New guide available for appeals of Medicaid Managed Care Decisions

Medicaid services are now provided through managed care organizations (MCO’s), which are required by federal law to provide a grievance and appeal process for the enrollees. An enrollee may be dissatisfied with the number of hours of service, or the services being provided, or a host of other issues. Three major nonprofits have collaborated on a new guide for advocates to help them in efforts to advocate for good regulations or to pursue these cases.

Justice in Aging , the Disability Rights Education and Defense Fund (DREDF), and National Health Law Program (NHeLP) have produced their ” Advocates Guide to Accessibility in Medicaid Managed Care Grievances, Appeals, and State Fair Hearing.” States are in the process of developing regulations and procedures on this issue, and the Guide is designed for those who are involved at any part of the process. You can download it through the website for Justice in Aging HERE.

The Guide provides useful general guidance on the typical procedures for these appeals. Of course, individual state laws will vary, and the guide doesn’t constitute legal advice that would apply to any particular case. If an adverse decision is received from an MCO, the individual must swiftly pursue the administrative remedies, as the appeal period is short, and it can be difficult to obtain waivers of that time limitation.

Contact us for representation on Medicaid eligibility or denials of services ……. 732-382-6070

NJ 2017-18 Budget Adds Funding for Medicaid Long-Term Care

After the Governor and the Assembly leader resolved their Fourth of July Weekend Budget Kerfuffle, some positivity came out of it for Medicaid long-term care providers and beneficiaries.

Nursing home reimbursements would be increased by $10.5 million, shifting funds from Managed Long-Term Services and Supports (MLTSS). This would be $5.25 million of state funds with an identical federal match. The funds would be distributed by a per diem adjustment based on the increase. Assisted living per diems would also see a moderate increase from $73.13 for assisted living facilities, $63.13 for comprehensive personal care homes and $53.13 for assisted living programs, to $75, $65 and $55 respectively.

The legislature’s budget would also increase the minimum monthly personal needs allowance (PNA) to $50, effective July 1st, 2017. It had been $35 for a very long time.  The PNA is the amount a resident can keep from his or her income to use for monthly personal needs.  This applies to persons residing in nursing homes, state or county psychiatric hospitals, and State Developmental Centers who are eligible for Medicaid or SSI benefits.  We are awaiting a MedComm (Medicaid policy memorandum issued by the NJ Division of Medical Assistance and Health Services) to provide guidance on implementation of this increase.

Trying to pay for nursing home care? Call us to find out the real options with Medicaid eligibility … 732-382-6070

Find your parents’ Long-Term Care Policies so you can help them plan

There is plenty of debate about the benefits and drawbacks of buying long-term care insurance.  The premiums are expensive for a person in their 70’s who is first considering a purchase. Potential buyers worry that they will pay premiums for years and never have to use the policy. The industry has been in flux and there aren’t too many carriers around. What I do know is that over the years, long-term care insurance policies have been a lifesaver for many of my clients, particularly if the policy pays for in-home care. The annual premium cost has always been well less than a single month in a nursing home. So LTC policies can be an important component of long-range planning for a person who will eventually enter what I like to call “the elder zone.”

All too often, the need for 24/7 care drops on the doorstep when there’s been no prior planning, and concerned family members are faced with making arrangements without any good information. Elsewhere on this Blog I’ve written about strategies such as assembling the team, compiling your financial & insurance data,  and getting legal help for an updated estate plan and power of attorney. Today I suggest that you dig out those long-term care policies from wherever they are being stashed, read them and get familiar with what the policies provide. Contact the company for an updated statement of benefits. What’s the daily rate? Compare that to the anticipated cost of care  in a nursing home ($350+ in most places) or at home ($165 /day or more). Ask questions about what it takes to start the typical 90-day elimination period — what documentation is required? Can it start when the patient enters the hospital if s/he will then transition to long-term care? Can it start if the patient has already had an in-home Aide who was paid off the books? Find out if premium payments can be switched to auto-debit from the checking account, to avoid the risk of lapse if the policy-owner starts forgetting to pay bills.

The Medicaid home care program under MLTSS/HCBS  does not provide 24/7 full-time care. Knowing what the benefits are in your parent’s  long term care insurance policy can make a huge difference in how you approach the discharge planning from hospital or “rehab” back home for senior planning. It may be the ticket to asset preservation.

Call us for advice about long-term care planning and asset protection for peace of mind …. 732-382-6070

The Special Needs trust is funded …. now what?

Funding a first party Special Needs Trust with alimony, an inheritance, or a personal injury settlement can preserve those assets for benefit of a person who is receiving or applying for means-tested government benefits such as SSI, DDD or Medicaid/MLTSS. There is quite a process to establish the trust and then fund it with these assets. But that’s just the beginning — not the end.

The person who receives these benefits has an affirmative obligation to notify the Agency when there is a change in assets or income. This duty still applies even though the assets that are held in a qualified Special Needs Trust are not counted as the person’s assets or income. This duty still applies even though the transfer of the person’s assets into the trust may be an exempt transfer. And this duty still applies even though a Court may have reviewed the trust and entered an order allowing the assets to be transferred to the trust.

If the person receiving the benefits has a Representative payee appointed for him/her by the Social Security Administration, the duty to report rests with the Rep. payee. If the Trust document meets all of the relevant criteria, benefits should continue or be approved, as the case may be. However if it turns out that the transaction or trust are defective, there may be wrongfully paid benefits and the representative payee and disabled person could be facing a demand for repayment years later.

What should be done? A copy of the fully executed trust and its EIN# paperwork should be promptly submitted to the agency for its review, along with the relevant court order and written verifications of the transfer and funding of the Trust, such as deposit slips and bank/brokerage statements for the trust. The Trustee should then maintain the account records on an ongoing basis as well as the receipts and copies of cancelled checks so that these verifications can be produced to the agency upon demand. If no response is received from the agency within a reasonable time of when the trust was submitted, the agency should be contacted.

The burden of proving and maintaining eligibility for public benefits rests with the recipient and the representative payee. Attending to these crucial steps can prevent problems down the road.

Call for advice on preparation, funding and administration of Special needs trusts … 732-382-6070.

 

Residence in Nursing Home not sufficient to defeat claim for Elective Share

The Medicaid program determines eligibility for a married applicant based on the amount of resources owned by the applicant and his spouse. If the community spouse dies first, the program will count as a resource the amount of assets that the surviving spouse is entitled to receive from the Estate to satisfy his claim for the “elective share.” If the individual fails to pursue his claim for the “elective share,” he may receive a transfer penalty for “giving away” the assets he should have received from the Estate. Alternatively, he may be deemed to have owned the amount of resources that he failed to seek. Also, the State imposes a lien against the estate of a deceased Medicaid beneficiary, and the lien attaches to all resources in which the individual had an interest at the time of death. One of the exceptions to having the right to claim an elective share is if the couple were living separate and apart at the time of the death under circumstances giving the deceased grounds for divorce.

The New Jersey Appellate Division has issued an opinion that examines many aspects of the claim for an elective share. Here is a pdf: Estate of Brown elective share case 2017.  Arthur Brown was married to Mary Brown. Arthur developed Alzheimers Disease and moved into Assisted Living. later he needed to move into a nursing home. He transferred his interest in the marital residence and other assets to his wife Mary and successfully applied for Medicaid benefits, which began in 2008. In 2010, Mary died, but Arthur did not claim the elective share and received no distribution from his wife’s Estate. The County Board of Social Services notified Arthur that it would impose a “transfer of assets penalty” on him and would discontinue benefits. One of Arthur’s positions was that at the time Mary died, they were living separate and apart and she would have had grounds for divorce due to his Alzheimers Disease. He pursued his appeals, and elected to have his Medicaid benefits continue during the appeal process. Arthur died in 2013 before the appeals were concluded. The State then imposed its lien, asserting that the amount of resources which would have comprised the elective share was subject to lien. That led to this case decision.

The case provides a detailed review of both the Medicaid lien statute as well as the issues involved with determining when the elective share applies. In particular, the Court held that there was no evidence that the marital relationship was disrupted or that either party had intended to seek divorce or initiated a complaint for divorce. Although the two of them had different residences, the presence of advanced Alzheimers Disease was not seen by the Court as proof in and of itself that grounds for divorce existed, so the Court agreed with the trial court Judge that allowing the exception to apply would create a broad risk that certain surviving spouses would be left with no support.

Every case is specific to its facts. Call us for advice on elective share claims and other Medicaid eligibility issues …….. 732-382-6070