MassHealth Long Term Care Jan Stiefel, J.D. Community Legal Aid - PowerPoint PPT Presentation

MassHealth Long Term Care Jan Stiefel, J.D. Community Legal Aid June 30, 2020

Financial Eligibility A. Assets: $2,000 limit 1. Excess assets may be offset by outstanding medical bills 2. Inaccessible assets: additional time to seek appointment of conservator 3. Non-countable assets (ex. burial account $1,500 or less/burial contract of any amount) 4. The home is non-countable, if equity interest less than $893,000 2

Penalty for transfer of assets B. Penalty for Transfers 1. Look back period: 5 years 2. Penalty start date for transfers 3. Penalty is calculated at $366.73/day; $11,155 per month 3

Penalty for transfer of assets 4. A transfer penalty can be “cured” 5. A transfer penalty may be “waived” a. If ineligibility will cause nursing home resident “undue hardship” b. Nursing facility must notify resident of its intent to initiate a discharge due to nonpayment for stay 4

Permissible transfers C. Permissible transfers 1. Spouse to spouse (of all assets) 2. Caretaker child residing in elder’s home 2 years, child under age 21, sibling residing in home at least 1 year with interest in home (of primary residence) 3. Disabled child of any age (of all assets) 4. Pooled trust for nursing home resident 5. Pooled, special needs trust for permanently disabled child and/or disabled person under 65 when trust created 5

Income D. Income 1. One month deductible/spenddown E. Deductions from income 1. Personal needs allowance (PNA) of $72.80 2. Minimum monthly maintenance needs allowance (MMMNA) for spouse in community 6

Deductions from Income 3. Family maintenance needs deduction for minor child or dependent child, parent and/or sibling 4. Home maintenance allowance 5. Health insurance 6. Medical/remedial expenses incurred and not covered (ex. dental) 7

Medical Eligibility A. ASAP medical assessment of need for nursing home care B. Short versus long term admission C. Score Three level of care criteria 8

Rights of Community Spouses A. Assets 1. Asset assessment (snapshot) on date of nursing home admission 2. Community Spouse Resource Allowance (CSRA) 3. First $128,640 deemed to community spouse 9

Rights of Community Spouses B. Income 1. Minimum monthly maintenance needs allowance: (MMMNA)$2,113.75/month minimum and $3,216.00/month maximum C. Can be increased by appeal 10

Liens and Estate Recovery A. Liens 1. “Notice” lien is placed on home of resident not reasonably expected to return home unless exceptions to lien placement 2. Sale of home post lien 11

Liens and Estate Recovery B. Estate Recovery 1. “Estate recovery unit” will file claim against an estate for reimbursement of all payment made by MassHealth on behalf of resident a. for all services provided while member was 55 or older; and b. on or after March 22, 1991, regardless of age, if client is institutionalized and could not be reasonably expected to return home 12

Liens and Estate Recovery 2. Exceptions to estate recovery 3. Deferral of or waiver of estate recovery 13

Nursing Facility Involuntary Transfers and Discharges A. Transfer of resident between beds with different certifications or discharge to another facility or to the community trigger right to appeal 1. Requirement of written 30-day notice specifying location to which resident is to be transferred/discharged 14

Transfers and Discharges 2. Permissible grounds for transfer/discharge: a. Resident requires higher level of care b. Resident’s health improved and no longer needs level of care provided 15

Transfers and Discharges c. Safety/health of other individuals in facility endangered d. Non-payment e. Facility going out of business 3. Resident who requests hearing shall not be discharged without a finding that the facility “has provided sufficient preparation and 16

Transfers and Discharges orientation to the resident to ensure safe and orderly transfer or discharge from the facility to another safe and appropriate place.” 4. Even after losing an appeal of [non- emergency] transfer/discharge, facility cannot transfer/discharge resident for at least 30 days from the date of the hearing decision. 17

Transfers and Discharges 5. Can only appeal transfers between beds within same facility with same certification to medical director of facility; limits rights previously afforded by regulations pursuant to Consumer Protection Act (93A) 6. Long Term Care Ombudsman Program – (800) 243-4636 to get local program info 18

Bed Holds in Facility Bed Hold a. 10 days per hospitalization b. 10 days per 12-month period for non- medical leave 19

Transfers and Discharges Transfer to hospital triggers right to be re-admitted (Brunelle case) a. Must re-admit to same bed if within bedhold period b. Must re-admit to first available bed in semi- private room if beyond bedhold period c. Refusal to re-admit considered discharge/transfer to which appeal rights apply 20

Appeals – Fair Hearing Appeals 1. Applicants and recipients have right to appeal any appealable claim 2. Actions denying, reducing, suspending, terminating, recovering, or restricting assistance 3. Coercive or otherwise improper conduct by a MassHealth employee 21

Appeals – Fair Hearings 4. Division of Hearings must provide an adequate and timely written notice of any appealable decision 5. Determine the legal basis of the appeal 6. Complete the appeal form, including all information and statement of disagreement with the action 22

Appeals – Fair Hearings 7. Request an interpreter if needed and 8. Request expedited hearing if appellant is not receiving benefits 9. Designate Authorized Representative if desired 23

Appeals – Fair Hearings 10. Appeal must be received by the Office of Medicaid Board of Hearings no later than thirty days from receipt of the notice 11. 10 day appeal limit for continuing benefits 24

Appeals – Fair Hearings Fair hearings 12. Right to have missing verification accepted as timely to get back to original date of application (& potentially 3 months before that as start date for benefits) 25

Appeals – Fair Hearings 13. Appellant may request a rehearing (within 14 days) or 14. Appeal adverse decision to Superior Court under Massachusetts General Laws, chapter 30A, within 30 days of decision 26

Rest Homes A. SSI payment for care a. Income less than $1,064 (SSI payment amount) b. Asset limits same as MassHealth c. PNA $72.80 d. 3-year look-back for transfers 27

Rest Homes B. EAEDC payment for care a. Income less than rest home payment b. Asset limit $250 c. PNA $72.80 d. 12-month look-back for transfers 28

Group Adult Foster Care (GAFC) & the SSI-G Assisted Living Benefits A. Income limit for individual is $1,237/month B. Asset limit for individual is $2,000 C. 3-year look-back for transfers D. GAFC pays for services/care &

SSI-G pays for room and board. E. One must ask specific AL facility if they accept GAFC & SSI-G to cover costs; very few do so. F. Assisted Living Ombudsman Program – (617) 727-7750