Medicaid Eligibility

MEDICARE’S OBSERVATIONAL STATUS

Published on: April 8, 2016 | by Ettinger Law Firm

SOME LIMITED RELIEF

Patients who rely on Medicare sometimes experience sticker shock after being released from the hospital only to find out that because some hospital administrator classified their stay as “observational” that they must pay a large portion of the final bill. Many times a doctor will seek to have a patient admitted for any number of reasons, only to have a bureaucrat reclassify the patient’s time at the hospital as observational. Such a designation will mean that Medicare will not pay for this time in the hospital. For Medicare to pay for a hospital stay, the patient has to be an admitted patient for at least three days (three midnights in the hospital).

Observational status does not equate to an admitted patient in Medicare’s own set of self defined definitions. That may be quite different to the patient who went to the hospital and received a number of drugs and tests during their time their and was consistent with the majority of their non-surgical stays in a hospital in life. In an effort to address these obvious problems that will only grow with time, President Obama signed a bill that required hospitals to warn patients that their stay will be considered observational in nature and that they are not being admitted under Medicare’s rules, which may result in a bill from the hospital that they will have to pay. The Notice of Observation Treatment and Implications for Care Eligibility Act would have to inform the patient that they are going to receive outpatient services under Medicare’s rules which requires cost sharing from the patient and that the observational status does not count towards the necessary three day inpatient in order to transition to a skilled nursing care facility.

Insurance Companies Receive Medicare Revenue Boost

Published on: April 30, 2015 | by Ettinger Law Firm

Health insurers across the United States received a welcome surprise when they discovered that they will be receiving a 1.25% increase next year in Medicare revenue benefits. This declaration reverses a previous proposal by the U.S. government to decrease the amount of Medicare benefits that insurance companies would receive in order to bring it in line with other government programs for the elderly and disabled.

Medicare Benefits for Insurance Companies

The U.S. government has been slowly decreasing the amount of Medicare benefits received by insurance companies in a bid to bring private Medicare coverage equal to other government aid programs. This year, insurance companies received four percent less in benefits than 2014, and the original proposal for 2016 included benefits cuts of another 0.9%.

Back to the Basics: NY Medicaid Eligibility & Protecting Assets

Published on: March 24, 2014 | by Ettinger Law Firm

The New York Medicaid program is a critical lifeline for millions of residents. Unfortunately, many remain confused by some of the complex details. It is common to have only a fragmented understanding of how Medicaid works from random discussions with friends and neighbors or by hearing snippets of news clips discussing the program.

One of the most misunderstood aspects of the system is the “spend down” requirement. Medicaid is a need-based program, and so qualification requires one to have assets below a very low threshold. But that does not mean that everything you own will be lost before qualifying for Medicaid.

Medicaid Misunderstandings.

New York Medicaid “Look-Back” Period & Proper Records

Published on: January 22, 2014 | by Ettinger Law Firm

The price of nursing home care in New York is staggering. It is not uncommon for a stay to cost upwards of $15,000 – $20,000 per month. This is a burden that many New York seniors can not afford to pay. After all , many local residents are only living on small fixed incomes, and coming up with $180,000 – $240,000 per year to live in a skilled nursing facility is unthinkable.

For most resident the only alternative is support via the New York Medicaid system. But residents can usually only qualify for Medicaid if their non-exempt assets are “spent down.” In our state, the allowable amount of total assets is only $14,550. There are complex rules about what assets count toward this amount, but a NY Medicaid lawyer can explain whether things like a long-time family home can be saved or if retirement accounts must also be drained.

Look-Back Period

New State Survey on Medicaid Managed Care Programs

Published on: June 4, 2013 | by Ettinger Law Firm

The Urban Institute recently released a new survey appraising the preparation for Medicaid expansion in many different states as part of the Affordable Care Act (ACA). The analysis discusses how eight individual states, including New York, are changing their programs to accommodate the implementation of the Affordable Care Act. The findings are part of the Robert Wood Johnson Foundation’s State Health Reform Assistance Network tracking program. A full online copy of the survey can be found here.

The study authors note that many states are using Medicaid “managed care” to expand eligibility. For example, as discussed in the report, New York “intends to move non-dual-eligible nursing home patients into managed care.” The goal is to complete the transition by October of this year. New York plans to participate in a special program to help manage care for seniors who are “dual eligible” for both Medicaid and Medicare. This includes many elderly community members. This program is know as the State Demonstrations to Integrate Care for Dual Eligible Individuals.

In addition, as part of the change, New York is switching from a voluntary managed care enrollment to a required one. In the past providers could participate if they chose, but now they cannot. New enrollments requirements mandate managed care participation. Over the long-term, of course, this requirement means that more and more Medicaid participants will be on managed care.

New York State Commissioner of Health On NY Medicaid Reform

Published on: May 10, 2013 | by Ettinger Law Firm

This week Dr. Nirav R. Shah–the Commissioner of Health for the state–issued a press release summarizing the positive impact of each of the Medicaid reform efforts that have taken place over the last few years. As many are aware, Governor Andrew Cuomo has been aggressive in his efforts to streamline the system, mostly motivated by financial concerns.

The Commissioner used the occasion to paint a positive picture of the New York Medicaid’s current situation. He noted how costs for the program are down while quality indicators are receiving good marks. Amazingly, all of this is coming at a time when actual enrollment in Medicaid is increasing. Lowering costs even with steady enrollment is difficult, and so do so while adding to the program is a real achievement. The press release points out that, all told, over $3.2 billion has been saved in New York City alone. That is not a trivial amount, particularly considering trends had been moving in the opposite direction for years.

Interestingly, the Commissioner noted that it was long-term care services which, in the past, were the main drivers of increased Medicaid spending. But the Medicaid Redesign Team has been able to “bend the cost curve,” mostly by shifting resources into less expensive but helpful programs–like at-home care.

New York Nursing Home Evacuation Plans

Published on: May 3, 2013 | by Ettinger Law Firm

The reverberations of Hurricane Sandy’s impact on the city are far from finished. We will be cleaning up and adapting for many months–likely years–into the future. Considering the predictions of some, we may even have to deal with large storms of this magnitude on a far more consistent basis. It affects all areas of life–including things like senior care and nursing home operations.

Many New Yorkers were shocked to learn of the goings-on at some long-term care facilities hit hardest by Sandy. Stories have been told of seniors stuck in upper levels of flooded facilities for days without power. Many questions have been raised about the management of the long-term care facilities and confusion over why the senior residents were not evacuated. In fact, in large part because of the struggle with NYC nursing home evacuations during Sandy, the Center for Medicare and Medicaid Services (CMS) will release new disaster planning for all nursing homes in the coming year.

Looking to the future, local residents are advised to understand evacuation plans for long-term care facilities where loved ones reside–or to ask about such plans when making nursing home choices. An AARP story recently profiled nursing home evacuation plans, pointing out the critical issues that facility caregivers need to consider. It is worth browsing the list to get an idea of the questions that owners and operators in New York need to be asked to ensure that seniors are protected in case any manner of natural or man-made disaster strikes requiring quick action.

NAELA Journal Article on Future of Medicaid

Published on: April 18, 2013 | by Ettinger Law Firm

It can can a confusing, scary, and stressful time for all New Yorkers who use the Medicaid system for necessary health care or for those who suspect they may need it down the road. Not a day goes by that news does not break at either the state or national level regarding payment cuts, service trimming, changes to qualifications, and more.

Considering the complex political dynamics involved in any major decision regarding the New York Medicaid system, it is next to impossible to make predictions with certainty. But many experts in the field are more than eager to share their ideas about what the program might look like in the future.

For example, some may be interested in a recent article a the journal published by the National Association of Elder Law Attorneys (NAELA). Entitled “Whither Medicaid,” the comprehensive article takes a look at all of the major notions about how Medicaid might disappear in coming years and how it may be saved via different alternative arrangements. The article can be read for free online in it’s entirety here.

Audit Raises Questions About New York Medicaid Financial Situation

Published on: March 22, 2013 | by Ettinger Law Firm

Reuters published a story this week on the latest audit of the New York Medicaid system which has given leverage to those hoping to use financial worry to trim the system and the state budget overall.

We have previously discussed the audit by the Centers for Medicare and Medicaid Services which found that the federal government overpaid the state by billions of dollars in recent years. The actual audit is still not yet complete, but federal officials are set to conclude by the end of this month. It is only then that the full scope of the situation will be known and the effect considered. The story notes how the overpayment may ultimately wreck havoc on the state’s financial health just as some were hoping things were finally settling down.

All of this has placed a pall over the current work in Albany where legislators are working to approve the state’s next budget–around $140 billion.

Verdict Still Out on Success of New York Medicaid Shift?

Published on: February 5, 2013 | by Ettinger Law Firm

Late last month the New York Health Department released a report that reviews the progress of a crucial shift in state policy affecting seniors needing long-term care. The full report (download it here), outlines the satisfaction of New Yorkers who have participated in the shift from traditional New York Medicaid coverage for long-term care to special HMOs to cover those care and costs. This report offers the first good opportunity to analyze whether these organizational shifts over the past few months have been positive for those seniors directly affected.

Somewhat quietly, thousands of elderly New Yorkers who previously received long-term care via Medicaid were shifted to HMOs managed by by private and non-profit companies. In total, 38 different companies are handling the work and, according to the NY Health Department, “providing high-quality services to consumers and helping them maintain or improve critical abilities associated with daily living.”

The law changed in 2010 to alter the way long-term care was provided by the state. The basic idea is that shifting long-term care costs to HMOs will save funds. In 2010, for example, the state spent more than $13 billion via Medicaid to provide long-term care to 300,000 residents. By shifting to HMOs, the costs will hopefully be kept in check, because the companies will receive a flat fee for patient care overall, regardless of the necessary services.