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Home Based Medicaid Serivices

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LTSS in Home and Community-Based Settings

Many older adults and people with disabilities who want to stay in their own homes cannot do so without help. The programs that can help you or someone you care for live comfortably and safely at home are called Home and Community Based Services.

Some programs can help you fill prescriptions or get meals or rides. Other programs will help you out at home with activities like personal grooming or getting in and out of bed. The programs you use will be based on your needs.

Medicaid LTSS provides medical care and covers most of the services and supports people need to stay in their homes or a community-setting. People who have the highest or high level of need may get Medicaid LTSS in the home or community setting.

Need to apply for LTSS Medicaid home waiver for a loved one? Contact us.

Will I Ever Live In A Nursing Home?

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How Much Care Will You Need?

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 Percent of people who use this type of care (%)
Any Services 3 years 69
 

At Home

Unpaid care only 1 year 59
Paid care Less than 1 year 42
Any care at home 2 years 65
 

In Facilities

Nursing facilities 1 year 35
Assisted living Less than 1 year 13
Any care in facilities 1 year 37

Who Pays for Long-Term Care?

The facts may surprise you.

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:

PLAN BEFORE YOU HAVE A NEED

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.

Does Medicare Cover Therapy Services?

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Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute

Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.

So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government’s initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until they got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke, and spinal cord or brain injuries.  Although it removes the necessity to show an improving health condition, the settlement does not affect other criteria and limitations on Medicare coverage.

“We still regularly get calls from people who are told they are being denied coverage,” said Peter Schmidt at the National Parkinson Foundation, based in Miami. Denials sometimes occur because physical therapy providers use a billing code that still requires the patient to show improvement. Although Parkinson’s is a degenerative brain disease, Schmidt said physical therapy and exercise can help slow its progress.

The agreement, approved in 2013, settled a class action lawsuit against the Centers for Medicare & Medicaid Services filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of five Medicare beneficiaries, including the late Glenda Jimmo, and  six nationwide patient organizations. Coverage, the Jimmo settlement said, does not depend on the “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

In August, U.S. District Court Chief Judge Christina Reiss in Vermont ordered the government to work with the beneficiaries’ attorneys to strengthen its education campaign about the policy aimed at bill-processing contractors, claims reviewers, providers, appeals judges, people who staff the 800-MEDICARE help line and others. (Beneficiaries, however, were not included.) After working during the fall, both sides acknowledged this month they could not reach a compromise on the best way to make revisions to the education campaign.

There was a long-standing kind of mythical policy that Medicare contractors put into place that said Medicare only pays for services if the patient could progress,” said Roshunda Drummond-Dye, director of regulatory affairs for the American Physical Therapy Association. “It takes extensive effort to erase that.”

Medicare’s proposals include educational efforts such as a special webpage with “frequently asked questions” spelling out the proper procedures for handling claims. The government would also issue a clear statement confirming that Medicare covers physical, speech and occupational therapy along with skilled care at home, and in other settings, even if the patient has “reached a plateau” — a term seniors still hear — and is not improving.

Attorneys for the seniors want to monitor how Medicare officials implement these new measures and have offered to write the policy statement disavowing what’s known as the “improvement standard.” They also want the government to repeat its 2013 conference call with providers, contractors and others involved in the process in order to correct mistakes, according to papers filed with the court Jan. 13.

“The major problem for us is that they do not want the plaintiff’s counsel to have any say or involvement in what they do,” said Gill DeFord, litigation director at the Center for Medicare Advocacy in Connecticut. “We think that’s exactly the reason the educational campaign was so riddled with inaccuracies in the first place.”

But in its filing, the government said, “The Plaintiffs’ plan seeks to address perceived deficiencies that were specifically not guaranteed under the [settlement] Agreement.” It added accepting the advocates’ plan “would also grant their counsel undue control in developing CMS educational materials and an outsize role in CMS’ corrective action efforts.”

The settlement affects care provided by a trained professional in a patient’s home, nursing home or the provider’s private office that is medically necessary to maintain the patient’s condition and prevent deterioration.

A Medicare spokesman declined to comment under agency protocol because the case is still pending.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.