Department of Public Health Survey on Health Needs for People with Disabilities
May 20, 2013
The Elderly & Special Needs Patients and the Fiscal Cliff
January 9, 2013
In all the fiscal cliff nonsense of the last few weeks, here are a few provisions that affect the elderly and the disabled:
1. Remember how doctors were being threatened with a 27% pay cut for their Medicare patients? That threat went away. For a year. Set your clocks now for December 2013 when we get to watch this debate all over again.
2. Extension of the Medicaid payment of the Medicare Part B deductible for low-income folks. That’s the $99.90 that is deducted from your Social Security check every month. For low-income folks, Medicaid picks up payment for Medicare Part B. That was threatened to disappear. It’s been saved… until December 2013, anyway.
3. CLASS has officially been repealed. This was Ted Kennedy’s project, it was the first national response to our long-term care funding crisis. Lots of folks didn’t like it right from the beginning. Now it’s gone, and so far we still don’t have a national agreement on where we stand as a society on providing for long-term care.
4. Creation of the Commission on Long-Term Care. This outfit is supposed to develop recommendations for a national approach to establishing, implementing,and financing a long-term care system that establishes quality long-term care and supports. American history is littered with study groups whose recommendations and good work are ignored by Congress (sometimes for the good). We will wait to see who is appointed to this commission before we can predict whether their recommendations will be thoughtful and balanced or stilted in one direction. If the Commission is to be staffed in the thoughtful and balanced direction, then I expect that NAELA will advocate to have one of our knowledgeable thought leaders involved.
The Nursing Home Stopped Medicare Payments Because my Loved One Stopped Improving, but I Heard that’s Illegal
January 3, 2013
For many years, Medicare has stopped paying for therapies or skilled care once the patient stopped improving, or plateaud. This is not what the regulations say, but somehow that became the practice across the country.
In December, the good folks at the Medicare Advocacy Project fought and won against this trend, and a federal judge ordered that nursing homes must now provide the full 100 days of coverage that patients are entitled to, so long as they need skilled care or therapies, whether to improve, to maintain their conditions, or to stop or slow a deterioration.
So what happens to patients who have received Medicare denials in the past few years, and had to pay out-of-pocket, often impoverishing themselves, so that they (or a loved one) could receive continued nursing home care? Will this federal case help them?
Yes. Denials going back as far as September 20, 2010 can be re-reviewed under the new (old) standard. So if you or a loved one were in a nursing home in the late summer of 2010 or later, and if you had to pay out-of-pocket for skilled care or therapies after a Medicare denial, then dig out your paperwork. As the federal case is implemented, Medicare will create a process for re-reviewing these denials in light of the new (old) standard. Check the Medicare Advocacy Project for updates on this process.
If you have a loved one currently in a nursing home and they receive a Medicare denial, if you think they need continuing skilled care or therapies in order to maintain their condition or to stop or slow their deterioration, then appeal. It will take some time for the appeal process to get up and running, but you want to make sure you appeal on time.
P.S. These rules also apply to home care and outpatient therapies.
Has the Nursing Home Told You that Medicare Coverage is Ending Because the Patient is No Longer “Improving”?
December 27, 2012
Every day, families of nursing home patients are told that Medicare coverage will be ending in a day or two, because the patient is no longer “improving.” Well, that has never been what the Medicare regulations say, but somehow, that has become the common practice across the country.
The good folks at the Medicare Advocacy Project brought these infractions to court and won. A federal judge in Vermont, whose order applies to the whole country, clarifies that nursing homes can no longer cut off Medicare just because a patient has “plateaued.”
Instead, the (old) new law is: so long as the patient needs skilled care, whether to improve, maintain her condition, or prevent or slow deterioration of her condition, she is entitled to Medicare payment for up to 100 days. Period. Looked at another way, if the patient needs skilled care on a daily basis, or if she needs physical, occupational, or speech therapy five days per week, then she is entitled to Medicare coverage for the full 100 days.
The doctor is the most important person for you to work with. If she agrees that the patient needs daily skilled care or therapies, then a written statement from her will help you win the full 100 days of Medicare coverage.
See here for a further understanding of the end of the “improvement standard,” and then review the self-help packets. These are straight-forward, easy to read packets that will help you explain to the nursing home administrator that the rules have changed (many of them haven’t heard yet), so that she will feel comfortable submitting the claim to Medicare and continuing the patient’s coverage.
P.S. These rules also apply to home care and outpatient therapy, as well.
Thank you, Medicare Advocacy Project!
More Fast Track Compassionate Care Allowances Added to Social Security Disability
December 19, 2012
Long-Term Care Insurance Tax Deductions
December 3, 2012
Thinking about long-term care insurance (LTCI)? Hesitant because it is expensive? Did you know that you might be able to deduct some of the premium on your taxes?
If you are an itemizer, then you can take deductions as follows (2013 figures):
|Attained age in tax year||Limitation on premiums|
|Age 40 or less||$360|
|Age 41 – 50||$680|
|Age 51 – 60||$1,360|
|Age 61 – 70||$3,640|
|Age 71 and older||$4,550|
Not an itemizer? You still can get a break – if all of your medical expenses, including LTCI premiums, exceed 7.5% of AGI, then you can claim a deduction on the portion of your medical expenses exceeding 7.5%.
So when you are looking at a LTCI quote, keep in mind that the actual cost to you may be a bit less than the annual premium.
And of course if you already have LTCI, make sure your CPA knows that you have it and how much you pay in annual premiums.
I Want to Give My Children More Than $13,000 Per Year but Then Something-or-Other Happens with My Taxes.
November 14, 2012
Yes and no. As with many areas where money and law intersect, it all depends on your goal. Let’s clear up a few things.
1. What is the $13,000 rule anyway? You can give up to $13,000 per person, anyone, not just your family, per year, without paying any gift taxes and without this affecting your estate taxes when you die. In other words, you can give up to $13,000 per person with no gift tax or estate tax implications. You can also give away more than $13,000, but just be sure to talk to your CPA about whether that would be a good idea for you. P.S. That figure is set to rise to $14,000 in 2013.
2. But are you really in a position to give money away? It costs a lot of money to get old in this country. As you age, if you want to stay at home or maybe move to assisted living but stay out of a nursing home, then you will need to use your own savings for your care. I can help you explore veterans’ benefits and MassHealth benefits for non-nursing home care, but even with these you will need to rely on your own savings. I am not a big fan of parents gifting money to kids. Keep your money. You will need it to stay out of a nursing home.
3. Doesn’t Medicaid let me give $13,000 to each of my kids and then get nursing home care? No. The $13,000 gift rule and the Medicaid nursing home rules have absolutely nothing to do with each other and were written for entirely different populations. If you gift money to your family and then within the next five years ask Medicaid (MassHealth) to pay your nursing home bill, they won’t. Even if you have a history of giving money to your children, as you age you need to reconsider this. Perhaps this is the year to tell your kids that the gifts will stop coming. If you feel a bit guilty about this, keep in mind that by keeping your savings intact, then down the road you will be in a position to hire help, making things a little bit easier for your kids.
Another Good Reason to Buy Long-Term Care Insurance
November 1, 2012
I talk to a lot of my clients about buying long-term care insurance (LTCI). Many people come to my office asking about “nursing home planning” – how to make sure they don’t use up all of their savings if they end up in a nursing home. And my response is always, “Your nursing home planning is to stay out of a nursing home.” And one key piece to keeping people in their homes with care, and out of the nursing home, is to have LTCI.
After seven long years of advocacy by MassNAELA (that’s the Massachusetts Chapter of the National Academy of Elder Law Attorneys), yesterday Governor Patrick signed a bill that makes LTCI an even better bet for seniors.
Until now, if seniors were lucky enough to have LTCI, they could of course use the policy to pay for care in their homes. But – they’ve had to keep a careful eye on how much of the policy they were using up at home. When home care is no longer medically viable, and the senior needs to go to the nursing home, then the LTCI would protect the value of their home from the cost of nursing home care – but only if they entered the nursing home with a certain amount of money still in the policy. This had the effect of either (1) forcing seniors to leave their homes before they wanted to, or (2) staying at home longer and using up the policy benefits, finally going to nursing home, and losing the house to the cost of nursing home care.
Now things will be different – and better. If a senior has a LTCI policy that meets MassHealth standards at the time of purchase, then she can use as much of that policy as she wants to stay in her own home for as long as she safely can. Then, if she ever needs to move to a nursing home, no matter how little benefit is left in the policy, her home will still be sheltered from the cost of nursing home care. This will help seniors stay at home longer, and will keep MassHealth’s costs down. A win-win for seniors and MassHealth.
Alzheimer’s Caregiver Conference Nov. 10
Medicare Long-Term Care Payment Structure Changing
October 23, 2012
Medicare payment structure will be changing. Historically, even though Medicare is supposed to pay for anyone needing skilled care, they’ve been cutting patients off when they “plateau” – so if therapy is no longer going to help you improve, Medicare stops paying (even though their regulations say otherwise). Now, this class-action law suit out of Vermont will change things. Medicare will pay for people who need skilled care (just like their regulations say) regardless of whether the patient is actually improving. This is huge news for elders and disabled individuals who need long-term skilled care. Very exciting stuff. Stay tuned for implementation.
Settlement Eases Rules for Some Medicare Patients
Published: October 22, 2012
Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is expected to improve.
Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.
Judith A. Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for the beneficiaries, said the proposed settlement could help people with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury. It could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care.
“As the population ages and people live longer with chronic and long-term conditions,” Ms. Stein said, “the government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people.”
In many cases, she said, the denial of coverage led to a denial of care because most people cannot afford to pay for these services on their own.
Neither she nor Medicare officials could say how much the settlement might cost the government, but the price of expanding such coverage could be substantial.
Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, called the settlement “a landmark decision for Medicare recipients with chronic illness and especially those with disability.”
“Disability frequently accompanies many chronic conditions,” Dr. Gerber said, “and we often have no cures, so people are likely to experience progressive disability. Rehabilitation, physical and occupational therapy and skilled care are incredibly important in maintaining a person’s functional ability, performance and quality of life.”
The lead plaintiff, Glenda R. Jimmo, 76, of Bristol, Vt., has been blind since childhood. Her right leg was amputated below the knee because of blood circulation problems related to diabetes, and she is in a wheelchair. She received visits from nurses and home health aides who provided wound care and other treatment, but Medicare denied coverage for those services, saying her condition was unlikely to improve.
Another plaintiff, Rosalie J. Berkowitz, 81, of Stamford, Conn., has multiple sclerosis, but Medicare denied coverage for home health visits and physical therapy, on the ground that her condition was not improving. Her family said she would have to go into a nursing home if Medicare did not cover the services.
The proposed settlement, negotiated with lawyers from the Justice Department and the Department of Health and Human Services, was submitted last week to Christina C. Reiss, the chief judge of the Federal District Court in Vermont. If she approves it, as expected, she would have authority to enforce it for up to four years.
Asked about the proposed settlement, Robert D. Reischauer, a public trustee of the Medicare program, said: “Unquestionably that would increase costs. How much, I can’t say.” Other independent experts expressed similar views.
While the settlement is likely to generate additional costs for the government, it might save some money too. For example, physical therapy and home health care might allow some people to avoid more expensive care in hospitals and nursing homes.
Charles S. Miller, a Justice Department spokesman, and Erin Shields Britt, a spokeswoman for the Health and Human Services Department, said government lawyers had no comment.
The changes will apply to the traditional Medicare program and to private Medicare Advantage plans. They apply to people 65 and older, as well as to people under 65 who qualify for Medicare because of disabilities.
The Obama administration initially urged the judge to dismiss the lawsuit. Medicare officials denied that they had a formal policy requiring beneficiaries to show their conditions would improve.
However, in a separate lawsuit in Pennsylvania, Medicare officials argued the reverse. In order for Medicare to cover skilled nursing care, they said in a legal brief, “there must be an expectation that the beneficiary’s condition will improve materially in a reasonable and generally predictable period of time.”
The same standard, in nearly identical language, is found in guidelines used by some Medicare contractors, which review and pay claims on behalf of the government. In a typical case, Medicare terminated coverage of skilled nursing care and physical therapy for an 81-year-old woman because she had “exhibited a decline in functional status.”
Under the settlement, the federal court in Vermont will certify a nationwide class of more than 10,000 Medicare beneficiaries whose claims for skilled nursing and therapy services were denied before Jan. 18, 2011, when the lawsuit was filed. Many of them will have an opportunity to have their claims re-examined under the revised standards.
Plaintiffs in the case include the National Multiple Sclerosis Society, the Parkinson’s Action Network, Paralyzed Veterans of America and the National Committee to Preserve Social Security and Medicare, an advocacy group.
Neither the Medicare law nor regulations require beneficiaries to show a likelihood of improvement. But some provisions of the Medicare manual and guidelines used by Medicare contractors establish more restrictive standards, which suggest coverage should be denied or terminated if a patient reaches a plateau or is not improving or is stable. In most cases, the contractors’ decisions denying coverage become the final decisions of the federal government.