Presenting a live 90-minute webinar with interactive Q&A Medicaid Eligibility Strategies in Long-Term Care Planning for the Elderly Navigating the Complex Requirements for Medicaid Qualification in a Climate of Services Cutbacks THURSDAY, JUNE 14, 2012 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: David Goldfarb, Managing Partner, Goldfarb Abrandt Salzman & Kutzin , New York Michael J. Keenan, Attorney, Keenan Law , Glastonbury, Conn. Yale S. Hauptman, Attorney, Hauptman & Hauptman , Livingston, N.J. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
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Strafford June 14, 2012 Medicaid Eligibility Strategies in Long-Term Care Planning for the Elderly David Goldfarb Goldfarb Abrandt Salzman & Kutzin LLP 350 Fifth Ave. Suite 4310 New York, NY 10118 212-387-8400 www.seniorlaw.com
6 I. Medicare v. Medicaid • Medicare is a federal program available to persons who are sixty-five years of age and older and certain disabled persons. • Medicaid is a joint federal, state and city program which provides medical assistance for persons with low incomes and limited assets.
7 Medicare Parts A & B • Basically Medicare is the health insurance component of Social Security. • There is a Medicare Part A which covers hospital care and a limited amount of "skilled" nursing care and home health care. • There is an optional Medicare Part B which covers part of physicians' costs and other medical services and supplies.
8 Medicare Parts C & D • There is Medicare Part C or Medicare + Choice, which is an option for Medicare Managed Care. • There is a Medicare Part D which is prescription drug coverage.
9 Medicare Gaps • Medicare is far from perfect; it is in fact a safety net with many holes. • Medicare has certain deductibles, limited payment periods, and restrictions on the types of services covered. • Two of the most severe restrictions are: ▫ It only covers nursing home care if it is "skilled" care rather than "custodial," ▫ and it covers only 100 days of nursing home care per spell of illness. ▫ A spell of illness begins with the first day of inpatient care in a hospital or nursing home and ends when the beneficiary has been hospital and nursing home free for 60 consecutive days.
10 Medicare Supplemental Insurance (Medigap) • Fill-in some of the gaps in Medicare coverage. • For example most Medigap policies cover the 20% of physician's charges not covered under Medicare. However, most policies do not cover the part of the physician charges above the Medicare approved level. • Medigap policies which cover nursing home care (Plan C or better) only cover 80 days of coinsurance and care which is "skilled" under the Medicare definition. • There are some guaranteed renewable policies which predate the federal regulation of Medigap which cover up to 365 days of nursing home care (for example, AARP policies M or N)
11 Medicaid • Medicaid is available to persons who are eligible for public assistance or SSI (Supplementary Security Income). • Medicaid is also available in some states for persons with higher incomes. • Spendown or Surplus Income Program: ▫ In states like New York the Medicaid Surplus Income Program is available for persons over sixty-five or who are blind or disabled whose incomes are too high to qualify for public assistance or SSI, but who spend down any excess income on medical costs until they reach the Medicaid income level.
Glastonbury, CT www.keenan-law.com (860) 657-2683 Medicaid: Medical Necessity Michael J. Keenan, Esq. Michael@Keenan-Law.com
Medicaid: Medical Necessity Criteria Used to determine level of care for Medicaid reimbursement for NH care or participation in long-term supportive services via a Medicaid waiver varies widely from state to state. – Such criteria can include: Medical conditions, or A combination of medical conditions and functional impairments, or Functional impairments alone, or A particular “score” through an assessment instrument. www.keenan-law.com 13
Medicaid: Medical Necessity – Medical Some states allow for admission to a nursing facility when nursing care is needed on a daily basis. Some states allow for admission when the resident requires intermittent skilled nursing care, daily skilled nursing assessment and 24/7 supervision by an RN or LPN. www.keenan-law.com 14
Medicaid: Medical Necessity – Medical/Functional Some states require that residents need skilled care on a daily basis, which may include nursing or rehabilitation therapies, or Full assistance with at least 3 ADL’s which may include transferring, ambulating, toileting, or eating; or One of several specified combinations of nursing and functional needs. www.keenan-law.com 15
Medicaid: Medical Necessity – Functional States may use ADL’s to establish its minimum criteria for admission. In such states, individuals need assistance with 2 or more ADL’s, or they may need 24/7 care for medical monitoring and nursing care, restorative nursing or rehabilitative care or medication administration. www.keenan-law.com 16
Medicaid: Medical Necessity – Scores Eligibility in states may be based upon determination of need scoring. May be derived from a “mini - mental state examination” (MMSE), identified minimum number of needs for assistance with ADL’s, ability to recognize and respond to danger when left alone. This process is designed to target services for individuals with higher level of impairments who may have informal supports, and to individuals with lower level of impairments without informal supports. www.keenan-law.com 17
Medicaid: Medical Necessity Federal regulations require that states limit eligibility for such services to individuals who meet the state’s criteria for institutionalization. Although states may apply stricter criteria limiting eligibility for admission to an institutional placement, the consequence is that such states would also be limiting participation for those why may be functionally or clinically eligible to participate in waiver programs. States must provide satisfactory assurances to the Centers for Medicare and Medicaid Services that necessary safeguards have been taken to protect the health and welfare of Medicaid recipients. www.keenan-law.com 18
Medicaid: Medical Necessity – Adequate standards for all types of providers of services under the waiver; – That standards of any state licensure, or certification requirements are met for service providers or individuals furnishing services under the waiver; – That all facilities in which home and community based services are provided are in compliance with state standards that meet requirements for board and care facilities; – Include periodic re-evaluations of level of care to determine if the recipient continues to require the level of care provided and absent the availability of waivered services, the individual would require institutionalization in either a hospital, nursing facility, or ICF/MR. www.keenan-law.com 19
Medicaid: Medical Necessity – States can and do change LOC in response to budget constraints. – The state of Georgia in particular revised it’s LOC criteria and screening procedures for children’s participation in the TEFRA/Deeming Waiver, resulting in the denial of LOC for hundreds of children who were previously participating, state-wide. – Anticipate that current economic conditions will continue to result in states making LOC criteria more stringent. www.keenan-law.com 20
Medicaid Eligibility Requirements Yale S. Hauptman (973) 994-2287 contact@hauptmanlaw.com 21
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