[PPT] - MassHealth Long Term Care Jan Stiefel, J.D. Community Legal Aid PowerPoint Presentation

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MassHealth Long Term Care

Jan Stiefel, J.D. Community Legal Aid June 30, 2020

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Financial Eligibility

A. Assets: $2,000 limit
1. Excess assets may be offset by outstanding

medical bills

2. Inaccessible assets: additional time to seek

appointment of conservator

3. Non-countable assets (ex. burial account

$1,500 or less/burial contract of any amount)

4. The home is non-countable, if equity interest

less than $893,000

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Penalty for transfer of assets

B. Penalty for Transfers
1. Look back period: 5 years
2. Penalty start date for transfers
3. Penalty is calculated at $366.73/day; $11,155

per month

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Penalty for transfer of assets

4. A transfer penalty can be “cured”
5. A transfer penalty may be “waived”
a. If ineligibility will cause nursing home resident

“undue hardship”

b. Nursing facility must notify resident of its intent to

initiate a discharge due to nonpayment for stay

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Permissible transfers

C. Permissible transfers
1. Spouse to spouse (of all assets)
2. Caretaker child residing in elder’s home 2 years, child

under age 21, sibling residing in home at least 1 year with interest in home (of primary residence)

3. Disabled child of any age (of all assets)
4. Pooled trust for nursing home resident
5. Pooled, special needs trust for permanently disabled

child and/or disabled person under 65 when trust created

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Income

D. Income
1. One month deductible/spenddown
E. Deductions from income
1. Personal needs allowance (PNA) of $72.80
2. Minimum monthly maintenance needs

allowance (MMMNA) for spouse in community

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Deductions from Income

3. Family maintenance needs deduction for

minor child or dependent child, parent and/or sibling

4. Home maintenance allowance
5. Health insurance
6. Medical/remedial expenses incurred and

not covered (ex. dental)

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Medical Eligibility

A. ASAP medical assessment of need for

nursing home care

B. Short versus long term admission
C. Score Three level of care criteria

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Rights of Community Spouses

A. Assets
1. Asset assessment (snapshot) on date of

nursing home admission

2. Community Spouse Resource

Allowance (CSRA)

3. First $128,640 deemed to community

spouse

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Rights of Community Spouses

B. Income
1. Minimum monthly maintenance

needs allowance: (MMMNA)$2,113.75/month minimum and $3,216.00/month maximum

C. Can be increased by appeal

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Liens and Estate Recovery

A. Liens
1. “Notice” lien is placed on home of

resident not reasonably expected to return home unless exceptions to lien placement

2. Sale of home post lien

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Liens and Estate Recovery

B. Estate Recovery
1. “Estate recovery unit” will file claim against an

estate for reimbursement of all payment made by MassHealth on behalf of resident

a. for all services provided while member was

55 or older; and

b. on or after March 22, 1991, regardless of

age, if client is institutionalized and could not be reasonably expected to return home

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Liens and Estate Recovery

2. Exceptions to estate recovery
3. Deferral of or waiver of estate recovery

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Nursing Facility Involuntary Transfers and Discharges

A. Transfer of resident between beds with

different certifications or discharge to another facility or to the community trigger right to appeal

1. Requirement of written 30-day notice

specifying location to which resident is to be transferred/discharged

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Transfers and Discharges

2. Permissible grounds for

transfer/discharge:

a. Resident requires higher level of

care

b. Resident’s health improved and

no longer needs level of care provided

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Transfers and Discharges

c. Safety/health of other individuals in

facility endangered

d. Non-payment
e. Facility going out of business
3. Resident who requests hearing shall not be

discharged without a finding that the facility “has provided sufficient preparation and

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Transfers and Discharges

rientation to the resident to ensure safe and
rderly transfer or discharge from the facility

to another safe and appropriate place.”

4. Even after losing an appeal of [non-

emergency] transfer/discharge, facility cannot transfer/discharge resident for at least 30 days from the date of the hearing decision.

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Transfers and Discharges

5. Can only appeal transfers between beds

within same facility with same certification to medical director of facility; limits rights previously afforded by regulations pursuant to Consumer Protection Act (93A)

6. Long Term Care Ombudsman Program –

(800) 243-4636 to get local program info

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Bed Holds in Facility

Bed Hold

a. 10 days per hospitalization
b. 10 days per 12-month period for non-

medical leave

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Transfers and Discharges

Transfer to hospital triggers right to be re-admitted (Brunelle case)

a. Must re-admit to same bed if within bedhold

period

b. Must re-admit to first available bed in semi-

private room if beyond bedhold period

c. Refusal to re-admit considered

discharge/transfer to which appeal rights apply

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Appeals – Fair Hearing

Appeals

1. Applicants and recipients have right to appeal

any appealable claim

2. Actions denying, reducing, suspending,

terminating, recovering, or restricting assistance

3. Coercive or otherwise improper conduct by a

MassHealth employee

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Appeals – Fair Hearings

4. Division of Hearings must provide an

adequate and timely written notice of any appealable decision

5. Determine the legal basis of the appeal
6. Complete the appeal form, including all

information and statement of disagreement with the action

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Appeals – Fair Hearings

7. Request an interpreter if needed and
8. Request expedited hearing if appellant is

not receiving benefits

9. Designate Authorized Representative if

desired

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Appeals – Fair Hearings

10. Appeal must be received by the Office
f Medicaid Board of Hearings no later than

thirty days from receipt of the notice

11. 10 day appeal limit for continuing

benefits

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Appeals – Fair Hearings

Fair hearings

12. Right to have missing verification

accepted as timely to get back to original date of application (& potentially 3 months before that as start date for benefits)

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Appeals – Fair Hearings

13. Appellant may request a rehearing

(within 14 days) or

14. Appeal adverse decision to Superior

Court under Massachusetts General Laws, chapter 30A, within 30 days of decision

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Rest Homes

A. SSI payment for care
a. Income less than $1,064 (SSI payment

amount)

b. Asset limits same as MassHealth
c. PNA $72.80
d. 3-year look-back for transfers

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Rest Homes

B. EAEDC payment for care
a. Income less than rest home payment
b. Asset limit $250
c. PNA $72.80
d. 12-month look-back for transfers

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Group Adult Foster Care (GAFC) & the SSI-G Assisted Living Benefits

A. Income limit for individual is

$1,237/month

B. Asset limit for individual is $2,000
C. 3-year look-back for transfers
D. GAFC pays for services/care &

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SSI-G pays for room and board.

E. One must ask specific AL facility if

they accept GAFC & SSI-G to cover costs; very few do so.

F. Assisted Living Ombudsman