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Posted on: July 19, 2018

Changes Are Coming to Long Term Care Medicaid for Residents in Nursing Homes

Elderly woman in wheel chair

JAMESTOWN, N.Y.:--Medicaid is a federal, state and local governmental public assistance program that pays for health care services for those with low incomes or very high medical bills relative to their income and assets.  New York State is the only state that requires local government to share in the Medicaid costs.  Chautauqua County is responsible for approximately $10 million annually in Long Term Care Medicaid services.


Long Term Care Medicaid covers the “long term care” services, which include care in a nursing home and care provided to an individual in their residence.  Plan Coordinators determine the level of care appropriate for the individual to enter a nursing home or to remain in their residence. 


State mandated changes are coming to Long Term Care Medicaid for those residents in nursing homes.  Currently nursing home residents are enrolled in a Managed Long Term Care Plan and the nursing homes would bill directly to the Managed Long Term Care Plans.  New York State has proposed changes and  residents will become “Fee for Service,” meaning the nursing homes will bill directly to Medicaid and no longer rely on the Managed Long Term Care Plans.  This is a new transitional phase and the State will be issuing new rules and directives to follow. 


“About 70 percent of people over age 65 require some long term care services and the likelihood of needing care increases as you age,” said Christine Schuyler, Director of the Chautauqua County Department of Health and Human Services.


Planning ahead helps you to understand what service options are available in the community, special conditions that may apply for receiving services such as age or other eligibility criteria, what services cost, and what payment options -- public and private – apply. Medicaid Long Term Care is one such option.


Currently, in order to be eligible to receive Long Term Care Medicaid, applicants are required to meet income limits and may retain a certain amount of resources.  When an individual becomes aware that he or she require “long term care” services, either at home or in a nursing home, it is important to complete an application and file the application with the Department of Health and Human Services at the South County Office Building located at 110 East Fourth Street, Jamestown, N.Y., or the North County Office Building located at 319 Central Avenue, Dunkirk, N.Y.  As an individual requiring long term care services may be unable to file an application, the law provides that any one may file an application for the individual requiring long term care services.  For example, a relative, a friend, a service provider may file an application for an individual requiring long term care services.   


As previously stated, in order to be eligible for Long Term Care Medicaid, the applicant must meet certain income and resource limits.  The Department is required to follow the laws and regulations when receiving and reviewing an application for Long Term Care Medicaid.  The Department is required to look back five years prior to the application date for nursing home coverage.  This is referred to a “look-back period.”  The resources of the applicant are reviewed to determine if there have been any transfers for less than fair market value during this five year period.  This “look-back period” covers all transfers. 


When the Department is reviewing the application and if it is determined that the individual gave away property for less than it is worth or for the sole purpose of becoming eligible for Medicaid, the individual will be denied Medicaid coverage for a period of time.  When transfers are for less than fair market value during the “look-back period,” a penalty is imposed for a period of time, known as the “penalty period.” 


The penalty period is calculated by taking the value of the uncompensated resource and dividing it by the regional rate for each month.  The regional rate for nursing home care is issued each year by New York State for each County and for 2018 the regional rate for Chautauqua County is $10,239 per month.  For example, if a mother gifted the $200,000 recreational vehicle to her son, the uncompensated transfer of $200,000 divided by the regional rate of $10,239 will determine the mother to have a penalty period of 19.53 months and would not be eligible to receive Long Term Care Medicaid for nursing home coverage for that period of time.  The Department would send out a notice of denial to the applicant and to the nursing home and the nursing home would have to take action to collect the outstanding bill.


There are exceptions to the transfer penalty which allows for certain property to be transferred and not be subjected to a penalty.  One exception is the homestead.  If an applicant expresses an intent to return home, the Department files a lien against the home.  Enforcement of this lien is delayed until the individual dies.  The lien will be removed upon the individual’s return home. 


An individual owning a homestead who does not express intent to return home will have the value of the home counted as an available resource and will likely be ineligible for Long Term Care Medicaid. 


If there is a married couple and one spouse has to go into a nursing home, the Department does not want to leave the other spouse (the spouse residing at home in the community, the “community spouse”) impoverished due to the placement of the spouse in the nursing home or in receipt of long term care services.  The community spouse is allowed to retain a certain level of resources.  As of January 2017, the community spouse may retain $74,820 or 1/2 of the couple’s total resources, up to a maximum of $123,600.  The community spouse is also entitled to a monthly income of $3,090.  These figures for the resource limit and monthly income are set by the State and may change year to year.  If there is a shortfall in the community spouse’s income due to the other spouse having to be in a nursing home and that income is being applied to nursing home or long term care services, the Department will determine the amount of resources needed to meet the shortfall for the community spouse.  So, the Department may adjust the nursing home spouse’s net adjusted monthly income that would have to be paid to the nursing home or long term care services.


There may be circumstances when the community spouse has assets or income in excess of the allowable amount and these excess resources would be considered available to pay for the nursing home care or long term care services for his/her spouse.  The Department may have to commence a legal action against the community spouse to compel support and obtain reimbursement of benefits paid on behalf of the spouse receiving long term care nursing home or services.       


Even if no intent to return home is expressed, the home will not be counted as a resource as long as it is occupied by a spouse, a minor child or a legally blind or disabled child and its equity value as for the year 2018 is less than $858,000.  The equity value is also established by the State and may change from year to year.


There are other assets not counted during the look-back period.  Those assets may include personal belongings, a vehicle, life insurance policy with a face value of $1,500, irrevocable burial trust, personal care contracts, promissory notes and mortgages, annuities, life estate, etc. 


Someone can apply for Long Term Care and receive services with homecare while at home.


There were approximately 853 applications filed with the Chautauqua County Department of Health and Human Services in 2017.  There are currently 4 staff members to review these applications.  The application process can seem burdensome to people because the laws and regulations require the Department to “look back” for a five-year period when the application is received.  It can be a daunting task for anyone to obtain records going back five years.  Therefore, it is important to maintain up-to-date banking, financial and other records so when the application is filed, that information can be easily obtained.  Some people change banks from year to year and may not be able to remember all the banks they have done business with in the past.  If the information is not included, it delays the processing of the application and potentially leaves the individual with no Long Term Care Medicaid to pay for the services they are receiving.  Should an applicant disagree with the Department’s decision to deny Long Term Care Medicaid, the applicant has the right to request a Fair Hearing before an Administrative Law Judge.      


“It is important for families to understand and educate themselves on these details so they can be better prepared for the future,” said Chautauqua County Executive George Borrello.



DISCLAIMER:  THIS IS FOR INFORMATION AND EDUCATIONAL PURPOSES ONLY.  THE INFORMATION IS NOT DEEMED TO BE LEGAL ADVICE NOR INTENDED TO CONTAIN THE FULL AND COMPLETE DESCRIPTION OF ALL NEW YORK STATE AND FEDERAL MEDICAID PROVISIONS.  FURTHER, MEDICAID LAWS, RULES, REGULATIONS AND POLICIES ARE CONSTANTLY CHANGING AND THEREFORE, THE INFORMATION CONTAINED HEREIN MAY BE DATED AND/OR INCORRECT.  YOU ARE ENCOURAGED TO CONSULT WITH AN ATTORNEY AND NOT RELY SOLELY UPON THE INFORMATION CONTAINED HEREIN.

 

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