Medicaid or Medicare?
Medicare and Medicaid sound the same, but they are very different.
Few people realize the limitations of Medicare—which winds up costing them a substantial loss of dignity if or when they get hit with long term care expenses. Medicare is the federal health insurance program provided on behalf of persons who are over the age of 65, blind, and/or disabled. Medicare does not provide long term care benefits (nursing home care, for instance). Medicaid, which is a poverty health care program, pays for 50% of the nursing home care in America today.
Medicare only cares about short-term or “acute care” health care. Medicare only cares about your health care expenses if you can get well! Medicare does NOT provide care when a person is diagnosed with a long-term illness and needs nursing home care. Essentially, our senior citizen health care is based on a “diagnosis lottery.” If you are “lucky enough” to have a heart attack or diabetes, then you are covered by Medicare. You are out of luck if you are diagnosed with Alzheimer’s, Parkinson’s, Huntington’s disease, or anything else that lands you in a nursing home. If you need a nursing home and you are not impoverished, you are on your own dime!
Medicaid is the safety net for the impoverished. Once you become sufficiently impoverished, then Medicaid is designed to provide care for you. To qualify for Medicaid nursing home benefits you must be very ill and have no more than $2,000 total assets.
An elder law attorney knows the ins and outs of the public benefit system and can provide the client with solutions that help to fulfill the requirements of the law and still provide a better future for themselves or their loved ones. . If you want more information regarding a specific client situation, please contact us.
Nursing Home Contracts
DO include a list of charges for any items not included in the basic daily rate.
DO include a notice of the right to apply for Medicare and/or Medicaid and the right to appeal those decisions.
DO make sure the home’s “bedhold policy” is consistent with Medicare and Medicaid requirements.
DO make sure that the agreement provides that the resident can be forced to leave the home only if it is necessary for the resident’s welfare, the resident’s health has improved such that nursing home care is no longer required, the health or safety of other individuals is endangered, the resident unreasonably fails to pay, or the facility ceases to operate.
DO address how decisions will be made regarding moving the resident to a different room.
DO make sure your attorney reviews the contract before you or the resident signs it.
DON’T sign the contract as a guarantor or responsible party unless you intend to pay for the resident’s care.
DON’T agree to a limitation on the home’s liability in the event the resident is injured.
DON’T agree to a limitation on the home’s liability for the resident’s personal property.
DON’T include a provision requiring the resident to deposit all income directly into an account controlled by the nursing home.
DON’T agree to a requirement of private-pay status or other up-front money if a resident is eligible for Medicaid.
DON’T allow a clause restricting visiting hours.
DON’T include a provision requiring the applicant to consent to medical procedures, have a living will, or have a health care power of attorney.
Source: Findlaw.com
Finding and paying for in-home care
Most people that have long-term care needs want to stay in their homes. Services to keep and individual in their home are available from for-profit companies, local non-profits, churches, friends, and family members. Individuals that can privately pay for these services often have more choices than those who can’t. The local Area Agency on Aging is a good starting point when searching for services available from the community. In addition, professional care managers (geriatric care managers) are available to develop a plan of care based upon an individual’s ability to pay. The MI Choice program is designed exclusively for individuals who require nursing home level care but wish to remain in their own homes. The vast majority of those individuals that qualify for MI Choice reside in their own homes, in the home of a relative, or in assisted living facilities. To qualify for MI Choice, applicants must pass the same eligibility screen that is used for nursing home residents. Unfortunately, this program currently has a long waiting list.
Understanding Care Needs
Understanding the long-term care needs of individuals and the options designed to serve them requires familiarity with the concept of activities of daily living. Activities of daily living include activities such as toileting, eating, bathing, dressing, and transferring. Assessing an individuals’ ability to perform the activities of daily living is generally done by health care and social service providers. A sliding scale is used and a score is assigned based upon whether or not the individual can perform the task independently, with suggestion or supervision, with some assistance, or is totally dependent on caregivers to perform the task.
An evaluation of an individual’s abilities is often required for a claim for benefits under a long-term care insurance policy. In addition, to qualify for Medicaid nursing home benefits, an individual must be assessed on how well he/she can perform the activities of daily living. An individual who can independently perform the all the activities of daily living is not likely to be eligible for publicly funded long-term care services.
Dealing with Nursing Home Disputes
Anytime that you place a loved one in the care of others, there is always room for disagreement. Some disagreements are not much more than a difference in opinion or a misunderstanding, others are relatively severe and cause for demanding immediate action and turning to authorities for resolution. No matter how sensitive and caring the staff of a nursing home, nursing home staff and the senior or the senior’s family can develop a misunderstanding or a disagreement.
When significant problems arise, it’s often best to involve a geriatric care manager (GCM). A GCM will act as independent expert who can evaluate the conditions and disagreements in light of state and Federal laws, industry norms, and the specific needs of the senior. The GCM can also often act as a mediator to talk to the administrator of the facility in terms that they understand, with less emotion because they are not personally involved. Administrators know that the opinion of a GCM is important as an independent person, should the case ever have to be resolved in court. In short, nursing home administrators often attempt to work with a GCM when they would not with an irate family member.
Medicaid and Estate Recovery
A national Medicaid estate recovery program has been in effect for many years. Just recently, Michigan became the last state to adopt an estate recovery law. The law seeks to recover from the probate estate of those individuals that have received Medicaid benefits. Certain probate estate property is exempt. This includes property to which a hardship waiver applies, that portion of the property that is the primary income-producing asset of the survivors, and only a portion of the Medicaid recipient’s homestead.
To learn more about estate recovery, contact a competent elder law attorney.
Personal Care Contracts
A good way to reduce a parent’s countable assets when trying to qualify for Medicaid nursing home benefits is by having the child charge the parent for caregiving services provided. A child or other family member is permitted to contract with the parent to provide personal care to the parent. Such payments will help to deplete the parent’s countable assets without causing the imposition of a penalty. The payments must be considered reasonable and in line with the going rate for similar services provided by outside companies in the same area. The following guidelines should be followed for personal care contracts:
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Prepare a written contract prior to the delivery of the personal care services.
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Detail what types of services are included.
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Both parties to the contract should sign in front of witnesses and a notary
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A doctor’s note should be obtained indicating that the parent needs the services being provided in the contract.
