On July 15, 2022, Xavier Becerra, Secretary of the Department of Health and Human Services, announced that the public health emergency related to COVID-19 still exists and therefore the public health emergency determination originally announced on January 31, 2020, continues. The determination continues in 90-day increments.
States must maintain Medicaid eligibility standards and cannot make procedures more restrictive than they were on January 31, 2020. In addition, if a Medicaid recipient is validly enrolled in any Medicaid program, then continuous enrollment applies. If a recipient is validly enrolled and reports a change in circumstance, then the change is processed as a redetermination but the individual is still deemed as being validly enrolled.
The duration and level of long-term care will vary from person to person and often change over time. Here are some statistics (all are “on average”) you should consider:
Someone turning age 65 today has almost a 70% chance of needing some type of long-term care services and supports in their remaining years
Women need care longer (3.7 years) than men (2.2 years)
One-third of today’s 65 year-olds may never need long-term care support, but 20 percent will need it for longer than 5 years
Distribution and duration of long-term care services
Type of care
Average number of years people use this type of care
Consumer surveys reveal common misunderstandings about which public programs pay for long-term care services. It is important to clearly understand what is and isn’t covered.
Medicare:
Only pays for long-term care if you require skilled services or rehabilitative care:
In a nursing home for a maximum of 100 days, however, the average Medicare covered stay is much shorter (22 days).
At home if you are also receiving skilled home health or other skilled in-home services. Generally, long-term care services are provided only for a short period of time.
Does not pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services
You will have to pay for long-term care services that are not covered by a public or private insurance program
Medicaid:
Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level and you must meet minimum state eligibility requirements
Such requirements are based on the amount of assistance you need with ADL
Other federal programs such as the Older Americans Act and the Department of Veterans Affairs pay for long-term care services, but only for specific populations and in certain circumstances
GOOD TO KNOW
Like public programs, private sources of payment have their own rules, eligibility requirements, copayments, and premiums for the services they cover.
Health Insurance:
Most employer-sponsored or private health insurance, including health insurance plans, cover only the same kinds of limited services as Medicare
If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care
There are an increasing number of private payment options including:
Planning for the eventuality of needing long term care is critical in reducing stress and uncertainty. Meeting with an Elder Law attorney familiar with the rules of Medicaid qualification is a step in the right direction. Contact our office for a no-obligation consultation to see if developing an estate plan with the goal of Medicaid qualification is a right fit for you.
The Coronavirus (COVID-19) Pandemic has impacted every corner of the world at this point. As medical experts, financial advisors, and our colleagues that specialize in healthcare law, employment law, and other related areas are busy advising clients on the best course of action for the weeks and months ahead, we – as estate planners – also want to remind our clients and friends of some important considerations during these uncertain times.
At this point, we would simply promote the following actions to ensure that your estate planning affairs are in order:
(1) Review your existing documents. Make sure that you have copies (either paper or electronic) of your existing estate planning documents, and review them to confirm that they still reflect your wishes. If you cannot locate your documents, consider calling or emailing your estate planning attorney to obtain copies.
(2) Pinpoint any items that require attention sooner rather than later. As you review, take note of any major changes that may have occurred in your family since you last updated your estate plan. These might include child births, deaths, marriages, divorces, etc. And also consider whether the individuals that you previously appointed to serve as your agents are still appropriate.
(3) Follow up with your loved ones and advisors.
Make sure that your loved ones know to contact your estate planning attorney in the event anything should happen to you. This includes your named executor (i.e. personal representative under your will, or trustee of your trust), guardian for your minor children, attorney-in-fact under your financial durable power of attorney, and patient advocate under your health care power of attorney.
Consider reaching out to your financial advisor, insurance advisor, etc. to ensure that your beneficiary designations are up to date and discuss any new planning opportunities relative to your current financial status.
If you require any medical attention in the near future, confirm that your medical provider has a copy of your patient advocate designation and is informed as to who you wish to have access to your confidential health information.
NOTE – If you do not already have an estate plan, now is as good of a time as any to consider the opportunity before you. Having a will/trust, a durable general power of attorney, and a healthcare power of attorney can certainly contribute to a healthy state of mind.
Medicare is an important piece of the American insurance landscape, not only for people age 65 and older, but for all Americans. That said, this benefit is not easy to navigate. Eligible individuals must be thoughtful about the coverage they need, the timing of enrollment, and coordination with other healthcare benefits, if they want to make the most of the Medicare program.
Attached is a report recently published by Northern Trust that recaps the Medicare program and is a good resource for people wanting to learn more.
It addresses the following questions:
What does Medicare cover? Do I still need Private Insurance?
How much does it cost?
I am thinking about early retirement but I am concerned about health insurance coverage and eligibility. What are my options?
I am turning 65 next year and still working, should I transition from private insurance to Medicare and if so, how do I do that?
Medicare is a critical component of every persons health insurance portfolio but it does not cover long-term skilled nursing. The Medicaid program covers eligible individuals cost for long term skilled nursing, however, there asset and income limits before someone becomes eligible. Generally, a person must have countable assets below $4,000 and monthly income below $10,000 to be eligible. A person who is on Medicare and then transitions over to Medicaid will be required to maintain their Medicare coverage. Medicaid being a welfare program, is an insurer of last resort, whereas Medicare is a primary insurance for people.
Still have questions about planning for your future healthcare needs including long term care planning? Contact us for a no cost consultation.
Federal law requires Medicare to pay indefinitely for home care
Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,” he said. He has Medicare.
Colin Campbell at his home in Covina, Calif., on Dec. 18, 2017. Campbell was diagnosed with ALS eight years ago. He has Medicare due to his disability but can’t use it for home care and instead is paying $4,000 a month for that service. His adjustable wheelchair allows him to recline, which makes breathing easier. (Heidi de Marco/KHN)
Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.
The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services.
That’s an incorrect but common belief. Medicare does cover home care services for patients who qualify, but incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients such as Campbell, who have debilitating conditions that won’t get better, according to advocates for seniors and the home care industry. Rule changes that took effect this month could make the problem worse.
“We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes,” said Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.
Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement. Those who qualify can also receive an aide’s help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.
Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient’s abilities or to prevent or slow decline. It also agreed to inform providers, bill auditors and others that a patient’s improvement is not a condition for coverage.
Campbell said some home health care agencies told him Medicare would pay only for rehabilitation, “with the idea of getting you better and then leaving,” he said. They told him that Medicare would not pay them if he didn’t improve, he said. Other agencies told him Medicare simply did not cover home health care.
Securing Medicare coverage for home health services requires persistence, said John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare’s decision denying coverage, and afterward Medicare paid for his mother’s visiting nurse as well as speech and physical therapy.
“You have to have a good doctor and people who will help fight for you to get the right company,” said Gillespie, of Orlando, Fla. “Do not take no for an answer.”
Yet a Medicare official did not acknowledge any access problems. “A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit,” said spokesman Johnathan Monroe.
But a leading industry group contends that Medicare’s home health care policies are often misconstrued. “One of the myths in Medicare is that chronically ill individuals are not qualified for coverage,” said William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation’s 12,000 home care providers.
Part of the problem is that some agencies fear they won’t be paid if they take on patients who need their services for a long time, Dombi said. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible or they suspect billing fraud. Rather than risk not getting paid, some home health agencies “stay under the radar” by taking on fewer Medicare patients who need long-term care, Dombi said.
And they may have a good reason to be concerned. Medicare officials have found that about a third of the agency’s payments to home health companies in the fiscal year ending last September were improper.
Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi said.
Another factor that may have a negative effect on chronically ill patients is Medicare’s Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency’s help. That effectively tells agencies who want top ratings “to go to patients who are susceptible to improvement,” Dombi said.
This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don’t will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt said.
Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor’s order. But that, too, could backfire.
“This is good,” Holt said. “But our concern is that some agencies might hesitate to take patients if they don’t think they can easily discharge them.”
This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Silver Century
Medicare Should Warn Enrollees on Steep Late Sign-up Penalties
For many Americans entering retirement, it comes as an unwelcome surprise: Medicare premiums become much more expensive if you do not sign up on time. The program tacks on a 10 percent penalty on monthly Part B premiums for each full 12-month period of late enrollment, and you keep on paying the penalties for the rest of your life.
The aim is to avoid “adverse selection,” which occurs when people sign up for coverage only when they think they will need it. That helps keep premiums lower for all Medicare enrollees.
The letter would explain the enrollment rules, and – importantly – how Medicare interacts with other insurance coverage you might have.
Roughly 750,000 Medicare beneficiaries paid late enrollment penalties in 2014, according to the Congressional Research Service (CRS). That is less than 2 percent of enrollees, but for those who do pay the penalties, the bite is painful. On average, total premiums for late enrollees were 29 percent higher, CRS reported.
Medicare is the primary source of health insurance for seniors, and choosing the correct Medicare plan is important. However, it only provides for 100 days of skilled nursing care. Planning for those potential costs are a critical component for anybody, regardless of when you sign up for Medicare.
Want to discuss your plan for paying for your care needs today and in the future? Contact us to discuss how you can plan for future long term care needs that are not covered by Medicare.
Fall and winter don’t just bring cooler temperatures and the holidays — the final seasons of the year also mean open enrollment for Medicare. For most seniors in the United States, the period between Oct. 15 and Dec. 7 is the only time they can switch or make changes to their Medicare plan insurance.
“As people age, their health care needs evolve,” says Dawn Maroney, chief growth and strategy officer for Alignment Healthcare. “When that happens, they may find the Medicare plan they first chose when they became eligible no longer meets all their needs. This open enrollment period is their yearly opportunity to re-evaluate whether to continue with their plan or switch to another, with changes becoming effective the first of the new year.”
Medicare basics
Most Americans are aware that Medicare is a government program designed to ensure people older than 65 have access to affordable health insurance. The program can also cover people younger than 65 who have certain disabilities.
* Medicare Part A helps pay for in-patient hospital stays, care in a skilled nursing facility and hospice care.
Drawing of Medicare with Stick Men and Clipping Path
* Medicare Part B helps cover care by doctors or other health care providers, outpatient services, some medical equipment and some preventive services.
* Medicare Part C (also known as Medicare Advantage) covers everything included in parts A and B, and usually includes Medicare prescription drug coverage as part of the plan. Medicare Advantage plans may include extra benefits and services for an extra cost. Medicare-approved private insurance companies, such as Alignment Healthcare’s Alignment Health Plan, run Medicare Advantage plans.
* Medicare Part D helps cover the cost of prescription medications and is run by Medicare-approved private insurance companies.
Original Medicare versus Medicare Advantage
Most people think of Medicare parts A and B as Original Medicare, in which the government pays directly for the health care services received. People with Original Medicare can see any doctor and hospital that accepts Medicare in the country, without prior approval from Medicare or their primary care physician. Most people do not pay a monthly premium for Part A if they paid taxes while working; everyone pays a monthly premium for Part B, based on income. The standard premium for Part B in 2017 was $134 per month, which is deducted from the individual’s Social Security benefits.
Original Medicare pays for about 80 percent of the total costs of health care. The patient is responsible for the remaining 20 percent, which can mean high out-of-pocket costs in the event of a hospitalization or other events requiring significant medical attention. To offset the financial burden of that 20 percent, some people choose to purchase supplemental insurance, called Medigap.
Private insurance companies offer Medigap to cover things Medicare doesn’t, such as deductibles, co-pays and co-insurance — but, keep in mind, Medigap only supplements Original Medicare benefits. Further, if you do not apply for Medigap in the first six months of becoming eligible, there’s no guarantee that an insurance company will sell you a Medigap policy.
With Medicare Advantage, government-approved private companies administer health plans that cover everything Original Medicare does, but can do so with different rules, costs and restrictions that can change every year. For example, a private Medicare plan may require your physician to request permission before performing a procedure in order to be paid by the plan. Medicare Advantage plans, however, usually cover extras that Original Medicare does not, like dental care, vision services, hearing exams and gym memberships.
Most Medicare Advantage plans also include prescription drug coverage (Medicare Part D), which is not included in Original Medicare, at no additional cost. If you elect to enroll in a Medicare Advantage plan, you still have Medicare — this means that you must still pay your monthly premiums for parts A and B, in addition to a monthly premium for Part C, if applicable. Many Medicare Advantage plans are available for no additional monthly premium.
Considerations when choosing
When choosing between Original Medicare and Medicare Advantage, you should consider these questions:
* How likely is it your health needs will change down the road? Since health changes as you age, chances are your treatment needs will, too. If you don’t enroll in the additional insurance and drug coverage when you first sign up for Original Medicare, you may pay a monthly penalty for enrolling later and may not be eligible for additional Medigap coverage.
* Are you still working past age 65? If so, you will probably want to enroll in Part A, because there generally are no monthly premiums, and it may supplement your employer’s insurance plan. You might choose to delay enrolling in Part B, but it depends on your health coverage. Everyone has to pay a monthly premium for Part B.
* Is it more important to you to have lower or no premiums or lower out-of-pocket costs? With Original Medicare, you may pay more out of pocket without supplemental insurance and prescription drug coverage. Medicare Advantage includes supplemental insurance and sometimes prescription drug coverage, too.
* How important is it to keep your doctor? Original Medicare is accepted by any doctor or hospital that accepts Medicare, without referral. Medicare Advantage plans allow you to select a doctor from the plan network, which is usually very large; your current health care providers are likely to be in the network already.
* Do you regularly take prescription medication for chronic conditions? Prescription drug coverage is not included in Original Medicare, and if you fail to sign up for Part D at the time you enroll, you could pay a penalty for adding it later. Most Medicare Advantage plans do cover prescription drugs.
“Medicare Advantage allows patients to receive the care they need to stay well and keeps their budgets in check with set costs and annual maximums,” Maroney says. “It’s an ideal solution for patients who need frequent care or who struggle to meet medical expenses.”
To learn more about Medicare, visit www.Medicare.gov. For information about Alignment Healthcare and its affiliated Medicare Advantage plans, visit www.alignmenthealthcare.com.
Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.
This care is a crucial part of integrated, people-centered health services, at all levels of care: it aims to relieve suffering, whether its cause is cancer, major organ failure, drug-resistant tuberculosis, end-stage chronic illness, extreme birth prematurity or extreme frailty of old age.
Fact 1: Palliative care improves lives
Worldwide, only about 14% of people who need care currently receive it. The quality of life of patients and their families who are facing problems associated with life-threatening illness, whether physical, psychosocial or spiritual are greatly improved by palliative care.
Fact 2: Pushing policy will drive palliative care forward
World Health Assembly resolution 67.19 on strengthening palliative care, adopted in 2014, emphasizes the need to create national care policies, to ensure secure access to opioids for pain relief, training for all health care staff in palliative care, and the integration of palliative care services into existing health care systems.
Fact 3: Most people in need of palliative care are in their own homes
Therefore, the most effective models of palliative care link supervised home care and care at community health centres to hospitals with more palliative care expertise.
Fact 4: Palliative care benefits everyone
Patients during treatment for serious illnesses, not only patients at the end of their lives, can take advantage of what palliative care can offer. For example, it can improve the quality of life of patients receiving radiation therapy for cancer or chemotherapy for cancer or drug-resistant tuberculosis.
Fact 5: Oral immediate-release morphine is an essential palliative medicine
Opioid laws and prescribing regulations must balance the prevention of illegal use of opioids with ensuring accessibility to morphine to relieve moderate and severe pain.
Fact 6: Children have little access to palliative care
They are at a higher risk than adults to face inadequate pain relief. For children, 98% of those needing palliative care live in low- and middle-income countries with almost half of them living in Africa.
Fact 7: Palliative care is “people-centered”
For example, it respects the values and confidentiality of patients, seeks to protect patients and their families from financial hardship due to the illness, and provides emotional support both during the illness and for the bereaved.
Fact 8: Palliative care shows global disparity
Lack of access to palliative care and pain control is one of the largest inequalities in global health. Most people in high-income countries have access, but only a small percentage of people in low- and middle-income countries do. Each year an estimated 40 million people are in need of palliative care, 78% of whom live in low- and middle-income countries.
Fact 9: The need for palliative care has never been greater
It continues to grow with the increase of chronic diseases and people living to an older age.
Fact 10: Integrating home care has multiple benefits
Palliative care that includes home care can improve the quality of life of patients and their families while also saving money for health care systems by reducing unnecessary hospital admissions.
PROVIDENCE, R.I. — Rhode Island ranks 32nd in the nation, and the worst in New England, when it comes to meeting the long-term care needs of older residents and people with disabilities, according to a scorecard released this week by the national nonprofit AARP.
The good news: Rhode Island showed improvement in all but one category.
“The vast majority of older Rhode Islanders want to live independently, at home, as they age — most with the help of unpaid family caregivers,” Kathleen Connell, state director of AARP Rhode Island, said in a statement released Wednesday. “Even facing tight budgets, Rhode Island is making progress to help our older residents achieve that goal. However, this scorecard shows we have more to do, and we need to pick up the pace.”
Rhode Island ranks 22nd nationally “support for family caregivers” and 24th in “quality of life and quality of care.” The state ranks 35th in “effective transitions,″ or how effectively the state transitions residents between nursing homes, hospitals and homes — the only category that showed a decline.
The report — “Picking Up the Pace of Change: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers” — is the third in a series that ranks states overall and on 25 separate indicators in five key areas: affordability and access; choice of setting and provider; quality of life and quality of care; support for family caregivers; and effective transitions between nursing homes, hospitals and homes.
Unpaid family caregivers provide the bulk of care for older Rhode Islanders, in part because the cost of long-term care remains unaffordable for most middle-income families, according to AARP Rhode Island. More than 134,000 Rhode Islanders help care for their aging parents, spouses and other loved ones so they can stay at home. AARP estimates the value of this unpaid care at about $1.78 billion.
“Many [family caregivers] juggle full-time jobs with their caregiving duties,″ Connell said, while “others provide 24/7 care for their loved ones.” Family caregivers “save the state money,″ she said, “by keeping their loved ones out of costly nursing homes – most often paid for Medicaid.″
Rhode Island improved its rank from 50th to 44th in the percentage of Medicaid long-term care dollars for older adults and people with physical disabilities that support care at home and in the community.
The report comes at a time when proposals in Washington are being considered to drastically cut federal Medicaid funding, which Connell said “would threaten these advancements, likely resulting in our most vulnerable citizens losing the lifesaving supports that they count on.″
The scorecard was developed AARP with the support of The Commonwealth Fund and SCAN Foundation.
The AARP Rhode Island has more than 138,000 members age 50 and older in the state.
Medicaid provides health coverage to more than 4.6 million low-income seniors, nearly all of whom are also enrolled in Medicare. Medicaid also provides coverage to 3.7 million people with disabilities who are enrolled in Medicare. In total, 8.3 million people are “dually eligible” and enrolled in both Medicaid and Medicare, composing more than 17% of all Medicaid enrollees. Individuals who are enrolled in both Medicaid and Medicare, by federal statute, can be covered for both optional and mandatory categories.
What Medicaid Covers for Medicare Enrollees
Medicare has four basic forms of coverage:
Part A: Pays for hospitalization costs
Part B: Pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
Part C: Medicare Advantage Plan (like an HMO or PPO) offered by private companies approved by Medicare
Part D: Assists with the cost of prescription drugs
Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid (e.g. MSPs, QMBs, SLBs, and QIs). Medicaid also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.
Qualifying For Medicaid
Qualifying for Medicaid is a two part test: Asset Rules and Income Rules. Generally speaking, a person can only have $4,000 of countable resources under the asset rules component. As for Income, a recipient generally can keep the first $50 of monthly income and the balance is remitted to the skilled nursing facility with Medicaid picking up the balance due to the facility. The rules are different for spouses and the overall qualification is subject to a 5 year look-back at all of your finances.
Want to learn more about Medicare and Medicaid and how you should plan your estate around these programs? Contact us for a no-cost consultation.
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