Monday, January 9, 2017

Diving Deeper into Approval of Short-Term Annuities in Medicaid Planning

3L Villanova Law Student Jennifer A. Ward has an interesting analysis of the Third Circuit's decision in Zahner v. Sec'y Pa Dept. of Human Servs., 802 F.3d 497 (3d Cir. 2015), published in a recent issue of the Villanova Law Review.  She begins with a summary of the Zahner decision and an outline of her analysis:

[T]he Third Circuit examined whether short-term annuities, a specific instrument used in Medicaid planning, qualified for the DRA's safe harbor provision. If so, assets used to purchase short-term annuities would be sheltered from factoring into individuals' eligibility for Medicaid. Holding that short-term annuities can qualify for protection, the Third Circuit's decision signifies that the DRA did not completely foreclose the “use of short-term annuities in Medicaid planning.”
 
This Casebrief argues that the Third Circuit's Zahner decision is a win for elder law attorneys and their clients, as it solidifies the viability of the use of short-term annuities in Medicaid planning. Part II examines how individuals take part in Medicaid planning, including a discussion of the DRA and the use of annuities in planning. Part III presents the facts of Zahner and reviews the Third Circuit's analysis. Part IV analyzes the Third Circuit's decision to approve the use of short-term annuities. Part V advises elder law practitioners on the use of short-term annuities going forward. Part VI concludes by discussing the long-term viability of short-term annuities.
 
The author recognizes the potential for Congress to change the outcome of the Zahner ruling: 
 
After Zahner, elder law practitioners are free to use short-term annuities while guiding their clients through the Medicaid planning process. The Third Circuit will not bar the use of qualified short-term annuities in Medicaid planning, instead leaving any change in policy to Congress. Therefore, until Congress acts, short-term annuities are a viable planning tool in the Third Circuit for the foreseeable future.For people who wish to leave assets to loved ones, Zahner presents good news. Rather than causing people to exhaust their savings on long-term care, Zahner provides individuals greater ability to protect resources through Medicaid planning.
 
The title of the article is Doctor's Orders: The Third Circuit Approves Short Term Annuities As a Viable Planning Tool, and is available through subscription on Westlaw and Lexis and appears to be forthcoming on a digital commons platform via the Villanova Law Review. 

January 9, 2017 in Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Thursday, December 29, 2016

Revised Nursing Home Regs-Resources Part II

The National Consumer Voice for Quality Long-Term Care has issued its second summary of the revised nursing home regulations. Summary of Key Changes in the Rule-Part II is a 19 page summary of phase 1 that covers changes to the resident assessment, comprehensive person-centered care planning, quality of life, quality of care, doctors and nursing services, behavioral health services, pharmacy services, lab, diagnostic and radiology services, dental, nutrition, and specialized rehab services, administration (the section that includes the ban on pre-dispute arbitration agreements), quality assurance, physical environment, controlling infection, and training (which includes training on recognizing, reporting and preventing abuse, neglect and exploitation). Read this, bookmark it, print it and save it!

December 29, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink

Wednesday, December 28, 2016

Student Loans and Social Security

Imagine a person who has at last retired, is drawing Social Security and still has outstanding student loans. Farfetched? Not at all. And, in fact, the GAO issued a report noting how Social Security checks are being reduced to repay these student loans. The Wall Street Journal explains about the report in the article, Social Security Checks Are Being Reduced for Unpaid Student Debt:

The report highlights the sharp growth in baby boomers entering retirement with student debt, most of it borrowed years ago to cover their own educations but some used to pay for their children’s schooling. Overall, about seven million Americans age 50 and older owed about $205 billion in federal student debt last year. About 1 in 3 were in default, raising the likelihood that garnishments will increase as more boomers retire.

Student loan debt isn't dischargeable in bankruptcy, but the effect of the government's actions is to leave some Social Security recipients below the poverty level.  "[C]onsumer advocates and some congressional Democrats say the government’s tactics have become too aggressive, targeting many borrowers who are destitute and have no hope of repaying. Most Social Security recipients rely on their checks as their primary source of income, other research shows."

The GAO report, Social Security Offsets: Improvements to Program Design Could Better Assist Older Student Loan Borrowers with Obtaining Permitted Relief offers the following findings

 Older borrowers (age 50 and older) who default on federal student loans and must repay that debt with a portion of their Social Security benefits often have held their loans for decades and had about 15 percent of their benefit payment withheld. This withholding is called an offset. GAO’s analysis of characteristics of student loan debt using data from the Departments of Education (Education), Treasury, and the Social Security Administration (SSA) from fiscal years 2001-2015 showed that for older borrowers subject to offset for the first time, about 43 percent had held their student loans for 20 years or more. In addition, three-quarters of these older borrowers had taken loans only for their own education, and most owed less than $10,000 at the time of their initial offset. Older borrowers had a typical monthly offset that was slightly more than $140, and almost half of them were subject to the maximum possible reduction, equivalent to 15 percent of their Social Security benefit. In fiscal year 2015, more than half of the almost 114,000 older borrowers who had such offsets were receiving Social Security disability benefits rather than Social Security retirement income.

In fiscal year 2015, Education collected about $4.5 billion on defaulted student loan debt, of which about $171 million—less than 10 percent—was collected through Social Security offsets. More than one-third of older borrowers remained in default 5 years after becoming subject to offset, and some saw their loan balances increase over time despite offsets. However, nearly one-third of older borrowers were able to pay off their loans or cancel their debt by obtaining relief through a process known as a total and permanent disability (TPD) discharge, which is available to borrowers with a disability that is not expected to improve.

GAO identified a number of effects on older borrowers resulting from the design of the offset program and associated options for relief from offset. First, older borrowers subject to offsets increasingly receive benefits below the federal poverty guideline. Specifically, many older borrowers subject to offset have their Social Security benefits reduced below the federal poverty guideline because the threshold to protect benefits—implemented by regulation in 1998—is not adjusted for costs of living (see figure below). In addition, borrowers who have a total and permanent disability may be eligible for a TPD discharge, but they must comply with annual documentation requirements that are not clearly and prominently stated. If annual documentation to verify income is not submitted, a loan initially approved for a TPD discharge can be reinstated and offsets resume.

A pdf of the 90 page report is available here. An accompanying podcast is available here.

December 28, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Social Security | Permalink | Comments (0)

Monday, December 26, 2016

Oregon Estate Recovery Rules Held Invalid

Attorney Tim Nay ( NAELA's first president by the way), recently posted on listservs about the Oregon Supreme Court's opinion on the state Medicaid agency's rules regarding estate recovery.  The Oregon Supreme Court, in Nay v. Department of Human Services, affirmed the court of appeals decision that the administrative rules were invalid:

In 2008, the department amended its administrative rules regarding the scope of that recovery. The amended rules allow the department to recover the payments from assets that the recipient had  transferred to a spouse up to five years before a person applies for Medicaid. Pursuant to ORS 183.400, petitioner Tim Nay sought judicial review of those rule amendments in the Court of Appeals. The Court of Appeals agreed with petitioner that the amendments were invalid ... and the department sought review. As we will explain, we conclude that the rule amendments are invalid under ORS 183.400(4)(b) because they exceed the department’s statutory authority. Accordingly, we affirm the Court of Appeals. (citations omitted).

After reviewing state family law and probate law (elective share) and the arguments advanced by the Department of Human Services, the Oregon Supreme Court concluded

The department promulgated rule amendments that allow it to obtain estate recovery from transfers made to a spouse within the five years before a person applies for Medicaid. Our standard for judicial review is whether the department exceeded its statutory authority ..., and more specifically whether the rule amendments depart from a legal standard expressed or implied in the particular law being administered.... Because “estate” is defined to include any property interest that a Medicaid recipient held at the time of death, the department asserted that the Medicaid recipient had a property interest that would reach those transfers. In doing so, it relied on four sources: the presumption of common ownership in a marital dissolution, the right of a spouse to claim an elective share under probate law, the ability to avoid a transfer made without adequate consideration, and the ability to avoid a transfer made with intent to hinder or prevent estate recovery. In all instances, the rule amendments departed from the legal standards expressed or implied in those sources of law. Accordingly, the rule amendments exceeded the department’s statutory authority..... The Court of Appeals correctly held the rule amendments to be invalid. (citations omitted).

The opinion is available here.

Congrats Tim and thanks for letting us know!

December 26, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, December 20, 2016

Rep Payee Interdisciplinary Training

Social Security has released a video series for Rep Payees that is an interdisciplinary training "to educate individuals and organizations about the roles and responsibilities of serving as a representative payee, elder abuse and financial exploitation, effective ways to monitor and safely conduct business with the banking community, and ways to recognize the changes in decisional capacity among vulnerable adults and seniors."  There are 5 videos (1 of which is a short introduction) with the 4 training videos running in length from 15-35 minutes, depending on the topic. The topics include technical training as a rep payeerecognizing financial exploitation and vulnerable adult abuse, strategies for dealing with the financial community and changes in a beneficiary's decisional capacity. A transcript is available in addition to the video.

 

December 20, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Social Security | Permalink | Comments (0)

Monday, December 19, 2016

FAQ on Wandering from CMS

Last week CMS issued an FAQ for Medicaid beneficiaries in the community who wander. FAQs concerning Medicaid Beneficiaries in Home and Community-Based Settings who Exhibit Unsafe Wandering or Exit-Seeking Behavior offers 4 FAQs. Each FAQ offers suggestions for providers. For example, FAQ 3 offers suggestions for staffing, "environmental design" and activities while FAQ 4 offers actions that the providers can take, such as "[e]nsuring that individuals have opportunities to visit with and go out with family members and friends, when they want this."  The 4 FAQs are:

  1.  How can residential and adult day settings comply with the HCBS settings requirements while serving Medicaid beneficiaries who may wander or exit-seek unsafely?

  2. Can provider-controlled settings with Memory Care Units with controlled-egress comply with the new Medicaid HCBS settings rule? If so, what are the requirements for such settings?

  3. What are some promising practices that HCBS settings use to serve people who are at risk of unsafe wandering or exit-seeking?

  4. How can residential and adult day settings promote community integration for people who are at risk of unsafe wandering or exit-seeking? What are some examples of promising practices for implementing the community integration requirements of the regulations defining home and community-based settings and simultaneously assuring the safety of individuals who exhibit these behaviors?

     

 

 

December 19, 2016 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Thursday, December 15, 2016

Pot Popular with Boomers?

Kaiser Health News (KHN) reported on a study about use of pot by Boomers. Seniors Increasingly Getting High, Study Shows explains the results of a recent study:

Baby boomers are getting high in increasing numbers, reflecting growing acceptance of the drug as treatment for various medical conditions, according to a study published Monday in the journal Addiction.

The findings reveal overall use among the 50-and-older study group increased “significantly” from 2006 to 2013. Marijuana users peaked between ages 50 to 64, then declined among the 65-and-over crowd.

The article notes that the researchers call for more study regarding the long-term effects of the use of pot and that health care providers should be careful to not assume that an elder doesn't use drugs: "Joseph Palamar, a professor at the NYU medical school and a co-author of the study, said the findings reinforce the need for research and a call for providers to screen the elderly for drug use... 'They shouldn’t just assume that someone is not a drug user because they’re older,” Palamar said."

The article discusses the disparity of approaches between states that have legalized marijuana use and the federal government position. 

The push and pull between state and federal governments has resulted in varying degrees of legality across the United States. Palamar says this variation places populations at risk of unknowingly breaking the law and getting arrested for drug possession. The issue poses one of the biggest public health concerns associated with marijuana, Palamar says.

But unlike the marijuana of their youth, seniors living in states that legalized marijuana for medicinal use now can access a drug that has been tested for quality and purity, said Paul Armentano deputy director of NORML, a non-profit group advocating for marijuana legalization. Additionally, the plant is prescribed to manage diseases that usually strike in older age, pointing to an increasing desire to take a medication that has less side effects than traditional prescription drugs.

The full article, Demographic trends among older cannabis users in the United States, 2006–13 is available for a fee here.  The abstract explains

Background and Aims

The ageing US population is providing an unprecedented population of older adults who use recreational drugs. We aimed to estimate the trends in the prevalence of past-year use of cannabis, describe the patterns and attitudes and determine correlates of cannabis use by adults age 50 years and older....

Findings

The prevalence of past-year cannabis use among adults aged ≥ 50 increased significantly from 2006/07 to 2012/13, with a 57.8% relative increase for adults aged 50–64 (linear trend P < 0.001) and a 250% relative increase for those aged ≥ 65 (linear trend P = 0.002). When combining data from 2006 to 2013, 6.9% of older cannabis users met criteria for cannabis abuse or dependence, and the majority of the sample reported perceiving no risk or slight risk associated with monthly cannabis use (85.3%) or weekly use (79%). Past-year users were more likely to be younger, male, non-Hispanic, not have multiple chronic conditions and use tobacco, alcohol or other drugs compared with non-past-year cannabis users.

Conclusions

The prevalence of cannabis use has increased significantly in recent years among US adults aged ≥ 50 years.

December 15, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, December 13, 2016

GAO: Nursing Home Compare Website Needs Improvement

The GAO recently issued a report on the nursing home compare website.

Here are the highlights:

 GAO found that the Centers for Medicare & Medicaid Services (CMS) collects information on the use of the Nursing Home Compare website, which was developed with the goal of assisting consumers in finding and comparing nursing home quality information. CMS uses three standard mechanisms for collecting website information—website analytics, website user surveys, and website usability tests. These mechanisms have helped identify potential improvements to the website, such as adding information explaining how to use the website. However, GAO found that CMS does not have a systematic process for prioritizing and implementing these potential improvements. Rather, CMS officials described a fragmented approach to reviewing and implementing recommended website changes. Federal internal control standards require management to evaluate appropriate actions for improvement. Without having an established process to evaluate and prioritize implementation of improvements, CMS cannot ensure that it is fully meeting its goals for the website.

GAO also found that several factors inhibit the ability of CMS’s Five-Star Quality Rating System (Five-Star System) to help consumers understand nursing home quality and choose between high- and low- performing homes, which is CMS’s primary goal for the system. For example, the ratings were not designed to compare nursing homes nationally, limiting the ability of the rating system to help consumers who live near state borders or have multistate options. In addition, the Five-Star System does not include consumer satisfaction survey information, leaving consumers to make nursing home decisions without this important information. As a result, CMS cannot ensure that the Five-Star System fully meets its primary goal.

The full report is available here.

December 13, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Monday, December 12, 2016

Medicare Observation Notice Form

You will recall the issues with Medicare patients on observation status, rather than having been admitted into the hospital. The NOTICE Act was intended to ensure patients knew whether they had been admitted or were on observation status.  CMS has released the observation status notice, known as MOON. The fact sheet explains

Enacted August 6, 2015, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of such status. 

The  notice, CMS-10611, is available here.  (click on the link to open the zip file).

December 12, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Thursday, December 8, 2016

New Brief: A Closer Look at the Revised Nursing Facility Regulations

The National Consumer Voice for Quality Long-Term Care, the Center for Medicare Advocacy and Justice in Aging have released the first in a series of briefs regarding the changes to the Nursing Facility regulations.  This first brief focuses on Assessment, Care Planning & Discharge Planning.

Here is the executive summary:

Revised nursing facility regulations broadly affect facility practices, including assessment care planning and discharge planning. The revised assessment process places greater emphasis on a resident’s preferences, goals, and life history. Regarding care planning, a facility must develop and implement a baseline care plan within 48 hours of a resident’s admission, with the comprehensive care plan to be developed subsequently. The care planning team has been expanded to require (among other things) participation by a nurse aide with responsibility for the resident, and the facility must facilitate resident participation. Care planning should include planning for discharge, and the facility must document any determination that discharge to the community is not feasible.

A facility now will have to complete an assessment as well as a baseline care plan that has to be done within 48 hours from admission, as well as a "'comprehensive, person-centered care plan; for each resident within seven days of the initial assessment."

As far as effective dates, the brief explains that "[t]he revised regulations’ assessment provisions are effective on November 28, 2016. Most care planning and discharge planning provisions will be effective on the same date, except for provisions relating to baseline care plans (11/28/2017) and trauma informed care (11/28/2019)."

Be sure to bookmark this brief (or save it to your important documents folder) and keep an eye out for the subsequent briefs. Kudos to these 3 amazing organizations!

 

December 8, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

21st Century Cures Act

The Senate passed the 21st Century Cures Act, HR 34, on December 7, 2016. Having already passed the House, the bill goes to the President for signature.  There are two specific provisions in the Cures Act that bear mention:

The Special Needs Trust Fairness Act in section 5007, which allows a beneficiary with capacity to establish her own first-party SNT (finally) and Section 14017 which deals with capacity of Veterans to manage money.

Section 5007 provides:

SEC. 5007. Fairness in Medicaid supplemental needs trusts.

(a) In general.—Section 1917(d)(4)(A) of the Social Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended by inserting the individual, after for the benefit of such individual by.

(b) Effective date.—The amendment made by subsection (a) shall apply to trusts established on or after the date of the enactment of this Act.

Section 14017 amends 38 USC chapter 55 by adding new section 5501A "Beneficiaries’ rights in mental competence determinations"

The Secretary may not make an adverse determination concerning the mental capacity of a beneficiary to manage monetary benefits paid to or for the beneficiary by the Secretary under this title unless such beneficiary has been provided all of the following, subject to the procedures and timelines prescribed by the Secretary for determinations of incompetency:

“(1) Notice of the proposed adverse determination and the supporting evidence.

“(2) An opportunity to request a hearing.

“(3) An opportunity to present evidence, including an opinion from a medical professional or other person, on the capacity of the beneficiary to manage monetary benefits paid to or for the beneficiary by the Secretary under this title.

“(4) An opportunity to be represented at no expense to the Government (including by counsel) at any such hearing and to bring a medical professional or other person to provide relevant testimony at any such hearing.”.

The effective date for the VA amendment is for "determinations made by the Secretary of Veterans Affairs on or after the date of the enactment...."

The President is expected to sign the bill soon. More to follow.

December 8, 2016 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Property Management, Veterans | Permalink | Comments (0)

Monday, December 5, 2016

First Annual Report - White House Legal Aid Interagency Roundtable

The 1st Annual Report of the White House Legal Aid Interagency Roundtable (WH-LAIR), Expanding Access to Justice, Strengthening Federal Programs  was released last month.  A fact sheet accompanying the report is available here.  According to the DOJ website, the reason for WH-LAIR is

to raise federal agencies’ awareness of how civil legal aid can help advance a wide range of federal objectives including improved access to health and housing, education and employment, family stability and public safety. The Legal Aid Interagency Roundtable’s message included that providing legal assistance to people who cannot afford it can also have substantial economic benefits by preventing outcomes that are harmful to them and expensive for the communities.  

WH-LAIR is made up of a number of federal agencies. The fact sheet highlights some of the accomplishments, including an ElderJustice AmeriCorp which provides teams of attorneys and paralegals to help elder abuse victims.  This first report covers the 4 years of operation of WH-LAIR.  The report highlights the participating agencies' efforts to incorporate legal aid into their programs. policy recommendations to improve access to justice, furthering strategic partnerships, furthering data collection, evidence-based research, and concomitant analysis. The full report has 3 sections: (1) legal aid overview and its correlation to advancing federal priorities, (2) how the agencies have incorporated legal aid into their programs and (3) future opportunities to continue and expand their work.

 

 

December 5, 2016 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Legal Practice/Practice Management | Permalink | Comments (0)

Thursday, December 1, 2016

FAQ on LTC Ombudsman Rule

The Administration on Aging (AoA) issued FAQ on the Long Term Care Ombudsman Program.  The purpose of the FAQs  is " to assist State Agencies on Aging, States’ Long-Term Care Ombudsman Programs, and other entities that work with Ombudsman programs with implementation of the State Long-Term Care Ombudsman Programs Rule." Each FAQ provides extensive explanation as well as cites to the appropriate sections of the CFR.

December 1, 2016 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (0)

Monday, November 28, 2016

Summary of Nursing Home Regs

The National Consumer Voice For Quality Long-Term Care has released a fact sheet explaining the changes to the Federal Nursing Home Regulations.   The 15 page fact sheet " provides a brief overview of key changes in the sections on Resident Rights; Freedom from Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge that will go into effect in Phase 1. The purpose of the summary is to highlight what is different between the prior rule and the final rule." The fact sheet is organized by sections of the CFR and explains what is amended and what is new./  Print this out and save it. It's invaluable!

 

November 28, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Medicare Beneficiaries with Physical/Cognitive Impairments and Nursing Home Placement

here.Last month the Commonwealth Fund published an issue brief about the correlation between Medicare beneficiaries with Physical and/or cognitive impariments and the connection to Medicaid and nursing home placements. With all the talk about changes to Medicare and Medicaid, this is a timely topic (but it always is timely), Risks for Nursing Home Placement and Medicaid Entry Among Older Medicare Beneficiaries with Physical or Cognitive Impairment. Here is the abstract:

Issue: More than half of individuals who age into Medicare will experience physical and/or cognitive impairment (PCI) at some point that hinders independent living and requires long-term services and supports. As a result of Medicare’s limits on covered services, Medicare beneficiaries with PCI experience financial burdens and reduced ability to live independently. Goal: Describe the characteristics and health spending of Medicare beneficiaries with PCI and estimate the likelihood of Medicaid entry and long-term nursing home placement. Methods: The Health and Retirement Study 1998–2012 is used to estimate long-term nursing home placement, as well as Medicaid entry. The Medicare Current Beneficiary Survey 2012 provides information on health care spending and utilization. Key findings and conclusions: Almost two-thirds of community-dwelling Medicare beneficiaries with PCI have three or more chronic conditions. More than one-third of those with PCI have incomes less than 200 percent of the federal poverty level but are not covered by Medicaid; almost half spend 10 percent or more of their incomes out-of-pocket on health care. Nineteen percent of individuals with PCI and high out-of-pocket costs entered Medicaid over 14 years, compared to 10 percent without PCI and low out-of-pocket costs.

The brief offers background, data and analysis. For expediency, I've included the conclusion here. I recommend you read the entire brief.

This analysis finds that:

  • A third of older adults have PCI in a given year; more than half of adults who age into Medicare will experience PCI over the remainder of their lifetimes. While the majority of older adults with PCI live in the community, they are at high risk for costly, long-term nursing home placement.
  • Individuals with PCI often have multiple chronic conditions, resulting in high Medicare expenses and out-of-pocket spending. Those with high out-of-pocket spending as a proportion of income as well as PCI were at greater risk for spending down their resources and entering into Medicaid over a 14-year period, compared to those with PCI but without high out-of-pocket spending.
  • The risk for Medicaid entry was greater for those at lower income levels at the beginning of the 14-year period. However, 14 percent of the highest-income group at baseline with high out-of-pocket spending and PCI entered Medicaid by the end of the follow-up period.

Improving financing for home and community-based care would help many beneficiaries with PCI continue to live independently and support families in helping them obtain the care they prefer. Our current health care system, which covers costly institutional services but not social support in the home, distorts the way Americans receive care as they age and die. After people with serious impairment become impoverished and qualify for Medicaid, they are covered for long-term nursing facility care. However, personal care services at home that might have prevented them from needing to turn to Medicaid or enter a nursing home are not covered by Medicare.

Intervening early to prevent nursing home placement and Medicaid enrollment may produce offsetting savings in Medicare and Medicaid. An accompanying brief describes two innovative approaches to providing long-term services and support benefits: a voluntary, supplemental benefit for home and community-based services for Medicare beneficiaries; and an expansion of the Medicaid Community First Choice program for people with incomes up to 200 percent of poverty. Both options show promise of maintaining independent living longer and avoiding costly long-term institutionalization and exhaustion of resources that result in Medicaid enrollment.

(citations omitted).

The brief is also available as a pdf here.

November 28, 2016 in Cognitive Impairment, Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Tuesday, November 22, 2016

Block Grants for Medicaid-How States Might Fare?

We blogged earlier about the discussion regarding switching Medicaid to block grants. The impact of doing so would be far reaching and the Commonwealth Fund released an issue brief, What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?

Here is the abstract from the issue brief:

Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans. Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee. Methods: Review of existing policy proposals and other documents. Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.

The article provides history, data and discusses strategies. The Brief concludes that the issue, and the resulting outcomes, are not as simple as may be presented.

As the country’s largest insurer, Medicaid is subject to the same cost drivers that affect all providers of health insurance: population growth and demographic trends that increase enrollment, health trends that influence how often people need care and what kind of care they require, and advances in technology that drive up costs, among other factors. But unlike commercial insurers, government-funded Medicaid, in its role as first responder and safety net, is more vulnerable to these trends and to cost increases. For more than 50 years, Medicaid has been rooted in a flexible federal–state partnership, constantly restructured over time to meet current challenges.

Any attempt to restructure federal financing for Medicaid and replace flexibility with strict spending limits—whether in the form of block grants, per capita limits on spending, restrictions on what counts as state expenditures, or a combination of all three—would divorce funding considerations from the real-life needs that have informed federal and state Medicaid policy for half a century. Crucially, a per capita cap would permit population growth to occur. But the limit of lawmakers’ appetite for continued growth in enrollment is unclear. Given how states responded to the relatively mild and temporary funding reductions the federal government enacted in 1981, sweeping changes like those currently under consideration are likely to produce far more substantial fallout.

The 10 page issue brief can be downloaded as a pdf here.

November 22, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, State Statutes/Regulations | Permalink | Comments (0)

New Handbook-Coordination of Benefits and Medicaid

CMS has released a new handbook, Coordination of Benefits and Third Party Liability (COB/TPL) In Medicaid (2016).  The explanation of the Handbook offers a section "About This Handbook":  "Purpose: The purpose of the Handbook is to provide an overview of COB/TPL policy on a variety of individual subjects... 2. Intended Audience: The Handbook is intended for CMS Central Office (CO) and Regional Office (RO) staff working on COB/TPL issues, state Medicaid agency staff, and all other parties interested in Medicaid COB/TPL policies... 3. Content: The Handbook contains policy guidance on a variety of COB/TPL topics that is current at the time of publication. .."

The manual is available here for download as a pdf.

 

November 22, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Wednesday, November 16, 2016

Deja Vu? Cutting Entitlements?

A colleague yesterday sent me a link to a story about Speaker Ryan's plan to introduce cuts to Medicare (or eliminate it in its current form as we know it).  (Of course, this was after the class where we had just finished covering Medicare).  All I could think was, not again.... By not again, I meant here is another proposal heading to Congress to change (or eliminate) one of the entitlement programs.  We've weathered the proposals to change Social Security (Remember the Commission appointed by President George W. Bush?). Now it's Medicare. 

There is information on Speaker Ryan's website about his plan to change Medicare.  A series of articles have popped up in the last few days as a result of his recent interview appearing on Fox.  In Talking Points Memo, Ryan Plans to Phase Out Medicare in 2017, the transcript of the interview appears. Here's a quote:

What people don't realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, medicaid is in fiscal straits. You have to deal with those issues if you are going to repeal and replace obamacare. Medicare has serious problems [because of] Obamacare. Those are part of our plan.

The article describes his position as a phase-out of Medicare, although current beneficiaries keep Medicare.

Money magazine also ran an article, questioning the Speaker's assertion that Medicare is going broke.  Is Medicare Really Going Broke, Like Paul Ryan Says?

Here’s the thing: Medicare is on an unsustainable spending path, but it’s not going broke. “The idea that we have a crisis is just nonsense,” says Dr. Robert Berenson, a fellow at the Urban Institute, a nonpartisan research organization, and formerly an official at the Centers for Medicare and Medicaid Services. And Obamacare is not the culprit for Medicare’s fiscal woes.

The article notes that his plan proposes 

changes [that] generally fall under the terms “privatization,” or “premium support.” While it remains unclear exactly what this would look like, it may mean giving beneficiaries some sort of fixed dollar amount to buy their own private insurance as an alternative to, or even replacement for, original Medicare... Under this type of system, beneficiaries who choose the lowest-cost coverage will stretch their government subsidy the farthest—which ironically, is how Obamacare works today.

The Washington Post ran an article about it, focusing on whether this is an "opportunity" for the Democrats, Paul Ryan’s plan to phase out Medicare is just what Democrats need. The Washington Post article offers a sobering assessment

If Ryan gets his way, Medicare as a universal insurance program will cease to exist. It will be replaced by “premium support,” or vouchers which seniors will use to buy private insurance. If you can’t afford any of the available plans with what the voucher is worth, tough luck. The whole point is to transfer the expense from Medicare to the seniors themselves. Half a century after Medicare brought health security to America’s seniors, Republicans would snuff it out, leaving some unknown number without any coverage at all and breaking the fundamental promise the government made.

Serious bummer folks.

November 16, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Monday, November 14, 2016

2017 Medicare Premiums

CMS announced the 2017 premiums on November 10, 2016. Since the 2017 SSA COLA is so low, the hold harmless provision will kick in for many.  For the Part B premium, most will pay $109.00 because of the "hold harmless" while others will pay $134.  The income adjusted part B premium for higher income beneficiaries starts at $187.50 and tops out at $428.60 for a single person. The 2017 annual Part B deductible will be $183. 

The Part A inpatient hospital deductible for 2017 will be $1,316, and the SNF co-pay for days 21-100 will be $164.50 in 2017. More of the 2017 figures are available here.

November 14, 2016 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Monday, November 7, 2016

Federal District Court Enjoins Pre-Arbitration Dispute Rule

A federal district court in Mississippi has entered an injunction prohibiting the CMS rule against pre-dispute arbitration from taking effect at the end of  this month.  According to a story on NPR, "[t]he reason for granting the injunction, the court explained in its order, is that it believes the new rule represents "incremental 'creep' of federal agency authority" — in this case the Centers for Medicare & Medicaid Services — 'beyond that envisioned by the U.S. Constitution.'"

The 40 page order is available here.

 

November 7, 2016 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)