Medicare pays only those medical bills that they determine to be "medically reasonable and necessary." Medicare uses a system called "Diagnostic Related Groupings" (DRG's) to determine what hospitalization expenses are reasonable and necessary for each "spell of illness" incurred. A simplified explanation of DRG's is as follows: when admitted to the hospital, a recipient is assigned a category within the list of possible DRG’s. Medicare pays a predetermined amount to the hospital based on this category no matter how long you are in the hospital and no matter what the actual costs of care.
Prior to the time Medicare runs out for a "spell of illness," the hospital must notify the recipient in writing that a discharge is upcoming. If that discharge is based on the lapse of Medicare coverage and the patient feels that a longer hospital stay is necessary, the patient may appeal the Medicare decision to the Peer Review Organization (PRO), which decides if Medicare was correct in determining coverage. By law, the PRO must decide the appeal within three working days of its receipt. If you disagree with the PRO decision, it can be appealed similar to any other Medicare decision. If a patient is in the hospital and wants to appeal the Medicare decision regarding length of stay, the patient should contact a social worker at the hospital concerning how to file an appeal.
Generally, Medicare coverage continues until the PRO makes its decision. If Medicare coverage runs out (i.e., the DRGs are exceeded), the patient will then be responsible for paying for the care. If the patient pays for the care and subsequently wins the appeal, Medicare will pay retroactive benefits.
How Insurance Payments Are Made
It is not necessary to send in any bills for care received from a participating hospital, skilled nursing facility, or home health agency under Medicare Part A. In addition, a hospice provider will normally make the claim for care received by a recipient and Medicare will pay its share of the costs directly to the proper agency. The recipient will receive a notice explaining what was paid under Medicare coverage.
Payment is made two ways under Medicare Part B. Medicare can pay the doctor or medical service provider directly, if that is agreed upon, or can pay the recipient directly. Direct payment to a doctor is called assignment. Under the assignment method, the doctor or health service provider completes the Request for Medical Payment form and submits it. Medicare then pays the doctor or provider 80% of the Medicare-approved charge (which is often less than the doctor charges) after subtracting that portion of the $100 deductible that has not yet been met. The advantage of this method is that the participating doctor or health care provider agrees to make the Medicare-approved charge his or her total charge – even if the actual charge is higher.
If the doctor or supplier does not agree to the assignment plan, the doctor still must file the Request for Medical Payment form. The medical insurance payment will then come to the patient. Remember that under the "payment-topatient" plan, the doctor or supplier can bill for the actual charge, even if that charge exceeds Medicare's approved charge. If that happens, the patient is responsible for the amount over the approved charge.
Whichever payment plan is chosen under Part B, the patient or the patient’s Medigap policy still must pay directly the doctor or health service supplier the 20% of the approved charge plus any unpaid portion of the $100 deductible. The patient should always ask the health care provider to provide an itemized bill.
Services Not Covered Even though the Medicare program has broad coverage, there are many services and supplies that Medicare does not pay. These charges include: custodial care in a nursing home, residential care facility, or in your own home; services not reasonable or necessary as defined by Medicare; services for which the patient has no legal obligation to pay; services paid for by a governmental agency; personal comfort items; routine checkups; full-time home nursing care; hearing aids; eyeglasses and examinations for eyeglasses; drugs; and medicine purchased for oneself with or without a doctor's prescription. In general, Medicare does not pay for cosmetic surgery, dental care, private rooms, orthopedic shoes, or most chiropractic services. Supplemental plans (Medigap) or Medicare + Choice may cover some of these items.
Qualified Medicare Beneficiary (QMB), Specified Low- Income Medicare Beneficiary (SLMB), and Qualified Individual Program (QI1) QMB is a program under which Medicaid acts as a supplemental (Medigap) policy for Medicare recipients whose income is higher than that allowed for Medicaid eligibility, but below the federal poverty level plus $20. In Missouri, the QMB program is handled through the Missouri Department of Social Services, Family Support Division (FSD) and the state pays the Part A and Part B Medicare premiums, deductibles, and co-insurance charges for eligible recipients. To qualify, an individual’s income must be less than $867 (+ $20 disregard) per month and assets must be valued at less than $4000. To qualify as a married couple, combined income must be less than $1167 (+ $20 disregard) and assets must be valued at less than $6000.
Individuals with income up to $1040 (+ $20 disregard) per month and couples with income up to $1400 (+ $20 disregard) may qualify for the SLMB program where the state pays the Part B Medicare premium. The QI1 program also pays for the Part B Medicare premium for individuals with income less than $1170 (+$20 disregard) and couples with income less than $1575 (+ $20 disregard). For both SLMB and QI1, assets must be valued at less than $4000 for an individual and $6000 for an eligible couple.
NOTE: The income limits change annually in April.
Inquiries about each of these programs should be made to the local FSD office.
Right of Appeal If a recipient disagrees with a Medicare decision on a claim, by law he or she is entitled to ask for a review. Generally, a Medicare appeal is only possible after care has been received and coverage denied. An individual may request a review—called a redetermination—within 120 days of the initial Medicare decision. A second level of appeal – called a reconsideration – may be requested within 180 days of the redetermination decision. An administrative hearing may be requested if the amount in controversy exceeds $120 for all claims. If the claim is under Part B, the patient must request a review within 120 days of the Medicare decision. Medicare Advantage appeals are handled initially by the HMO; an administrative hearing may be requested if the claim is at least $120.
Other rights may also be available, including appeal to the Federal Courts. If a patient determines that an appeal is warranted, it may be wise to consult with a friend, relative, or an attorney regarding the appeal process. Check the listing at the end of this book for legal assistance information.
If You Need More Information This section on Medicare cannot present all the information that may be needed regarding hospital and medical insurance programs. One resource for more information is Missouri’s Free Senior Health Insurance Assistance Program which uses the name, CLAIM. They can be reached at 1-800-390-3330.
Other sources for information on benefits, eligibility, or any Medicare question, is the local Social Security Administration Office. In addition, you may wish to obtain the booklet Medicare Handbook, available from that office. CMS also has a publication that may be helpful, which is entitled Medicare and You 2009. Information on obtaining the publication is available from CMS at 800633-4227. In addition to contacting CMS for general information on Medicare, the Medicare Intermediary in your area may be contacted.
Medicaid (MO HealthNet)
By Julie Berkowitz, Esq. and Amy Smoucha. Ms. Berkowitz is certified as an elder law Attorney by the National Elder Law Foundation. She is a sole practitioner who focuses her practice on MO HealthNet issues, Disability and Estate Planning, Probate issues, Guardianships and Conservatorships. Ms. Smoucha was a Public Benefits Specialist in the Public Benefits Project at Legal Services of Eastern Missouri.
Editor's Note: The information in this booklet on MO HealthNet is designed to give a brief description of this program, what the benefits are and how one qualifies. This information is current as of January, 2009, but is subject to change at any time. For more detailed information call your local Family Support Division office or seek the advice of an elder law Attorney.
Introduction
Effective August 28, 2997, the MO HealthNet program in Missouri was renamed “MO HealthNet”. MO HealthNet is a joint Federal-State program designed to help pay some of the costs of health care for financially needy individuals. The Family Support Division (FSD) of the Missouri Department of Social Services administers the MO HealthNet program in Missouri. The FSD decides who is eligible for the program based on federal and state requirements.
The MO HealthNet program is different from the Medicare program. The Medicare program is run by the Social Security Administration. There are no financial need requirements for eligibility for the Medicare program. Most Medicare recipients have a red, white and blue card. Medicare recipients can also receive MO HealthNet assistance if eligible. Missouri MO HealthNet recipients have a red MO HealthNet card.
The MO HealthNet eligibility rules and applicable regulations are extremely complex. If an individual is interested in applying for MO HealthNet benefits, he or she may benefit by seeking the assistance of an attorney who is knowledgeable in MO HealthNet eligibility issues.
Expenses Covered by MO HealthNet Generally, MO HealthNet will cover the following: physician's services, some prescription drugs, emergency ambulance services, hospice services, in-patient and out-patient hospital services, laboratory and x-ray services, periodic diagnosis and screening, and some home health services.
There is a procedure that allows a MO HealthNet recipient to make a "medical exception" request for MO HealthNet to pay for a service not included in the MO HealthNet program. If the MO HealthNet Division (formerly the Division of Medical Services (DMS)) denies coverage for a procedure or service, a recipient may call the Recipient Services' number on the back of the MO HealthNet card to ask about a medical exception. A person's doctor must provide documentation to establish that a service or equipment should be provided and is medically necessary.
Some drugs and services require prior authorization under the MO HealthNet program. Usually medical services providers (for example, the doctors) will apply for prior authorization. Certain prescriptions, however, require prior authorization forms completed both by the patient and by the doctor. In most cases, the MO HealthNet office will notify the medical service provider, not the individual recipient, of its decision to grant or withhold prior approval of payment. If an individual learns from the medical service provider that MO HealthNet approval was withheld, one may appeal the decision. (See next section for how to appeal.)
Vendor MO HealthNet benefits will help to cover the cost of nursing home care for those who qualify. A Vendor MO HealthNet recipient must be in a "MO HealthNet certified bed", in a nursing home. Generally, a Vendor MO HealthNet recipient must use his or her income to pay for the nursing home care, and MO HealthNet benefits cover the balance to the nursing home.
No provider of medical services can be forced to accept payments from MO HealthNet if he or she does not wish to do so. If the health care provider will not accept MO HealthNet, one has two options: change the health care provider or pay with one's own funds.
Missouri MO Health Net Programs There are a number of different MO HealthNet programs that provide assistance with health care costs for individuals who meet certain medical and financial requirements. This section outlines some of the main MO HealthNet programs for elderly and disabled individuals.
Eligibility for a MO HealthNet Program In order to qualify for a Missouri MO HealthNet program, an individual:
- must be a U. S. Citizen or "qualified alien," and -must be a Missouri resident, and
- must be 65 years or older (elderly), blind or permanently and totally disabled, and
- must meet the financial eligibility requirements of the MO HealthNet program to which he or she is applying.
MO HealthNet for Basic Medical Care (Medical Assistance- Non-Vendor) Medical Assistance - Non- Vendor is the MO HealthNet program that provides coverage for certain Medical expenses for elderly, blind or disabled individuals. This program does not provide benefits to cover nursing home costs. See MO HealthNet for Nursing Home Care.
Non Financial Eligibility Requirements: An individual must meet all of the requirements set forth above under Eligibility for a MO HealthNet Program.
Financial Eligibility Requirements: Income Limit Requirements: Individuals applying for Medical Assistance must have incomes below the program's income standards. These amounts change every year. The figures below are current as of January, 2009.
- an unmarried individual must have monthly income of $737 or less, after allowable deductions.
- a married individual and his or her spouse must have a combined monthly income of $992 or less, after allowable deductions.
Individuals with incomes above the applicable limit, but who meet all of the other eligibility factors, may still qualify for assistance, He or she will be given a "spenddown" amount. This is like a monthly deductible. See
"Spenddown MO HealthNet ".
Asset Limit Requirements
These asset limits are not tied to the federal poverty level and have never been increased. They do not change every year like the income limits.
- an unmarried individual must have no more than $999.99 in non-exempt assets.
. a married individual and his or her spouse must have less than $2,000 in combined non-exempt assets.
Exempt vs. Non-Exempt Assets The $999.99, or $2,000 if married, asset limits apply only to non-exempt assets. Certain assets are considered exempt and their value is not counted in the applicable asset limit total.
The assets that are exempt and that do not count include: the applicant's home (up to an equity limit of $500,000) and furnishings, one motor vehicle, personal effects, burial lot, certain income producing property, and either a pre-paid irrevocable funeral plan or up to $1,500 in cash surrender value in life insurance.
"Spenddown MO HealthNet" If an individual has a "spenddown" amount, he or she is responsible for a certain amount of medical expenses each month, before MO HealthNet benefits will cover other medical costs. The spenddown amount is based upon the individual's income. An individual's spenddown amount is calculated by totaling monthly income from all sources, and applying certain deductions as follows:
(1) Subtract the first $65 of any
earned income (wages or self-employment income) and then subtract one-half of the remainder. For example: the deduction is ((earned income -$65) ÷ 2).
(2) Total the adjusted earned income and all unearned income, such as Social Security, SSDI, private pensions and VA benefits.
(3) Subtract payments for any medical insurance premiums paid (including Medicare and private insurance):
(4) Subtract $20 (personal income exemption).
(5) Compare the resulting net income to the program's income limit. (currently $737 for a single individual and $992 for a married couple)
The remainder, after all allowable deductions, is your monthly spenddown amount. Note: If there are minor children in the household, do not include their income or expenses in the spenddown budget.
An individual can meet his or her spenddown in one of two ways:
- by paying a monthly premium to the State, so that one has no break in coverage; or
- by submitting incurred medical expenses to his or her caseworker each month.
If you choose the second option, your MO HealthNet coverage for each month will become effective the day bills meet or exceed the spenddown amount. (Bills given to the caseworker to meet spenddown will not be paid by MO HealthNet.)
If you are eligible under the spenddown program, your case will stay open whether or not you meet spenddown in any one month. You will receive an invoice each month that you can use to pay your spenddown "up-front" for the next month. When you receive an invoice, you are being billed for the next month's premium in advance. However, you can also pay your premiums retroactively for certain months. If you do not meet spenddown for six consecutive months, you will no longer receive invoices, but your case will still stay open.
MO HealthNet for Nursing Home Care (Vendor MO HealthNet) MO HealthNet may cover some of the cost of nursing home care. The eligibility requirements are slightly different than stated above for basic Medical Assistance eligibility. In addition certain transfer of assets rules apply. MO HealthNet for nursing home care is referred to as "Vendor MO HealthNet."
Non Financial Eligibility Requirements: In addition to the non-financial requirements set forth under Eligibility for a MO HealthNet Program, an individual must reside in a "MO HealthNet vendor bed" in a nursing home that is eligible with the State to receive MO HealthNet funds.
Financial Eligibility Requirements: Income Limit Requirements: There are no actual income limit requirements for Vendor MO HealthNet. However, as a practical matter, an individual's income must be less than the monthly cost of his/her nursing home care, otherwise MO HealthNet benefits are usually not needed.
An individual is required to use his or her income (minus allowable exemptions) to pay for his or her nursing home costs. Vendor MO HealthNet benefits cover the remaining nursing home and uninsured medical costs.
Asset Limit Requirements: These asset limit requirements apply to non-exempt assets.
For information on what is an exempt asset, see "Exempt vs. Non-Exempt Assets ".
- an unmarried individual must have no more than $999.99 in non-exempt assets.
- married individuals both of whom reside in a nursing home must have no more than $2,000 in combined nonexempt assets.
- married individuals whose spouse does not also reside in a nursing home, must have no more than $999.99 in nonexempt assets. However, the spouse who does not live in the nursing home is entitled to a "Community Spouse Resource Allowance" (“CSRA”).
Community Spouse Resource Allowance. The FSD will compute a "Community Spouse Resource Allowance" for the spouse of a married individual applying for Vendor MO HealthNet assistance. The Community Spouse Resource Allowance is calculated during a Division of Assets Assessment.
During the Division of Assets Assessment, the FSD caseworker determines the non-exempt assets that the individual and the spouse own individually, together, or with someone else. These non-exempt assets are totaled together. The total amount of these non-exempt assets is divided. The Community Spouse Resource Allowance is calculated by dividing the assets in half and applying a minimum and maximum standard amount.
The community spouse will be entitled to one-half of the nonexempt asset total as long as that amount is greater than the minimum, and no more than the maximum. If the total assets are less than the minimum, then the community spouse will be entitled to the minimum. If one-half of the nonexempt assets is more than the maximum amount, then the community spouse will only be entitled to the maximum amount. The minimum and maximum standard amounts are increased each year. For the year 2009, the minimum Community Spouse Resource Allowance amount is $21,912 and the maximum amount is $109,560.
Once the couple's total non-exempt assets are equal to or are less then the couple's Community Spouse Resource Allowance, the spouse in the nursing home will be eligible for benefits.
In addition to the Community Spouse Resource Allowance, a community spouse is also allowed to keep the couple's exempt assets. Also, the community spouse's income is his or hers to keep and is not a factor in the other spouse's eligibility.
In certain situations the community spouse may be entitled to additional income from his or her spouse and/or be entitled to an increased Community Spouse Resource Allowance. Such a situation occurs when the community spouse has low income (according to State standards) and/or has high living expenses or extraordinary costs. An Administrative Appeal is required in order to increase the community spouse's portion of assets. The assistance of an elder law attorney is strongly recommended in these circumstances to ensure that the community spouse receives the maximum amount to which he or she is entitled.
Transfer of Assets Rules Apply The rules regarding transfers of assets were changed by the Federal Government in the beginning of 2006 in legislation entitled the Deficit Reduction Act. The new law became effective in Missouri as of February 8, 2006, and applies to transfers occurring after that date. Transfers occurring prior to February 8, 2006, are governed by the prior law.
Under the current law, if a MO HealthNet applicant gives away or transfers property for
less than fair market value within 60 months (5 years) of applying for vendor MO HealthNet, that individual will be ineligible for MO HealthNet benefits for a certain period of time (penalty period). The length of the penalty period will be based upon the amount or value involved in the transfer of property.
The penalty period will begin to run when the MO HealthNet applicant has no more than $999.99 in non-exempt assets, is otherwise eligible for benefits, and has applied for MO HealthNet benefits. Essentially, the penalty period will run from the
date of application and not the date of transfer.
Consult an elder law attorney
before making such a transfer, and
before filing a MO HealthNet application. The date that an applicant files a MO HealthNet application has legal significance. In addition, some transfers are not subject to penalty. There are limited exceptions.
MO HealthNet Estate Recovery While an individual can own certain exempt assets, such as a home, while receiving Vendor MO HealthNet assistance, the Department of Social Services has a
right of recovery against the MO HealthNet recipient's estate at his or her death. However, there are certain exceptions and circumstances in which the State does not have a legal right to such a claim. Potential beneficiaries of a deceased MO HealthNet recipient who have been contacted by the State regarding a recovery claim should consult with an elder law attorney to determine their rights.
In addition to a right of recovery against a MO HealthNet recipient's home
after his or her death, the Department of Social Services also has a right to file a
lien against the MO HealthNet recipient's home while the MO HealthNet recipient is still alive. Just as in the case of a post-death recovery action, the Department of Social Services does not have this right in every case. There are limited exceptions.
If Your MO HealthNet Application is Rejected If an individual is denied MO HealthNet eligibility, that individual has a right to an appeal. The appeal is initiated by making a request to the caseworker or other FSD personnel for a hearing. This request must be made within 90 days of the denial of the MO HealthNet application. It is advisable to get the help of an attorney if you are requesting an appeal.
If an individual is receiving MO HealthNet benefits and FSD attempts to terminate or reduce said benefits, the individual may also appeal that decision. If the individual appeals within 10 days of notice of the termination or reduction, the individual has a right to continue receiving full benefits pending the outcome of the hearing. If the individuals continue to receive full benefits during the appeal process and lose the appeal, the state can seek repayment from the individual for those expenses.
Nursing Homes
By Kerry Kauffmann, administrator of Normandy Nursing Center, a position she has held for 10 years. Prior to that, Ms. Kauffman was the assistant director of the St. Louis Long Term Care Ombudsman Program, and she has sat on various boards and committees concerning the elderly. Kerry has been involved with various projects with Legal Services of Eastern Missouri since having a paralegal internship there in 1987.
Introduction
If you are looking for a nursing home for yourself, a friend or family member, this section hopefully will help you choose a long-term care a facility that will meet your needs, medically and financially. You will also be able to use the information provided to handle problems or concerns that may arise in the nursing home during residency.
Regulatory Agencies
The Department of Health and Senior Services (formerly the Division of Aging) provides licensure and inspections to all long-term care facilities in the State of Missouri. When inspecting a nursing home, the Department of Health and Senior Services considers all aspects of the resident’s living environment, in accordance with the state law and regulation. This not only includes nursing care and procedures, but also housekeeping, dietary needs, safety standards, resident funds, activities, and social services.
Federal regulations, set forth under the Centers for Medicare and Medicaid (CMS) [formerly Health Care Financing Administration (HCFA)], also cover the facilities that are in the Medicare and/or Medicaid programs. Therefore, the Department of Health and Senior Services inspects nursing homes based on both state and federal requirements.
Nursing homes receive two unannounced inspections every year and may be subject to other inspections based upon complaints received through the Elder Abuse Hotline (1-800392-0120). Residents and families are encouraged to participate in the inspections.
Levels of Care
There are four levels of nursing home care that are licensed and regulated by the State of Missouri based on services offered and staffing available.
Skilled Nursing Facilities (SNF) provide a skilled level of nursing care and treatment for individuals requiring 24-hour-aday care by licensed nursing personnel, including: physician-ordered treatments; medication administration; IV therapy; physical, speech and occupational therapy; and specialized care. This is a step away from the hospital, although some hospitals have distinct parts that are set up as SNFs within the hospital itself. A patient at the hospital has the choice of using the hospital’s SNF or choosing an outside long-term care facility.
Many SNFs accept Medicare and Medicaid as payment. Those facilities are not only licensed by the State of Missouri, but are also certified by the Medicare and Medicaid programs and are regulated under their guidelines.
It is the choice of the facility whether or not to participate in either the Medicare or Medicaid program. The facility may also choose the number of beds offered through either program. Even though a facility may have Medicare or Medicaid certified beds, that does not mean that there is always one available for a resident when that individual enters the facility or depletes assets.
Intermediate Care Facilities (ICF) also provide 24-hour protective oversight and nursing care, including distribution of medications. These facilities are a step down from a skilled nursing facility and provide more custodial care. Medicare does not pay for custodial care. However, Medicaid will pay for custodial care if financial requirements are met and the resident is in a Medicaid-certified bed.
Residential Care Facility II (RCF II) provides more of a boarding home-like atmosphere for the resident with protective oversight. The facility provides all meals, helps in the bathing, dressing and grooming of the resident, and also distributes medications. An RCF II can provide medical care for a resident returning from the hospital and needing minimal care for a temporary period of time.
Residential Care Facility I (RCF I) is the least restrictive living arrangement for a resident in licensed long-term care. It provides protective oversight, meals, medications, and minimal grooming.
Assisted Living is a new type of living arrangement that has become very popular in the past few years. This is an independent type of living arrangement and is not licensed or regulated by the Department of Health and Senior Services. These facilities are not licensed, so there are no inspections of the premises or services provided.
Assisted living usually consists of the resident occupying an apartment and being provided with one or more meals a day, light housekeeping and laundry services. It does not include medical care. However, many places offer some personal aide services. At this time there is no financial aid provided for residents in assisted living facilities.
Choosing a Nursing Home
Choosing a nursing home for yourself or someone else can be a difficult and frustrating task. To make matters a little easier, you need to first look at what the needs are of the individual. Consider some of the following questions:
Is this going to be a long or short-term stay?
Does the individual need therapy?
Is the facility able to meet any of the special needs of the individual?
Are there other residents who have the same needs as the individual, people he/she can relate to?
Is the facility easily accessible for family members and friends to visit?
By understanding the needs of the potential resident, you can better match up the facility to the individual.
Be honest about the needs of the potential resident and the expectations of both the resident and the family. If the resident has wandered away from home several times, it is important for the facility staff to be aware of this so safeguards can be put into place to protect the resident. Remember, the nursing home is not a hospital nor is it set up to do private nursing. The nursing home must provide services within the constraints of the law and financial capabilities. Not every nursing home is going to be right for every resident.
Once you determine a resident’s needs, you can begin searching for a facility. Some of the attributes that you want to look for in a long-term care facility are:
1) Licensure: Make sure the home is licensed and that the license is in good standing with the State of Missouri. Ask to see the most recent inspection report and make sure that whatever was cited has been corrected.
2) Nursing Service: Talk to the nurses and make sure that the level of nursing services matches the resident’s needs. If there is a closed or locked unit, find out if this unit is appropriate for the individual.
3) Physician: Determine if your physician will provide services at the particular nursing home. Not all physicians go to nursing homes to provide services. If the attending physician does not go to the facility, you may need to make provisions for the resident to see the physician in the physician’s office. Each facility has a number of physicians associated with it. The resident may choose from one of the physicians offered through the facility if he/she wishes to, or continue to use their private physician.
4) Finances: The facility should be able to provide you with a list of all charges involved, including items not paid for by Medicare or Medicaid. If the resident is eligible for Medicare and/or Medicaid, the facility should be able to provide information on both programs and assist the resident as needed.
5) Dietary Services: Try to stop by the facility during a meal. See if the meals look appetizing and attractive. Pay attention to whether or not the other residents are enjoying their meals and the entire dining experience. Ask to see a copy of the planned meals and find out if special diets can be provided.
6) Therapy: If the resident is going to need physical therapy, occupational therapy and/or speech therapy, check out the therapy department. Find out when therapists are available and what special equipment they have that can help meet the resident’s needs. If the resident is Medicaid only, the facility must still provide the therapy needed. Find out if there is an active restorative program in the facility that will continue with therapy after the resident is discharged from the actual therapy program.
7) Medications: Most nursing homes have a contract with a pharmacy to provide medications. The resident has the choice of using the facility pharmacy or another of their choice. If the resident chooses another pharmacy, that pharmacy must meet the guidelines set by the nursing home as far as packaging and delivery needs. The facility must also develop a plan for supplying emergency medications when required.
8) Activities: Each nursing home should have a program that provides the residents with daily activities. Activities are important because they help to keep the resident alert and involved. Talk with the activity director and other residents about the facility’s program. Ask to see a calendar of future activities.
9) Safety: As you walk through the facility, check for safety issues. Make sure the handrails are on the walls tightly, wet floor signs are used, evacuation plans are posted, etc.
10) Cleanliness: The facility should have a housekeeping department that keeps the resident areas, including bedrooms and bathrooms, neat and clean.
11) Policies: Talk to the admissions coordinator or social worker about any facility policies that could affect the resident’s stay.
12) Access to Administration: The nursing home staff, including the administrator, social workers, the bookkeeper, the director of nursing and other department heads should be accessible to residents and family members. Ask about their hours and availability in off-hours.
It is important to ask the facility about care plans and when the resident’s care plan meeting will be held. The care plan is formed in a meeting when all disciplines work together on mapping a plan to meet the resident’s needs. This plan should be discussed with the resident and family so that all parties involved understand what the goals are and what is to be expected.
Nursing homes are supposed to provide a homelike environment for the resident. That means that the staff should show a friendly attitude to both residents and visitors. They should try to make the residents feel good about themselves and find ways for the residents to attain their highest possible goals. The staff should create a respectful and caring environment. Watch resident reactions to the staff and other individuals. Look and see if the residents look happy, clean and neat.
Lists of nursing homes can be provided through the following agencies:
The Department of Health and Senior Services, P.O. Box 1337, Jefferson City, MO 65101; Division of Family Services, your local office; Area Agency on Aging, your local office; Ombudsman Program, your local office; Hospital the individual may be in or a physician with whom he or she may be associated; Disease-related organizations often carry lists of appropriate facilities, and there are now listings you can receive through on-line services.
Resident Rights
While a resident is living in a nursing home, the resident is entitled to a dignified existence and to exercise his or her rights without fear of interference, coercion, or reprisal.
Federal and state laws guarantee that, as a nursing home resident, you have the right to:
(1) Be free from physical, verbal, mental or sexual abuse, or mistreatment or neglect of any type;
(2) Be free from any chemical or physical restraints, without a physician’s order that shows the restraint is treating a medical symptom and is only approved for a specific period of time;
(3) Participate in your care, including choosing a doctor, being informed of your care and treatment, and any changes in your health or treatments;
(4) Make choices about your life that are important to you, such as what clothes you wear or when you bathe;
(5) Receive services based on your individual needs and preferences;
(6) Manage your own financial affairs, including giving the facility written permission to hold any monies for you, spending your money as you choose, and receiving a quarterly financial report if the facility is to hold your funds;
(7) Be fully informed of your rights during your stay and any rules that are set by the facility;
(8) Review all your medical records upon request;
(9) Have access to the latest facility inspections without requesting them;
(10) Privacy for all treatments, telephone calls, visits, mail, resident meetings and all of your records;
(11) Receive or refuse visits from friends or relatives;
(12) Receive visits 24 hours per day from family members; and
(13) Remain in the facility (see section on transfers/discharges).
These rights are guaranteed under both state and federal laws. Residents who feel that their rights have been violated should talk to a representative from the facility first. Each nursing home needs to have a written process in place to handle residents’ grievances.
The process should be one that takes into consideration the resident’s physical, medical and emotional condition. A specific staff member, such as the social worker, should be identified to the resident as to whom to make the complaint. The complaint should be dealt with to the resident’s satisfaction within a reasonable amount of time.
If the complaint is not resolved to the satisfaction of the resident, there are additional steps a resident can take. The resident may file a complaint with the Ombudsman Program in his/her area. The Ombudsman Program, usually found in conjunction with the local Area Agency on Aging, can help mediate between the resident and the facility to find an adequate solution. This is often the best solution, in that the Ombudsman is a trained resident advocate and mediator.
The alternative is to contact the Department of Health and Senior Services, 1-800-392-0210. Depending upon the seriousness of the complaint, it may not be resolved immediately. Any complaint that is not risking the welfare of the resident may be delayed by the Department of Health and Senior Services until the next inspection, which may be months away.
Should the complaint pertain to abuse or neglect, the Department of Health and Senior Services, 1-800-392-0210, should be notified immediately. The resident’s health and safety could be in jeopardy. By notifying the Department of Health and Senior Services, an inspector can take the action necessary to protect the resident immediately.
Discharges from a Nursing Home
It is the resident’s right to remain in the nursing home for as long as they choose. A facility may only discharge a resident if:
1) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;
2) The resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;
3) The health and safety of the individuals in the facility is endangered.
4) The facility issues an emergency discharge; 5) After notice, the resident fails to pay for a stay at the facility; or
6) The facility ceases operation.
When the facility discharges a resident, they must provide the resident with a 30-day written notice of their intent to discharge. In this notice, the resident must be the given the right to appeal the discharge. The appeal is made to the Division of Legal Services in Jefferson City. A resident may represent himself or herself at the hearing or have a friend, family member, or legal counsel represent him or her. An attorney will represent the facility. It the responsibility of the facility to provide enough information to show that the resident cannot remain in the facility for one of the above reasons.
If the facility transfers the resident based on an emergency discharge, the facility must immediately notify the resident as to their intent not to take the resident back and the reason, plus give the resident the right to appeal.
After the appeal process, the resident and facility will be provided the results of the hearing in written form. If the resident wins the appeal, the resident has the right to remain in or return to the facility. Should the resident lose the appeal, the resident needs to find placement somewhere else within 10 days. The facility must help the resident to relocate if this is the case.
Financial Information
There are a few different ways to pay for nursing home care. However, not every nursing home accepts every type of payment. You must make sure the nursing home meets not only the medical needs but also the financial needs of the individual.
Medicare: With a three-day prior hospitalization, a resident may be eligible for Medicare coverage for up to 100 days. The first 20 days are completely covered under Medicare and all services are paid for. After the twenty-first day, there is a co-insurance payment of $101.50 per day. This can be paid privately by the resident, covered under Medicaid, or paid through a medi-gap insurance plan.
Medicare only pays for a resident in a Medicare bed and only covers those residents who need a high level of care, such as tube feeding, ventilators, IVs, or therapy. It does not cover custodial care and there is no guaranteed coverage time. Medicare coverage is dependent upon what services the resident requires and continues to require. The facility must provide appropriate notice as to when the resident will be taken off Medicare. The decision to take the resident off Medicare can be appealed by the resident. The nursing home should provide the resident with information on this appeal process.
Medicaid: The Missouri Family Support Division (FSD) administers the Medicaid Vendor program, which is designed to pay for the care of nursing home residents when they do not have the resources to pay themselves. Not every nursing home is Medicaid-certified. Therefore, you must make certain that the facility has a Medicaid bed if this payment source is, or may become, a necessity.
Under the Medicaid program, all resident needs are provided for, including room and board and medical needs. The facility must provide a resident with a list of any services or items not provided for under Medicaid. The resident must turn over the amount of money listed by FSD as his or her surplus. This amount will be shown on the IM62 received from DFS. In other words, if a resident’s Social Security is $500 per month, the resident needs to turn over $470 to the nursing home as his/her share of payment and is allowed to keep $30 for personal needs. Oftentimes, the nursing home becomes the representative payee of the Social Security check and provides to the resident the $30 personal needs allowance.
To qualify for Medicaid payments, you must:
(1) Be in a Medicaid-certified bed;
(2) Have resources (assets) less than $1,000 (a house is no longer considered a resource if you move from your home to the hospital and then to the facility, or from your home into a long-term care facility);
(3) Meet the minimum 21-point medical qualification; and
(4) Have an insurance policy not greater than $1,500 (cash surrender value). Instead, an individual can have a prepaid burial plan of the same value or an irrevocable burial trust in a “reasonable amount.”
Medicaid and Married Couples: There are special provisions under the Medicare Catastrophic Coverage Act of 1988 that provide for married couples when one must enter a long-term care facility. Upon entering a Medicaid-certified bed, you and/or your spouse may request a “division of assets” assessment for the local Division of Family Services office.
Under this provision, a married couple’s assets are divided by the caseworker. The amount the community spouse will be permitted to retain will depend on the total amount of assets. Once the institutionalized spouse’s share is spent down to under $1,000, he/she would then be eligible for Medicaid, and the community spouse has his/her share for his/her needs while living in the community, plus a monthly allotment if eligible.
A Medicaid-certified resident in a nursing home is entitled to equal treatment just as if he/she were a private-pay resident. Admission policies must not require that a resident “private-pay” for a certain number of months before applying for Medicaid. Transfer or discharge cannot be based upon Medicaid eligibility unless the facility does not accept Medicaid or there are no Medicaid beds available. Should a resident feel that he/she is being discriminated against because of Medicaid eligibility, contact the local Legal Services office, as well as the local Long-Term Care Ombudsman office, seeking advice, information, and advocacy.
Supplemental Nursing Care (Cash Grant): This Medicaid program partially pays for a resident’s care in either a licensed Residential Care Facility or a Skilled Nursing Facility. You must meet the guidelines (above) for Medicaid eligibility.
This program pays between $157 and $356 a month for care depending on the level of care being provided. The resident will also get a monthly allowance of $25 for personal needs.
Private Pay: If a resident is going to be paying privately for his/her long term care, it is extremely important that he/she reads the nursing home contract, which should describe the daily rates, any increases for levels of care, and specific costs for special services or medical items. The facility should provide you with a list of all these items and the costs involved. Private pay residents need to consider the extra costs which may be charged to them, including but not limited to pharmacy, physicians, labs, x-rays and medical supplies.
Long-Term Care Insurance: Many insurance companies offer long-term care insurance policies. If a resident is using this as a form of payment, make sure that the nursing home is informed and agrees to accept the payment. Most long-term policies ask the facility to provide monthly statements listing the resident’s level of care, diagnosis, and special needs. The policy also may not pay the full daily rate, so the potential resident needs to determine what out-of-pocket expenses are going to be required.
Life Care Contracts: Although not as popular as they once were, many facilities still offer life care contracts. A life care contract is a binding agreement between the facility and the prospective resident that usually calls for the facility to provide room, board and other incidentals for the resident in consideration for the resident’s assignment of property and money to the facility.
A life care contract should only be entered into after careful consideration. Consult an attorney and try to insert items in the contract that expressly define the type of care and service that the facility is to provide. If a contract is entered into with the belief that the resident has an illness which will require care until death, or has a possible terminal illness, it may be wise to insert a clause in the contract which will allow for cancellation of the contract if the person improves in health such that care will no longer be needed at the facility.
When considering a life care contract, it is important to get in writing the facility’s responsibility to the resident should the resident require a higher level of care than the facility can provide or in the event that the facility should close. Either of these issues could potentially become a problem if there is no guarantee from the facility as to what steps the facility would take to provide for the resident. It is always a good choice to have an attorney review any contracts prior to signing them.