Applying for Medicaid? Order the PAS early

“You have to get a PAS.” This is a cryptic statement frequently made to the families of patients who will be discharged from hospitals to sub-acute facilities for skilled nursing or rehabilitation care.  If someone is entering a sub-acute facility and may become financially eligible for Medicaid within 180 days, the receiving facility is obligated by state regulations to order a PAS for their patient. If a person is entering a nursing home directly from home, and may become Medicaid-eligible or is already financially eligible, the facility will typically require them to “get a PAS” before agreeing to provide a bed for them.

What is this mysterious thing? It refers to the clinical assessment called the Pre-Admission Screening that must be performed by a nurse from the Office of Community Choice Options (OCCO) to confirm that a potential Medicaid applicant meets the medical/clinical criteria to receive Medicaid services. Once the request is filed with OCCO, a “PAS-nurse” is assigned to go see the patient and perform the assessment to see if s/he is dependent in three or more Activities of Daily Living (ADL’s) and thus “meets nursing home level of care.” Once the PAS is issued, it is good for 6 months so that it will be applicable when the person becomes financially eligible for Medicaid. You can read the regulations at N.J.A.C.10:54-7.7 and N.J.A.C. 8:85-1.8: 105477 PASRR and PAS Screens – Necessity for nursing facility services 885-18 Pre-Admission Screening (PAS) admission and authorization

The law requires this assessment to be done within 30 days of receipt of the request. However, I was just informed by the business administrator of an Essex County nursing home that — at least in Essex — it is taking 3 to 4 months for the assessment to be done because there is an abundance of requests and perhaps a shortage of personnel. I have seen this problem in other counties as well.

The trap is that until a PAS is issued, a person cannot receive Medicaid benefits even if they are financially eligible.

So the legal news you can use is that you need to make sure that the PAS is ordered as early as possible if you anticipate Medicaid eligibility or nursing home placement within 6 months. Then stay on top of the process and do your best to advocate for the applicant’s medical & nursing needs so that the PAS is issued.

For legal advice on all aspects of clinical and financial Medicaid eligibility, preparation of applications and representation on appeals, call us at 732-382-6070.

Baby Boomers looking ahead: long term care insurance or Medicaid?

There’s no doubt about it, long-term care insurance is expensive, and the premiums can be steep if you wait until after age 70 to first buy a policy. Some companies have gotten approvals for big premium increases on old policies. The marketplace has shrunk as companies have left the business, and some companies create bureaucratic barriers to paying claims. However, there’s also no doubt that nursing home care is expensive — in New Jersey it is not uncommon for the monthly costs to hit $12,000 to $14,000 a month. Hiring a live-in to help you at your home can cost $6,000 a month.  If there’s no money and no insurance, then Medicaid is the only source of payment.

The Baby Boomers and those starting to plan their retirement years have to think way ahead, as life expectancy is lengthening and therefore the statistical risk of needing long-term care in one’s 80’s is real. The Boston College Center for Retirement Research has interesting articles and useful statustics on this subject. Their recent research shows that more people are trending towards waiting to see what happens, and then embarking on a Medicaid spend-down plan, rather than purchasing long-term care insurance. The benefit is the savings in premium dollars, of course. The downside is that the state Medicaid program may only provide a complicated or inadequate home health aide program for people residing outside of nursing homes.

As I see it, the main benefit of long-term care insurance is the way it helps people age in place at home. To remain in the home in a “naturally occurring retirement community (NORC)”, a person needs to plan out their need for hands-on assistance, transportation, medical services, grocery shopping & food preparation, and attending social & cultural events,  If you have the means, insuring for long term care costs can make a big difference in how quickly you can get your home care started and in the administrative process that’s involved after that. Policies frequently  have a 90-day waiting period. This means that once you require hands-on home health care because you’ve become dependent in two or more of the Activities of Daily Living (ADL’s), you need to cover the cost of that care during the waiting period. Depending on the circumstances, this may not be a big financial burden, because many patients are tending to their own needs at home and it isn’t until they are hospitalized due to illness or injury that they begin to have care in the home. For those patients, they may receive skilled care or “rehab” during this initial waiting period, paid for by Medicare part A or their Medicare Choice plan.

For those without such insurance, the only way to obtain in-home care is to pay for it privately or apply for Medicaid when the assets are below the required level ($2,000 in available assets; the home is not counted; there can also be a share of assets reserved for the spouse). The application is filed after the applicant’s assets reach this level, and then the long wait begins , as the application is being processed.  However, New Jersey’s MLTSS Home and Community Based Services programs  have been undergoing a massive reorganization since 2013 with an apparent shortage of staff to fully and swiftly implement the program. Everyone hopes that the snags will be worked out soon. The law requires that the county welfare agency notify the applicant within 90 days if there is a reason the application can’t be approved. This is often the opening volley in a protracted experience. So based on past experience, I think that it is still likely to take a very long time for  the county welfare agencies to process and approve the many home care applications they receive under MLTSS.

Careful planning can prevent a crisis and improve your ability to direct the course of your care plan.

Call us about planning for a good old age… 732-382-6070


Schedule a Family Meeting before Leaving Rehab

If you have assisted a family member through a course of subacute rehabilitation (up to 100 days under Medicare Part A following a hospitalization), you are no doubt familiar with the process of the “family meeting.” This is a meeting at the facility attended by the members of the patient’s treatment team — the head of nursing, dietary, recreation, physical therapy, occupational therapy, speech therapy, and even the physician — where the patient and their family advocate discuss the goals that are in place for the patient, the progress being made, and the patient’s ongoing “skilled needs.” These meetings take place every few weeks during the skilled care/rehabilitation process.

Then there comes the day that the patient is advised that s/he will be discharged. Decisions have to be made quickly — is the patient staying in the facility for long term care? Is the patient going back to the community? If the patient is returning to the community, there may be a myriad of issues to address. Sometimes patients have multiple needs — the house may be inaccessible; they may need a companion in the home; they may be unable to prepare their own meals; they may have ongoing clinical problems that need specialized nursing attention; they may have behavioral disorders related to dementia which require special handling. Each patient has unique needs, and they may not be as capable as they were before this latest medical crisis.

When you are coordinating the discharge, the facility’s treatment team can be an invaluable source of information and suggestions.   Since home health aides for the basic activities of daily living (ADL’s) often must be hired privately — as generally the cost cannot be billed to Medicare —  family caregivers may be inclined to set up an informal casual volunteer arrangement rather than bring in many hours of professional hired help. However, the team at the facility may have an objective viewpoint on what is actually needed for a safe and successful return home, and this can be very useful to the family.

What are the questions to ask? Not just “can he come home?” Patients can usually go home if the proper supports are in place. You need to go well beyond the equipment that may be needed. Instead, try these concrete questions: 1.What do your aides have to do for him every day, starting when he wakes up? 2. Does he need physical assistance with showering, or just a shower stool to sit on and someone standing by? 3. Do you recommend that he have someone next to him while he is walking around? 4. Can he move his wheelchair around by himself? 5. Are there any special dietary issues we need to know about? 6. Does he get out of bed at night and try to walk around, or does he sleep through the night? 7. Do you think he needs to have an aide in the house throughout the night? 8. Does he ask for assistance, or just wait until someone comes in and asks him a question? 9. Does he eat his meal without someone assisting or prompting?  10. Do you have any thoughts on whether he can safely be left alone in the house?

Careful planning can prevent a crisis. Take advantage of the skills and knowledge of the rehab team to help you prepare for a good transition home.

 Contact us for legal advice and advocacy on a wide array of elder care issues, including participation in family meetings … (732) 382-6070