WhoPaysforLong-TermCare?

PalisadesAllianceforSeniorsJanuary13,2020

CenterforHealthCareRights(CHCR)

§  A non-profit organization that provides information and help with Medicare and

Medi-Cal to Los Angeles County residents

§  Financial support for our services is provided by the California Department of Aging Health Insurance Counseling and Advocacy Program (HICAP) grant

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CenterforHealthCareRights(CHCR)

Call our telephone hotline 1-800-824-0780

Open Monday – Friday 8 am to 5 pm

Visit our web site www.healthcarerights.org C

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CHCRCanHelpYouUnderstand• Your Medicare benefits • Who is eligible for Medi-Cal • Health insurance options for supplementing

your Medicare: Medicare Advantage plans versus Medigap Insurance

• How to pick a Medicare Part D drug plan • Access financial assistance programs that

pay prescription expenses and Part B premiums

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CHCRCanHelpYouResolve• Medicare and Medi-Cal eligibility problems • Medicare claim or service denials •  Problems getting care in a Medicare Advantage

plan or Medi-Cal health plan • How to apply for Medi-Cal long term care •  Problems getting medical equipment covered by

Medicare

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WhatWeWillReviewToday

Ø What are long-term care services?

Ø Who pays for long-term care?

Ø Medicare and Medi-Cal coverage of long-term care

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WhatIsLong-TermCare?• Medical and non-medical care for people who

have a chronic illness or disability

• Many long-term care services are personal care services such as helping with bathing, feeding, dressing, walking, and medication supervision

• Personal care services are frequently defined

as “custodial” care

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Long-TermServicesandSupports(LTSS)Spending,byPayer,2016

Source:CongressionalResearchService,August2018

Center for Health Care Rights 2019

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Thepreviousslideshowsthatthemajorpayersof

long-termcareservicesare:

• Medicaid– 42%• Medicare– 22%• Outofpocketcostsbyconsumers–15%

Privatelongtermcareinsurancepaysfor7.5%of

longtermcarecosts

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MedicareCoverageofLong-TermCare

•  Medicare pays for long term care services under the Part A killed nursing facility (SNF) benefit and home health benefit.

•  To use Medicare SNF and home health benefits, you must need skilled nursing or therapy services and meet other requirements.

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MedicareSkilledNursingFacilityBenefit

• To qualify for the SNF benefit, the Medicare beneficiary must meet the following requirements:

ü Have a three-day prior hospital stay ü The SNF stay must be ordered by a

physician ü The SNF must be a Medicare provider ü The patient must need daily skilled nursing

or therapy services (five to seven days per week)

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MedicareSkilledNursingFacilityBenefit

• Examples of Medicare skilled services are: •  skilled nursing services, • physical therapy •  speech therapy • occupational therapy services

• Medicare pays for custodial care in a nursing home only when the beneficiary is using the Medicare SNF benefit and is getting daily skilled nursing/therapy services.

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MedicareSkilledNursingFacilityBenefit

� The Medicare skilled nursing facility benefit is the only nursing home care paid for by Medicare.

� Medicare pays for up to 100 SNF days per benefit period. A new benefit period starts when the beneficiary has been out of a hospital or has not received skilled care in a Medicare skilled nursing facility for at least 60 days.

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Days1-20 Coveredinfull

Days21-100 $170.50/day

MedicareHomeHealthBenefitServices covered include:

• Skilled nursing care • Physical, speech and occupational therapy • Medical social services • Home health aide services • Medical supplies and equipment

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To qualify for the Medicare home health benefit, the beneficiary must meet all four of the following requirements:

1.  The patient must need intermittent skilled nursing care, physical therapy or speech therapy;

2.  The patient must be homebound (have difficulty leaving his/her home due to a disability or illness);

3.  The patient’s doctor works with the home health agency to set up a plan of care; and

4.  The home health agency is a Medicare provider.

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• There are no copayments for Medicare

home health. • Medicare home health are provided on a

visitation basis and are not available for an indefinite period of time.

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MedicaidCoverageofLong-TermCare

• Medicaid is the major payer of long-term nursing home care in the United States.

• Medicaid also pays for community based

non-institutional long-term care such as adult day health care and the PACE Program for persons who meet Medicaid eligibility and other requirements.

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Medi-CalCalifornia’sMedicaidProgram

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Medi-CalBenefits

• Hospital care • Doctor services • Prescription drugs • Ambulance • Lab, x-rays • Emergency

services • Mental health • Substance abuse

services

•  Hearing aids •  Incontinence supplies •  Vision services •  Dental care •  Medical transportation •  Non-medical

transportation •  Long Term Services

and Supports •  Nursing home care •  Adult day health care

(CBAS) •  IHSS •  MSSP

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Medi-CalLongTermServicesandSupports

•  In-Home Supportive Services (IHSS) are personal care services for people who need help to live safely in their homes.

•  Community-Based Adult Services (CBAS) is daytime health care at centers that provide nursing, therapy, activities and meals for people with certain chronic health conditions.

•  Multipurpose Senior Services Program (MSSP) provides social and health care coordination services for people ages 65 and older.

•  Long-Term Care (LTC) and Skilled Nursing Facilities (SNF) provides medical, social, and personal care services in a nursing home. Most LTC services are provided in Skilled Nursing Facilities.

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2019Medi-CalLong-TermCareEligibilityRequirementsforNursingHomeCareEligibilityrulesforasinglepersonProperty/assetlimit: $2000• Propertycountedtowardthislimitincludescash,bankaccounts,retirementaccounts,stocks

• Propertynotcountedtowardthislimitincludes:Yourhome,personalbelongings,onecar,lifeinsurancewithfacevalueof$1500orless,burialplots.

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2019Medi-CalLong-TermCareEligibilityRequirementsMarriedCouple/SameSexSpousesandRegisteredDomesticPartners:

�  These eligibility rules apply when one spouse enters a nursing home and applies for Medi-Cal Long-Term Care and the other spouse remains at home.

Ø The spouse at home is allowed to keep up to

$126,420 in combined assets. The home is not counted toward this limit.

Ø The spouse at home is also allowed to keep up to $3161 in monthly income.

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Medi-CalLong-TermCare–EligibilityRequirements• Medi-Cal has a 30-month look back period

for eligibility. • A nursing home resident who gives away

resources or sells them below fair market value may be ineligible for Medi-Cal for a period of time.

• Before transferring assets, persons applying for Medi-Cal long-term care should seek legal advise from an elder law attorney with experience in Medi-Cal.

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EligibilityforMedi-CalIfYouLiveintheCommunityAgedandDisabledFederalPovertyLevel

Program(A&DFPL) 2019IncomeandResourceLimits Income Resources

SinglePerson $1271/month $2000MarriedCouple $1720/month $3000•  ProgramusesSSIresourcelimits•  ApplyforthisprogramatDPSSbymail,onlineorinperson

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Medi-CalCoverageofCareatHome–In-HomeSupportiveServices(IHSS)

• The In-Home Supportive Services (IHSS) Program helps pay for services provided to eligible persons who are 65 years of age or over, legally blind, or are disabled adults and children so they can remain safely in their own homes. C

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WhoIsEligibleforIHSS?

Ø Must be a California resident; Ø Must live at home; Ø Must be a United States citizen or legal

resident; Ø Must be eligible for Medi-Cal; Ø Personal property may not exceed $2,000

for a single person and $3,000 for a married couple.

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IHSS–ServicesAvailable

Ø Household chores such as house cleaning, laundry, meal preparation, food shopping and errands.

Ø Personal care services such as toileting, feeding, bathing, grooming, dressing, assistance walking, help in and out of bed and help with medication supervision.

Ø Accompaniment to medical appointments. Ø Protective supervision. C

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ApplyingforIHSS• Call or visit a county IHSS office to complete

an application. • Once IHSS has your application, a case

worker will be assigned to complete an in-home needs assessment to determine if you are eligible for IHSS.

• The case worker will ask questions about your mental and physical ability and limitations. This is done to determine what activities you can perform safely and what activities you need assistance.

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Medi-CalRulesonEstateClaimsØ Medi-Cal will seek repayment from Medi-Cal

members who received benefits on or after their 55th birthday and who own assets at the time of death.

Ø Repayment will be limited only to estate assets

subject to probate that were owned by the deceased member at the time of death.

Ø Repayment will be limited primarily to payments

made for Medi-Cal long term care services.

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FormoreinformationonMedi-Callongtermcareandnursinghomequestions

callCaliforniaAdvocatesforNursingHomeReform

(CANHR),aCaliforniahealthcareadvocacyorganizationthatspecializesinconsumernursing

homeadvocacyissuesat(800)474-1116orvisittheirwebsite

www.canhr.org.

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ForquestionsaboutMedicareorotherhealthinsurancecalltheCenterforHealthCareRights

at1-800-824-0780.

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