MEDICAID’S ROLE IN LONG-TERM CARE

Medicaid is a complex program, and when it comes to senior care, there are a few terms that people commonly mix up. In this blog post, we attempt to clarify any confusion between Medicaid, Medicaid Long-Term Care, and the Medicaid Waiver Program.

Medicaid

Medicaid is a social program that provides health insurance to millions of Americans including people with low income, children, pregnant women, elderly adults, and people with disabilities. It is administered by the state, according to federal requirements, but it is funded jointly by the state and the federal governments. It does not provide full coverage, meaning not all things medical are covered under Medicaid. Federal law requires that states provide certain mandatory benefits including: inpatient hospital services, outpatient hospital services, clinic visits, doctors’ office visits, and transportation to medical care. While it is common for folks to say that Medicaid does pay for a stay at a nursing home; just because someone has Medicaid doesn’t mean Medicaid will pay for his or her permanent stay at a nursing home.

Medicaid Long-Term Care

To have Medicaid pay for a permanent stay at a nursing home, a person must meet the law’s income and medical criteria, even if he or she is already covered under general Medicaid. If approved, the person is said to be covered under Medicaid Long-Term Care.

To be medically eligible for Medicaid Long-Term Care, a person must need routine skilled services or help with his or her activities of daily living (“ADLs”). Examples of skilled services include:

  • Medication management
  • Immunizations
  • IV care
  • Podiatry
  • Wound care (level 3 and 4)
  • Tube feeding
  • Assistance with breathing
  • Help with catheters

Nursing homes also provide aides that will help a patient with his or her ADLs. Transferring, walking, using the bathroom, showering, dressing, and eating are the six ADLs. The rules are vague as to how many ADLs one needs help with to qualify for Medicaid Long-Term Care, but at Senior Advisors Plus, we’ve generally seen that people who need help with three or more on their worst day would qualify for Medicaid Long-Term Care.

To financially qualify for Medicaid Long-Term Care, a person must meet two criteria, assets and income. Each state differs on its income and asset restrictions but generally the laws work like this:

  • A person can’t have more than $2,000 in countable assets to qualify.
  • A person can’t have monthly income that exceeds the average cost of a nursing home in the state.

A person who makes less than the income limit but has too many countable assets may need to spend down his or her savings to qualify for Medicaid Long-Term Care. In this situation, he or she may also benefit from talking to an elder law attorney. After spending down assets, the person should qualify for Medicaid Long-Term Care. Medicaid will then pay the difference between the person’s income and the cost of the nursing home.

Medicaid Waiver Program

A hospital is the most expensive setting of care, while nursing homes are not far behind. After a patient stabilizes following a procedure done in a hospital, he or she may be discharged to a nursing home or skilled nursing facility to recover and build strength. A skilled nursing facility’s goal is to help the patient transition back to the community. Commonly, people are forced to stay in nursing homes because they can’t afford to hire help at home. The Medicaid Waiver Program was designed to help these people transition back to the community, despite their financial constraints. The Medicaid Waiver Program may pay for home care services, assisted living, and other services that may prevent someone from returning to a nursing home. While people under the Medicaid Waiver Program do need assistance, the cost of the assistance that they need is far less than the cost that the Medicaid fund would incur if they remained in a nursing home. To be medically eligible for the Medicaid Waiver Program, a person may need help with the activities of daily living but not routine skilled services. Here’s the tricky part: it’s harder to qualify for the Medicaid Waiver Program than it is Medicaid Long-Term Care. The asset restriction is the same—$2,000—but the income limit is generally lower. We’ve generally seen the income limit to be around $2,300 per month; however, the income limit depends on the state. If a person makes over the income limit, then he or she is required to pay for assistance themselves. If a person makes less than the income limit, needs at-most intermittent skilled services, and needs help with some of their activities of daily living, then he or she may qualify for the Medicaid Waiver Program.

If you’re confused or worried about your current situation or the future, it may help to talk to someone. We offer free advice; just contact us.

ASSISTED LIVING VS. NURSING HOMES

In this post, we describe the general differences between assisted living communities and nursing homes. We gathered the information below from Washington D.C. and Maryland sources. While the laws vary from state to state, generally, assisted living communities and nursing homes of each state operate similarly. Prior to your loved one moving into a nursing home or assisted living community, a nurse will assess him or her to make sure that he or she qualifies for the level of care that you are applying to. To save on costs, we recommend applying for the lowest level of care first. With that said, here is a guide to help you determine the appropriate setting of care for your loved one.

Assisted Living Communities

Assisted living communities may prepare meals, do house chores, organize activities, manage medications, and provide custodial care for their residents. Custodial care means helping with the six activities of daily living, which include: transferring, walking, toileting, bathing, dressing, and eating. Before becoming a resident, a nurse may assign a level of care to an applicant1.

Level 1 – Needs oversight of one or more of the ADLs
Level 2 – Needs occasional hands-on assistance with one or more ADLs
Level 3 – Needs frequent hands-on assistance with one or more ADLs

The community will charge the applicant based on the level of care the resident requires. If a person requires too much care, then the assisted living community may reject the application. A person cannot live in an assisted living community if he or she2:

  • Is dangerous to him/herself or to others
  • Needs more than intermittent skilled nursing care(generally needs more than 35 hours of home health or skilled care per week)
  • Need treatment of stage 3 or 4 ulcers
  • Needs ventilator services
  • Needs treatment for an active, infectious, and reportable disease or a disease or condition that requires more than contact isolation.

Nursing Homes

Nursing homes must provide three meals a day, housekeeping, laundry, and maintenance to the building. Just like assisted living communities, nursing homes also provide custodial care and medication management. They differ from assisted living communities because they can provide routine skilled care.

Most nursing homes employ nurses, physical therapists, occupational therapists, and doctors. With these professionals onboard, nursing homes can provide a higher level of care than assisted living communities. While some of the following services may be provided at an assisted living community, those who need the following on a routine basis should consider moving into a nursing home.

  • Immunizations
  • Feeding tubes
  • Catheters
  • Treatments requiring direct nurse supervision and observation

Those who require the following, even on an intermittent basis, should consider moving to a nursing home:

  • Ventilator services
  • Wound management, particularly stage 3 or 4 ulcers

Again, these are general rules, so if you are confused if your loved one requires too many skilled services or not, check with a nurse. If you don’t know one, then have one come assess your loved one from the assisted living community that you are considering. From our experience, nurses from assisted living communities are happy to qualify potential residents. If you’re not comfortable with that option, then some states have programs set up at local health departments to provide assessments. In Maryland, the program that does assessments is called Adult Evaluation and Review Services (AERS).

We also wanted to shed some light on the costs of assisted living communities and nursing homes. Here are the average monthly costs that we’ve researched in the DC, Maryland, and Virginia areas:

​Here are several payers for each type of care. Some payers require the applicant to qualify before the payer will sponsor the care. Not all counties have the same sources of payers as the ones we’ve listed below, but it’s worth checking with your county to see if the county has the program and if you qualify.

Once you’ve selected a care setting, if you still need help choosing the right community, we do an assessment using the following criteria: health, wealth, lifestyle, and preferred location. You can contact us here. You may choose to use our services for free or for a fee. We’re happy to help in the capacity that you choose.

Sources:

  1. https://app.smartsheet.com/b/publish?EQBCT=8a0359466ab14c5c9225533ac6891da7
  2. https://dchealth.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/AssistedLivingLaw.PDF

VIDEO CHAT IS CHANGING HEALTH CARE FOR THE BETTER AMID COVID-19

Telehealth was once restricted by the Health Insurance Portability and Accountability Act (“HIPAA”) because the law limited the use of telehealth meetings through popular channels such as Skype and Zoom. As people quarantined to limit the spread of COVID-19, the government relaxed regulations, which now allow professionals to share health care-related information via Skype and Zoom. A range of health care providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, are using telehealth to give advice to their patients. While these former restrictions had merit and did help to protect patient privacy, the new rules allow for a vastly different health care system. Here’s what we see:

​Check-in visits, medication refills, and mental health support are among the most popular reasons that people use telehealth services. Many insurance providers, including Medicare, now reimburse payers for telehealth services. This has been in response to keep people in their homes and away from others; however, the problem with that is they don’t interact with their doctors as often. Many people must visit their doctor routinely for prescription refills and general health check-ups. Doctor’s office visits have dropped significantly. In fact, health care jobs have declined, which seems counterintuitive given we are in the middle of a medical crisis. Regardless, telehealth services have a real opportunity to fill a void in this type of environment, that is to provide a medium by which practitioners can give health care advice to their patients.

The other thing we see is that video conferencing has helped social workers and patients with care coordination. Lessened HIPAA restrictions and “no visitors” policies at nursing homes have limited assisted living communities from accessing patients in person. Some nursing homes we work with are setting up video conferencing lines so that the homes can interview patients remotely. This has been a tremendous opportunity for the industry and patients, particularly for low-income patients. Previously, few homes wanted to interview a low-income client because it was a lot of work for not a lot of money. With the ability to interview patients over video, the communities protect their time and money—no more sending a nurse to a skilled nursing facility to maybe get a client. As a result, more communities are willing to interview more clients, which means hospitals and skilled nursing facilities have a better chance of discharging patients who no longer require their respective level of care.

As of now, the new terms of telehealth and video chat are temporary, but we hope that the channels, such as Skype and Zoom, alter their platforms to be HIPAA compliant so that when the rules tighten back up, those channels can still cater to a need.

THE GUARDIANS OF SOCIETY—SOCIAL WORKERS

I have met and developed great relationships with several social workers through this business. From the start I was amazed by how much they do and what they are responsible for. I wanted to write a piece about them, particularly the ones who work in a hospital or skilled nursing facility. I know there are other types of social workers, but these are the ones that I have come to know. Through this piece, I hope at least one additional person develops a newfound respect for the profession and for the people who dedicate their lives to helping others.

A social worker is someone who helps people adapt to society, which could be orchestrating medications, medical devices, or services for a proper and safe discharge from an establishment. A social worker’s job is intense. They are often managing cases where a patient’s lifestyle has changed such that the appropriate plan is not appealing to the patient or is hard to achieve because the patient lacks resources or family support. The latter of these two issues is far too common, which means social workers are constantly having to create solutions with very little resources—multiply that by 60 and that is why this profession is one of the most intense I can imagine. Social workers routinely look out for people who don’t have a support system to look out for themselves. This is also why I call them “The Guardians of Society.”

Patient, compassionate people tend to excel at the profession. In my opinion, that’s because they have to win their patients’ trust in order to suggest a plan. As a result, social workers are tasked with remaining patient and compassionate in the midst of chaos and deadlines. Here’s an example of a typical problem they may face: an insurance company ceases payments to a facility because the patient no longer meets a certain level of care to justify his or her stay. As the patient remains at the facility, his or her costs may exceed tens of thousands of dollars a month. The facility will have to pay for the costs itself. The facility administration will look to the social worker to create a plan to get the patient out of the facility as quickly as possible without compromising the safety of the patient, because if that patient is readmitted into a hospital, then the “system,” particularly CMS, will penalize that facility in the form of reduced future payments. The social worker must balance the safety of the patient and the economic impacts on the facility—this can create a very stressful situation.

You may share the opinion that social workers are the hidden centerpiece of today’s health care system. So much relies on them. And to do their jobs well, they must have a breadth of skill sets including business acumen, knowledge of medical terminology, legal knowledge, communication skills, and relentless work ethics. A social worker must combine the intel from the doctors, in-house counsel, family, patient, and administration to make a plan for the patient. What a task!

It’s amazing with the caseload that social workers have that they are so successful at what they do. In the US, approximately 15% of all patients admitted to the hospital were readmitted within 30 days during 2019 1. Considering the typical case load at any given hospital or skilled nursing facility, that number is outstanding. And it’s as low as it is because we have a system in which social workers help coordinate all the different stakeholders at play. As that 15% number decreases, tax dollars can be allocated elsewhere, insurance premiums may go down, and individual patient outcomes will improve. For the reasons that social workers help patients and, bigger picture, help our society function, I think it’s appropriate to deem them America’s Guardians.

March was Social Work Appreciation Month, but there is no time like the present to thank social workers for all that they do, particularly now as their case loads begin to build and as they stand on the front lines of this battle against the invisible enemy.

Sources:
1.https://www.americashealthrankings.org/explore/senior/measure/hospital_readmissions_sr/state/ALL