Will Medicare ever pay for nursing home care?

Consumers of health care in old age likely consider nursing home care to be part of the continuum of health care that a patient may require. Yet health insurance plans do not pay for nursing home care because it isn’t defined as “treatment.”  Instead, it is classified as long-term care rather than “health care,” because the care is maintaining the individual and not really treating-to-improve a chronic or permanent health condition.

The 2017 Long-Term Care trends poll of the Associated Press-NORC Center for Public Affairs Research Survey revealed that more than half of those polled believe that Medicare and health insurance companies should cover some or all of these costs and that the federal government should be doing more to provide financial support to those who are providing the care in the home setting. This was the survey’s finding among those who identified as Republican as well as those who identified as Democrat.

A bill to start addressing an aspect of this issue was introduced in Congress by Sen. Orrin G. Hatch, R-UT, and is S-870.— “Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017.” So far, the bill has been approved/passed by the full Senate. The Act  is designed to give some Medicare providers additional flexibility in the way they care for people with chronic conditions. This could be a first step toward including chronic, non-improving conditions in the category of “health conditions” for which Medicare dollars could be applied.  Co-sponsors include Ron Wyden (D-OR), Johnny Isakson (R-GA) and John Warner (D-VA). Read the legislation.

If this issue is of interest to you, contact your Representatives.

For advice and representation on nursing home care planning and challenges, contact us at …… 732-382-6070

CCRC Refund Bills are under consideration in NJ Legislature

When a person moves into a unit in a Continuing Care Retirement Community (CCRC),s/he is paying hundreds of thousands of dollars up front for the privilege of exclusively occupying a certain unit. There will also be  ongoing monthly service fees, and typically an extra fee if another person resides in the unit such as spouse or friend. The contract must contain explicit provisions explaining what the refund policy is for when the individual vacates the unit, whether that happens as a result of death or choosing to move out. The percentage to be refunded is related to the price paid for the unit, and generally there are a few choices in that regard. Also, the timing for release must be specified in the contract. Click HERE for the New Jersey consumer handbook on CCRCs.

The main problem people run into is that the refund is contingent upon the unit being re-leased to a new individual. At times when the market is very slow, this has caused extravagant delays which have an adverse impact on either the individual or the heirs of their Estate. Legislation was again introduced in the New Jersey legislature this session to try to put limits on how long a CCRC could hold back the release of the deposit. The bills would require the deposit to be refunded no later than 60 days after the unit is resold or one year from the date the individual vacates the unit, whichever is sooner. 

I think the bills should be supported. It it is imminently reasonable to put some frame around the refund process, because there are interests on both sides, and so far, it’s been one-sided. If this issue is of interest, spread the news to your colleagues and senior citizen social groups. Contact your legislators. The bills are S1411 and A880. 

Call for review of CCRC contracts, senior life care planning, and individualized long term plans … 732-382-6070

Tips on Residents’ Rights in Nursing Homes: Individualized Plan of Care Required

Once a person has moved into a nursing home, they are situated in a health care facility and receiving patient care, but they are also living there, and are therefore referred to as a “resident” rather than as a “patient.” The critical laws governing Residents’ Rights are the federal Nursing Home Reform Act, 42 USCS ‘ 1395i-3(b) and 42 CFR ‘ 483.10, and its state counterpart statute (N.J.S.A. 30:13-1 et seq.) and regulations.  It is plain that some of the rights contained in the law reflect privacy rights that pertain to a citizen no matter where he or she lives.

A nursing home is required to provide services for each resident in manner designed to preserve the resident’s dignity and to attain and maintain highest practicable physical, mental and psycho-social well-being of the individual resident based on his or her individual needs, and must abide by the Nursing Home Resident’s Rights Act, 42 USC 1395i-3(b), (c), 1396r; 42 CFR  483.10 et. seq., 483.12, 13, 15; 4.25, 483.30B; 483.60, 483.65, and 483.70; NJS 30:13-1 et. seq.; NJAC 8:39-4.1. For case discussions, see; In re Keri, (NJ Supreme Court. 2004); Profeta v. Dover Christian Nursing Home, (N.J. App. Div. 1983).

The federal regulations implementing the Nursing Home Reform Act, 42 CFR ‘ 483.12, requires the facility to develop an individualized plan of care that will maximize the well-being of the individual resident. Services must be provided without discrimination based on payor source. This means that the same level of service must be provided to the private pay resident as to the Medicaid recipient. Input from the resident, resident’s next of kin or fiduciary, and the attending physician and registered professional nurse responsible for the resident’s care should be obtained whenever possible. 42 USC 1395i-3(b)(2), 42 USC1396r(b)(2). An initial plan of care is developed and is then reviewed at regular intervals.

The resident has an enforceable right to have a specific level of care to maintain or assist the resident to perform daily living activities which include but are not limited to maintaining nutrition and hydration and avoiding accidents.  This means that if the resident cannot feed herself, the facility must include manual feeding in the personal plan of care. The facility cannot maintain that it’s too time-consuming to do so. Similarly, if the resident tends to try to get out of bed or walk on her own, the facility has to include safety arrangements such as higher supervision within her plan of care. The facility cannot insist that the family provide extra personal aides to deliver services that are needed to protect these residents’ rights.

 

Tips on Residents’ Rights in Nursing Homes: Bed Holds

The Federal Nursing Home Reform Act and New Jersey Nursing Home Residents Bill of Rights along with their regulations create numerous enforceable rights and protections for nursing home residents. Among these are the obligations to keep the bed available for certain amounts of time if a resident is temporarily out of the facility.

There are times that a resident must be transferred to a hospital or psychiatric facility. As part of the admissions agreement, and again at the time a patient transfers to a hospital or elsewhere for therapeutic treatment, the facility must provide specific written notice of all bed-hold procedures that would apply in situations where a patient was transferred elsewhere for care. 42 CFR 483.12(b)(1). That notice must explain exactly how long the nursing home will hold the resident’s bed open. At the time of an actual transfer, another notice must be given to the resident and a family member or representative about bed hold policies and the duration of the hold for that absence.

When a NJ resident is transferred to a general or psychiatric hospital, New Jersey regulations require that the nursing home hold the bed open for up to 10 days. NJAC 8:85-1.14(a)(1). If the resident is receiving Medicaid, then Medicaid pays for the bed-hold days at the per diem rate. If the resident is private pay, the days are billed to the resident at the customary rate. If the resident stays away longer than the 10 days, the resident will receive the next available bed. NJAC 8:85-1.14(a)(3). If a physician certifies that the resident requires a “therapeutic leave” for rehabilitative home and community visits, the bed hold protections cover up to 24 such days out of the facility per year, separate and apart from the 10 bed-hold days for hospital care. . NJAC 8:85-1.14(b)(1) – (3). For Medicaid recipients, if the resident requires more than 24 days therapeutic leave in one calendar year, authorization can be sought from NJ DMAHS to pay bed holds for additional days. NJAC  8:85-1.14(b)(6). Of course, a private pay resident can simply make arrangements with the facility to keep the bed available, and will pay the normal daily rate.

 

For contract review, advice and representation in selecting a nursing home, navigating the admission process, protecting residents’ rights, and evaluating payment options, call us at 732-382-6070