The greater Boston and Worcester metropolitan regions have been able to provide these services for years now, mainly because earlier Medicaid home care models were aimed at serving communities with higher populations. These models, because of the densities of elderly communities, had the best chance of operating in a cost-effective manner. So the introduction of MassHealth elderly care services at home on Cape Cod is in some ways revolutionary, especially since the region is a retirement destination and growing increasingly older. We’ve written this article to summarize what we’ve been told to expect in the coming year, by the providers themselves.

Getting MassHealth at Home Step 1

Almost all elders should have a kind of Medicare coverage (or Medicare alternative), perhaps in addition to a supplement. Open enrollment for Medicare programs occurs every fall, and interested applicants should either visit the Medicare/SS website at www.cms.gov for guidance, or else try to visit their local senior center during the summer in order to be prepared and to obtain more information.

How to Qualify for MassHealth Home Health Care Step 2 – Medicaid

To begin with, new visitors to our site should quickly review our page describing the differences between MassHealth, Medicaid and Medicare. These programs overlap in a variety of instances, and cannot always be easily distinguished from one another. In fact, even nurses and caregivers themselves may confuse which service is paying their salaries! But it is also important and useful to take the time to learn the principles around the asset test or “spending down” to qualify for Medicaid under MassHealth. By doing so, our clients are already half way towards understanding the qualifications for receiving care at home. And that is because the same MassHealth application is used whether the individual seeks long term care at a nursing home or in their own home.

Generally, the same requirements apply whether the applicant is applying for long term care in a facility or home health care. The individual cannot have any more than $2000 of assets (except for the certain exemptions described in our MassHealth & Medicaid information page). And, most importantly, the applicant and his spouse cannot have made any “gifts” defined by MassHealth as “disqualifying transfers” within the past 5 years. Qualifying for MassHealth is an area that we specialize in as attorneys, and we recommend that every family come see us before proceeding with an application. The risk of inadvertently disqualifying an applicant all too common, and all too expensive.

MassHealth at Home Care Step 3 – Waiver

The “Frail Elder Waiver” is actually the key to all MassHealth home care programs. This is the section of the agency’s regulations that describes how someone becomes eligible to stay at home. The agency itself basically requires that A) Be at least 65 or older (or disabled), B) Be physically eligible to need care and stay at home as determined by the program, C) Have countable income below certain federal guidelines ($2,873 for an individual in 2013) and D) Have essentially no assets.

The two programs administering home based Medicaid on Cape Cod, Tufts SCO and Navicare, have similar yet different sets of requirements for their programs at the time of this writing. The coordinators in these programs have different opinions of what income levels will qualify an applicant, but it is their back offices which ultimately make the eligibility determination. These back offices are very good at crunching numbers, but they are not equipped to deal with helping applicants qualify for Medicaid liability exemptions, or to cure disqualifying transfers. That is why we at McNamara & Yates always emphasize that a no-cost consultation with us is absolutely necessary for families.

Benefits Offered by MassHealth in the Home Programs

These at-home programs for administering Medicaid are helpful not only because they coordinate in-home care for Massachusetts residents (including personal care attendant services in the home); but also because they effectively coordinate all of the MassHealth member’s insurance coverage under Medicare and Medicaid into one plan. In addition, there are some added benefits. Here are some highlights that each of the two companies offer:

Navicare – Fallon Community Health Plan – HMO/SNP or SCO

• No monthly premiums, no copayments or coinsurance
• Prescription Drugs – $0 per prescription
• Certain OTC drugs w/prescription – $0 per prescription
• Transportation to Medical Appointments – $0 for authorized transport
• Dental Care – $0 for Services ranging from Preventive Cleanings to Root Canals
• Supplemental Benefits – $0 for Fitness, Smoking Cessation & Weight Loss Programs.

Tufts Health Plan – Senior Care Options – List of Included Services

• $0 Plan Premiums, $0 Deductibles, $0 Copays
• Approved Prescription as well as OTC Drugs & Supplements
• Dental Services – Fillings, Dentures & More
• Eye exams & eyeglasses
• Hearing Exams & hearing aids
• Transportation to & from Medical Appointments
• Personal Care Manager – works with the member, their family, their physician & other providers to help coordinate care.

Start Your Research on Cape Cod MassHealth in the Home Services ASAP

Both Tufts SCO and Navicare welcome the opportunity to help residents of Barnstable County understand their home care options under MassHealth. Feel free to contact Gina Kupski at Gina_Kupski@tufts-health.com for more information about Tufts SCO on Cape Cod. Jennifer Nocella is the person you will want to speak with regarding Navicare on the Cape at Jennifer.Nocella@fchp.org.

If you need specialized advice on applying for MassHealth and would like to know more about how the 5 year look back rule works, what kind of transfers are “disqualifying,” or what types of transfers might be made to the applicant’s children, feel free to call our office anytime at 508-888-8100 or email atty.mcnamara@comcast.net.

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How Much is Enough (or Too Much) to Avoid a MassHealth Lookback?

Some of these facts are simply numbers, like the size of the estate. This is the first and most important factor to consider when looking at a Medicaid planning strategy. The cost of nursing home care is high, but the cost of giving away control of assets for at least 5 years can be much higher. Probably 75% of attorneys will put assets into an irrevocable trust in the instant they are asked to. We do not. Families with their home as a primary asset, for example, should almost never put that asset into an irrevocable trust! Consider, for example, what would happen if the family wanted to move, or use equity in the home for unforeseen expenses. The same rule goes for any primary asset relied upon by a family. Moderately wealthy clients by contrast can afford to put a second home in an irrevocable trust, and very wealthy clients shouldn’t be concerned with Medicaid at all. Therefore about two thirds of clients who ask us to draft an irrevocable trust to avoid Medicaid liability are advised by us not to do so.

What if a MassHealth Applicant is Married?

Marital status plays a very important role in applying for MassHealth. When one spouse is at risk of needing long term care at a nursing home in the near future, the other spouse might be hesitant to initiate an application. And that is because, for purposes of the MassHealth application, the assets owned by one member of a marriage are also owned by the other. But the regulations actually provide many protections for this other spouse, known as the “community spouse.” A transfer of any marital assets to the name of the community spouse only, for example, is a transfer that avoids the 5 year lookback rule. And the community spouse is able to own a substantial sum of assets by him or herself, but there are some limits.

(Read: Calculating Eligibility for MassHealth and Medicaid)

The house of a married MassHealth applicant, in addition to the sum of other assets, will similarly not be subject to a MassHealth lien if it is transferred in a timely manner to the community spouse. There again are value limitations in the regulations on the amount of equity in real estate, mainly to prevent people with $2 million dollar estates from getting free benefits, but the limitations are very reasonable. The right to a certain amount of income too, can be transferred from the nursing home resident to his or her community spouse. All of these provisions and allowances are in place to ensure that when one spouse goes into a nursing home, the other is not left out in the cold. So for our married estate planning clients, we’re always keeping these provisions in mind.

Children of the MassHealth Applicant at Home or in Need

Clients calling us for immediate MassHealth application counseling are often the children themselves, but with our MassHealth/Medicaid planning clients, we learn of the children from our initial consultation. Like those provisions allowing for transfers to the applicant’s spouse, Medicaid regulations also find that transfers made to children in certain instances may overcome the 5 year look back rule.

If one of the applicant’s children is taking care of him or her prior to a nursing home entry, the law does allow monetary transfers to such a child under certain circumstances. Although very difficult in Massachusetts, it is possible to set up a contract so that the child is paid for taking care of his or her parent. The key in these contracts is that they must be done in advance, and adhere to most of the formalities of any employment relationship.

Another option may arise if the child of an applicant is disabled. Assets may be transferred to that child provided that he or she meets the MassHealth definition(s) of “disabled.” Like with a personal care contract, satisfying MassHealth on this definition can be a challenge, but a specialized MassHealth attorney knows what type of individuals qualify. In many of these cases, our attorneys will often set up a special trust to hold these assets for the disabled individual’s benefit. Primary residences and retirement accounts are the most common assets granted with our clients.

By far the most frequent transfer to a child is in a situation under which MassHealth defines a “caretaker child” exception to the 5 year lookback. Provided that the child has lived in the applicant’s home for at least two years, and has provided a certain level of care to the parent, he or she may be granted that home when the parent is admitted to a nursing home. Certain medical records and proof of residency are required of course, but the MassHealth regulations in this instance are not overly burdensome.

How to Prepare for MassHealth & Avoid the 5 Year Look Back Period

What we want as attorneys is for new clients to visit with us as soon as possible. There is no monetary motivation for this since our initial meetings are provided at no cost, but analyzing a situation earlier rather than later always makes MassHealth preparation easier. Even though many times we simply advise clients to hold off on taking any action, ensuring that a client is informed of his or her options tends to streamline work to be done down the road.

For more information on how assets can be structured or titled in anticipation of a MassHealth application, or for strategies on how to overcome the five year look back provisions, our attorneys are just a click or phone call away. Visit our contact page or call 508-888-8100.

Consumer’s Guide to Medicaid Planning

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Does Medicare Pay for Nursing Home Care in Massachusetts?

The answer to that is no . . . but sometimes. Reflecting on the situation we just described, Medicare doesn’t normally cover the type of care received in a nursing home, or “custodial care.” Again, this can be defined as that care required whenever assistance with activities of daily living is needed; e.g. eating, bathing, getting out of bed and getting dressed. And while Medicare does not offer benefits for such long term care needs, it does continue to provide insurance for traditional Medicare services like prescription drugs (Part D), hospital & doctor visits (Parts A & B) during the period of time someone is living or staying in a nursing facility.

Although Medicare doesn’t cover long term custodial care, it will in some instances cover temporary benefits at a “skilled nursing facility.” These facilities are in fact nursing homes in many instances. Medicare will cover services administered in a skilled nursing facility only if certain criteria are met, namely:

• The facility must be Medicare certified as a skilled nursing facility. Assisted living homes, by contrast, generally do not qualify.
• The patient/resident has Medicare Part A hospital coverage.
• The patient must have spent 3 days in the hospital as an admitted patient. Hospital visits deemed less necessary, for example staying merely “under observation” do not qualify.
• A doctor must recommend that skilled nursing services are necessary to recover for the illness that placed the patient in the hospital, or else an illness related to that placement.
• The resident may only be admitted on an inpatient basis, and not for long term care.

How Long Will Medicare Cover Nursing Home Care, and for How Much?

The length of time a patient’s nursing home stay is covered, and how much must be paid varies according to Medicare plans, any Medicare supplement plans, and long term care insurance, but the formula generally goes as follows:

• The first 20 days of care at a skilled nursing facility after a qualifying hospital visit (see above) will be 100 percent covered for the patient. This stay is granted on a “per illness” basis, which is addressed by regulations. In essence, going in and out of such a facility for the same illness will not reset the 20 days.

• The second 60 day term is covered with a daily co-payment that adjusts each year, that was $146 per day for 2012.
• The co-payment period may last as long as 80 days after the initial 20 day period, but days used in excess of the 60 day secondary term will be taken from a “lifetime amount.”

Again, these formulas can vary, and each patient needs to speak with the business office of the facility in order to determine coverage. More detailed information is available on the Medicare website with this guide. It is more important, however, that the patient be aware of his or her options after Medicare benefits run out. If there is little to no improvement, then the patient may need to consider long term residence at the nursing home.

Who Pays the Nursing Home After Medicare Runs Out?

The complete answer to this question depends, but the payment of Massachusetts nursing home care will either come directly from the patient, or else from Medicaid through MassHealth. What varies in this situation is how much the patient has in assets, and whether he or she can “spend down” assets in order to qualify.

Note: By far one of the most difficult situations we encounter in qualifying for Medicaid is a client that has begun gifting or trying to spend down based on amateur advice. If you are planning to spend down assets for Medicaid, please do not delay in calling a MassHealth long term care attorney at our office.

Whether or not the resident chooses to spend down or private pay will be determined by factors such as how much the resident owns in assets, whether the resident is married or not, and whether the resident owns a home. As mentioned in the note above, such determinations need to be made with the assistance of someone familiar with the Medicaid application process in Massachusetts such as a Medicaid specialist or MassHealth lawyer.

If the resident has no assets, or if the decision is made to spend down in order to qualify for MassHealth, then the next step is to complete the MassHealth application for long term care. While the business office of a nursing home will often assist the family or resident in completing this application, these staff members are far from experts in the field. If the resident even made modest gifts in the past 5 years, for example, staff members will not know how to handle an appeal if benefits are denied. The safest bet when a Medicaid application is begun, is to hire an attorney in the field.

We are always available to answer your questions or legal concerns. For more specific information about your particular Medicaid situation, please feel free to call or email us at anytime at atty.mcnamara@comcast.net

The post Paying for Nursing Home Care with Medicare or Medicaid | How MassHealth Works appeared first on McNamara & Yates.

NOTE: This article not a legal analysis but a summary of Massachusetts Division of Medical Assistance regulations, specifically 130 CMR 456.409 et seq. Actual regulations and their applications are a lot more complex, and require a professional assessment in each situation. For a free consultation contact Mass Health and Medicaid Attorneys Yates or McNamara at 508-888-8100 or on our Contact Us page.

What Are Activities of Daily Living According to MassHealth?

In broad terms, activities of daily living can be thought of as the basic functions that each of us need to perform in our lives on a daily basis; for instance getting into and out of bed, bathing, eating and moving around independently. MassHealth eligibility depends on the level of assistance that is necessary in these tasks. Someone who was unable to cook for herself, for example, would not necessarily require assistance for MassHealth purposes whereas someone who was unable to feed herself would. Likewise, an individual who uses a wheelchair to move around would not need assistance like one who is unable to move himself around in a wheelchair at all. The regulations provide brief examples like this for the assistance of each activity by which MassHealth will screen for eligibility.

In addition, at least one of the three ADLs must require assistance that rises to a level of a “Nursing Service.” Such a service is, as one might imagine, something a bit more intensive than assistance with bathing, eating, and moving around. Usually, nursing services are those associated with a written care plan. An applicant needing to be positioned or re-positioned in bed at regular intervals due to his own inability to do so is receiving a nursing service. Someone who needs frequent monitoring and intervention due to irrational, disruptive or abusive behavior is also in need of a nursing service. Needs rising to a level more consistent than a daily check-in are usually of this sort.

Who Determines Whether ADLs Need Assistance for MassHealth Purposes?

A patient may be admitted to a long term care facility for a variety of reasons. Some may come directly from living on their own or with a spouse at home, while some arrive at a facility after visiting the hospital for an illness. In either case, the admissions and social work staff are pretty knowledgeable about whether the resident requires enough assistance to qualify for MassHealth long term care benefits. And many times, these staff members are the first to flag the applicant’s family about this option or probability.

When a patient initially enters a nursing facility, and that patient is elderly, they are covered for a short time by Medicare (Info on differences between Medicare, Medicaid, and MassHealth is here). When that Medicare coverage runs out, the patient has to either pay privately, or if she has no assets, to go on the Medicaid program for long term care. At this time the facility will notify MassHealth and the regional elder services organization that the patient is scheduled to go on Medicaid. The relevant elder services organization, (e.g. Elder Services of the Cape Cod & Islands), will then send a screening team to the facility for that assessment. The team then sends their report to MassHealth for its review.

Problems and Issues with the MassHealth Physical Screening

There are times that the screening process, or the elder services organization itself might raise some issues with an individual’s MassHealth application. Some of these issues come about as a result of the timing and chain of communications that must take place between the applicant, the nursing facility, the elder services organization and the MassHealth agency. Suffice it to say that there can be a lot of uncertainty when 4 different entities must determine who should notify whom, and when.

In other situations, the elder services organization may determine that an individual applying for MassHealth long term care benefits does not medically qualify. Depending on the time of day, caretaker or nurse’s notes, and other factors within the screening team, an applicant that is marginally qualified may not pass the organization’s analysis. This can occur even if the applicant’s family and the nursing facility know very well that the applicant cannot survive on his or her own. When these difficulties arise it is usually recommended to get a second opinion from a doctor.

Resolving MassHealth Screening Issues

As part of the application process, our MassHealth long term care attorneys work with clients to qualify not only on the financial side of the application, but also on the medical screening side. Most clients take comfort in this fact, that we are able to manage the entire application process and address such unexpected issues that might arise.

For more information please don’t hesitate to call our office and speak with Attorneys Yates or McNamara, or submit a general inquiry on the cape law contact page.

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Medicaid Denial Reason Number 1: Too Much in Assets

Medicaid was designed to take care of those who are too poor to pay for their own medical care. Because of this, the program naturally has several requirements that an applicant or patient must meet before any benefits are given.

Savings accounts or checking accounts are easy indicators that a person is over the asset level, but other less used accounts (like CDs, mutual funds etc.) are at times difficult to discover for a family member. While some may find it hard to believe that such accounts could be “forgotten,” we frequently encounter issues like this with the elderly who are seeking long term care. Many have split their assets between several accounts over the years, and passbooks can be easily lost when they are not used on a regular basis.

Owning a home does not necessarily result in a Medicaid denial, but an unmarried Massachusetts homeowner seeking benefits for long term care at a facility will need to take certain steps in order to qualify (Keep in mind that there are different protections/allowances for married MassHealth applicants, including the ability to transfer the home). The main step will be to place the home on the market, in anticipation of applying proceeds to MassHealth for any benefits incurred by the applicant.

Other assets that could flag the attention of MassHealth include art or antique collections, vehicles, equipment, second homes and other real estate interests.

Medicaid Denial Reason Number 2: Disqualifying Transfers

By far, the disqualifying transfer is one of the most compelling reasons to hire an attorney to qualify for MassHealth Medicaid benefits in Massachusetts. Such transfers do not have to be fraudulent to be “disqualifying,” and so potential applicants for long term care under MassHealth must be very careful on gifts made to friends or family. Attorneys are the most reliable resource for current MassHealth rules on such gifts. An applicant in such situations must either find a reason to qualify the transfer, or else “cure” the transfer (i.e. take the asset back into his or her possession).

The following are some transfers that might seem legitimate, but that MassHealth will nevertheless declare “disqualifying”:

Situation A: Conveying the Family Home to a Child

Mayna is a widowed woman who believes that she soon will need long term care benefits. Her son, Christopher, is her only child and does not yet own his own home. In anticipation of applying for MassHealth, Mayna and Christopher agree that Mayna will convey the home to her son. By doing so, they figure, Mayna will qualify for MassHealth benefits, and, because she no longer has assets there will be no charges assessed to her. Unfortunately, Mayna and Christopher are mistaken. Under the five year look back period under MassHealth, any transfers made for less than fair value within five years will be considered disqualifying.

Options that Mayna and Christopher might have considered if they had spoken to a MassHealth attorney:

• Caretaker Child Exception – Whereby Christopher might have safely inherited the home.
• Disabled Child Provisions – If Christopher qualified the transfer might be validated.

Situation B: Non-taxable Gifting

Arthur is single, and notices that as time has gone on he is less able to safely perform normal daily tasks without assistance; getting out of bed and dressed, and cooking all his meals have become a lot more burdensome. At some point soon, he figures he would like to enter a long term care facility to better care for his daily needs. Having significant money left in a retirement fund, he begins gifting $13,000 to each of his sons Sam, Mike and Andrew. By doing so, he figures he can legally give about $39,000 per year without consequence. And while this is true under IRS tax law, these amounts are disqualifying transfers under MassHealth rules. If Arthur needs to visit a long term care facility within five years, he will need to get these assets back from his sons.

Here are some suggestions an attorney might have made:

• Don’t make these transfers! If long term care was anticipated, Arthur might have opened CDs in his sons’ names for the same amount, allowing for a refund if the money needed to be cured – or a valid gift if the 5 year period passed.
• Start a personal care contract with one or more of the sons. This allowance, though complex, might also help Arthur stay in his home for a longer period of time.

Medicaid Denial Reason Number 3: Not Medically Qualified

To qualify for Medicaid, a MassHealth applicant needs to not only qualify financially, but also medically. In essence this means that the individual will need assistance with 3 activities of daily living (“ADLs”) such as mobility, dressing, eating and hygiene. These requirements might seem easy to fulfill, but in practical application they will likely preclude most all applicants who just need some assistance.

The practical implications of these regulations mean that MassHealth benefits are generally not available to those who only need limited assistance. Some of our clients ask, for example, whether MassHealth benefits are available in the home, or whether Medicaid covers those living in assisted living facilities. Almost without exception the answer is no. Though there would certainly be cost savings in the long run if the government helped some of the elderly maintain independence, such programs are quite limited as of today in Massachusetts.

Final Thoughts

Applying for Medicaid is a fairly straightforward process, but doing so to maintain family assets (and sanity!) requires a great deal of knowledge. If your family decides to do the application by themselves, then beware of these common pitfalls. But if there are any assets at all to be protected, hiring an attorney like one of us is highly recommended. Chances are high that an applicant will need to spend down to apply for MassHealth, and any legal assistance that the family needs will be a valid expense in that process.

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What is MassHealth and What are the Benefits?

MassHealth is basically the consumer branch of the Massachusetts Department of Health and Human Services. In the words of its mission statement, MassHealth “provides comprehensive health insurance – or help in paying for private health insurance—to more than one million Massachusetts children, families, seniors, and people with disabilities.” In addition, MassHealth is the second largest insurer in the state. However this description of MassHealth sounds, the truth is that the question has no easy answer, since benefits and services under MassHealth are often changing with rising costs and changing client needs.

This system was used as a model for the nationwide healthcare plan known also as the “Patient Protection and Affordable Care Act” or “Obamacare.” In that sense it is a system that covers all insured persons within the state.

What is Medicaid and Who Gets It?

Medicaid is the federal government’s welfare, or safety net, plan for people who are without the necessary means to pay for essential medical care. The program provides emergency care to those who are without assets, but it also covers general care needed for certain vulnerable populations like children, parents of children, pregnant women and unborn children. The law generally requires that a person have less than $2,000 in assets if he is applying for Medicaid benefits due to lack of resources.

One of the main (and fastest growing) services administered by Medicaid provides for benefits to elderly individuals requiring long term care, specifically those who need 24 hour care in a nursing home. Because the cost of a nursing home in Massachusetts averages approximately $9,000 to $10,000 a month, most elderly individuals of modest means will qualify financially for long term care benefits under Medicaid fairly quickly. Of course, Medicaid planning addresses the asset and spending strategy that individuals and families can take prior to liquidating large amounts of money on the private payment of such care. In addition to the elderly, Medicaid can also provide coverage for disabled persons needing long term care.

Although Medicaid comes primarily from federal funds, one should remember that the program is administered by state agencies. In Massachusetts, that agency is of course MassHealth. And so people applying for MassHealth are in many cases also applying for Medicaid.

What is Medicare and When Do I Need It?

Medicare is described as a “social insurance program,” meaning in practice that its primary financing is obtained by a tax on all wages. About 2.9% of a person’s income will go towards this program via the payroll tax, and all legal U.S. citizens (having 5 years of residency) are entitled to the benefits after reaching the age of 65. Certain disabled persons qualifying for SSDI may also be covered. In this way the risk is spread across a diversity of the population.

The benefits under Medicare are divided into parts A through D. Part A (the primary part covered by the payroll tax) is used for hospital visits, while Part B is for Doctor’s visits. Anyone using Medicare for a hospital stay must show improvement, however, and this is usually where the most confusion between Medicare and Medicaid occurs.

The situation is usually a variation of the following: An elderly person falls and breaks a bone, and goes to the hospital for emergency treatment. After being treated, the hospital retains the patient until her condition is stabilized. The patient is then moved to a rehabilitation facility, many times a place that also treats persons for long term care. During the patient’s stay, several therapists work with her to improve mobility and other activities of daily living until the patient is capable enough to return home.

If the patient does not improve, then Medicare benefits can only continue for a certain period of time, usually up to 60 days per visit. After that time, the patient will need to pay either privately with her own funds, or will apply for Medicaid benefits if she has no assets.

Conclusion

So, just to summarize things for purposes of memory: MassHealth is the state administrator of Medicaid, Medicaid is the low income welfare system for people of limited resources, and Medicare is the social insurance that we’ll all receive when we reach a certain age.

For more questions about these programs, and specifically how to qualify for Medicaid for long term care under MassHealth, contact one of the MassHealth attorneys at our office.

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But aside from dry economic analyses of Medicaid, nursing home costs are real, and surprisingly high to many individuals and families. And while it is difficult to find up-to-date and accurate information about these costs, we have conducted a bit of research to help our clients understand where nursing home costs in Massachusetts are today in 2012, and more importantly where they are likely headed.

Current Costs of Nursing Home Care in Massachusetts

Without delving too much deeper into reasons why, the cost of nursing home care in Massachusetts is relatively high. To be fair, however, the costs are in part due to the fact that Massachusetts has such a high concentration of globally recognized medical centers. But enjoying such benefits do come with a cost, and according to a survey done by MetLife, Massachusetts is the fifth most expensive in the nation behind Alaska, Hawaii, New York and Connecticut. As illustrated in the chart, the average per day cost of nursing home care in Massachusetts came in at about $329. An individual could stay at some of the finest hotels in Boston at that rate.

But not all of these nursing home costs fall under Medicaid coverage. According to the Massachusetts Medicaid Policy institute, MassHealth accounts for over half of nursing homes’ revenues in the state. So while 50% of total nursing home costs in the state are currently covered by Medicaid, the figure above includes what residents are paying at more expensive private facilities, of which the state has no shortage.

Massachusetts and Cape Cod Nursing Home Cost Trends

As we noted above, the cost of nursing home care is increasing rapidly. In fact, according to a study recently released by Genworth, nursing home costs are increasing faster than even the out of control college tuition market!

The report examined the company’s own cost of care survey conducted between the years of 2005-2011. According to those numbers, in 2011 across Massachusetts the median cost of long term care in a semi-private room came in at $320 daily, or $116,800 annually. The same cost of nursing home care in Barnstable, the largest town on Cape Cod was slightly higher at $328 per day or $119,600 annually.

Numbers that the company compiled for private rooms were of course more expensive, and the whole state registered a median daily cost of $345, or $125,925 annual. Again Barnstable nursing home costs were a little higher at $350 daily and $127,750 annually.

These costs are significantly affected by inclusion of private pay (non Medicaid) institutions, and are re-published here merely to illustrate the company’s findings regarding how quickly the these costs are increasing. According to Genworth, the cost of care from 2005-2011 increased annually at an average of 4% state wide and 6% for nursing home care in Barnstable. So for anyone that is considering Medicaid planning under MassHealth, these numbers indicate significant spikes in the cost of long term care on Cape Cod and Massachusetts in the not too distant future.

Real World Numbers from a Cape Cod MassHealth Attorney

As any Cape Cod Medicaid attorney will tell you, these rates are not quite the average for most facilities. In our experience, for example, the Massachusetts Medicaid reimbursement rate contributes $300 per day (2014) to nursing homes for the cost of care. This means that a long term care facility will receive $300 daily for each elderly person without assets that it houses. We rarely find that these same facilities charge as much as $70 over that daily rate as the above figures indicate, but even $300 per day can deplete assets rather quickly.

All of this nevertheless just reinforces what most already know; that early Medicaid planning is important. Our clients come to us at all stages of the planning process, and we do our best to help achieve the goals of the MassHealth applicant and any family members involved in the process. While we wouldn’t necessarily describe the process as easy, our experience has been a help to many successful MassHealth benefit recipients.

If you have any clarification on these statistics, this article, or even the cost of nursing home care on the Cape or Massachusetts more generally, don’t hesitate to call us at 508-888-8100 or through our contact us page.

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While Medicaid denial rate statistics are not easy to find, attorneys, (being the problem solvers of the system), tend to see a disproportionate number of MassHealth application denials. In fact, unfortunately some of our clients come to us for the first time after they have been denied. So what are the applicant’s options when a Medicaid application for long term care is denied? Below is a chronology of the Medicaid application and appeal process in Massachusetts.

I. MassHealth Application is Filed

Medicaid benefits will be paid via MassHealth to the applicant from as far back as three months prior to the month when MassHealth received the application. So if the application was received on August 31, the applicant can be eligible for benefits beginning in the three prior months, including all of May, June and July.

II. The MassHealth Request for Information

It is quite common for the applicant to receive a request for additional information from MassHealth within a few weeks of submitting the application. Many times the MassHealth case worker at the regional Enrollment Center (“MEC”) finds a discrepancy or omission that needs clarification. Common examples include property valuations or transfers of funds over $1,000. Most frequently, however, the case worker sends out this form merely to request items listed under “Long-Term-Care Information,” e.g. that the long term care facility should request a screening to determine that the applicant is physically eligible for Medicaid. The MassHealth Request for Information form is basically in a checklist format with room for the case worker to write specific directions.

III. The MassHealth Denial Notice

This is the first Notice the applicant will receive that indicates there is a significant problem with the Medicaid application. It will often include a statement requiring that a certain piece of omitted information be provided, and perhaps that an “ineligibility period” will be imposed based on an disqualifying transfer of assets during the Medicaid 5 year look back period. Other information provided on the Denial are citations to the regulations that were used to make the decision (e.g. 130 CMR 516.006).

Reasons for a denial will vary, and this notice should be read carefully. Sometimes there is a valid reason for the decision, but many times there isn’t. Keep in mind that the Mass Health rules on disqualifying transfers operate in a guilty-until-proven-innocent manner, and that the experience levels of Mass Health case workers (those that review the applications) vary quite a bit. These factors combined can lead to unfair consequences for the novice applicant.

The applicant has two options after receiving a denial. She may send in the requested information (thereby resetting the application date for purposes of receiving past benefits to the date of receiving new information), and hope for the best. But she may also request a fair hearing that works to appeal the decision. Depending on the nature of the information requested and the need to “preserve the application date” the applicant may want to do both.

IV. The MassHealth Fair Hearing

A MassHealth Fair Hearing is the last administrative remedy available to the applicant wishing to receive benefits from Medicaid. In order to request a fair hearing for Mass Health, the applicant needs to file her request within 30 days of receiving a decision on benefits (e.g. the denial notice). This is where the applicant can make the case that benefits were not received, or that a decision by MassHealth was made in error, or that the facts underlying the decision were incorrect. The hearing is conducted by a Mass Health hearing officer at the enrollment center for the applicant’s region.

Convincing Mass Health to rule in the applicant’s favor usually requires a solid understanding of the rules and how they are interpreted. The appellant-applicant should be prepared with a concise narrative of her case on why the decision should be modified or overturned. If the applicant did not use an attorney to assist with the application, contacting a Massachusetts Medicaid attorney at this point should be a priority. The cost of losing benefits is simply too great, and the attorney’s expertise will help in a number of ways, for example:

• Illustrating why a disqualifying transfer actually qualified within the rules
• Knowing when it is necessary to bring witnesses for corroboration.
• Determining what types of new evidence will illuminate the foundation for the appeal.
• Identifying whether the Mass Health denial complied with statutory requirements.
• Knowing how and why to ask the hearing officer to keep the case open.

V. Judicial Review of a MassHealth Decision

After all administrative remedies are exhausted, there is a possibility for judicial review of the decision in the courts. Of course coming to this stage of a MassHealth application is very undesirable due to the finality, expense and time of the proceedings. Similar to the limitations on an appeal from a MassHealth denial to a Fair Hearing, judicial review must be filed within 30 days of a Fair Hearing decision.

The post The Medicaid Fair Hearing Under Mass Health | After the Medicaid Denial appeared first on McNamara & Yates.

In many areas of law outside of the court system, laypersons will frequently attempt to educate and counsel themselves to save money. While this may not always be a bad idea, many times the self-help method might cause actual losses, not savings. A Cape Cod Medicaid attorney by contrast can actually help save money in the MassHealth application process. Such savings might materialize in the form of actual money, in successfully qualifying for expensive long-term benefits, or in the potential hundreds of hours you might spend on research and putting the application together. Below we have listed some of the benefits of hiring a MassHealth attorney.

Hiring an Attorney Ensures You Will Consider the Entire “Estate”

MassHealth, the Massachusetts agency responsible for administering long term care Medicaid benefits, is very thorough in its investigation of an applicant’s assets. Given that the Medicaid lookback period goes back 5 years, the Medicaid applicant has a relatively high burden to satisfy with respect to financial and transaction records. At the same time, there are certain classifications of assets that will not be counted as assets when there is a community spouse. A Medicaid attorney aids in this process by providing expertise on these distinctions, by identifying countable assets that are convertible to uncountable ones, and by executing the legal documents necessary to make such conversions.

A Massachusetts Medicaid Attorney Contributes Impartial and Qualified Advice

Quite often, in order to speed up the process for all parties involved, employees at a nursing home will offer advice on the Mass Health application process. And while such employees usually have the best intentions, their goals are not entirely consistent with the applicant’s. First, the facility will be paid regardless of whether the money comes out of the government or applicant’s pocket. Second, the nursing home has no incentive to protect the assets of its residents, nor does it have the expertise to do so. If the goal is to guarantee an applicant will be approved for Medicaid benefits as soon as possible, with minimal losses, a Medicaid attorney must be employed.

Late Expert Attorney Advice May Yet Streamline the Application

Even though the most successful asset protection strategies should begin well before the Medicaid application, there are still options available to the applicant at the last minute. A Medicaid Attorney is the most experienced party to help you identify these options. Moreover, when the application process is just begun after admission, the applicant’s interest in qualifying for benefits becomes a great deal more urgent. It would be unfair to the entire family if a MassHealth applicant became disqualified, and lost eligibility for Medicaid benefits simply because no one thought to consult an expert.

Legal Expertise Pays for Itself When Translating Medicaid Rules

In truth, even a doctor in the English language couldn’t understand how MassHealth interprets the Medicaid rules, if he never went through the process himself. Navigating the application process is an extremely complex process that, while attempting to provide for those in need, actually creates an overly confusing experience. Reading, for example, that the validity of an asset transfer depends in part on the meaning of the term “otherwise eligible,” means nothing to the non-practitioner without an expert’s advice.

An Attorney Will Stop You From Giving Away Your Assets

Perhaps the most frequently encountered Medicaid crisis occurs when an applicant mistakenly believes she can simply give away her assets to qualify for long term care benefits. While there are certain acceptable gifts that may be made, and certain asset transfers that won’t affect eligibility, such transactions should be looked at by an attorney. Spending down assets is one of the most misunderstood strategies in the Medicaid process, and should not be followed on advice from a layperson. Doing so could result in extremely disastrous consequences! Contact a Massachusetts Medicaid Attorney today.

The post 5 Ways a Medicaid Attorney in Massachusetts Helps Your Application appeared first on McNamara & Yates.

Qualifying for long term care under the Mass Health Medicaid program requires a certain commitment to detail, and also some understanding of pitfalls in the process. At our office, we frequently counsel clients hoping to minimize the extent to which Medicaid will reduce the family’s assets. What follows is the second part of an article on some mistakes and myths to avoid when planning for Medicaid.

Using a Living Trust to Protect Assets from Medicaid

One myth is that a living trust will protect one’s assets from Medicaid. But statements like this are typically heard from a salesperson. A living trust is “revocable,” meaning that the grantor may revoke it at any time. This means that for purposes of Medicaid, the grantor applicant still has full access to those funds, and therefore still has control. An irrevocable trust, by contrast, will not be a countable asset. Still, any transfer into an irrevocable trust within the 5 year look back period will be considered a disqualifying transfer, which again demonstrates why an experienced Massachusetts Medicaid attorney should be consulted by anyone considering long-term care planning.

Mistakenly Believing an Old Annuity will Protect Assets

In the past, prior to the Deficit Reduction Act of 2006 [DRA], couples were encouraged to purchase annuities by their insurance agent or other financial planner in advance of any potential Medicaid application. The goal was to protect the funds from Medicaid liability. But the Act made some important changes to what annuities are uncountable in the application process, resulting in many annuities no longer having protective value. Annuities offered after the act as DRA compliant will still have protective value, but note that these annuities must be “immediate” as opposed to “deferred.”

Gifting Assets Too Early or Too Late

While the reasons why may not be clear at first, having a potential applicant gift assets to members of his or her family too early can lead to undesirable consequences from many unanticipated events. First of all, the applicant’s financial security should be a primary concern before any assets are given away. It would be unfortunate, for example, if a parent gave away his or her home when the assets retained to live on, e.g. mutual funds, lost half of their value 4 years down the road. Moreover, it would be equally painful if the home was given to a son who subsequently went through a divorce, or incurred substantial liabilities in a serious automobile accident. Transferring too late, by contrast, may substantially impact your eligibility for long term care under Mass Health. Being deliberate and thoughtful over the available options is therefore paramount.

Failing to Use the Spousal Protections of a Medicaid Applicant

Without consulting an attorney, a married applicant and her family might not be aware of certain protections available to the spouse. A husband and wife are entitled to protecting certain assets belonging to the both of them up to certain limits. Assets that may be saved include income coming to the community spouse, the primary residence, and other assets up to around $110,000. Do not fill out the Mass Health application before forming this part of your Medicaid planning strategy!

Not Consulting a Massachusetts Medicaid Attorney to Save Money

Attempting to gain eligibility for Medicaid is a complex process that most people, (and even most attorneys), will only go through once in their life. This application process, however, is also extremely risky in terms of losses to both family assets and the delivery of vital care. Because of these factors it is crucial that the applicant contact and enlist the expertise of an experienced Massachusetts Medicaid attorney. Moreover, scheduling a free consultation with our office ensures that you’ll be able to project all the necessary costs up front instead of playing what is often a dangerous guessing game.

Go back to Part 1 of 10 Tips From a Massachusetts Medicaid Attorney by clicking here

The post Qualifying for Mass Health | 10 Tips from a Massachusetts Medicaid Attorney Part 2 appeared first on McNamara & Yates.