Medicaid and Long-Term Care Services
Medicaid and Long-Term Care Services
Medicaid is funded and administered through a state-federal partnership. Although there are broad federal requirements for Medicaid, states have a wide degree of flexibility to design their program. States have authority to establish eligibility standards, determine what benefits and services to cover, and set payment rates. All states, however, must cover these basic services: inpatient and outpatient hospital services, laboratory and X-ray services, skilled nursing and home health services, doctors services, family planning, and periodic health checkups, diagnosis and treatment for children.
Long-term care recipients of Medicaid come almost exclusively from the aged, blind and disabled group of eligible beneficiaries but very few of those are actually receiving SSI (Supplemental Security Income). SSI is a welfare payment for certain disabled or handicapped individuals who are unable to work, have no assets and have no extended family financial support. Certain provisions of the enabling Act, as well as congressional amendments since 1965 have allowed the aged, blind and disabled who don't qualify for SSI to receive Medicaid under an alternate set of eligibility rules.
Medicaid enrollment almost doubled over the period of 1990 to 1998 from about 25 million U.S. recipients to about 40 million in 1998. Today, 47 million people--a little over 1 in 7 of all Americans--are receiving Medicaid. In 1998 about 10.6 million aged, blind and disabled were receiving Medicaid assistance, in the form of medical and long-term care services. Although this group only represented 1 in 4 of all Medicaid recipients in 1998, the group accounted for a large portion of the budget. For the group receiving old age (65+) long term care, Medicaid spends more per recipient than for any other group.
During the 1990's there was a large one-time influx of younger Medicaid enrollees due to changes in governing Federal law. This skewed the picture such that growth of long-term care services was hidden. But in the future, a growing larger proportion of aged and disabled are expected to receive benefits.
The number of long-term care enrollees went up by 80% between 1990 and 1998. As impressive as that may appear, actual spending on long-term care increased 3 times faster than enrollment. From 1990 to 1998, Medicaid spending for long-term care skyrocketed an astronomical 225%.
Federal Medicaid grants to States now account for the fifth largest federal budget item, after Social Security, defense, federal debt and Medicare, but Federal Medicaid is growing at such a fast rate it will soon overtake Medicare and move into fourth place. State Medicaid budgets in most states account for the second or third largest budget item expenditures after education and transportation.
A doubling in expenditures every 7 years, which we experienced this last decade, would eventually bankrupt government budgets. The growth of Medicaid spending, including long-term care, cannot go unchecked without some sort of offsetting reduction in services.
Federal and State Partnership
Federal reimbursement for Medicaid is in the form of block grants to States. The Federal Medical Assistance Percentage (FMAP) is determined annually for each State by a formula that compares the State's average per capita income with the national average. By law, the FMAP can be no higher than 83% nor lower than 50%. As an example, in 2000, Connecticut, Massachusetts, New Jersey, New York and Maryland had the highest per capita income in that order. Federal matching funds for Connecticut will be 50% and the other 50% will come from its state budget. On the other hand, Mississippi, West Virginia, Arkansas, New Mexico, Montana and Utah had the lowest per capita income in that order. In this case, the Federal grant for Mississippi will 83% of its Medicaid costs and the other 17% will come from its state budget. All other states fall somewhere between 50% and 83% for FMAP.
Overall the Federal Government provides about 70% of total Medicaid costs and the States provide the other 30%. From 1990 to 1998, Federal outlays for Medicaid rose about 12% a year. Estimates for the longer period from 1990 to 2001 put the average annual increase at about 11%. Total combined State and Federal Medicaid costs from 1990 to 1998 went up about 10.2% per year. The higher Federal spending increase compared to a lower combined increase means the Federal Government has been shouldering an ever-increasing share of costs whereas the States' portion has been decreasing. Total Medicaid spending is estimated to be a little over $200 billion for 2002. Medicaid costs will soon surpass those of Medicare, since Medicaid is going up at a much faster rate.
Congress is concerned about rising Medicaid costs and over the years, attempts have been made to curtail spending. In 1988, legislation was directed at tightening financial eligibility. This mostly affected the elderly population receiving long-term care since this is the fastest growing segment of expenses. In 1993, legislation directed States to implement a mandatory estate recovery program for recipients over age 55, who are receiving nursing home and community waiver care. And in 1998 Congress mandated that States set up recovery service agencies. Again the targeted group was primarily the elderly long-term care beneficiaries. Apparently Congress is concerned that some recipients are qualifying for Medicaid by shifting assets that could be used for care, to their children, thus forcing tax payers to pick up the cost.
States, on the other hand, are not so anxious to tighten up payment rules for long-term care recipients. States feel that most elderly long-term care recipients are truly impoverished by long-term care costs and attempts to "squeeze" these people only create a greater burden for overextended family members. West Virginia most recently lost a lawsuit over this issue.
The West Virginia State Medicaid refused to enforce estate recovery rules and subsequently the Feds withheld matching funds. The state sued over withheld funds and lost the suit. West Virginia is probably representative of many states. The feeling is that elderly recipients are truly deserving and shouldn't be punished. Besides, state governors and legislators are well aware of the political power of elderly Americans and the politicians probably tone down programs like estate recovery in order to avoid offending this group. Even states like California that seem to be more aggressive at weeding out undeserving Medicaid coverage, appear to exhibit more bark than bite.
The only state that has an effective recovery program is Oregon. As of 2004, a few states had no functiong recovery program and it's estimated that all states recover about 0.3 % of state Medicaid budgets nationwide. So far recovery is a dismal failure.
Income and Resource Rules for Institutions (Nursing Homes)
Resources are defined as any asset that can be utilized to produce income. There are numerous rules as well as gifting lookback provisions that define what a resource is and what a so-called "disregard" resource is. Some important resources that often aren't required to be counted are a personal residence and a car. If the recipient is married, the spouse keeps the residence and a vehicle worth any value. Also if the recipient is single but plans on returning home, the residence is not included. Disabled dependents living at home also "disregard" the residence. Also money invested in an income annuity is a disregard. Only the income counts. Assets that don't produce cash are subject to estate recovery at the death of the recipient.
Lookback provisions require any gift or so-called transfer-for-less than- value within 36 months of a community waiver or nursing home stay to be counted as a resource and any irrevocable trust assets created in the prior 60 months to be counted. Revocable trusts or any other arrangements in which the beneficiary has a "life interest" are counted as resource. Counting these transferred resources, even though they haven't been spent down on medical care or become subject to recovery, requires adding the equivalent dollar amount to a nursing home or waiver stay before Medicaid starts to pay for care.
Here's how it works. Suppose Mary gives her daughter her $120,000 dollar residence, 2 years before entering a nursing home. It takes Mary 5 months in a nursing home before she has spent her remaining liquid resources down to less than $2,000 at which point she would normally become eligible for Medicaid. But she still must incur a penalty period or sanction because the $120,000 transfer occurred within 3 years. The sanction period is determined by dividing the sanctioned resources by the average Medicaid reimbursement rate in the state which in this example is $3,000 per month. The result, in this case, is a period of 40 months in which someone other than Medicaid pays for care. In this case it may be Mary's daughter. Her daughter can also transfer the title to the house back to Mary and avoid a sanction. The sanction period starts on the date of transfer and runs concurrently with a spend down so that Mary or her daughter have to pay for 11 months of care before Medicaid takes over. (40 months minus the 29 months since the gift) Mary is single but if she had a husband, the community spouse resource protection which we will discuss next still applies even during a sanction period.
Also note that the sanction is longer by four months, then the three year look back. This is a paradox. If Mary had given the gift exactly three years before entering a nursing home, she would have only had to wait 36 months before Medicaid paid for care as opposed to 40 months before Medicaid would pay with a sanction. With a large gift, penalty periods could last up to five to ten years or more. A shorter look back provides a planning opportunity for gifting prior to receiving Medicaid. Look in the Medicaid planning section for more details.
Most recipients in nursing homes or on community waivers are not receiving SSI payments. Special rules allow aged (over 65) and disabled people in nursing homes or receiving waivers and who are not receiving SSI to meet alternate income tests. Most states have a "Medically Needy Program" that allows individuals to deduct the cost of care from their income. This spend down allows them to meet the alternate income test levels typically set at 100% of SSI.
States that do not follow Federal guidelines for Medicaid eligibility and that apply stricter rules, are called 209(b) states. Eleven states are 209(b) but most of them have a medically needy program. Federal law requires 209(b) states without medically needy to allow spend down to trigger Medicaid eligibility. Spend down means that all nursing home and medical costs not covered by Medicare, are deducted from a person's income until the person meets the income test. In some 209(b) states this is set at the state dictated level and in others there is no level. The difference between what a person can afford and what care costs determines eligibility.
States that are not 209(b) and who don't have a medically needy program are called income test states. Twelve of these states set income eligibility for Medicaid nursing home coverage at 300% of SSI--$1,692 per month in 2004. Delaware, the 13th of these states, sets income at 250% SSI. A person who makes more than the income level is not eligible for Medicaid in these states. Income is gross income, not medically adjusted income. Federal law requires these states to allow a person to establish a Miller Trust in order to circumvent the income test.
A Miller Trust is a legal document that transfers all of a person's income to another individual--the trust. The trust must be set up to pay the long-term care costs for its beneficiary--the person transferring income. Thus the person transferring income, has no income and comes in below the state income eligibility trigger. A Miller Trust must be set up so that the State can recover money at the death of the Medicaid beneficiary.
After meeting the income, resource and level of care (need for care assessment) tests and qualifying for Medicaid, a recipient is required to share Medicaid costs by contributing all of his or her total income to the total cost of care and Medicaid picks up the balance, if any. An allowance is added back in to provide monthly personal care. (a Federal minimum of $45 per month but as much as $75 in some states) Also, an allowance for medical costs and insurance premiums not covered by Medicare is added back in.
Income and Resource Rules for Medicaid Community Waivers
Eligibility requirements for waivers are determined by the States, sometimes varying among different waiver types. Waivers might be designed to cover recipients who are: aged (over 65) or disabled, mentally retarded or developmentally disabled, children, AIDs infected, mentally disturbed and so on. The number of participants is controlled, probably due to funding and administrative constraints. Federal rules require that waiver participants meet State Medicaid level of care eligibility rules for nursing homes and that the cost for waivers be neutral, meaning they can't exceed equivalent nursing home costs.
Medicaid community waiver care is often a more desirable alternative to nursing homes and generally those receiving care prefer to stay at home or use community programs, but the availability of such care is still widely restricted. There are at least 4 reasons for this:
The 1999 Supreme Court, Olmstead decision, will have a great impact on the availability of Medicaid community care. Olmstead requires that care for the disabled under ADA be provided in the most suitable setting not just nursing homes, regardless of cost. Since most Medicaid nursing home recipients are also disabled--requiring help with ADLs--States will have to find ways to offer alternative care through community programs. All the states and the CMS are now grappling with the solutions to Olmstead compliance.
Many states have programs already in place. If you want to see what's happening in your state, go to National Conference of State Legislatures.
Community Spouse Protected Resource Standard for Institutions
Here's how it works. The resource spend down rule requires the couple's liquidable assets to be lumped together. The resources are then divided in half. The resulting amount is compared to the State's resource standard. If the amount is less than the resource standard, the community spouse keeps it all. If the amount is between the community standard and the maximum Federal allowable, the community spouse keeps the larger of the two--the amount or the standard. If the amount is more than the maximum Federal standard, the community spouse may only keep an amount equal to the maximum. Whatever portion is attributed to the spouse needing care must be spent down. (Spend down does not necessarily have to be spent on care, it just needs to be spent.)
Money invested in qualified accounts--IRA, 401(k), 401(a ), 403(b), 457, SEPP, SIMPLE, etc.--is not subject to spend down if the owner is older than 70 1/2. Instead, the IRS required minimum withdrawal or larger withdrawals are treated as income.
Federal minimum standard for 2004 is $18,554. Federal maximum standard for 2004 is $92,760.
Here are some examples: 1) John and Jane have $200,000 combined resources. The State standard is $24,000. Dividing $200,000 in half yields $100,000. Jane keeps $92,760 and John must spend down $107,240 to $1,999. 2) George and Ann have $80,000. State resource standard is the maximum, $92,760. Half of $80,000 is $40,000. Ann keeps $80,000. No spend down required. 3) Same as #2 except State resource is the minimum allowable, $18,554. Ann keeps $40,000 and George spends down $40,000. 4) Same as #2 but State resource standard is $56,000. Ann keeps $56,000 and George spends down $24,000. Click here for current resource limits.
Community Spouse Protected Resource Standard for Waivers
Spouse Income Protection for Institution
Income rules for Medicaid eligibility require each spouse in a couple to claim the amount of income that actually belongs to that person. Shared income is divided in half. For example, suppose Henrie gets $3,500 a month in Social Security and pension income. His wife Frieda gets $750 in Social Security. Together they get $800 a month in rental income from property in both of their names. Henrie has a disabling stroke and will go in a nursing home, probably for many years since he is otherwise healthy. His State allows income spend down to qualify for Medicaid. He and Frieda apply for Medicaid even though he doesn't yet qualify. Medicaid determines that his income is $3,900 ($3,500 plus $400 of the rental income--his half). Frieda keeps $1,150, her Social Security plus $400--half the rental income. Henrie also must spend down $20,000 of their liquid assets before becoming eligible for Medicaid. His nursing home costs $4,000 a month. Subtracting the $4,000 a month from his income allows Henrie to meet the income test for Medicaid. Once having spent down to below $2,000 in remaining resources (He doesn't have to necessarily spend it on care.) , Medicaid should cover $145 of Henrie's costs. He pays the other $3,855 and keeps $45 for a personal needs allowance. The problem is Frieda can't maintain the rental property and pay the rest of her bills with $1,150 a month and her remaining community spouse allowable resources.
Federal Medicaid rules have spousal impoverishment provisions for situations like this. The community spouse is allowed to take back enough of the couple's income to bring his or her income to the minimum state impoverishment standard. Federal rules set a minimum and maximum standard and States can choose an amount between the two standards. The CMS sets the amounts each year based on inflation. The minimum impoverishment standard for 2004 is $1,515 a month and the maximum is $2,319 a month.
From the previous example, suppose Henrie's State sets its standard at the Federal minimum of $1,515 a month. Instead of getting $1,150 a month, Frieda now gets $1,515 a month. Henrie now pays $3,531 a month of his nursing home cost and Medicaid pays the balance of $469. Click here for current income protection limits.
Spouse Income Protection for Community Waiver
Protected and Spouse Maintenance Incomes for Community Waivers
Source: National Association of Medicaid Directors
Explanation of Table:
(1) Income and Resource Rules for Institutions--Eplanation of Code
1=States that have a medically needy program to allow spend down for nursing home eligibility. With the exception of a few states with different income rules, for the majority of states, the spend down triggers Medicaid eligibility when income reaches 100% of SSI.
2=States that don't have a medically needy program and don't follow Federal guidelines for Medicaid nursing home eligibility, so-called 209(b) states. Eleven states are 209(b) but most of them have a medically needy program. Federal law requires 209(b) states without medically needy to allow spend down to trigger Medicaid eligibility.
3=States that are not 209(b) and who don't have a medically needy program. These 13 states are the so-called income test states. Twelve of these states set income eligibility for Medicaid nursing home coverage at 300% of SSI--$1,692 per month in 2004. Delaware sets income at 250% SSI--$1,410 per month in 2004. A person who makes more than the income level is not eligible for Medicaid. Income is gross income, not medically adjusted income. Federal law requires these states to allow a person to establish a Miller Trust in order to circumvent the income test.
(2) Eligibility for Community Waivers--Explanation of Code
4=State does not allow spend down to qualify and does not allow use of a Miller Trust to circumvent lack of spend down. An income test pegged at 300% SSI is used in 8 of the 11 states in this category. Of the other 3, Alabama uses 100% SSI. (It would be pretty tough to get a waiver in Alabama), the District of Columbia and Nevada use 100% FPL (Federal Poverty Level, which is for 2002, $8,860 per year in 48 states & D.C. and $11,080 in Alaska and $10,200 in Hawaii.)
5=State does not allow spend down but does allow a Miller Trust.
6=State does allow spend down similar to a medically needy program for nursing home eligibility.
(3) Community Spouse Protected Resource Standard for Institutions--Explanation of Code
max=State uses maximum allowable Federal standard. $92,760 for 2004.
min=State uses minimum allowable Federal standard. $18,552 for 2004.
($ amount)=State uses stated amount for a standard.
(4) Community Spouse Protected Resource Standard for Waivers--Explanation of Code
max=State uses maximum allowable Federal standard. $92,760 for 2004.
min=State uses minimum allowable Federal standard. $18,552 for 2004.
($ amount)=State uses stated amount for a standard.
none=State provides no resource protection
(5) Spouse Income (Impoverishment) Protection for Institutions--Explanation of Code:
max=State uses maximum allowable standard. $2,319 for 2004
min=State uses minimum allowable standard. $1,515 for 2004
(6) Spouse Income (Impoverishment) Protection for Community Waivers--Explanation of Code:
max=State uses maximum allowable standard. $2,319 for 2004
min=State uses minimum allowable standard. $1,515 for 2004
none=State has no spouse impoverishment program
(7) Individual's Protected Income for Community Waivers and
SSI=Supplemental Security Income. $564 per month for 2004.
FPL=Federal Poverty Level. For 2002, $8,860 per year in 48 states & D.C. and $11,080 in Alaska and $10,200 in Hawaii.
MNIL=Medical Needs Income Limit
Medicaid Level of Care Eligibility for Nursing Homes
A need for skilled nursing care will automatically qualify a person in any state. It's also likely that a candidate already in a nursing home but not needing skilled care will still qualify. Skilled care must be needed on a frequent basis. Examples of skilled care might include the need for: frequent monitoring of vital signs, wound dressing changes, maintenance of mechanical ventilation equipment, maintenance of a catheter, help with elimination problems, maintenance of IV administrations, careful monitoring of medication usage, managing colostomy problems, careful supervision of severe diabetes, frequent injections, maintaining a feeding tube and many more problems requiring the skill of a nurse or doctor.
People who are otherwise able to manage their own health problems or who are healthy but mentally impaired must meet the minimum level of care defined by the State Medicaid regulations. These regulations define whether a person qualifies for a minimum level of care provided by a nursing home. Even if Medicaid intends on providing a qualifying candidate with home care through a community waiver, a candidate must still meet the minimum level of care for a nursing home.
The minimum level is tied to a person's ability to perform a certain number of activities of daily living (ADLs) without assistance. Consideration is also given to people with mental impairment such as dementia, Alzheimer's or disabling mental illness, who may be able to perform ADLs but nevertheless require supervision. The mentally ill disabled may be provided services in special Medicaid intermediate care facilities licensed for this type of care. The most commonly used ADLs are transferring, dressing, bathing, toileting and eating. Some states define more ADLs such as wandering or medicating. Some states give consideration to instrumental activities of daily living (IADLs) such as: meal preparation, medication management, shopping, housework, doing laundry, using the telephone and handling finances.
Assistance or supervision required to manage a care recipient with ADLs and IADLs is defined differently by the States. Some states allow only a presence or verbal coaching for some ADLs. Some states require hands-on assistance for some ADLs. A person needing care in one state may not qualify under that state's rules but might qualify under the rules of a neighboring state. Of particular concern are candidates suffering from dementia or Alzheimer's. It's difficult to quantify their need for care and in some states, those people who are cognitively impaired might not get help with Medicaid even though their needs might be greater than the needs of those who are physically disabled.
Some states use a scoring system based on verbal tests and questions. Meeting a minimum score qualifies. Most states determine the minimum number of eligibility rules met in order to qualify a person.
A person might meet the ADL and supervision criteria from one state but not those of another state. Families should consider moving loved ones who have been declined in one state, to live with a member of the family in another state and possibly qualifying in that state.
Medicaid Reimbursement of Nursing Homes
It's estimated that in 2002, Medicaid will pay about 44% of all nursing home costs. Medicaid is also paying part or all of the costs of about 70% of all elderly and functionally disabled nursing home residents. Decisions and reimbursement policies of State Medicaid Departments have a profound impact on the operations of U.S. nursing homes.
Medicaid reimbursement is carried out at a state level. Generally the States employ some rather convoluted and arcane rules to reimburse nursing homes. Most states reimburse with a prospective payment system like Medicare but a few states reimburse actual costs up to certain predetermined statewide maximum amounts. Some states pay directly, others pay through privately-contracted managed care administrators. Medicaid reimbursement to nursing homes is not uniform from state to state. In many states, nursing homes are not given enough money to cover their actual costs. One state nursing home association claims that 85% of its member nursing homes are not meeting costs with Medicaid. In other states nursing homes may be faring better.
Medicaid reimbursement has a direct impact on the daily bed rates of private-pay residents. These are residents who are paying out-of-pocket for their own care. They may be spending money from their own income and assets or their family may be pitching in as well. Many of these people are going through Medicaid spend down--depleting assets until they qualify for Medicaid. If the nursing home is losing money on government Medicaid reimbursement it may be charging private-pay residents higher daily rates to make up the difference. But one should not assume this is always the case. At least 2 states, Minnesota and North Dakota, prohibit nursing homes from charging more than the Medicaid reimbursement rate. In addition, not all homes lose money on government reimbursement. These facilities may be charging the same for all residents. Finally, although most states prohibit nursing homes from charging private-pay less than the Medicaid reimbursement rate, in those states that allow it, private-pay residents may be paying less than with Medicaid.
Medicaid Estate Recovery
The property is exempt from estate recovery if: 1) the recipient's spouse is living there 2) A blind or permanently disabled child lives there or 3) If as a result of a state lien, additional protection for siblings and adult children can be satisfied. If all of these conditions cease to exist then the property becomes subject to recovery.
Interestingly, if a person had a spouse living in the home at the time of Medicaid qualification, the home didn't have to be counted as a resource for the qualifying beneficiary. Yet at the death or Medicaid confinement of the surviving spouse, the home becomes subject to recovery.
For recovery purposes, Federal law gives States the directive to go after property that would be subject to probate. Probate is a court process by which title to a deceased's property is changed and creditors of the estate--in this case, Medicaid--can get their claims satisfied. This property may include real property not in joint tenancy with survivorship, vehicles and equipment (however most states employ a simplified ownership change avoiding the courts), and noncorporate business ownership. Contractual arrangements of assets with beneficiary provisions are not subject to probate and might include: life insurance death benefits, IRA's, 401(k)s, profit sharing, deferred annuities, trusts, and bank accounts or securities with written provisions that transfer assets at death. Also, property held as joint tenancy with rights of survivorship, transfers to the living tenant(s) at death, avoiding probate. It should be noted that even though many of the cash accounts listed above are not subject to probate they are subject to Medicaid resource spend down requirements and transfer lookback rules. Also, any assets retained by the community spouse under resource protection standards are not subject to her husband's Medicaid estate recovery. This boils down the list of nonprobate assets, not subject to spend down or estate recovery to: joint tenancy, trusts, community spouse protected resources, life insurance and retirement contracts such as IRA's, 401(k)'s etc..
Based on the lists above, about the only assets Medicaid might commonly claim for recovery would be a home or land held solely in the name of the deceased or the deceased's spouse when she dies. If the surviving spouse sets up a trust or joint tenancy with a family member prior to her death or the Medicaid beneficiary does the same, Medicaid would have no claim on the property. Or transferring assets to an income annuity would also avoid probate. An income annuity works this way: all liquid assets must be spent down; and transferred assets are subject to lookback rules, but an income annuity simply converts those assets to income which then falls under Medicaid income rules and helps pay for Medicaid costs. In the case of income annuities, the probate avoidance process exempts any residual value in the annuity at the death of the annuitant which could then pass to heirs, avoiding estate recovery.
Congress recognized the flaw in just limiting recovery to probate and so the 1993 legislation for estate recovery allowed the States, at their discretion, to expand their definition of estate to include the other nonprobate assets listed. In addition, allowance was made for States to place a lien against real property preventing a sale until the lien is satisfied. These are called TEFRA liens after the law authorizing them. Most States, probably for political reasons, have not been enthusiastic about estate recovery so only a few States have an expanded definition of probate estate and less than a third of States do TEFRA liens. Only a handful of states have expanded their estate definitions to go after such assets as funded trusts, joint tenancy property, life insurance proceeds or residual annuity value.
Congress also recognized the dire effects of encumbering a farm or business with the additional financial burden of recovery, thus jeopardizing the ability of children or siblings to make a living. Also considered were the effects a lien may have on the use of property by spouses, siblings and dependent children. As a result, provisions were included which gave the states authority to exempt property where recovery might cause undue hardship. A number of protective exemptions were also granted in the use of liens. Finally, States were allowed to exempt property below a state-established minimum value.
The chart below was derived from a North Carolina Department of Health and Human Services survey. The survey was done in 1997-1998 by intern Beth Kidder under the direction of Susan Harmuth. An attempt was made to see how other states are fairing with estate recovery. Data are from 1997. It's interesting to note that four years after OBR 93, the mandatory Federal enabling legislation, four states--Alaska, Georgia, Texas and Michigan--still had no recovery program. It's also interesting to note the total recovery rate for all responding states of 0.26% of all 1997 Medicaid expenditures. That's virtually a drop in the bucket. Either there are very few assets available for recovery or the States are doing a poor job or both. However, at the time of the survey, about 16 states were considering strengthening their programs. Click Here for the Full text of the Survey
Table of State Medicaid Estate Recovery Programs
(1) Type of Estate Recovery
(2) Assets Subject to Recovery--Assets the States, who have an expanded definition of probate, go after
(3) Use of TEFRA Liens
(4) Surviving Spouse Dependent in Home--State's procedure in going after a home when the surviving spouse lives there.
(5) Undue Hardship Criteria--Related to (4) above but these are State procedures towards going after all assets when it may cause undue hardship
The following information was copied from the New York site:
About the NYSPLTC
SAY THAT AGAIN?
WHY WAS THE PARTNERSHIP CREATED?
WHAT ARE THE BASIC BENEFITS?
WHY SHOULD I CONSIDER A POLICY?
WHERE DO I FIND THESE POLICIES?
WHAT IF I MOVE?
HOW MUCH DOES IT COST?
HOW CAN I FIND OUT MORE ABOUT THE PARTNERSHIP POLICIES?
HOW CAN I FIND OUT MORE ABOUT MEDICAID?
1. Call the state's toll-free hotline (inside New York State) and leave your name and address:
The Partnership also has won two regional awards since 1994. These include:
I am planning to move out of New York State. Can my Partnership policy cover me in other states?
Can I use Medicaid Extended Coverage in other states, including other Partnership states (Connecticut, Indiana, or California)?
I am planning to move to a non-Partnership state and have no plan to come back to New York. Is a Partnership policy good for me?
b) if you buy a non-Partnership policy, you must think about the issue of benefit duration. If you buy a traditional policy with a coverage term less than lifetime, you run the risk of paying out of pocket for any period of care beyond the coverage term. (For example, if you buy a 5-year coverage term and need a 7-year nursing home stay, you will be paying out of pocket for the last 2 years of care). Therefore, comprehensive long term care insurance coverage to protect you outside New York State would be a policy which includes a lifetime benefit duration, inflation protection and nursing home and home care benefits.
How can I tell if my insurance company is solvent?
I purchased a group long-term care insurance certificate through my company's group policy that is not a Partnership policy. Can I change it to a Partnership policy?
If a Partnership policy is not one of the purchase options available under the group contract, you cannot convert to a group Partnership policy. You might want to contact your benefits coordinator to ask about the future possibility of a Partnership policy offering under the group plan. You also might wish to contact your insurer about purchasing an individual Partnership policy. In general, however, you should not cancel any existing coverage you have before clarifying your situation and being approved for any new coverage for which you have applied.
As the owner of a Partnership insurance policy, am I able to receive care in any nursing home facility in New York State? In other words, do all nursing facilities accept Medicaid?
In addition, there are a few New York State nursing facilities which only accept Medicaid, or only accept Medicare. The Medicare-only facilities do not accept private payments or Medicaid; the Medicaid-only facilities would not be able to accept private insurance payments from Partnership participants.
Therefore, it is important for Partnership program participants to be knowledgeable about such circumstances when choosing the nursing facilities in which they wish to receive care. In other words, it is recommended that you know beforehand which methods of payment and/or reimbursement are accepted by a particular nursing facility in order to make an informed decision about your care.
Copyright © 1998-2002 New York State Partnership for Long Term Care. All rights reserved.
Medicare and Medicaid Long-Term Care Test Programs for The Aged
Social Health Maintenance Organizations (S/HMO)
Current S/HMO Sites
* Kaiser Permanente, Portland Oregon
* SCAN, Long Beach California
* Elderplan, Brooklyn, New York
* Health Plan of Nevada, Las Vegas, Nevada
Program of All Inclusive Care for the Elderly (PACE)
* Be at least 55 years of age.
* Live in the PACE service area.
* Be screened by a team of doctors, nurses, and other health professionals.
* Sign and agree to the terms of the enrollment agreements.
Generally, these services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need. This includes such services as medical specialists, laboratory and other diagnostic services, hospital and nursing home care.
An enrollee's need is determined by PACE's medical team of care providers. PACE teams include:
* Primary care physicians and nurses.
* Physical, occupational, and recreational therapists.
* Social workers.
* Personal care attendants.
Generally, the PACE team has daily contact with their enrollees. This helps them to detect subtle changes in their enrollee's condition and they can react quickly to changing medical, functional, and psycho-social problems.
Persons enrolled in PACE also may have to pay a monthly premium, depending on their eligibility for Medicare and Medicaid.