Those who accept Medicare as payment–meaning almost every hospital, almost every nursing home and most doctors and rehab specialists in the country–sometimes worry about being audited. Their records can be checked a year or so after they have billed for services, and been paid, for services. It might make an administrative person with such providers anxious–what if they have to pay back something to Medicare, after all?
Audits are smart and help reduce error and fraud. But if providers over-react and become too cautious because of audits those who use Medicare can suffer. This is so because for a long time an informal and improper metric has been used by providers, and the metric puts Medicare users at a real disadvantage.
Watch out for these old terms, still used at times now: “failure to improve” or “plateau.” Those terms have been used informally for a long time. You might hear it even now when you are trying to see about services for a loved one who has Medicare coverage. Coverage denials based on that alone are improper and unfair.
Those on Medicare who want more therapy or services, in hopes of maintaining some small part of their health or abilities, or better levels of care that might let them return home, have been often told by facilities or providers that Medicare wouldn’t help reimburse or pay for such services. Scary stuff, as many seniors would find it tough to pay for much in the way of such services themselves for more than a few weeks.
Medicare does not provide unlimited coverage, as we know. But be prepared to challenge some denials of care coverage if it seems proper. Remember, the “failure to improve” or the “he/she’s reached a plateau” is not the right metric. Actually under the regulation and law, maintaining a patient’s current condition or preventing or slowing a patient’s further decline or deterioration is a sufficient reason to obtain services.
Feel free to gently push back against providers if you are given this line, or call an elder law firm like ours to review the situation.
Rather than writing a full dissertation though, I suggest folks check this website–a feisty group sued (the case is Jimmo v Siebelius) to get clarification of this issue to help the aged and disabled, and here is their question and answer page about the issue: http://www.medicareadvocacy.org/jimmo-v-sebelius-the-improvement-standard-case-faqs/
In the world of health care and assistance, terms can make a difference. And in the nursing home setting or settings akin to a nursing home, one will eventually hear terms like “skilled care” or “custodial care.”
When a loved one needs help in a nursing home, or sometimes their own home, these distinctions can play a role in the services delivered, and the willingness of various systems or insurances, to pay!
Sometimes nursing home staff or doctors will suggest your loved one will only need or benefit from custodial care, whereas you may think that skilled care would help them maintain their current health or possibly improve their current health.
The amount Medicare or long term care insurers or others will pay for skilled services versus custodial services vary too–in fact some will only pay for skilled services and not custodial services–so if you have a hassle with these issues, that you cannot quickly resolve, you might want to check with an elder law attorney too. Don’t be afraid to find an advocate or be an advocate yourself…sometimes nursing home staff or doctors will suggest your loved one will only need or benefit from custodial care, when more care or services–skilled care–services are warranted.
Have a look at the quick graphic or explanation published by the feds here: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/infograph-CustodialCarevsSkilledCare-[March-2016].pdf
My 89 year old father was in Florida, in a hospital for a few days, before hospice care had been elected.
When some health problems had piled up on him before, he typically still had his wits about him, even if frail, and could communicate. Up until 10 days before his death in late 2010, my dad, a former Marine stationed in the Pacific during WW II, and former plumber and heater contractor for decades, often did a few crossword puzzles a day. And my father wasn’t adverse to taking action when called for, to be in charge of his own life–in fact once at a youthful 83 or so, he left a hospital against medical advice, pulling out the various “iv’s” getting dressed and walking out of a hospital and saying “enough of this, I’m going home” (or more colorful words to that effect that I won’t quote here).
But he wasn’t able to communicate much of anything, in this very last week of his life, in 2010. He had care more or less 24/7 in the hospital just before hospice was chosen, and a wonderfully sweet care attendant was helping to spoon feed him breakfast. One of the items she was feeding him was oatmeal. My dad really hadn’t said anything coherent to us for a few days now, his mumbling or tormented statements seemed a bit like “word salad” to us. We couldn’t really understand him.
But at that moment in a hospital room in Fort Myers Florida, my dad said, as the aide dutifully tried feeding him: “I hate oatmeal.” Many of us kids were in the room, some of my siblings and even in-laws, and many of us had taken up jobs and roles in helping my dad stay at home as long as humanly possible. I was very certain of his medical wishes, his thoughts on treatment, as well as when medical treatments could end, and we all knew that he was less energized at the tail end of his life, having lost his wife of more than 44 years (a second marriage) almost 4 years previous.
I knew a lot about my dad, and his wishes, and his finances, but I didn’t know my dad didn’t like oatmeal.
I knew where he kept investments, knew where he banked, had a rough idea of the value of his home (we kids had been urging him to sell his place and move in with one of us or to an assisted living place or a senior apartment for almost a year–another story for another day–let’s just say he only reluctantly agreed to that idea in concept and only on the last few months of his life), knew what special things he wanted allocated and to whom, knew what some of his favorite meals were, knew which bills he paid regularly, but I had no clue he hated oatmeal. But perhaps I should have.
Given how long many of us are living now, and given the medical interventions that might allow us to live longer, even with some tough medical conditions that might have killed us in earlier eras, it might be smart for all of us to also leave a bit of values/quality of life statement around.
After all, most all the legal things that attorneys suggest we get in place, such as a medical power of attorney, a durable power of attorney for finances, and documents that come into play largely after we die, such as a trust, or especially a will, leave instructions. And by their crafting, such documents might provide a hint of our values or speak to the quality and dignity of our lives, even if we can’t.
But far and away, these documents don’t typically speak much to what is also important. What kind of music or food do we love, what colors please us, what we’d want on a desert island or, were we reduced to a single room in an assisted living facility, what stick of furniture or piece of artwork, or photographs do we treasure, and should be brought along? What visitors would we be happy to see, or conversely, which folks would we rather not have around again? What religious traditions did we grow up with, if any–and what religion do we now embrace or eschew? What clothing do we like to wear if the choice is ours? How do we see ourselves?
If our life “shrinks” some or our independence fades, and perhaps we become more dependent upon others, will those who care for us know these things? And particularly if we no longer (or never) have a spouse around, nor kids, how will this knowledge–how will these small but important things–ever be noted?
At our office, we don’t make a big production of this, but we do encourage, folks to think about this–using a one page (2-sided) document as a cheat sheet. We encourage clients to jot down some notes about these sort of things. We want the folks who might care for you if and when you are disabled, to know just a bit more about you than a legal document or medical chart might convey.
As we tend to live longer these days, there could well be a time when life “shrinks” for us, or communication or control of some aspects of our life fades or is transferred to others. And we think it only right that those others have a clue about you. We want folks to know what you like and hold dear, and we want them to know whether or not you hate oatmeal. Remember, there may come a time when our caregivers don’t know us personally, and won’t really know much about us, know much about our values and likes and dislikes. A little document like this, informal as it may be, might be a good thing, and add to our quality of life as we go forward.
At the law offices of Bradley Vauter & Associates, P.C. we often help address the very human and personal parts of our life, parts that intersect with the law. Should you have any questions and want to set up an appointment for your own new (or updated) estate planning, or if you’d simply like to request the loves/values/life document we give out, feel free to call us at 517 853-8015, or write us at Bradley Vauter & Associates, P.C., 912 Charlevoix Dr. Ste. 120, Grand Ledge, MI 48837.
How do you cover nursing home bills, which can run from $7500 to $9000 a month in Michigan, and average about $8200?
If you are old enough, or younger and on disability, there is a good chance Medicare will help–but Medicare typically only covers 100 days if you require skilled nursing or rehab–and afterwards people need to find other ways to cover the bill. In addition, Medicare seldom if ever pays for what is called custodial nursing care.
Privately paying by using your monthly income and dipping into saving is a typical approach. But even some who think they have salted away enough for retirement realize they might quickly deplete their savings. And while a few folks have good long term care policies in place, most experts say the percentage of folks with such coverage is low–very low–perhaps five per cent or less of us.
This means that many middle class individuals and lower income individuals will turn to Medicaid to help pay a part of the nursing home bill. Medicaid is a program that comes together through Federal and State resources, and it can help pay for a number of medical services, including nursing home services (and nursing home type services arranged so that a person can stay in their own home). Medicaid can also pay for simpler custodial care nursing home services–a level of service that is not covered by Medicare.
Medicaid however is a means tested program, and to qualify, not only must you have medical needs, but you must qualify by way of income and assets. (Medicare really is provided regardless of our resources. But not so Medicaid.) Medicaid rules and regulations change from time to time, and some of the allowable resources or assets one may keep, and still qualify, are adjusted for inflation. As a practical matter, most of the planning to become eligible for Medicaid assistance is done for a married couple, where only one of them needs nursing home care. We work to make sure the community spouse doesn’t go broke while still providing proper care for the spouse who needs nursing home care. That said, even single persons may have some chance to qualify before becoming dead broke.
We help families review their entire situation, and working within the constraints of the program, analyze their assets and income, separate out the exempt assets (assets that won’t “count against” a person becoming eligible for assistance) and then work to speed their eligibility if they might seem to be over assets or if they may have given away assets within the 5 years before application. Another matter we look into is income–while typically a person getting nursing home type Medicaid must turn over their income first, to the nursing home, and Medicaid picks up the deficiency, there might be a chance to give some of the income to the community spouse instead. We also work to preserve their homestead as allowed by the program, if they desire, and we also see if other program regulations might work in their favor.
It can get complicated, as you might guess. particularly when there are even more wrinkles in the program that allow other opportunities to help others in the family.
But our firm, like other elder law attorneys, have developed some tools we can apply depending on the individual situation–and since thousands of dollars might be at stake, it might be worth exploring this with us. Pre-planning and Medicaid crisis planning both crop up.
These following terms may not be familiar to you, but they cover some of the asset or income limitations or easy protections allowed under Medicaid. Remember, these figures do change, but as of July 1, 2017, for Michigan’s Medicaid program, we work with the following numbers:
Monthly Divestment Penalty Divisor: $8,018.00
Individual Resource Allowance: $2,000.00
Minimum Community Spouse Resource Allowance: $24,180.00
Maximum Community Spouse Resource Allowance: $120,900.00
Minimum Monthly Income Allowance (spouse at home): $2,030.00
Maximum Monthly Income Allowance ” $3,023.00
Personal Needs Allowance per Month: $60.00