Hook Law Center: Hospitalization as an Inpatient vs. "Under Observation:" If You’re Medicare Eligible, the Difference Can Be Very Costly
- 10-30-2012
11:21
AM - Author:
Hospital Admission Advisory
Do you know the difference between being admitted to a hospital as an INPATIENT or as someone UNDER OBSERVATION? If you’re eligible for Medicare, the difference can be very costly. Consider the scenario of Laraine Sickels, a retired teacher from Whidbey Island, Washington. At 71 she went to the hospital because she had fallen at a friend’s house. It was determined that she had 3 breaks to her pelvis. She spent 5 days in the hospital, but during that time she was only considered “under observation.” Unaware of this, when it came time to be discharged, she was released to a skilled nursing facility. That’s where the problem started. She got good care there, but because she had not been spent 3 days in a hospital as an inpatient, her 10-day stay at the skilled nursing facility was hers to pay. Medicare covers the first 20 days in a skilled nursing facility completely as long as you’ve been in the hospital at least 3 days classified as “inpatient”. In addition, that same patient who was classified as “inpatient” will pay for days 21-100 at the skilled nursing facility at the rate of $144.50, a fraction of the true cost. (Amanda Gengler, “This could hurt–a lot,” Money Magazine, August 2012, p. 72-3)
So what’s happening? Well, Medicare is attempting to trim expenses. One way they’ve decided to do this is that, for certain cases, the patient who may have only one ailment gets classified as “under observation” while tests are run. This classification allows them to reimburse hospitals at a lower rate. “In 2009, the most recent data available, observation stays topped 1 million, up 25% from 2007, according to a study published by researchers at Brown University.” (Gengler, p. 72) From their point of view, your care is the same. Medicare just winds up paying a lot less.
So how can you ensure that you will have the favorable classification of “inpatient?” Well, first of all, you must ask what your classification is. If it is not “inpatient” then you must ask that your doctor review your situation and possibly take it to a hospital review committee. The time to get your status changed is while you are in the hospital, not after discharge, when it is impossible. Make sure everyone is aware of your past medical history or other risk factors which may favorably influence the classification. (Gengler, p. 74-75)
If you still remain “under observation,” you have the option upon discharge of receiving home help, if that is a workable option. Medicare will cover some in-home help, even if you weren’t “inpatient.” Also, if you must go to the nursing home to recuperate, you can ask the nursing home to bill Medicare. That gets you in the system. You will be denied by Medicare, but after 2 denials, your case then goes to an administrative law judge. At that point, you will need the doctor involved in your care to testify or write a letter on your behalf. You may also want to consider help from an elder law attorney or from the nonprofit Center for Medicare Advocacy at medicareadvocacy.org. (Gengler, p. 74-75) The attorneys at Hook Law Center are experts in Medicare advocacy.
Hook Law Center has been providing the highest quality of legal advice to the communities of Hampton Roads for more than 80 years. Our practice is dedicated to seniors, and disabled persons, their families and advocates. Our professional staff can respond to our client’s care needs on a 24 hour basis, and our Attorneys are available to provide expertise on every issue facing senior citizens from long-term and life care planning to estate and trust issues as well as financial, investment, public benefit, and insurance assistance. Visit their website for more information.
….
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Medicare May No Longer Use Improvement Standard to Deny Short-Term Skilled Care
- 10-30-2012
13:11
PM - Author:
The beginning of open enrollment and intense speculation about the election’s impact on Medicare are not the only Medicare-related headlines these days. A new development may greatly help Medicare beneficiaries with chronic conditions who need skilled nursing and rehabilitation.
In the past, Medicare would continue to cover skilled nursing care and short-term rehabilitation, like physical and speech therapy, only if the patient demonstrated that he had the potential to improve as a result of treatment. Obviously, those with chronic conditions like Alzheimer’s Disease, heart disease, Parkinsons, Lou Gehrigs disease, arthritis – in other words, those who could not meet the so-called improvement standard — were most impacted by this rule. (In fact, the so-called “improvement standard” was technically never a part of Medicare law; it had simply become the de facto standard used by Medicare decision makers.)
Now, a federal court has ruled that the improvement standard cannot be used to deny Medicare coverage for skilled nursing care and rehabilitation. The settlement in the class action lawsuit Jimmo v. Sibelius requires Medicare to cover skilled nursing and therapy even if it just maintains a person’s medical condition or prevents further deterioration. The proposed settlement was reached in federal district court on Oct. 16, 2012.
However, it’s critical to note these important caveats:
- The case does not change the maximum number of days of skilled care Medicare covers per benefit period. Medicare will pay 100% for a maximum of 100 days, and only if it follows a hospital stay or stay in a rehab facility.
- The case does not impact whatsoever on long-term, custodial nursing care, which is still not covered by Medicare, but may be covered under certain circumstances and with proper planning by Florida Medicaid.
More details here.
Attorney Joseph S. Karp is a
Florida Bar Certified and Nationally Certified Elder Law Attorney focusing on
Elder Law, Probate, Estate Planning, Asset Protection, Special Needs Planning
and Estate Litigation. He is AV rated by Martindale Hubbell. Mr. Karp is the
founder of The Karp Law Firm, a South Florida law firm with offices in Palm
Beach Gardens, Boynton Beach and St. Lucie, Florida. Mr. Karp was named a
2011 SuperLawyer by SuperLawyer Magazine and a member of the 2011
Florida Legal Elite by Florida Trend Magazine. He is admitted to
practice law in New York as well as Florida. Visit Mr. Karp’s Florida Elder Law and Estate Planning
website.
. . . .
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Medicare May No Longer Use Improvement Standard to Deny Short-Term Skilled Care
- 10-30-2012
13:11
PM - Author:
The beginning of open enrollment and intense speculation about the election’s impact on Medicare are not the only Medicare-related headlines these days. A new development may greatly help Medicare beneficiaries with chronic conditions who need skilled nursing and rehabilitation.
In the past, Medicare would continue to cover skilled nursing care and short-term rehabilitation, like physical and speech therapy, only if the patient demonstrated that he had the potential to improve as a result of treatment. Obviously, those with chronic conditions like Alzheimer’s Disease, heart disease, Parkinsons, Lou Gehrigs disease, arthritis – in other words, those who could not meet the so-called improvement standard — were most impacted by this rule. (In fact, the so-called “improvement standard” was technically never a part of Medicare law; it had simply become the de facto standard used by Medicare decision makers.)
Now, a federal court has ruled that the improvement standard cannot be used to deny Medicare coverage for skilled nursing care and rehabilitation. The settlement in the class action lawsuit Jimmo v. Sibelius requires Medicare to cover skilled nursing and therapy even if it just maintains a person’s medical condition or prevents further deterioration. The proposed settlement was reached in federal district court on Oct. 16, 2012.
However, it’s critical to note these important caveats:
- The case does not change the maximum number of days of skilled care Medicare covers per benefit period. Medicare will pay 100% for a maximum of 100 days, and only if it follows a hospital stay or stay in a rehab facility.
- The case does not impact whatsoever on long-term, custodial nursing care, which is still not covered by Medicare, but may be covered under certain circumstances and with proper planning by Florida Medicaid.
More details here.
Attorney Joseph S. Karp is a
Florida Bar Certified and Nationally Certified Elder Law Attorney focusing on
Elder Law, Probate, Estate Planning, Asset Protection, Special Needs Planning
and Estate Litigation. He is AV rated by Martindale Hubbell. Mr. Karp is the
founder of The Karp Law Firm, a South Florida law firm with offices in Palm
Beach Gardens, Boynton Beach and St. Lucie, Florida. Mr. Karp was named a
2011 SuperLawyer by SuperLawyer Magazine and a member of the 2011
Florida Legal Elite by Florida Trend Magazine. He is admitted to
practice law in New York as well as Florida. Visit Mr. Karp’s Florida Elder Law and Estate Planning
website.
. . . .
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….
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Hook Law Center: For Medicaid, Long-Term Care Costs of Elderly are Rising
- 11-01-2012
09:35
AM - Author:
It should be no surprise that the costs for the long-term care of the elderly are rising. The baby boom generation is now aging, and there are many more of them to take care of. Many of their parents are still requiring services as well. While some people may think only the indigent utilize Medicaid to pay for in-home care or a nursing home, think again. Many middle class people are accessing Medicaid’s benefits, too, because longer lives are requiring more financial resources than ever before.
Medicaid is an extremely costly program. “Medicaid spends more than five times as much on each senior in long-term care as it does on each poor child, and even more per person on the disabled in long-term care.” (Nina Bernstein, “With Medicaid, Long-Term Care of Elderly Looms as a Rising Cost,” The New York Times, September 6, 2012) The presidential election could have a profound effect on the future of Medicaid. Republicans are proposing to replace Medicaid with block grants that reduce spending by a third over the next 10 years. With their proposal, states could change such things as minimum eligibility, standards of care, and federal rules that now shield adult children from the liability of paying their parents’ Medicaid bill. (Bernstein, see above)
Experimentation with such cost-cutting ideas is already underway in some states through the waiver mechanism. 26 states are seeking or have obtained waivers, including New York, California, Illinois, and Texas. These are states with large populations. If they can successfully tinker with Medicare, then other states may follow their lead. Look at New York, for example. It has the biggest Medicaid budget in the country– $54 billion. 41% of that amount is spent on long-term care, and almost half of that 41% is spent on nursing home care.
By 2015, New York will start requiring 78,000 nursing home residents to enroll in a choice of managed care plans or randomly be assigned to one. (Bernstein, see above)
However, some doubt the success managed care will have. H. Stephen Kaye, a professor at the Institute on Health and Aging at the University of California, San Francisco is one who thinks there is not much evidence about whether managed care saves money in the long run for those who need long-term care. What could happen is the unintended consequence that there will be an increase in requests for in-home care. “While home care is generally much cheaper than nursing homes, states may wind up unleashing a pent-up demand for home care from eligible people who could never have entered a nursing home anyway.” (Bernstein, see above)
So stay tuned. Currently, even with Medicaid coverage, individuals/families are supplementing costs for nursing homes. Individuals/families pay 22% of the $178 billion expended for nursing home care. (Bernstein, see above) This percentage is likely to rise, no matter who wins the presidential election. The public wants the coverage, but they want someone else to pay it. One thing is sure–medical costs are certain to rise as more is learned about prolonging life. The only thing that is not certain is who is going to pay for that care. The attorneys at the Hook Law Center can assist families confronting the high cost of long-term care for a loved one by assisting them in qualifying for VA and Medicaid long-term care assistance.
Hook Law Center has been providing the highest quality of legal advice to the communities of Hampton Roads for more than 80 years. Our practice is dedicated to seniors, and disabled persons, their families and advocates. Our professional staff can respond to our client’s care needs on a 24 hour basis, and our Attorneys are available to provide expertise on every issue facing senior citizens from long-term and life care planning to estate and trust issues as well as financial, investment, public benefit, and insurance assistance. Visit their website for more information.
….
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Hook Law Center: For Medicaid, Long-Term Care Costs of Elderly are Rising
- 11-01-2012
09:35
AM - Author:
It should be no surprise that the costs for the long-term care of the elderly are rising. The baby boom generation is now aging, and there are many more of them to take care of. Many of their parents are still requiring services as well. While some people may think only the indigent utilize Medicaid to pay for in-home care or a nursing home, think again. Many middle class people are accessing Medicaid’s benefits, too, because longer lives are requiring more financial resources than ever before.
Medicaid is an extremely costly program. “Medicaid spends more than five times as much on each senior in long-term care as it does on each poor child, and even more per person on the disabled in long-term care.” (Nina Bernstein, “With Medicaid, Long-Term Care of Elderly Looms as a Rising Cost,” The New York Times, September 6, 2012) The presidential election could have a profound effect on the future of Medicaid. Republicans are proposing to replace Medicaid with block grants that reduce spending by a third over the next 10 years. With their proposal, states could change such things as minimum eligibility, standards of care, and federal rules that now shield adult children from the liability of paying their parents’ Medicaid bill. (Bernstein, see above)
Experimentation with such cost-cutting ideas is already underway in some states through the waiver mechanism. 26 states are seeking or have obtained waivers, including New York, California, Illinois, and Texas. These are states with large populations. If they can successfully tinker with Medicare, then other states may follow their lead. Look at New York, for example. It has the biggest Medicaid budget in the country– $54 billion. 41% of that amount is spent on long-term care, and almost half of that 41% is spent on nursing home care.
By 2015, New York will start requiring 78,000 nursing home residents to enroll in a choice of managed care plans or randomly be assigned to one. (Bernstein, see above)
However, some doubt the success managed care will have. H. Stephen Kaye, a professor at the Institute on Health and Aging at the University of California, San Francisco is one who thinks there is not much evidence about whether managed care saves money in the long run for those who need long-term care. What could happen is the unintended consequence that there will be an increase in requests for in-home care. “While home care is generally much cheaper than nursing homes, states may wind up unleashing a pent-up demand for home care from eligible people who could never have entered a nursing home anyway.” (Bernstein, see above)
So stay tuned. Currently, even with Medicaid coverage, individuals/families are supplementing costs for nursing homes. Individuals/families pay 22% of the $178 billion expended for nursing home care. (Bernstein, see above) This percentage is likely to rise, no matter who wins the presidential election. The public wants the coverage, but they want someone else to pay it. One thing is sure–medical costs are certain to rise as more is learned about prolonging life. The only thing that is not certain is who is going to pay for that care. The attorneys at the Hook Law Center can assist families confronting the high cost of long-term care for a loved one by assisting them in qualifying for VA and Medicaid long-term care assistance.
Hook Law Center has been providing the highest quality of legal advice to the communities of Hampton Roads for more than 80 years. Our practice is dedicated to seniors, and disabled persons, their families and advocates. Our professional staff can respond to our client’s care needs on a 24 hour basis, and our Attorneys are available to provide expertise on every issue facing senior citizens from long-term and life care planning to estate and trust issues as well as financial, investment, public benefit, and insurance assistance. Visit their website for more information.
….
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Deducting the Cost of Life in a Retirement Community
- 11-06-2012
07:41
AM - Author:
Many Sarasota and Manatee County Florida residents in our aging population are transitioning from home ownership to living in a “continuing care retirement community” (“CCRC”). To enter a Sarasota or Manatee County Florida CCRC, an individual will pay a one-time entry fee and then ongoing monthly charges for housing and services (meal plans, housekeeping, transportation, and social and recreational activities). The benefit of a Sarasota or Manatee County Florida CCRC is that when a resident’s health and personal care needs become more acute, they are not forced to move to a new facility as their level of service can be increased to include assisted living, long-term care and skilled nursing care. Although the costs of a CCRC can be substantial, a percentage of the costs can be deducted as a medical expense income tax deduction either by the individual or third party (if they are providing more than half of the resident’s support).
Section 213(a) of the Internal Revenue Code allows as a deduction any expenses that are paid during the taxable year for the medical care of the Sarasota or Manatee County Florida resident, his spouse, and dependents and that are not compensated for by insurance or otherwise. Estate of Smith v. Commissioner, 79 T.C. 313, 318 (1982) [enhanced version available to lexis.com subscribers]. The deduction is allowed only to the extent the amount exceeds 7.5 percent of adjusted gross income. Sec. 213(a); sec. 1.213-1(a)(3), Income Tax Regs. For purposes of Sec. 213 the term “medical care” includes amounts paid “for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body”.
Support for the medical expense deduction is derived from the 2004 U.S. Tax Court decision of Delbert L. Baker v. Commissioner, 122 TC 143, 2004 [enhanced version available to lexis.com subscribers]. In Baker the taxpayers resided in an upscale California CCRC. On their income tax returns, the Bakers claimed medical expense deductions equal to about 27% of their first-year entry fee and about 40% of their monthly fees. The IRS denied a large percentage of the Baker’s claimed deductions, and the couple took the case to the Tax Court and mostly won (losing only with respect to their attempt to claim medical deductions for expenses allocable to the CCRC’s swimming pool, spa, and gym). The Tax Court ruled that the amount of CCRC fees that can be treated as medical expenses for tax purposes depends only upon the CCRC’s aggregate medical expenditures in relation to its overall expenditures or overall revenue from fees paid by its residents.
Types of CCRC’s and Calculation of Medical Expense Deduction
There are three basic types of CCRCs, each categorized by the amount of healthcare covered in the resident agreement and how and when the resident pays for the healthcare. The categories are: Type A (extensive contract), Type B (modified contract), and Types C and D (fee-for-service contracts). The cash outflows associated with these options are entrance fees and monthly fees. The category of the facility will affect the tax consequences for the resident.
The medical expense deduction can be calculated by the percentage method or the actuarial method. While the IRS supports use of the actuarial method based on healthcare utilization and longevity, the Tax Court in D.L. Baker v. Comm’r , 122 TC 143 (2004) [enhanced version available to lexis.com subscribers], upheld the use of the percentage method calculated on an allocation percentage based on the number of community residents and the weighted-average monthly service fees. The CCRC is responsible for determining the amount of the entrance fee and the monthly fee that should be allocated to prepaid healthcare.
The deductibility of Sarasota and Manatee County Florida assisted-living monthly fees requires reference to IRC Section 7702B(c) and Notice 97-31 and definition of the term “chronically ill.” This definition is crucial to the deductibility of the monthly fees because certain tax deductions that exist if the taxpayer enters assisted living as a chronically ill individual do not exist if the taxpayer enters for basic custodial care. To qualify as chronically ill, a Sarasota or Manatee County Florida resident must be certified by a licensed healthcare provider as unable to perform (without substantial assistance) at least two “activities of daily living” (eating, toileting, transferring, bathing, dressing, and continence) for at least 90 days due to a loss of functional capacity, or must require substantial supervision for protection due to severe cognitive impairment.
Additional Tax-Planning Opportunities
A Sarasota and Manatee County Florida resident who is planning their transition to a CCRC can obtain additional tax planning benefits by timing the payment of their entrance fee and liquidation of their investments to pay the fee. A combination of the tax-deductible portion of the entrance fee and monthly fees attributable to healthcare may result in significant itemized deductions. The deductions may reduce the individual’s taxable income to a level that will result in their capital gains and qualifying dividends being taxed at the lower rate (5% instead of 15%).
View more information from Marc J. Soss at http://www.fl-estateplanning.com/ and http://info.fl-estateplanning.com/
Marc Soss’ practice focuses on estate and tax planning; probate and trust administration and litigation; guardianship law; and corporate law in Southwest Florida. Marc is a frequent contributor to LISI and has published articles and been quoted in the Florida Bar, Rhode Island Bar, North Carolina Bar, Association of the United States Navy, Lawyers USA, Military.Com, Forbes.Com, and CNN Business. Marc also serves as an officer in the United States Naval Reserve.
….
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In Pennsylvania, if Your Elderly Parents Can’t Pay for Their Long-Term Care, Then You Might Be on the Hook for It
- 11-13-2012
09:58
AM - Author:
Colonial Poor Law Imposing Liability on Today’s Adult Children
Last April, Julian Gray and Frank Petrich, both elder law
attorneys, authored a Pittsburgh-Post Gazette article on a Pennsylvania law that can
potentially saddle children with the unpaid costs of their parents’ long-term
care. The law, 23 Pa.C.S. § 4603, states:
(a)(1) Except as set forth in
paragraph (2), all of the following individuals have the responsibility to care
for and maintain or financially assist an indigent person, regardless of
whether the indigent person is a public charge:
(i) The spouse of the indigent
person.
(ii) A child of the indigent
person.
(iii) A parent of the indigent
person.
Section 4603 is described as a holdover from the Colonial “poor
laws.” Colonial poor laws, as defined by
the Social Security Administration, “featured local taxation to support the
destitute; they discriminated between the ‘worthy’ and the ‘unworthy’ poor; and
all relief was a local responsibility.”
Liability for a Parent’s Long-Term Care
The Gazette article underscores the fact that § 4603 is now being
used “regularly” to tie family members to care costs. It offers two interesting
examples:
1)
A nursing home sued an out-of-state adult child
to recover for care despite the fact that the adult child had no contact with the
parent; and
2)
A nursing home sued two adult children after
their sibling stole money from the parent.
In May, a son was found liable, pursuant to 23 Pa.C.S. § 4603, for the outstanding debt incurred as a result of his mother’s treatment and care. Health Care Ret. Corp. of Am. v. Pittas, 2012 PA Super 96 (Pa. Super. Ct. 2012) [enhanced version available to lexis.com subscribers]. The mother, after completing rehabilitation for injuries sustained in a car accident, had been transferred to a facility for skilled nursing care and treatment. The Pittas case reaffirmed a broad definition of “indigence:”
the indigent person need not be helpless and in extreme want, so completely destitute of property, as to require assistance from the public. Indigent persons are those who do not have sufficient means to pay for their own care and maintenance. “Indigent” includes, but is not limited to, those who are completely destitute and helpless. It also encompasses those persons who have some limited means, but whose means are not sufficient to adequately provide for their maintenance and support. Savoy v. Savoy, 433 Pa. Super. 549, 641 A.2d 596, 599-600 (Pa. Super. 1994) [enhanced version available to lexis.com subscribers].
The Pittas court noted that despite the mother’s social security income and her share of Veteran’s Administration benefits, the sources of income were insufficient to adequately provide for the mother’s maintenance and support.
Difficult Exceptions to the Rule
Section 4603 does offer two exceptions. Section 4603 is inapplicable
when:
1)
an individual does not have sufficient financial
ability to support the indigent person; or
2)
a parent abandons a child and persists in the
abandonment for a period of ten years during the child’s minority.
However, as the article notes, the exception is somewhat self
defeating. The authors pose the following question: “How does a person without
‘sufficient financial liability’ to assist a parent defend himself [against
expensive § 4603 litigation]?” The article further notes that proving indigence
is not necessarily an easy (nor cheap) thing to do.
The moral of the story: adult children in Pennsylvania need
to start paying attention to their parents’ health and wealth. There is, however, potential relief in sight. In early 2011, the Pennsylvania House introduced a bill to repeal §
4603.
….
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Medicare Part D: It Pays to Shop Around
- 11-26-2012
09:09
AM - Author:
[Originally posted Oct 16, 2012]
Medicare Open Enrollment began yesterday, October 15, and continues through December 7, 2012. The enrollment period ends earlier than in previous years, so those considering making a change should not procrastinate.
Medicare beneficiaries should pay particular attention to their choice for Part D (prescription drug) coverage. A recent study from the University of Pittsburgh shows that seniors tend to overpay for Part D coverage. The study looked at 2009 data and compared seniors’ choices of plans to the least expensive that would serve their needs. The results: only 5% of Medicare beneficiaries chose the most cost-effective plan. Thirty percent of those in the study group overspent by $300 – $500, and 20% overspent by $500 – $1000.
Researchers chalk up the findings to over-cautiousness. Many of the subjects were determined to stay out of the doughnut hole, or to avoid all deductibles, at any cost; others paid more for features they didn’t need, like generic drug coverage in the coverage gap. They also tended to choose their plan based on the monthly premium alone. Moreover, other studies reveal that seniors are reluctant to change plans and often stick with the same insurers, even when better options are available.
Politicians often tout the value of the free market, arguing that more choice results in a better deal for consumers. In the case of Medicare Part D coverage, the array of choices don’t always translate into better decision-making and more savings. Perhaps there are too many choices. Plans change from year to year, a drug that may have a high co-pay on one plan may have a tiny co-pay on another. A drug that was covered by a particular plan one year may be dropped from coverage the next. The researchers conclude that “beneficiaries need more targeted assistance from the government to help them choose plans, such as customized communications about the most cost-effective plans that would cover their medication needs.”
This enrollment period, you can avoid spending money on more coverage than you need by using Medicare’s online tool to enter your prescriptions and dosages and then compare plans that fit your needs. The plans are rated on a one to five star rating scale.
Attorney Joseph S. Karp is a
Florida Bar Certified and Nationally Certified Elder Law Attorney focusing on
Elder Law, Probate, Estate Planning, Asset Protection, Special Needs Planning
and Estate Litigation. He is AV rated by Martindale Hubbell. Mr. Karp is the
founder of The Karp Law Firm, a South Florida law firm with offices in Palm
Beach Gardens, Boynton Beach and St. Lucie, Florida. Mr. Karp was named a
2011 SuperLawyer by SuperLawyer Magazine and a member of the 2011
Florida Legal Elite by Florida Trend Magazine. He is admitted to
practice law in New York as well as Florida. Visit Mr. Karp’s Florida Elder Law and Estate Planning
website.
….
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Caregivers Facing More Challenges Than in the Past
- 11-27-2012
10:44
AM - Author:
Caregiving for an aging loved one: It’s not just about bathing, shopping and handling finances anymore.
A recent study from AARP’s Public Policy Institute and United Hospital Fund finds that caregivers are increasingly taking on tasks that were once performed only by trained medical staff and hospitals. The study found that almost half of family caregivers administer injections and IVs, perform wound care, use various types of medical monitors and other specialized medical equipment, manage multiple medications, prepare food for special diets, etc.
And we are not talking about a handful of people. According to a 2009 study conducted by the National Family Caregivers Alliance and AARP, 65 million people have cared for a chronically ill, disabled or aged relatives in any given year. Chances are today, the numbers are even higher. The study also found that the typical caregiver is a 49-year-old woman, and among them, 37% have children under the age of 18 living at home. That does not leave a lot of time for a caregiver to bone up on IV administration and managing multiple medications throughout the day.
Often the person being cared for is released from a hospital to their home, or to the caregiver’s home, and the caregiver has gotten only a quick tutorial on how to perform these tasks. If your loved one is being discharged from a medical facility and you don’t feel you have sufficient information about how to care for his needs, persist in asking for more guidance and tutoring. You may also want to take a look at this hospital-to-home discharge guide prepared by the United Hospital Fund’s Next Step in Care Program.
If your loved one is in a rehabilitation facility, you may learn, often not until discharge is near, that his/her needs are so great that long-term care is needed. If this occurs, additional challenges present themselves, including the problem of how to pay for long-term care. If your loved one is a Florida resident, please contact us for help. We can often help someone tap into Medicaid benefits and/or Veterans benefits before the family loses everything to the nursing home expense.
For a good guide from Next Step in Care on how to manage the rehabilitation facility-to- nursing home transition, click here.
Attorney Joseph S. Karp is a
Florida Bar Certified and Nationally Certified Elder Law Attorney focusing on
Elder Law, Probate, Estate Planning, Asset Protection, Special Needs Planning
and Estate Litigation. He is AV rated by Martindale Hubbell. Mr. Karp is the
founder of The Karp Law Firm, a South Florida law firm with offices in Palm
Beach Gardens, Boynton Beach and St. Lucie, Florida. Mr. Karp was named a
2011 SuperLawyer by SuperLawyer Magazine and a member of the 2011
Florida Legal Elite by Florida Trend Magazine. He is admitted to
practice law in New York as well as Florida. Visit Mr. Karp’s Florida Elder Law and Estate Planning
website.
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Medicare to End "Improvement Standard"
- 12-04-2012
07:55
AM - Author:
For years I have counseled clients that if they enter rehab after a hospital stay that for a practical perspective they will only get 20 days of skilled cared (covered under Medicare) unless they can show they are “improving”. This so-called “improvement standard” was never law, and now Medicare is changing its rules to make it clear that no such standard exists.
Why was this happening. My best guess is that most acute care facilities are in nursing homes. When you are providing “skilled care’ you are covered by medicare, and the nursing home must accept the medicare rates. However, the sooner “skilled care” ends, and “companion care” begins the sooner the nursing home can get paid the private pay rate, which may be more profitable.
A quick summary care of this sweeping change from www.eldercareanswers.com:
In a major change in Medicare policy, the Obama administration has agreed to end Medicare’s longstanding practice of requiring that beneficiaries with chronic conditions and disabilities show a likelihood of improvement in order to receive coverage of skilled care and therapy services. The policy shift will affect beneficiaries with conditions like multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS (Lou Gehrig’s disease), diabetes, hypertension, arthritis, heart disease, and stroke.
For decades, home health agencies and nursing homes that contract with Medicare have routinely terminated the Medicare coverage of a beneficiary who has stopped improving, even though nothing in the Medicare statute or its regulations says improvement is required for continued skilled care. Advocates charged that Medicare contractors have instead used a “covert rule of thumb” known as the “Improvement Standard” to illegally deny coverage to such patients. Once beneficiaries failed to show progress, contractors claimed they were delivering only “custodial care,” which Medicare does not cover.
In January 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a class action lawsuit, Jimmo v. Sebelius, against the Obama administration in federal court, aimed at ending the government’s use of the improvement standard. After the court refused the government’s request to dismiss the case, and the administration lost in a similar case in Pennsylvania, it decided to settle.
As part of the settlement, Medicare will revise its manual to make clear that Medicare coverage of skilled nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement” but rather depends on whether or not the beneficiary needs skilled care.
Deirdre R. Wheatley-Liss is a shareholder of the Law Firm of Fein, Such, Kahn Shepard, P.C., with offices in Parsippany and Toms River, New Jersey. She concentrates her practice in the areas of Elder Law, Estate Planning and Administration, Business Planning and Tax Law. Deirdre’s individual clients range from their 20’s to their 80’s and beyond, while her business clients range from start-ups with exciting new ideas to 100+ year old business ventures. Clients seek Deirdre’s advice and assistance with a variety of planning issues relating to identifying and meeting their personal, family and business goals, whether in a planning or crises situation.
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