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Know Your Benefits: Payment Options for LTC and Medi-Cal Recovery CLTCOA Ombudsman Training October 20, 2014 Presenter: Pauline Mosher CANHR.

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Presentation on theme: "Know Your Benefits: Payment Options for LTC and Medi-Cal Recovery CLTCOA Ombudsman Training October 20, 2014 Presenter: Pauline Mosher CANHR."— Presentation transcript:

1 Know Your Benefits: Payment Options for LTC and Medi-Cal Recovery CLTCOA Ombudsman Training October 20, 2014 Presenter: Pauline Mosher CANHR

2 California Advocates for Nursing Home Reform (CANHR) Services Website: Consumer Hotline: (800) 474-1116 Pre-Placement Counseling Medi-Cal Information/Counseling Resident Rights Issues Elder Abuse Issues Lawyer Referral Service Legislative and Administrative Advocacy Litigation

3 LTC Funding in California Private Pay Long Term Care Insurance Medicare Medi-Cal VA Aid and Attendance SNF = $90, plus $35 PNA RCFE = $1,130-$2,085 At home = unreimbursible medical expenses/dependents Single Veteran: $1,759 Married Veteran: $2,085 Surviving Spouse:$1,130

4 Some Payment Options for LTC At Home: Home Health (some Medicare/Medi-Cal – but limited) LTC Insurance Private Pay Aged & Disabled Program (no SOC Medi-Cal & IHSS) VA Aid & Attendance (unreimburseable medical costs) IHSS (Medi-Cal eligible) MSSP (Must be Medi-Cal eligible) PACE (must be on Medicare/depends on county)

5 Residential Care for the Elderly Payment Options 85% of residents = private pay SSI/SSP rate = $1,133 ($130=PNA) Some LTC insurance coverage VA Aid and Attendance Assisted Living Waiver Program (ALW) Only in some counties RCFE & Medi-Cal: does not cover RCFE care, but can be eligible for Medi-Cal

6 Nursing Home Care Payment Options Medicare: after 3 day acute care stay Rehab in Skilled Nursing Facility – up to 100 days under Medicare (average about 23 days) Select Medicare/Medi-Cal certified facility Private pay Medi-Cal = 64% all or part of the cost of care $2,000 or less in assets Spousal Impoverishment if there is a spouse Income generally not a barrier to Medi-Cal in NF

7 CRITERIA FOR LONG-TERM CARE SERVICES Criteria for admission to SNFs are contained in state regulations (Title 22, CCR, Section 51335) and are applied on a statewide basis. I. Criteria for Determining Admission to SNFs II. Continuing Care Determinations III. Subacute Level of Care-Criteria for Determining or Extension of Stay

8 CRITERIA FOR LONG-TERM CARE SERVICES Cont’d. II. Continuing Care Determinations III. Subacute Level of Care-Criteria for Determining or Extension of Stay

9 Debunking the Myths of Short Term Stay Beds Fiction: Beds are designated as either long term or short term. Fact: If a nursing home is licensed in California, it must meet California nursing home standards.

10 Debunking the Myths…Cont’d. If you are being discharged from the facility while still being covered under the 100-day Medicare benefit period, you have a right to appeal. If you do not win the appeal and your Medicare coverage is terminated, you should not be forced to leave the facility. You may stay. However payment must be arranged, as the resident is then financially responsible for services received. If the facility accepts Medi-Cal and you qualify, the facility will be prohibited from discharging/evicting you once the Medi-Cal application has been submitted.

11 Selected 2014 COLAs Community Spouse Resource Allowance = $117,240 Minimum Monthly Maintenance Need Allowance = $2,931 Average Private Pay Rate = $7,628 APPR SSI Board and Care = $1,133 ($130 Personal NA) Aged & Disabled Federal Poverty Level Individual = $1,203 (4/1/14) Couple = $1,621 (4/1/14)

12 Medi-Cal Eligibility At Home or in the community: no penalties for transfers $2,000/$3,000 in Assets No look back period In a Nursing home: Look Back of 30 months for transfers Spousal Impoverishment applies Share of cost ($35 PNA)

13 Medi-Cal Exempt Assets  Home  Other Real Property  Business Property  Household Goods and Personal Effects  Jewelry (single v. spousal)  One Car  Term Life Insurance; whole life of $1,500 or less face  Burial Plots & irrevocable burial plan and $1,500 designated burial fund  $2,000 cash reserve or other assets  CSRA = $117,240 (2014)

14 Principal Residence Almost always an exempt asset and can transfer during life without impacting Medi-Cal eligibility: Intent to return home Multi Unit dwelling Buildings, land contiguous to or appertaining to the residence Proceeds of sale Out of state residence

15 Transfer of Assets: 2014 Date of Transfer v. Date of Application Date of Transfer v. Date of Application Still date of the transfer(s) Still date of the transfer(s) Period of Ineligibility Period of Ineligibility Runs from month of transfer Runs from month of transfer No partial months of ineligibility No partial months of ineligibility Concurrent periods of ineligibility still in effect Concurrent periods of ineligibility still in effect Sample transfer of $12,000 in February 2014 Sample transfer of $12,000 in February 2014 ($12,000 ÷ 7,628 = 1.6 months) May: ineligible June:eligible

16 Transfer of Assets- Sample #2 Multiple Transfers: Total Amount = $21,000 May 15:$7,000 to Joe May 15:$7,000 to Sue May 15:$7,000 to Amy Period of Ineligibility: $7,000 ÷ APPR ($7,628) =.92 month 0 month = period of ineligibility How Calculated: Each transfer calculated separately Transfer periods run concurrently May: eligible (as long as under $2,000 asset limit in May)

17 When Transfer Penalties Do Not Apply No transfer penalties for community-based Medi-Cal - only if enter a nursing home Asset is exempt Any asset of any amount to blind or disabled child (not a minor - unless it’s a home) Intended to transfer for fair market value or valuable consideration Denial of eligibility would result in undue hardship

18 Community Spouse Resource Allowance (CSRA) & MMMNA $117,240 CSRA $2,931 MMMNA Expandable (Court Order/Fair Hearing) After Acquired Assets 90 days to remove Medi-Cal beneficiary

19 Impact of CSRA on Spouses Snapshot of assets at application No distinction between community and separate property At home (community spouse) can retain CSRA of $117,240 (any non-exempt assets) IRAs/pensions in his/her name all other non-exempt assets After-acquired assets

20 Increase in CSRA Spousal Income & Assets: John (SNF) Mary (At Home) Income =$2,500/Month$500/Month Income $50,000 IRA $30,000 IRA Other Spousal Assets: $150,000 In other joint assets - 117,240 CSRA for 2014 - 2,000 John’s cash reserve $30,760 Above CSRA

21 Same Sex Spouses & RDPs AB 641 (Feuer): Spousal Impoverishment extended to same sex spouses and registered domestic partners (RDP) for transfers of property and income allocations. ACWDL 12-36: Undue hardship shall be found to exist if the institutionalized spouse verifies/attests that they have a same sex spouse or RDP via: Statement of facts, or A signed statement by the applicant, or A copy of the marriage license  Transfers of property: Net market value must not exceed the CSRA $117,240.  Income Allocations: Share of cost shall be reduced to allow allocation if spouse’s income does not exceed the MMMNA $2,931  Income allocations and CSRA: Amounts may be increased via fair hearing or court order

22 CCI & Nursing Home Issues Cal MediConnect = Dual Demonstration Project/Coordinated Care Initiative Medicare/Medi-Cal dual eligibles Combine care into single benefit package (acute, primary, institutional, HCBS) Administered by MMPs – Medicare/Medicaid Plans = managed care Active or passive enrollment

23 Passive Enrollment Calculation that determines which providers were highest used or highest prescribers for person in past 12 months Example: NF resident has been in facility for past 12 months, match resident with plan that contracts with facility

24 Impact on Current NF Residents Already in a facility – long term care resident prior to enrollment – can stay for duration of the project IF NF is licensed by state Meets “acceptable” quality standards NF and MMP agree to Medi-Cal or plan rates whichever is greater

25 Questions: What is the definition of “long term”? What are “acceptable standards”? What if NF refuses to agree to contracted Medi-Cal rate? Excuse to discharge Medi-Cal residents for non- payment and free up a bed?

26 Enrollment Issues for current NF residents Who will assist residents in choosing a plan if NF can’t assist? How do residents know what plans NF participates in? “Unrepresented” residents – who will assist them in choosing a plan? If passively enrolled in non-participating plan = eviction for non-payment Beneficiaries may disenroll and choose participating plan if available

27 Cal MediConnect: Issues for Prospective Residents Rates: NFs receive facility-specific Medi-Cal rates. Nothing to keep plans from contracting with lowest paid and lowest performing NFs. (quality standards are determined by the plan) Contracting: Some plans will contract with all NFs in a county. Others only contract with some. How do consumers find out which plans contract with which NFs? (HICAP CHART) If $ is an issue: What is the incentive to send beneficiaries to higher quality facilities? – maybe costly readmissions to acute care?

28 Cal MediConnect Issues Ancillary services in nursing homes Ancillary services = therapy, supplies, lab, x-rays, etc. – currently billed separately Under new program – Plans will decide, will require pre-authorization and will have an economic incentive to only use providers in their network Result = reduction in services to NF residents

29 Potential Problems with CCI/Cal MediConnect Intent maybe to provide “coordinated care” – but goal is to save money Could result in even worse care for dual eligibles Delayed admissions to NFs Reduction in therapy and other ancillary services Continuity of care provisions leave most decisions up to the plan

30 Potential Problems with CCI /Cal MediConnect Appeal rights: no change for now, but later will have to appeal to plan Very complex rules for consumers to understand - how to retain current providers? Too much MMP discretion as to whether a service or a provider will be included Forcing seniors to turn their care over to managed care – MMPs will chose the care & the providers

31 CCI/Cal MediConnect Resources Continuity of care website: Office of the Ombudsman: 1-888-452-8609 Department of Managed Health Care (DMHC) Help Center (Not DHCS)1-888-466-2219 Cal MediConnect Ombudsman: (855) 501-3077 help navigating plans

32 What is Medi-Cal Recovery? Federal Law (42 U.S.C. §1396p) requires states to recover from: Those who are inpatients in NF, ICF-MR or other medical institution and not expected to return home 55+ years of age: received NF services, HCBS & related hospital and prescription drug services OR At option of state, can recover for any items and services under the state plan (California exercised that option and recovers for everything Medi- Cal paid for)

33 What Is Medi-Cal Recovery? California can recover from your estate after you die if: You were over 55 years of age when you received (any) Medi-Cal benefits or Medi-Cal paid while you were in a nursing home, ICF- MR or other medical institution at any age

34 When Can the State Recover? The State cannot recover: Until after you die If you are survived by a spouse – until the spouse dies If you are survived by a minor child If you are survived by a disabled child of any age – does not have to live with you

35 What Can the State Recover?  Amount of the claim or value of the estate whichever is less: Example: Donald received $120,000 worth of Medi-Cal Benefits and his estate received an estate claim of $120,000 after he dies for the benefits paid. He left nothing in his estate. No recovery, since there is nothing left in his estate in his name.

36 What Can the State Recover? Amount of the claim or value of the estate whichever is less: Example: Donald leaves a house worth $250,000 and the estate claim is $50,000. The state can only claim up to $50,000 from his estate.

37 What is the Value of My Estate?  Amount of the claim or value of the estate whichever is less  Fair Market value at time of decedent’s death  Name(s) on the property at time of death  Joint tenancy – your % of the property  Living Trust (be careful what you put in)  Annuities purchased on or after 9/1/2004 are subject to recovery

38 What Property in Exempt from a Claim?  Property transferred prior to death  Irrevocable Life Estates  Occupancy Agreements= right to occupy for life  Life Insurance*  Retirement Accounts *  *Unless the estate is the named beneficiary or it reverts to the estate. Always check the beneficiary and beware putting these into living trusts)

39 Amount of Claim  Check itemization  IHSS payments exempt (But if payments made to managed care, then will no longer be exempt)  SLMB and QMB Medicare premiums, co-payments and deductibles exempt  Deduct outstanding mortgages, burial costs, estate settlement costs, etc. from the amount of the claim

40 What about my home? Primary asset usually home and home is exempt asset State does not put a lien on your home – unless in a nursing home and you indicate you do not have an intent to return home Always put “yes” – intend to return home Can transfer an exempt asset at any time

41 What About My Home? Can transfer an exempt home prior to death by: Gift deed with life estate Gift deed with occupancy agreement Outright transfer Joint tenancy – can only recover your % Irrevocable trust

42 What about my Home? Beware of tax consequences and/or losing your home prematurely Problems with transfers of home Joint tenancy=can still claim your % of home Outright transfers – taxes and can lose home Irrevocable trusts- can’t access the equity Living trusts – not immune from recovery

43 How Can I Avoid Recovery? Leave nothing in your estate when you die Execute a Durable Power of Attorney with gifting and real estate transfer clauses Do planning, depending on your age and health If already living with grown, responsible children, consider a transfer with a life estate

44 How Can I Avoid Recovery? If receiving nursing home or long term care services, consider transfers If spouse enters a nursing home or needs LTSS, consider transferring the home to the well spouse – then no recovery after the Medi-Cal spouse dies Check to see if there is an exempt child or if a hardship exists. Prepare your heirs/survivors on what to do

45 Notice of Death to DHCS After a Medi-Cal beneficiary dies, heirs/survivors must send a notice and copy of death certificate to DHCS DHCS Recovery Unit will send a questionnaire – do not complete until you consult with legal services or CANHR DHCS will send a notice of an estate claim

46 EXEMPTIONS FROM RECOVERY  Spouse (while alive)  If receipt by distribution or survival, then after death of surviving spouse - but not if property transferred  Minor (under age 21) - if minor at time of death  BLIND OR DISABLED CHILD of any age  Does not have to be an heir  Does not have to be living in the property  Verification of SSI or SSA as of date of claim  Plus, birth certificate or adoption papers

47 HARDSHIP CRITERIA The Department shall waive an applicant’s proportionate share of the claim if a hardship exists: 1. PUBLIC BENEFITS 2. BUSINESS 3. AGED, BLIND OR DISABLED LIVING IN THE HOME 4. CAREGIVER 5. NO CONSIDERATION 6. EQUITY NEEDED Contact CANHR or Legal Services if you plan to file for a hardship!

48 How to find out the amount of the claim  Claims detail report: how much is owed DHCS 6236 (for individual) or 6237 (for agent) Can download this form online Although living beneficiaries can obtain information on how much in Medi-Cal benefits were paid, the State cannot collect or file an estate claim until after the beneficiary has died.

49 If you have questions about Medi-Cal or Medi-Cal Recovery and go Medi-Cal for Long Term Care Call (800) 474-1116 and speak to an Advocate California Advocates for Nursing Home Reform 650 Harrison Street, 2 nd Floor San Francisco, CA 94107

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