Author Archives: Administrator

What Is Survivors Pension with Aid and Attendance?

September 3, 2019

August 20, 2019 | by the National Care Planning Council

Survivor’s Pension – also known as Death Pension – is a disability income program available to the single surviving spouse and/or dependent children of a deceased veteran who served during a period of war.

Eligibility requirements for the deceased veteran include active duty service for at least 90 days – with one of those days during a period of war – and an honorable discharge or a discharge classified as other than dishonorable. Service in combat is not required. For deceased veterans of the Gulf War, the service requirement is 24 months or completion of the requirement for active duty service, whichever comes first.

Here is the Period of War chart for benefit purposes:

Period of War Beginning and Ending Dates
World War 2 December 7, 1941 through December 31, 1946
Korean Conflict June 27, 1950 through January 31, 1955
Vietnam Era August 5, 1964 through May 7, 1975; for veterans who served “in country” before August 5, 1964, February 28, 1961 through May 7, 1975
Gulf War August 2, 1990 through a date to be set by law or Presidential Proclamation

Definition of Surviving Spouse and Rules Pertaining to Application

The rules pertaining to application for Survivor’s Pension for a single surviving spouse – who was married to a veteran– are very much the same as the rules pertaining to application for Pension for a living veteran. There are, however, some minor but very important differences.

The single surviving spouse can be any age and does not have to be permanently and totally disabled prior to age 65. The veteran, who died, did not have to be totally disabled if death occurred before age 65. The veteran who died does have to qualify based on active duty service days as well as serving during a period of war.

Application should not be made unless it is certain that the surviving spouse meets the rules to be a surviving spouse. All of these following conditions must apply or the surviving spouse is not eligible for Death Pension:

  1. The surviving spouse must have met the conditions to be married under VA rules. Generally this means a marriage lasting at least one year or a child was born as a result of the marriage regardless of the length of time married. Under certain conditions, VA will also accept common-law marriages or marriages where the couple held themselves out to be married and can prove that was their intent.
  2. The surviving spouse must have lived continuously with the veteran while they were married unless they were separated due to the fault of the veteran. Evidence regarding such a separation will be required.
  3. The surviving spouse must have been married to the veteran when the veteran died. Divorcing the veteran while the veteran was alive bars any entitlement to this benefit.
  4. The surviving spouse cannot have remarried after the veteran ‘s death even if the surviving spouse is currently single. There is one exception to this rule. If the surviving spouse remarried after the veteran’s death and that marriage has been terminated either through death or divorce prior to November 1 of 1990 and the surviving spouse has since remained single, that person can still receive the benefit.

2019 Maximum Annual Survivor ‘s Pension Rates (MAPR)
Effective December 1, 2018 – 2.8% COLA Increase

If you are a surviving spouse…  

Annual

Monthly

MAPR Without Dependent Child

$9,078

$756

No dependents, medical expenses must exceed 5% of MAPR

$453

$38

MAPR With One Dependent Child

$11,881

$990

With dependents, medical expenses must exceed 5% of MAPR

$594

$50

Housebound Without Dependents

$11,095

$924

Housebound With One Dependent

$13,893

$1,157

A&A Without Dependents

$14,509

$1,209

A&A Without Dependents (SAW Veteran’s Surviving Spouse)

$15,097

$1,258

A&A With One Dependent

$17,309

$1,442

A&A With One Dependent (SAW Veteran’s Surviving Spouse)

$17,833

$1,486

SBP/MIW Annuity Limitation

$9,078

$756

Add for Each Additional Child

$2,313

$192

MAPR FOR CHILD ALONE

$2,313

$192

Child Earned Income Exclusion effective 1/1/2000

$7,200

$600

The Rating for Aid and Attendance

A Rating Allows for Special Deductions and Additional Income Allowances VA will provide additional income in the form of an allowance on top of the basic Survivor’s Pension benefit of $9078/year or $756/month if the widow has a regular medical (care) need for assistance or a need for supervision due to disability. This is sometimes called “Improved Survivor’s Pension” or “Survivor’s Pension with an allowance.”

A medical need for assistance or supervision due to disability is, in most cases, crucial to getting the Survivor’s Pension benefit or not getting it.  A so-called “rating” from VA recognizes either the regular need for aid and attendance from another entity or the condition of being housebound. This rating, determined by a doctor’s examination is determined from VA Form 21-2680, and allows certain medical and care expenses and ancillary non-medical expenses to be subtracted or deducted from future income.

A “rating” also increases the allowable Survivor’s Pension rate as seen above in the MAPR Chart. For example, a surviving spouse with no rating is only eligible for basic Survivor’s Pension, up to $756/month. If the same surviving spouse becomes unhealthy and proves a need for the ongoing aid and care of another individual, he or she would be eligible for up to $1209/month.

Except for very poor households, most widows could not get the Survivor’s Pension benefit without this special rating provision for the deduction of personal care and medical-related expenses simply because their income is too high.

The high cost of medical and medical-related expenses associated with long term care such as home care, assisted living or nursing home care are usually the main deductible expenses VA counts when calculating the benefit. A surviving spouse, for example, who is paying $3,000/month for care at assisted living and has income of $2,800/month would qualify for the full Survivor’s Pension benefit with the aid and attendance allowance of $1209/month IF that surviving spouse was “rated” for the need of aid and attendance of another person.

Unfortunately, very few of all eligible surviving spouses are actually receiving Survivor’s Pension. Most do not know of the benefit nor this special deduction.

How Survivor’s Pension Is Calculated

For Surviving Spouses without an “Aid and Attendance or Housebound Rating”,

VA calculates Survivor’s Pension Benefits as follows:

  1. Gross Household Income – Income Exclusions – Certain Ongoing Medical Expenses = Income for VA Purposes (IVAP). We will discuss Medical Expenses and IVAP below.
    Then,

2.  Applicable MAPR – (IVAP + 5% deductible) = Actual Benefit

For Surviving Spouses with an “Aid and Attendance or Housebound Rating”  VA calculates Survivor’s Pension Benefits as follows:

1.  Gross Household Income – Income Exclusions – Income Exclusions – Most         Ongoing Medical Expenses = Income for VA Purposes (IVAP). We will discuss Medical Expenses and IVAP below. Then,

2.  Applicable MAPR – (IVAP + 5% deductible) = Actual Benefit

The Net Worth Limit

The net worth limit for Pension or Survivor Pension entitlement is $127,061 for effective dates of payment starting December 1, 2018 through November 30, 2019. This limit is increased by the same percentage as the COLA in Social Security benefits each year on December 1 of each year and will parallel Medicaid’s Community Spousal Resource Allowance (CSRA). The divisor for calculating the penalty period to be used for 2019 is $2,230 a month.

Definition of Net Worth and the Bright Line Test Effective

October 18, 2018, the Department of Veterans Affairs (VA), changed the net worth criteria for Pension claims. Net Worth on or after October 18, 2018 is the sum of a claimant’s:

  • assets

PLUS

  • income for VA purposes (IVAP), including the income of a spouse and dependent children under certain circumstances

Please note when IVAP is a negative number, it is to be considered zero dollars. As a result, assets cannot be further reduced by negative income. Net worth can only be reduced to the extent that there is no income to add to the assets and thus if IVAP is zero, the net worth is the value of the assets alone. Also, the IVAP calculation is based on an initial application for Pension. This means that only reasonably predictable medical expenses can be subtracted from household gross income such as recurring insurance premiums, the recurring cost of paying caregivers or care services and possibility the recurring cost of renting medical devices.

Income for net worth purposes includes the income of the claimant and spouse or the income of a single surviving spouse.

Defining Assets

Assets are the fair market value of all property that an individual owns, including all real and personal property, unless excluded under 38 CFR 3.275(b). If the total value of an annuity or similar financial instrument is used when calculating the asset amount, VA does not include the monthly income derived from the same annuity or similar financial instrument when calculating income for net worth. This would result in double counting for calculating net worth.

Fair market value is the price at which an asset would change hands between a willing buyer and seller. VA will use the best available information to determine fair market value, such as inspections, appraisals, public records, and the market value of similar property. Fair market value is determined based on valuations at the time of application.

The following are rules for asset inclusion for net worth:

  • If the claimant is a veteran then the veteran’s assets include the assets of the veteran as well as the assets of his or her spouse.
  • If the claimant is a surviving spouse, the assets include only the assets of the surviving spouse.
  • If the claimant is a surviving child and he or she has no custodian or is in the custody of an institution, the child’s assets include only the assets of the child.
  • If a surviving child has a custodian other than an institution, the child’s assets include the assets of the child as well as the assets of the custodian. If the child is in the joint custody of his or her natural or adoptive parent and a stepparent, the child’s assets also include the assets of the stepparent.
  • VA will not consider a child to be a veteran’s or surviving spouse’s dependent child for Pension purposes if the child’s net worth exceeds the net worth limit.

The total value of an annuity, trust or other similar financial instrument is counted as an asset if the claimant establishes that he or she has the ability to liquidate the entire balance. For example, if the entire asset is locked up in an irrevocable trust and unavailable, it is not an asset. Likewise if an income annuity is income only and has no feature to get to the original purchase amount, it is not an asset. Other such arrangements as limited partnerships, private stock or an installment sale would likely not have an option to sell or liquidate and as a result would also not be counted as assets.

If the claimant cannot liquidate the value of the annuity, trust or other similar financial instrument or information about the liquidity of an annuity is unavailable, VA counts the monthly income received as income for net worth purposes and excludes the financial instrument value from assets. The same would be true of any other financial arrangement that locks up the asset but produces income.

What Type of Burial Assistance Does the Government Provide?

September 3, 2019

August 20, 2019 | by the National Care Planning Council

General Observations

Death and dying are issues typically overseen by the states. There are very few federal programs to help with burial as compared with numerous federal programs for eldercare. Only when death is a consequence of participation in a federal program is it covered. For example, assistance for burial is covered by Social Security, the Department of Veterans Affairs for veterans, the Department of Defense for military and some minimal support from Medicaid through Medicaid matching funds for states.

States, counties and cities themselves typically offer little assistance for burial unless the deceased is indigent and no funds can be found to pay for cremation or burial. And in many states, the only indigent people who are covered are those who die and the body remains unclaimed. In these cases, local county governments have no recourse but to cover the cost of a cremation. There are some exceptions to this general practice of no support with some states, but over the years more and more states have opted out of programs to help families with burial costs.

By and large, responsibility for funerals and burial or cremation rests with the family. It is therefore very important when planning for the final years of life to have money set aside or available for death. We will discuss below a number of community support options for those who do not prepare. In general, very few community or government assistance programs will pay for a burial. Cremation is generally the rule. A funeral service is optional for the family but typically not paid for with assistance funds.

Social Security Death Benefit

You may receive a one-time payment of $255 when a family member dies, depending on your relationship to them and how long they have worked. Generally, only surviving spouses and children of deceased workers qualify for the one-time death benefit. In addition, the deceased family member must have worked long enough to be insured under Social Security, but it doesn’t matter if they were already collecting Social Security or not.

The death benefit payment is made to the surviving spouse living with the deceased person at the time he or she passed, or if there is no surviving spouse, the payment is made to a child of the deceased person. Spouses who are not living together when one spouse dies may still receive the death benefit if they were eligible for benefits on the deceased spouse’s earnings in the month the spouse passed. If there is no surviving spouse or child who qualifies for the payment, then no payment will be made.

This is a one-time, lump sum benefit; however some survivors may qualify for a monthly benefit in addition to the one-time death benefit. You must apply for the lump-sum death benefit within two years of the family member’s death.

In addition to the one-time payment, certain family members may receive a monthly benefit for a deceased person. For widows or widowers without dependents, this amounts to receiving the larger of the two social security benefits if both were receiving benefits or receiving the deceased person’s benefits if the survivor was not receiving any. The following family members may qualify for Social Security survivor benefits:

  • a widow or widower, beginning at age 50 if disabled or 60 is not disabled;
  • a widow or widower who is caring for your child under the age of 16, regardless of the age of the widow or widower,
  • unmarried children of the deceased also qualify if they are under age 18 (or age 22 if they are disabled).
  • in some cases, even grandchildren, step children or adopted children may qualify for survivor benefits.

If you are divorced, you may qualify for survivor benefits on an ex-spouse if you were married for at least 10 years, and you are age 60 or older when your ex-spouse passes (you only need to be age 50 if you are disabled).

You should notify Social Security and apply for Social Security benefits right away after a family member has passed. To do so, you can call the Social Security Administration or visit the closest office to you. You will need to provide proof of death (death certificate or proof from a funeral home), your Social Security number and your deceased family member’s Social Security number, your birth certificate, marriage certificate if married, divorce papers if you are divorced, and income information for the deceased family member (from W-2s or income tax returns) for the most recent year

Veterans Death Benefits

These monetary benefits are for veterans who were receiving disability income from either Disability Compensation or Veterans Pension.

SERVICE CONNECTED DEATH

$2,000

NON-SERVICE CONNECTED DEATH (Reimbursement; veteran dies while hospitalized by VA)

$762.00

NON-SERVICE CONNECTED DEATH (Reimbursement for Veterans not hospitalized by VA)

$300.00

NSC DEATH STATE CEMETERY (Paid to a state veterans cemetery for the plot/burial)

$762.00

NSC DEATH PLOT ALLOWANCE (This amount will be paid to reimburse for a private-paid plot)

$762.00

A service-connected death is one where the veteran was receiving monthly payments for Disability Compensation and the death was due to the disability or condition for which the veteran was receiving pay. It is also possible to receive a service-connected death if the disability or condition was not the direct cause but the disability or condition contributed substantially to the death.

A non-service-connected death is one where the veteran was receiving monthly payments for Disability Compensation or Veterans Pension but the death was due to some other cause not related to the disabilities or conditions for which the veteran was receiving pay.

It should be noted that generally a non-service-connected death can produce $1,062 a month if the survivors have to pay for a funeral plot. Note that if the veteran died while hospitalized by VA and the survivor has to pay for a funeral plot the total amount available is $1,524.

Disaster Associated Burial Benefit

The most tragic disaster-related loss imaginable is that of a loved one. Under the Individuals and Households Program’s (IHP) Other Needs Assistance (ONA) provision, an applicant may qualify for certain eligible funeral expenses.

FEMA Funeral Assistance is provided to help with the cost of unexpected and uninsured expenses associated with the death of an immediate family member when attributed to an event that is declared to be a major disaster or emergency.

Eligible funeral expenses may include:

  • Cost of casket
  • Mortuary services
  • Transportation of the deceased and/or up to two family members into the area to identify the decedent (if required by state/local authorities)
  • Two Death Certificates
  • Burial plot
  • Interment or cremation
  • Cost of re-interment if disinterment is a) caused by the declared disaster, and b) occurs in a family cemetery on private property
  • Eligibility Criteria

Typically, federal and state personnel at the FEMA Joint Field Office review the supporting documentation from the applicant and payments are approved by the Federal Coordinating Officer (FCO) or designee and his/her state counterpart.

To be eligible for funeral assistance, applicants must provide:

  • A death certificate for the decedent
  • Documentation from a designated, authoritative state or local entity (attending physician, Medical Examiner’s office, or Coroner’s Office as appropriate) that attributes death or the injury causing death to the declared emergency or major disaster
  • Proof that the applicant is the official “next of kin” as defined by the appropriate state or local authority
  • Confirmation that funeral expenses have not been paid for by other resources (Social Security and Veterans Affairs benefits, for example, would duplicate Funeral Assistance and would be subtracted from an award)
  • Evidence of an unmet funeral expense (a receipt from a service provider)
  • Ineligible Costs

Not all applicants reporting funeral expenses will be eligible for Funeral Assistance. Some common reasons for ineligibility include:

  • The death was not attributed to the declared incident
  • Funeral expenses are fully covered by other sources of assistance
  • Insufficient and/or incomplete documentation
  • If disinterment was the result of the disaster, FEMA will provide Funeral Assistance only for a disinterred coffin under the following conditions:
  • The unearthed coffin(s) were located in a family cemetery on their private property
  • The coffin(s) were removed from the ground by the declared disaster

Private Sector and Community Programs

There are a number of ways where the private sector and certain community groups or church denominations will help cover a burial and possibly a funeral.

Taxpayer Interment Benefits

Local taxpayers in many cities and counties qualify for reduced interment costs in cemeteries.

Church Members and Members of Civic Organizations Benefits

Church members and members of civic and other organizations may qualify for funeral assistance or for reduced costs. Some church denominations will also provide burial for their members in the church cemetery. This is principally for Greek Orthodox, Jewish and Catholic faiths but may include other faiths as well.

Crime Victims’ Compensation Fund

A Crime Victims’ Fund often provides funeral benefits in instances of death by a criminal act. There are many crime victim funds across the United States. Most are funded by the state or county. Ask the prosecutor’s office in your area or do a computer search using the name of your county or city and the term “crime victim fund”.

Death Benefits from Pensions, Societies and Other Organizations

Organizations affiliated with some professions, such as the Railroad Retirement Board, as well as some social groups, unions and pensions, offer allowances to defray funeral costs. Some organizations and pension funds include an automatic group life insurance policy on their members. This may include unions and other fraternal organizations as well as veterans service organizations. These may be small amounts of coverage such as $1,000, but adding up benefits from a number of sources might produce enough for a burial or cremation. Here are some examples of funds that will defray costs.

  • Workman’s compensation, if death was work-related,
  • Civil service (federal, state, county or local) retirement pension fund,
  • Federal Employees Life Insurance (Includes a lifetime benefit even after retirement)
  • Railroad fund,
  • Teacher’s fund,
  • Miner’s benefits fund,
  • Trade union fund,
  • Credit union fund,
  • Fraternal organizations fund.

Discounts or Gratis Services from Funeral Homes

For families who simply cannot come up with enough money to bury a loved one, funeral homes may be surprisingly accommodating. Even though they may not advertise it, funeral homes may offer charity for a number of people in the community when no other way to bury a loved one is possible. This might include steep discounts, extended monthly payment plans, extremely affordable economy plans and possibly even providing the burial — in this case very likely a cremation — for free.

Government Pays for Only about 16% of Long Term Care

September 3, 2019

April 2, 2019 | by the National Care Planning Council

Government programs such as Medicare, Medicaid and the Veterans Administration will cover the cost of long-term care under certain conditions. Medicare will cover rehabilitation from a hospital stay or limited care at home if there is a skilled need. The Veterans Administration will cover the cost of nursing home care if the veteran is at least 70% service-connected disabled. The VA will also cover other forms of home-based or community-based care if there is a medical need.

Medicaid will cover both medical and non-medical related long-term care but in order to qualify for Medicaid a person has to have less than $2,000 in assets in most states and income that is insufficient to pay the cost of care. In other words a person must be impoverished. Otherwise Medicaid will not pay.

Government literature and government websites claim that state and federal governments pay a large proportion of long term care costs in this country. That is only true because the majority of long-term care services are provided free of cost. In order to understand the private versus government burden for long-term care we need to look at the actual hours of care provided and not the cost.

Based on our analysis of yearly, one-on-one care hours, we estimate that about 84% of all long-term care is not covered by government programs. Conversely, this means only 16% of long term care service hours are covered by the government. The 84% that is not covered is primarily family-provided home care to help with activities of daily living, or help with maintaining a home, providing meals and support, or care services providing supervision or companionship or providing transportation and shopping services. Care costs not covered by the government are also care provided from family out-of-pocket payments in nursing homes and assisted living facilities. Families are also hiring more and more private services to help with care at home.

Based on the charts below about 71% of all long-term care hours are provided in the home by family. (We have excluded home care hours from Medicaid and Medicare programs.) . Most of this care is provided free of charge by family members, friends or volunteers. However some is provided by professionals or aides paid from family funds or from insurance. Some care is also paid for privately for assisted living and nursing homes as well. If we were to multiply the total number of care hours we derived for the chart below times the average hourly cost for what private aides would provide, we would have a rough equivalent yearly cost of family-provided and family-funded care in this country. We estimate about 16,556,400,000 hours per year of care hours in 2000 (it is difficult to find current figures). The number of elderly has grown about 1% per year since then. This gives us roughly 19,221,000 hours currently. We use a cost of private health aides at $25 an hour.

Multiplying the two figures together gives us about $480.5 billion of equivalent, current family-provided care cost. This is roughly 3 times the total current amount the state and federal government pay yearly for all long-term care services. If the Federal government alone had to pay all home care costs in this country combined with what it already pays for long-term care, the cost would be the third largest single expenditure in the federal budget exceeded only by Social Security and defense.

Many people are pushing the government to do just that – pay an increasing amount of home care services for the elderly.

Reports Find Hospice Deficiencies Go Unaddressed

September 3, 2019

Hospice care is supposed to help terminally ill patients maintain their quality of life at the end of their life, but two new government reports find that serious problems in some hospices may be actually causing harm to hospice patients. The reports propose that additional safeguards are needed.

Medicare provides a comprehensive hospice benefit that covers any care that is reasonable and necessary for easing the course of a terminal illness. Most hospice care is provided in the home or in a nursing home. State agencies or private contractors survey hospices to make sure they comply with federal regulations. If a hospice fails to meet a standard, the surveyor cites the hospice with a deficiency.

A pair of reports by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) found that from 2012 through 2016, more than 80 percent of hospices surveyed had at least one deficiency and one in five had a deficiency serious enough to harm patients. About 300 hospices were identified as “poor performers” and 40 had a history of serious deficiencies.

The reports found that the most common types of deficiencies involved poor care planning, mismanagement of aide services, and inadequate assessments of beneficiaries. Some of the most serious problems that were found included a beneficiary who developed pressure ulcers on both heels, which worsened and developed into gangrene, requiring amputation of one leg. Another beneficiary developed maggots around his feeding tube insertion site. Both of these beneficiaries had to be hospitalized, which hospice is meant to prevent.

Meanwhile, the OIG found that it is hard for consumers to learn about which hospices are doing a good job. The Centers for Medicare and Medicaid Services (CMS) launched the Hospice Compare website in 2017, but the site does not include information from the surveyors’ reports. Hospices also do not have as strong reporting requirements as nursing homes. In addition, CMS has limited ability to discipline hospices other than to drop the hospice from Medicare.

The reports provide a number of recommendations to CMS to improve monitoring of hospices, including the following:

  • Expanding the data that surveying organizations report to CMS and using these data to strengthen its oversight of hospices
  • Taking steps to include the survey reports on Hospice Compare
  • Educating hospices about common deficiencies and those that pose particular risks to beneficiaries
  • Increasing oversight of hospices with a history of serious deficiencies
  • Strengthening requirements for hospices to report abuse, neglect, and other harm
  • Ensuring that hospices are educating their staff to recognize signs of abuse, neglect, and other harm
  • Improving and making user-friendly the process for beneficiaries and caregivers to make complaints.

To read the OIG reports, click here and here.

For National Public Radio’s coverage of the reports, click here.

Medicaid’s Gift to Children Who Help Parents Postpone Nursing Home Care

September 3, 2019

In most states, transferring your house to your children (or someone else) may lead to a Medicaid penalty period, which would make you ineligible for Medicaid for a period of time. However, there are circumstances in which transferring a house will not result in a penalty period.

One of those circumstances is if the Medicaid applicant transfers the house to a “caretaker child.”  This is defined as a child of the applicant who lived in the house for at least two years prior to the applicant’s entering a nursing home and who during that period provided care that allowed the applicant to avoid a nursing home stay.  In such cases, the Medicaid applicant may freely transfer a home to the child without triggering a transfer penalty.  Note that the exception applies only to a child, not a grandchild or other relative.

Each state Medicaid agency has its own rules for proof that the child has lived with the parent and provided the necessary level of care, making it doubly important to consult with your attorney before making this (or any other) kind of transfer.

Others to whom a home may be transferred without Medicaid’s usual penalty are:

  • Your spouse
  • A child who is under age 21 or who is blind or disabled
  • Into a trust for the sole benefit of a disabled individual under age 65 (even if the trust is for the benefit of the Medicaid applicant, under certain circumstances)
  • A sibling who has lived in the home during the year preceding the applicant’s institutionalization and who already holds an equity interest in the home

Medicare Will Cover Pioneering Cancer Treatment Nationwide

August 30, 2019

NAELA eBulletin:

August 7

Medicare will cover an innovative but high-priced cancer treatment nationwide, a step Trump administration officials said Wednesday would ensure patients have “consistent and predictable access” to a potentially lifesaving therapy.

In announcing the decision, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, said that until now, Medicare’s regional administrators had decided whether to cover the treatment, which led to confusion.

Verma said the agency, which had scheduled this coverage decision originally for late May, has been struggling to figure out how to cover and pay for the treatment, called CAR T-cell therapy. The treatment costs $375,000 or $475,000, depending on whether it is used for advanced lymphoma or pediatric leukemia. Hospital stays can add hundreds of thousands of dollars to the cost of care.

Drugmakers note CAR T-cell therapy is designed to be given just once and to be a potential cure for patients who have run out of other options. But not all patients benefit from it and because it is so new, it’s too soon to know whether it will deliver long-term cures.

Such expensive treatments are “begging the question of how the system is going to pay for this over the long term,” Verma said, especially given Medicare’s considerable financial strains. “This is something we are extremely concerned about,” she added.

The coverage decision announced Wednesday is different in some important aspects from an agency proposal from February. That proposal called for “coverage with evidence development” — which would have required hospitals to collect and report data on patient outcomes over a long period. Hospitals said the data collection would be overly burdensome.

CMS’ final decision dropped that requirement. Instead, the agency said it will rely on patient information collected by the Food and Drug Administration and the National Cancer Institute. The FDA is requiring the two manufacturers of the therapy — Novartis and Gilead Sciences — to follow patients for years and report on outcomes. Such data will be put in a registry supported by NCI.

The Medicare decision also said it will cover the therapy when it is administered at health care facilities enrolled in an FDA-mandated safety program requiring special training on handling side effects. That means the treatment could be given on an outpatient basis, which would be much less costly.

The American Society of Hematology praised the decision, especially the elimination of the “coverage with evidence development” requirement. It said the proposed mandate would have prompted some hospitals not to provide CAR T-cell therapy.

The group also praised the decision for saying Medicare would cover all FDA-approved uses for CAR T-cell therapy and off-label uses recommended in CMS-approved compendiums, which are used to determine medically accepted uses of drugs and biologics.

The Medicare decision was the second step in a week taken by CMS to bolster CAR T-cell therapy. Last Friday, the agency said it would increase the reimbursement for CAR T-cell therapy, but didn’t go as far as many hospitals had wanted. Medical centers have complained they are losing money on Medicare patients because reimbursements have been too low.

The FDA approved two versions of CAR T-cell therapy, which stands for chimeric antigen receptor T-cell, in 2017. Kymriah is made by Novartis for certain types of lymphoma and childhood leukemia, and Yescarta is manufactured by Gilead Sciences for lymphoma. Other CAR T-cell therapy products are in development.

The complicated treatment involves extracting and genetically altering the patient’s T cells to attack a protein on the surface of cancer cells. The cells are then infused back into the patient.

Self-Help Packet for Medicare “Observation Status”

August 30, 2019

NAELA eBulletin:

  1. Introduction
  2. How to Use This Packet
  3. Observation Status Self-Help
  4. Federal Regulations – Requirements for Medicare Coverage for Skilled Nursing Facility Care
  5. Pertinent Federal Regulations for Medicare Appeals
INTRODUCTION

Dear Medicare Patient:

The Center for Medicare Advocacy has produced this Self-Help Packet to help you understand Observation Status and options for beneficiaries who are placed on Observation Status.

Medicare is the national health insurance program to which many disabled individuals and most older people are entitled under the Social Security Act.  All too often, Medicare claims are erroneously denied.  It is your right to appeal an unfair denial; we urge you to do so.

However, the situation for Observation Status appeals is unique. Medicare currently has no official method to appeal Observation Status. This may be illegal. As of August 2017, the Center is pursuing a class action lawsuit on behalf of Medicare beneficiaries to establish a way to appeal Observation Status. Sign up for the Center’s Alerts and follow us on social media for important updates to the case. In the meantime, if you are placed on Observation Status, use this Packet to understand and review your options.

If you have any questions, contact the Center for Medicare Advocacy at (860) 456-7790.


HOW TO USE THIS PACKET

We’ve organized this packet so that it provides you with the information needed to understand observation status and to attempt to rectify the problems created by it.

    1. Read the document entitled, Observation Status Self-Help included in this packet.
    2. If you decide to file an appeal, follow each of the steps in the following Self-Help document.
    3. Review the enclosed regulations to assist you with the appeal.
    4. If you have questions, contact the Center for Medicare Advocacy at (860) 456-7790.

OBSERVATION STATUS SELF-HELP

Typical Experience

You are a Medicare beneficiary hospitalized for three or more days.  At the hospital, you signed paperwork, slept in a hospital bed, underwent many tests, and saw various physician specialists.  At some point during the hospitalization, you were told that you were not admitted as an inpatient but were, instead, an outpatient receiving “observation services.” (“Observation services” is the term Medicare uses for “observation status.”)  You should have received the Medicare Outpatient Observation Notice(MOON) discussed below and it should have been explained to you.  The MOON informs you that Medicare will not pay for care in a skilled nursing facility (nursing home) if you need that type of care after you are discharged from the hospital.

Introduction

Observation status is not new.  However, its use by hospitals to avoid losing money, financial penalties, and accusations of Medicare fraud is growing.  Observation status seriously affects Medicare beneficiaries’ access to care and finances.  Attempts have been made to remedy the problem legislatively.  For instance, bills have been introduced in Congress to eliminate the problem.  In addition, the Center for Medicare Advocacy (Center) filed a nationwide class action lawsuit, now known as Alexander v. Price (formerly Barrows v. Burwell and Bagnall v. Sebelius), that is currently pending and seeks to establish a right for Medicare patients to appeal placement on observation status.  While we wait for action on the legislation and the lawsuit, individual beneficiaries continue to be negatively affected by observation status.

This Packet includes information about observation status and outlines steps you might take if you are considered a hospital outpatient in observation status.  For more information about observation status, visit the Center’s webpage at:  www.medicareadvocacy.org.  The process of challenging observation status is complicated and confusing.  If you have questions, call the Center for Medicare Advocacy at (860) 456-7790.

  1. Inpatient Admission

Medicare Part A pays for hospital inpatient care.In traditional Medicare, there is an initial deductible and, if you are hospitalized for more than 60 days, there are daily copayments.While you are hospitalized as an inpatient, Medicare Part B pays for the care provided by physicians, usually covering 80% of the Medicare-approved cost.Medigap policies or other supplemental insurance usually pays for the hospital deductible, copayments, and Part B cost-sharing.

Medicare Part A will pay for hospital care only if a physician orders inpatient care.  To assist physicians with determining whether a patient/beneficiary should be admitted to the hospital as an inpatient, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, published the following guidance in its policy manuals:

The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use the expectation of the patient to require hospital care that spans at least two midnights period as a benchmark, i.e., they should order admission for patients who are expected to require a hospital stay that crosses two midnights and the medical record supports that reasonable expectation. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.[1]

This language reflects new regulations that created a “two-midnight rule” – the direction to physicians to order inpatient admission for patients whom they expect will be hospitalized for at least two midnights.[2] Note that the two-midnight rule did not change the requirement that patients be hospitalized as an inpatient for three days, not including the day of discharge, in order for Medicare to cover post-hospital skilled nursing facility care.

If a hospital participates in the Medicare program, all of its physician inpatient admission orders must be reviewed by the hospital’s Utilization Review Committee (URC).  The URC has the power to overturn any admitting physician’s admission order and to reassign patients to observation status, with the physician’s consent.

  1. Observation Status

Observation status is defined by CMS in its policy manuals as:

…a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.  Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.  Observation services are covered only when provided by the order of a physician or other individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.  In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.  In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.[3]

However, despite this language, there are actually no services that are specifically observation services.  CMS in fact tells physicians that they can order whatever care and services their patients need, whether they are inpatients or outpatients.  In the Center for Medicare Advocacy’s  view, observation status is actually a Medicare billing issue (the question is whether a hospital will bill Medicare Part A or Medicare Part B for a patient’s care), not a question of medical necessity or appropriateness of care.

When a Medicare patient is placed on observation status, despite the fact that the patient may be physically in the hospital for many days, for Medicare billing purposes the stay is considered outpatient care.  The hospital bills Medicare Part B for each service provided (such as lab tests, intravenous medications, MRIs, EKGs).

If you are put on observation status, you will be responsible for the hospital Part B copayments and for the cost of any self-administered (prescription or over-the-counter) medications you receive while hospitalized.[4]  On the other hand, you will not be responsible for the Part A inpatient deductible.  If you do not have Part B, the hospital services will not be covered.

  1. The Heart of the Problem

When Medicare beneficiaries are put on observation status, Medicare Part B generally covers most of their care.  The Part B cost-sharing is usually paid for by a Medigap policy or some other form of supplemental health insurance.  However, if the beneficiary has opted out of Medicare Part B entirely, the hospitalization under observation could be very expensive because nothing will be covered by Medicare.

As a general rule, most beneficiaries are not burdened with the financial cost of the hospital stay, except for medications, but by the care they receive after the hospitalization in a nursing home.

Medicare Part A will pay for care in a skilled nursing facility (nursing home) only if the care follows a Medicare Part A covered three day inpatient stay in a hospital.  For purposes of measuring days, the Medicare program uses calendar days, not 24-hour periods.  For example, if a person is admitted to the hospital at 11:50 p.m., Medicare will count that day as the first day of admission, even though the person was “admitted” for only ten minutes. Also, the day of discharge is not counted toward the three-day period.  The shorthand way of describing the three-day qualifying hospital stay requirement is “three midnights.”

Any “midnight” on observation status does not count towards the three day qualifying hospital stay.  Thus, if the patient requires care in a nursing home after a hospital stay on observation status, even if that stay was for three or more days, Medicare will not pay for it.  Of course nursing home care is very expensive.

What You Can Do

Step One: Find Out Your Admission Status

Understandably, patients think that if they are kept in the hospital and spend the night in a hospital room, they are inpatients.  Now that hospitals are increasingly using observation status, however, you cannot make this assumption.  So when you are hospitalized, find out whether you have been admitted as an inpatient or on observation status.

Since March 8, 2017, hospitals have been required to give patients the Medicare Outpatient Observation Notice (MOON) within 36 hours if the patients are in observation status for 24 hours.[5]  Hospitals must also orally explain observation status and its financial consequences for patients.  The MOON cannot be appealed to Medicare.

Step Two: Try to Get Your Status Changed

If you find out that you are on observation status and are concerned about Part B cost-sharing, the cost of self-administered medications, and/or Medicare payment for care in a skilled nursing facility after you leave the hospital, try to get the status changed while you are at the hospital.  This will be difficult to do.  Your best chance of success is having your community physician (regular doctor) talk to your treating physician at the hospital.  Ask your community doctor to intervene on your behalf.  He or she knows your medical history and speaks the same medical jargon as the hospital physician.  Your community doctor might be able to convince the hospital physician that your status at the hospital should be changed from observation to inpatient.

You can try to use Medicare’s “two-midnight rule” to show the doctor or hospital that inpatient admission is appropriate.[6]  The two-midnight rule is supposed to be a way for doctors and hospitals to decide whether a patient should be admitted as an inpatient or not.  Medicare states that if the doctor reasonably expects that a patient requires hospital care that will cross two midnights, she can admit the patient as an inpatient and Medicare should pay the claim under Part A.[7] The documentation in the medical record should support the expectation of the physician. Remember that any inpatient stay is only counted from the time of the inpatient order. Time already spent in observation is not counted toward the inpatient stay even if inpatient admission is eventually ordered. So it’s important to address this question early in the hospitalization.  Also remember that there is no prohibition against changing a patient’s status from observation to inpatient if, for example, his medical condition worsens.

Step Three: Prepare For Discharge

In the event that you are not successful with changing your hospital observation status, but need follow up medical care, you have some decisions to make. If you can safely return home, ask your hospital or community physician to order home health care.As long as you are “homebound,” (leaving home requires considerable effort (“taxing” effort, in the language of Medicare) and occurs infrequently) and you require skilled care (skilled nursing or physical or speech therapy), Medicare should pay for this care.Have this care set up for you by the hospital before you leave.You can find out more about home health care on the Center’s website at www.medicareadvocacy.org.

If you need more medical care and therapy than you can get at home, ask your physician about going to an inpatient rehabilitation hospital (IRH, also known as an inpatient rehabilitation facility, IRF).This type of hospital does not require a three-day inpatient hospital stay.Unfortunately, not every community has an IRH and the more rigorous therapy provided by an IRH may be more intense that you can handle.But if you can participate in the level of therapy that an IRH offers, you will not need to worry about observation status and, a bonus, you may get better more quickly (and go home) than if you go to a SNF.

Step Four: Understand that Medicare Will Not Pay for Nursing Home Care After a Hospitalization on Observation Status

If you cannot safely return home, you can’t go to an IRH, and the hospital physician has ordered care for you in a nursing home, check to see if the nursing home participates in the Medicare program, as most do.However, since you were not admitted to the hospital as an inpatient, Medicare will most likely not pay for this necessary care without a significant effort on your part. Even with significant effort it is very difficult to get Medicare coverage in these circumstances.

There is currently no official way to appeal observation status.[8] Medicare claims that “only the doctor” at the hospital can decide whether you should have been admitted as an inpatient or placed on observation status and that a beneficiary cannot appeal this issue to Medicare. However, we outline some steps below that you can try. Once in a while, people succeed, though it’s important to understand that is very rare.

You might be able to appeal the denial of coverage for your nursing home care as long as you spent at least three midnights in the hospital (not in the emergency room).Unfortunately, this appeal process can take a year or longer to resolve and, if you can manage to get a case into the appeal system, winning the case is difficult.  Also, filing an appeal does not prevent the nursing home from requiring you to pay for your care pending the outcome of the appeal.  Remember that an appeal is worth trying only if you receive the level of care that Medicare covers in the skilled nursing facility – five days a week of therapy or seven days a week of skilled nursing or a combination of therapy and nursing equaling seven days a week.  If you are not in a Part A stay, the nursing home can bill Medicare Part B for your therapy services.

Patients who receive five days of therapy per week in the nursing home have a better chance of winning their appeals than patients who are relying on claims of skilled nursing care, since most care is provided by unlicensed aides.

Step Five: Start the Nursing Home Appeal

If you decide to get care in a nursing home and it will be provided on a daily basis (five days a week of therapy or seven days a week of skilled nursing), let the nursing home know that you are going to appeal the denial of Medicare coverage.  Medicare will only pay for a nursing home stay if it includes daily skilled care.  Skilled care is care that is so inherently complex that it must be done by a skilled professional.  The skilled nursing and/or therapy can be to improve or maintain your condition.  Medicare will not pay for care in a nursing home when it is only custodial.  Examples of custodial care include the administration of oral medications or assisting a patient with bathing or toileting.  For more information about Medicare coverage of skilled nursing facility care, and how to appeal a denial visit our website at www.medicareadvoacy.org.

To start the appeal, ask the nursing home to submit a “demand bill” to Medicare for your entire stay.  You can make this request after you leave the nursing home.  However, note that nursing homes must bill Medicare within one year of the time the care began, so do not wait too long to make this request.  In response to the nursing home’s demand bill, CMS will issue a denial of payment from which you can appeal.  You can also ask the nursing home to give you a Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (NEMB-SNF),[9] which is a form for so-called “technical denials” of coverage.

A technical denial means that you need the care the nursing home provides but that you do not qualify for Medicare coverage for technical reasons, such as not having a three-day inpatient hospital stay (the first box) or having used all 100 days in a benefit period.  Check Option 1 so that the nursing home will submit the claim to Medicare for a decision about coverage.

Step Six: Request a Redetermination for the Nursing Home Denial 

You will receive a Medicare Summary Notice (MSN) in the mail which will reflect the nursing home’s bill to Medicare.  The MSN will indicate that Medicare has denied payment for your care in the nursing home because you did not have a three day qualifying hospital stay.  Read the last page of the MSN.  It will tell you that you have 120 days to appeal the denial of coverage.  Follow the instructions on how to and file an appeal.  Circle the denial of payment for your nursing home care.  Write that you are appealing because you did receive three days of hospital inpatient care.  If you have a copy of your hospital discharge summary reflecting that you were hospitalized for three days, send a copy of it with your MSN requesting an appeal.

If you have submitted the NEMB-SNF, you will receive a response that will tell you how to appeal the decision.

Step Seven: Gather Hospital Records

Write to the hospital and ask for a copy of your medical record.  Ask that it send you the following documents: emergency room records; admission records; physician orders; consultation reports; lab reports; diagnostic imaging; medical records; nursing narratives; discharge summary; and social service documentation.  The hospital may charge you for copying and sending the documents, although charges for records in support of Medicare claims are not allowed in some states, including Connecticut and Massachusetts.  When you get the records, give a copy of them to your community physician.  Ask your physician to review the records and to write a statement explaining that the care you received while hospitalized was inpatient hospital care.

Check the records carefully for any inpatient orders. If you were actually admitted as an inpatient for a period of time that crossed three midnights, that is the strongest type of appeal you can make.  Without such an order, it will be exceedingly difficult to win your appeal. You can try to argue that the care you received was inpatient hospital care, but Medicare’s position is that without an inpatient order, there can be no inpatient coverage under Part A.

Step Eight: Gather Nursing Home Records

Write to the nursing home and ask for a copy of your medical record.  Ask for the following documents:  MDS forms; physician orders; physician progress notes; medication records; therapy records (physical, occupational, and speech), nursing narrative notes; and physician certifications.  As with the hospital medical records, the nursing home may charge you for copying and sending these documents.  Also write to the nursing home physician and ask that he or she write a letter for you explaining that while you were a patient at the nursing home, you required and received a skilled nursing facility level of care.

Step Nine: Request a Reconsideration for the Nursing Home Denial

You should receive a “Redetermination” decision in the mail for your nursing home care.  It will be “unfavorable.”  You will have 180 days to appeal.  Follow the directions on the form for requesting a “Reconsideration.”  On the nursing home appeal request, write that you are appealing because you were hospitalized and received an inpatient level of care for three consecutive days prior to receiving care at the skilled nursing facility.  If you have letters from physicians in support of your case, send copies with your request.

Step Ten: Request an ALJ Hearing

You should receive a “Reconsideration” decision in the mail for your nursing home care.  Again this will be a denial.  You will have 60 days to appeal.  Follow the directions on the form for requesting an administrative law judge (ALJ) hearing.  ALJ appeals are often successful.

Step Eleven: Respond to the Notice of Hearing

You will receive a written notice of hearing in the mail.  Respond to the notice as directed.  Note: Unrepresented beneficiaries have a right to hearing by video teleconference, which is generally a more effective method for making a case than a telephone hearing. Make sure that the notice states that a video teleconference is scheduled.  If it does not, contact the ALJ and request that the hearing be rescheduled as a video teleconference.  In addition, ask the judge to send you a copy of the exhibit list and hearing file.

Step Twelve: Prepare for the Hearing

When you receive the hearing file, make sure that it includes all the medical records that you have obtained from the hospital and the skilled nursing facility.  If it does not, send the missing records to the ALJ.  Be sure and send a copy of the letters of support you received from your physicians.  Contact the nursing home and ask if a therapist or nurse will testify at the hearing on your behalf.

Step Thirteen: Argue your Case

Attend the hearing.  Make sure the judge has the additional records that you sent in.  If you can, have someone from the nursing home testify that the care you received while there was skilled care and that it was performed on a daily basis.  Explain to the judge that your care at the skilled nursing facility was not covered by Medicare because the hospital erroneously billed your inpatient hospital level of care to Medicare Part B rather than Part A.  Ask the judge to find that your hospital care was an inpatient level of care and that you’ve met the three day qualifying hospital stay requirement for skilled nursing facility care.  Then ask the judge to find that your skilled nursing facility care was medically reasonable and necessary and coverable by Medicare Part A.

Step Fourteen: If You Lose the Appeal

You will receive the Administrative Law Judge’s decision in the mail.  If it is favorable, send a copy to the nursing home and ask that it reimburse you if you previously paid for any care or ask that it stop any collection efforts started against you.  If it is unfavorable, follow the directions on the hearing decision for filing a Medicare Appeals Council request.

Conclusion

Trying to fix placement on observation status is very difficult and, in the rare cases where people succeed, it generally takes a long time.  Should you have questions during the process, you can call the Center for Medicare Advocacy at (860) 456-7790.  You can also report your difficulties with observation status to your Senators and Representative in Congress, as it’s important that they understand the hardships people are facing. Finally, please continue to monitor our website www.medicareadvocacy.org for updates on proposed changes to the law and on our lawsuit.


[1] Medicare Benefit Policy Manual, Publ. 100-2, Ch. 1, § 10, which can be found at:   http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
[2] 42 C.F.R. §412,3(d)(1).
[3] Medicare Benefits Policy Manual, Pub. 100-02, Chapter 6, § 20.6, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
[4] The Office of the Inspector General (OIG) of the Department of Health and Human Services has stated that hospitals can discount or waive charges for an outpatient’s self-administered drugs. Patients who are charged for such drugs should point the hospital to this statement. https://oig.hhs.gov/compliance/alerts/guidance/policy-10302015.pdf  Also, patients who have a Part D plan may request that the plan pay for the drugs as an out-of-network pharmacy provider.  See Center, “Submitting Claims to Part D for Prescription Drugs Administered in the Hospital During an Observation Status Stay” (CMA Alert, May 1, 2014), https://www.medicareadvocacy.org/submitting-claims-to-part-d-for-prescription-drugs-administered-in-the-hospital-during-an-observation-status-stay/
[5] CMS-10611, available at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html.  The Notice of Observation Treatment and Implications for Care Eligibility (NOTICE) Act requires hospitals to inform patients, orally and in writing, that they are in observation status, not inpatients, and the consequences of that status.  Pub. L. 114-42, U.S.C. §1395cc(a)(1)(Y).
[6] A summary of the two-midnight rule put out by Medicare can be found at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html
[7] Even patients who are expected to require less than two midnights of hospital care can be admitted as inpatients on a case-by-case basis.
[8] As noted in the Introduction, this may be illegal and the Center is currently pursuing a class action case to establish a method of appeal.
[9] CMS Form 20014, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/CMS20014.pdf.

Federal Regulations
Medicare Coverage of Skilled Nursing Facility Care
42 CFR 409.30 – 409.36

All the links below can be found at:
https://www.law.cornell.edu/cfr/text/42/part-409/subpart-D


Pertinent Federal Regulations for Medicare Appeals
42 CFR §§ 405.900 – 405.1140

All the links below can be found at:
https://www.law.cornell.edu/cfr/text/42/part-405/subpart-I

Initial Determinations (§§ 405.920 – 405.928)

Redeterminations (§§ 405.940 – 405.958)

Reconsideration (§§ 405.960 – 405.978)

Reopenings (§§ 405.980 – 405.986)

Expedited Access to Judicial Review (§ 405.990)

ALJ Hearings (§§ 405.1000 – 405.1058)

Applicability of Medicare Coverage Policies (§§ 405.1060 – 405.1063)

Medicare Appeals Council Review (§§ 405.1100 – 405.1140)

Got a Question About Social Security Retirement?

August 30, 2019

NAELA eBulletin:

By Rebecca C. Morgan Stetson Law

The New York Times recently ran an article, 7 of Your Most Burning Questions on Social Security (With Answers).

The questions include the future of Social Security, spousal and survivors benefits, the length of benefits, delayed retirement vs. “break even” claiming,  the lowered amount of benefits for those who temporarily leave the work force for caregiving, taxing benefits, and self-employment.

These are all really good questions (I hope they do another article, cause we all know there are more than 7 burning questions.)  The answers are clear and to the point. I plan to have my students read the article before we cover the topic this fall semester (which will be starting before we know it!) You should read it, too!

Could You Afford Home Health Care? New Study Says Maybe Not

July 31, 2019

courtesy of Elder Law Answers:

By Dennis Thompson
HealthDay Reporter

THURSDAY, June 6, 2019 (HealthDay News) — The seniors most likely to need paid home care to maintain independent living are the least likely to be able to afford it long-term, a new study reports.

Only two out of five older adults with significant disabilities have the assets on hand to pay for at least a couple of years of extensive in-home care, researchers found.

Without some help, those elderly are much more likely to wind up in a nursing home, said lead researcher Richard Johnson. He is a senior fellow with the Urban Institute’s Income and Benefits Policy Center, in Washington, D.C.

“We have this perception that the risk of becoming frail is evenly distributed across the population, but it’s really not,” Johnson said. “It is more concentrated among people with less education, lower lifetime earnings and less wealth.”

Aging folks increasingly want to stay out of nursing homes as their health declines, maintaining their independence by living in their own houses, Johnson said.

But there hasn’t been a large increase in the number who are shelling out for paid home care, national statistics show.

To see why that might be, Johnson and his colleagues turned to data gathered by the University of Michigan’s Institute for Social Research.

The researchers broke paid home care down into three scenarios: limited care of 25 hours each month costing $475; moderate care of 90 hours a month costing $1,170; and extensive care of 250 hours per month costing $4,750 per month.

Initial results looked promising.

The investigators found that 74% of all seniors aged 65 and older could afford at least two years of moderate home care if they cashed in all their assets, and 58% could afford two years of extensive home care.

Then the researchers turned their attention to people most likely to need home care — those suffering from severe dementia or who require help with two or more activities of daily living. These activities can include eating, bathing, dressing, using the toilet, getting out of a chair or walking across a room, Johnson said.

Only 57% of those most frail seniors could afford two years of moderate home care, and only 40% could afford extensive home care for two years, the findings showed.

For these people, the burden will fall hardest on their family at first, Johnson said.

“Most people who become frail at older ages rely on unpaid family caregivers,” he said. “Those are the people who provide the vast majority of care.”

Paid home care provides relief for family caregivers, giving them a “respite from the grind of constantly being on call to help a frail loved one,” Johnson said.

Without that respite, family caregivers are more likely to wear down. That makes it even more likely that an elderly person who suffers a setback will wind up in a nursing home, Johnson said.

The findings are “disturbing,” said Eliot Fishman, senior director of health policy at Families USA, a consumer health care advocacy group. “But it’s not surprising to me,” he added.

“It’s an issue I worry gets lost in the health care reform discussion, because there tends to be a huge and understandable focus on health insurance and the affordability of health care,” Fishman said.

At the moment, paid home care tends to be expensive — an average $22 an hour — and isn’t typically covered by insurance, the study authors said in background notes.

Only 11% of seniors aged 65 and older have long-term care insurance, and Medicare doesn’t cover home care services, the researchers noted. Medicaid does cover home care, but there’s a waiting list and people have to be financially wiped out to qualify.

There’s also a looming shortage of home care workers, which the Trump administration’s immigration crackdown could make even worse, according to a Harvard Medical School study published this week in Health Affairs.

Immigrants account for one in every four people working in long-term care and direct care, that study showed. Reducing immigration will make the labor-starved field even less stable.

So what can be done?

Johnson points to a recent innovation by Washington state as one path forward.

Washington passed a law that imposes a 0.58% payroll tax on workers — a premium that pays into a fund to pay for home care, nursing home stay or family caregivers if they become disabled, Johnson said.

“We could think of some sort of public insurance like that as a way to deal with this problem,” he suggested.

Fishman said another option is to change Medicare and Medicaid to cover long-term care. Consideration of such a change probably should be pursued outside the larger health care reform discussion, he added.

Discussions of paying for long-term care have typically tied into other health care reform. “I wonder if that historically has been a mistake,” Fishman said.

The new study appears in the June issue of the journal Health Affairs.

More information

The U.S. Department of Health and Human Services has more about healthy aging.

 

Nursing Home Ratings: Who Can You Trust?

July 31, 2019

courtesy of Elder Law Answers:

By Richard Eisenberg

(An update on the following Next Avenue story, which appeared in March 2019)

On June 3, 2019, Sen. Bob Casey (D-Pa.) and Sen. Pat Toomey (R-Pa.) released a report called Families’ and Residents’ Right to Know: Uncovering Poor Care in America’s Nursing Homes. It included a list of nearly 400 nursing homes around the country where inspectors found serious ongoing health, safety or sanitary problems but whose names had not been publicly disclosed by the government. These nursing homes, with a “persistent record of poor care” do not appear on Medicare’s Nursing Home Compare site with a yellow triangle icon resembling a “caution” sign the way other homes, in the government’s Special Focus Facility program, do. The reason, according to the report by Senators Casey and Toomey:”a result of limited resources” at the Centers for Medicare and Medicaid Services.

You probably saw the viral Facebook post by the Texas man who said he planned to move into a Holiday Inn rather than a nursing home because it would cost  less. That’s a radical idea, and not an especially smart one. But with the average annual cost of a private room in a nursing home topping $100,000, according to Genworth, it pays to do diligent research to find a facility for your parent. And that means looking at nursing home ratings.

This type of detective work can be especially helpful if your mom or dad live in a rural part of the United States. As The New York Times reported this week, nursing homes in those places are increasingly shutting down. More than 400 rural nursing homes have closed or merged over the past decade, the Times said. That means families are being forced to expand their search for nursing homes just to find some.

What Is a Nursing Home?

Before I describe the Medicare and Yelp rating systems, a brief definition:

Nursing homes generally provide nursing care, meals, assistance with everyday activities and rehab services.

Assisted living facilities, by contrast, focus on helping residents with daily living activities and don’t offer as much medical care.

Medicare and Yelp Ratings of Nursing Homes

Both Medicare and Yelp rate nursing homes (sometimes called skilled nursing facilities) on a one-to-five-star scale. Medicare’s ratings of facilities it regulates are in the Nursing Home Compare part of the Medicare.gov site. The ones on Yelp show up if you do search for them with that online service.

But the two types of ratings are done very differently. So much so that Anna Rahman, an assistant professor at the USC Leonard Davis School of Gerontology who has studied them, recommends reading the Medicare reviews as well as the Yelp reviews to get a complete picture.

Rahman and her fellow researchers looked at 51 Yelp-rated nursing homes in California; they previously reviewed the Nursing Home Compare tool.

“We found the Yelp scores did not align well with the scores on Nursing Home Compare,” Rahman told me. “There are lots of possible reasons.”

Why the 2 Types of Nursing Home Ratings Are So Different

The biggest one: Medicare’s Nursing Home Compare star ratings measure facilities based on quantifiable data. Yelp’s reviews are more personal and qualitative. Rahman and her colleagues found that most Yelp reviews commented on “intangibles” like staff attitudes and responsiveness.

Put another way, Medicare can help show how well a nursing home is run and Yelp can show what nursing home residents, or their families, say it’s like to live there.

The Medicare Nursing Home Compare ratings are geographically comprehensive. When I looked for facilities near where I live in New Jersey, I received 160 ratings. (You can modify your search by number of miles, the name of a nursing home, star ratings and whether the facility accepts Medicare or Medicaid.)

By contrast, it’s harder to find many Yelp ratings for a particular area. And even if a nursing home is rated on Yelp, odds are there won’t be many reviews. When I did a Yelp search for nursing homes near me (I found 22), most had fewer than five consumer ratings. They rarely had more than eight.

How the Nursing Home Ratings Are Done

Nursing Home Compare gets its data from three sources: the federal government’s health inspection database; a national database of resident clinical data and Medicare claims data.

Medicare requires on-site inspections every 12 to 15 months. The nursing homes themselves typically report the staffing and quality measures. Critics believe some nursing homes game them.

To arrive at a star rating for a nursing home, Medicare starts with the health inspections rating, then adds a star for a good staffing rating or subtracts one for a one-star health inspections rating. Next, Medicare adds a star if the quality of resident care rating is five stars and subtracts one if that rating is just one star. And if the health inspections rating is just one star, the overall Nursing Home Compare rating can’t be upgraded by more than one star based on the staffing and quality of resident care ratings.

At Yelp, anyone can post a review based on any criteria he or she chooses to use.

When Rahman and her fellow researchers compared Medicare and Yelp nursing home ratings, they often found four or five stars on one but not the other. That’s not because one of the services is wrong; it’s that the raters rate different things.

An Expert’s Take on the Medicare and Yelp Ratings

Rahman is “frustrated” that Medicare has no consumer voice in its ratings system “even though we are supposedly moving to a patient-centric, family-directed health care system.”

Her advice when using its ratings: look for nursing homes that fare well in each of Medicare’s three broad measures: health inspections, quality of resident care and staffing.

“If I saw that a nursing home got five stars for quality measures, but two on staffing and two on health inspection, I’d move on,” she says. “I’d assume they were lying about quality. You can’t get great quality care when your staffing score sucks. You need staff to provide that care.”

Rahman also says the Yelp platform “has its own set of flaws,” although “they allow well-intended consumers to express an opinion about services they have been receiving.” But, she adds, family members often write these reviews. “And [loved ones who are] the residents, don’t necessarily agree. They often disagree.”

Merging Medicare’s Nursing Home Ratings With Yelp’s

She thinks “a nice solution” would be if Medicare and Yelp collaborated, because “people would like a Yelp-like score” on Nursing Home Compare.

“I don’t think it will happen,” says Rahman.

So for now, if not forever, check out nursing home ratings from Medicare and Yelp. Then be sure to visit facilities you’re considering to see for yourself. And don’t be shy about asking questions of administrators or staff (the Medicare Nursing Home Checklist can help).

With the steep cost of nursing homes, and often an urgency to locate a facility, you can’t afford to be.