The Legal Checkup Blog

I've been following and periodically providing updates on a class action lawsuit known as "Jimmo v. Sebelius" (Kathleen Sebelius, Secretary of Health and Human Services), which was filed in The United States District Court for the District of Vermont.  Plaintiffs include six individual Medicare beneficiaries and seven national organizations (including the National Committee to Preserve Social Security, Parkinson's Action Network, Paralyzed Veterans of America, American Academy of Physical Medicine and Rehabilitation, Alzheimer's Association, and United Cerebral Palsy).

Plaintiffs alleged that the Secretary has adopted an unlawful and clandestine standard to determine whether Medicare beneficiaries are entitled to coverage, resulting in the wrongful termination, reduction, and denial of Medicare coverage for beneficiearies with medical conditions that are not expected to improve. 

Plaintiffs alleged that this unlawful standard is implemented at the lower levels of Medicare's administrative review process, and denies coverage where the beneficiary needs "maintenance services only," has "plateaued," or is "chronic," "medically stable," or not improving.  This "rule of thumb" or clandestine policy is what plaintiffs refer to as the "Improvement Standard."  If you or a loved one has ever been in a rehabilitation facility, you have probably received such a notice.  This Improvement Standard is contrary to the Medicare Act and federal regulations and precludes coverage for beneficiaries with conditions that are not expected to improve or that have not improved over the course of treatment.

Plaintiffs allege that this standard has been implemented without proper rulemaking procedures against beneficiaries that have little or no understanding of its application and no ability or reasonable opportunity to confront it.

Well, we have GREAT NEWS to report!!

The Center for Medicare Advocacy and the Centers for Medicare and Medicaid Services (CMS) have agreed to settle the "Jimmo" case, also known as the “Improvement Standard” case, and have filed a proposed settlement agreement with the Court.  If the judge approves the proposed agreement, a process that could take several months, the Medicare Benefit Policy Manual will be revised to correct any suggestion that continued coverage is dependent on the beneficiary improving.  CMS will undertake an Educational Campaign to inform providers, contractors, and adjudicators that they can not base coverage on the potential for improvement, but on the need for skilled care.

Bravo to the attorneys from the Center for Medicare Advocacy and Vermont Legal Aid, who have undertaken this cause on behalf of the Plaintiffs.  This unlawful "Improvement Standard" is an issue elder law attorneys and their clients face on a daily basis, so this is fantastic news!  If you are interested in viewing the proposed settlement agreement, you may view it here.   

http://www.medicareadvocacy.org/wp-content/uploads/2012/10/Proposed-Settlement-Agreement.101612.pdf

Long-term care planning is a significant part of most elder law practices. While the ideal clients seek counsel long before there is a crisis, the usual clients do not. It is in these crisis situations that clients benefit most from an elder law attorney's knowledge of the resources available in their communities and an understanding of the medical and financial criteria for eligibility.
PACE, the Program for All-Inclusive Care for the Elderly, is a national comprehensive health program created to help elders remain at home as long as possible. While PACE is a valuable resource for many elders, it remains a fuzzy concept for many attorneys and is, thereby, under utilized.

WHERE IS PACE?
Unfortunately, PACE is not available in all cities and towns, but is available in:
Allston, Arlington, Avon, Beverly, Boston, Braintree, Brighton, Brookline, Cambridge, Canton, Charlestown, Chelsea, Danvers, Dedham, Dorchester, East Boston, Essex, Everett, Gloucester, Hamilton,Hudson, Hyde Park, Ipswich, Kenmore, Lynn, Lynnfield, Magnolia, Malden, Manchester, Marblehead, Marlboro, Mattapan, Medford, Middleton, Milton, Nahant, Norwood, Peabody, Quincy, Randolph, Revere, Roslindale, Rockport, Roxbury, Salem, Saugus, Sharon, Somerville, South Boston, South Hamilton, Stoughton, Swampscott, Topsfield, Wakefield, Wenham, West Roxbury, Weymouth, Winthrop, all towns in WorcesterCounty,

WHO IS ELIGIBLE FOR PACE?
In order to be eligible for PACE, applicants must be 55 years of age or older, live in a PACE service area as outlined above, and must be certified by the state as eligible for nursing home care but able to safely remain in the community with the additional supports PACE offers. Members must also agree to receive all health services exclusively through the Elder Service Plan. While many elders are initially hesitant to give up their primary care physicians or other medical professionals, it is the interdisciplinary team model of PACE that allows each member to maximize his or her potential to remain in the community and ensures that nobody falls through the cracks.

HOW IS PACE FUNDED AND WHAT SERVICES DOES PACE COVER?
PACE is jointly funded by Medicaid (2/3) and Medicare (1/3) in a capitated system. In other words, Medicaid and Medicare each pay a set rate per member per month. Medicaid presently pays $3,497 per member per month, with the Medicare rate dependent on the diagnosis codes of each member. Each PACE program must offer a number of Core Services, and may offer elective services based on the various needs of their members. This flexibility allows each program to customize individualized care plans designed to help each member maximize his or her potential.

Interdisciplinary teams of doctors, nurses, social workers, therapists, nutritionists, and other medical staff work together to provide primary medical care, home health, adult day health (recreation), rehabilitation services, transportation, medications, podiatry, optometry, dental, social services, and more. While the majority of PACE services are provided at an adult day center to encourage socialization and activity, services are provided in the home when appropriate. Some PACE programs offer residence in certain Assisted Living Facilities. PACE members never pay more than their income for a PACE apartment in an assisted living facility. If nursing home care becomes necessary, it is paid for by PACE and PACE continues to coordinate the member’s care, so long as the member does not disenroll from the PACE program.

WHAT IS THE FINANCIAL CRITERIA FOR MEMBERSHIP?
PACE accepts Medicare, Medicaid, and private payment. For married couples, only the income and assets of the applicant are countable. For members with monthly income of $2,094 or less per month, there is no monthly spenddown and they can keep the entire $2,094. For members who have income over $2,094, there is a monthly spenddown to $542. Members with monthly income over $4,039 (which represents the MassHealth amount of $3,497 plus the deductible of $542) would pay privately, while members with income below $4,039 would apply for MassHealth in order to keep the $542 monthly. Private pay members pay only the portion that Medicaid would pay, or $3,497 per month.

WHY SHOULD YOU CONSIDER JOINING PACE?
The most significant reason that PACE is appealing is that its primary goal is to provide each member with the individual supports needed to remain in the community as long as possible. Another benefit to consider is that PACE is covered by Community MassHealth, under which transfers of assets are presently not penalized. Therefore, for people who have not done prior planning who are suddenly faced with the need for long-term care services, the option of joining PACE should be explored for 1) quality of life issues and 2) additional planning options. In addition, the application process for Community MassHealth/PACE is far less burdensome than the long-term care MassHealth application, requiring only a few months of financial statements to verify assets (as compared with up to five years of verifications for long-term care MassHealth). Members are free to disenroll from PACE at any time. PACE is not for every body, but if you are fortunate enough to live in a PACE service area, this is an option that warrants consideration.

Call my office at 781-681-6638 if you are interested in exploring the PACE program to help you remain safely in your home.

Note:  Rockland and Mansfield Boot Camps are fully booked!  We are maintaining a wait list and an additional date will be added when filled. 

IT'S BACK BY POPULAR DEMAND AND SURE TO "SELL OUT" QUICKLY ... 

THE LEGAL CHECK UP BOOT CAMP (c)

Families come in all shapes and sizes. Whether you are young, a boomer or a senior, single, married (traditional or same-sex), divorced, have children or not, have a family member with special needs, want to leave your estate to your pets ... whatever your situation, you need a comprehensive assessment and and an Estate Plan that is just right for you. Depending on your goals and your situation, your plan might focus on probate avoidance, tax minimization, asset protection, or special needs planning.

"I don't have enough to worry about" you say?

Well, be aware that whether you are wealthy, barely getting by, or somewhere in the middle -- there are basic documents you need to have in place in the event you become temporarily or permanently unable to act for yourself due to a physical or mental incapacity.

You can't afford not to have these basic documents in place in the event of an emergency.  If you don't have basic disability documents that appoint an agent to act on your behalf in such cases, your loved ones would need to petition the probate court for a guardianship and/or conservatorship to obtain the authority to act on your behalf.  These court processes can cost thousands of dollars.

So, delay no more.    

Come and learn how to protect yourself, your family, and your assets in the event of disability or death.

Not just another boring seminar ... in this free, comprehensive workshop you will learn every thing you need to know about Estate and Long-Term Care Planning.  Part of the workshop will be interactive to allow attendees to discuss particular problems, concerns and situations.

This workshop will cover:

* what estate planning documents you need in the event of disability;

* what estate planning documents you need in order to achieve your goals and objectives;

* how to properly select Agents, Personal Representatives, and Trustees;

* whether you need a Will, a Trust, or both;

* long-term care costs and payment options (Medicare, VA benefits, Long-Term Care Insurance, Private Pay and Medicaid);

* how to protect your home and other assets;

* how to provide for your child with special needs in a way that improves his or her quality of life without disrupting eligibility for public benefits;

Each attendee will receive a workbook and will "graduate" from the Boot Camp with a detailed, comprehensive plan of action.

The Fall workshops will be offered during the day (from 12-3 pm) and in the evening (from 5-8 pm).  Seating is limited to 12 in each session in order to provide individualized guidance to each attendee.  Session dates will be posted soon, but preference will be given to those who pre-register at:

http://www.thelegalcheckup.com/legal-check-up-boot-camp-registration/

Most seniors I speak with feel that they have worked hard their entire lives, and that they should not have to spend all of their hard-earned assets on nursing home care.  They would like to pass some assets on to their children or grandchildren.

The problem with this, however, is that without proper guidance and advocacy, many seniors are often rushed into an Asset Protection plan that “protects the assets from the nursing home" and "protecs the assets for their children or grandchildren" ... and leaves the senior unprotected and vulnerable.  They fall victim to the many misleading ads in print on the radio that make false claims about asset protection, use scare tactics that are simply unconscionable, or offer deep discounts to sign up "today only."  No attorney worth dealing with is going to use any of these tactics to get your business.  Let me explain.

There are THREE FUNDAMENTAL RULES that you must understand about ASSET PROTECTION ...

1) You have not “protected” an asset until you have given it away, either to a person or a trust, with no legal right to change your mind and take the gift back in the future.

2) There is a five-year lookback period, which means that MassHealth can look at all of your financial statements going back five years, and they will impose a penalty for any gifts you made during that five years.  So, the assets are not fully protected until FIVE YEARS after you give them away.

3)  You could unintentionally be forced to a nursing home if you run out of funds to pay for continued care in your home.  If you “protect” assets by giving them away and getting through the five-year lookback period as outlined above, you will have no legal right to get the assets back and you may be left "unprotected" and unable to pay for the care you need to remain in your home.  

Certainly it is not any senior's intent to end up having to move to a nursing home because they "protected" their assets years earlier ... but it happens.  Part of the problem, in my opinion, is the prevalence of misleading ads that serve to scare and confuse seniors.

BEWARE of legal ads that encourage you to “Protect your Assets” while leading you to believe you are protecting yourself in the process … this is one example of an ad that I find to be very misleading, if not absolutely FALSE.

Learn about Asset Protection Trusts that:

      1) allow you to control your assets until death;

      2) allow you to retain all income from your assets

      3) enable you to protect your assets from the nursing home

     4) ensure you qualify for Medicaid in the shortest period of time

Let’s look back at the Fundamental Rules of Asset Protection.

Number 1 is FALSE because, while you may serve as trustee of the asset protection trust, it is not YOUR assets that you are controlling ... you gave the assets to someone else in order to "protect" them!

Number 2 is FALSE because, while you can retain the right to the income generated by the assets in an asset protection trust, the assets in the trust are no longer YOUR assets!  You gave the assets to someone else in order to "protect" them!

Number 3 is TRUE and FALSE - True because after five years the assets will be protected from the cost of your nursing home care, but FALSE because, once again, they are not YOUR assets any more -- you gave them to someone else in order to "protect" them.

Number 4 is FALSE because there is a 5 year lookback.  Assets transferred to an asset protection trust will not be fully protected until 5 years after they are transferred to the trust, and there is no attorney who can make you eligible with this strategy in less than 5 years.  In fact, there may be ways to make you eligible sooner based on your specific situation, but not with an asset protection trust.

Some asset protection strategies may be appropriate for you, but only if you can ensure your own future security in the process.  This is why a comprehensive assessment of your specific family situation, health and care needs, income and assets, and goals is critical to a successful Long-Term Care Plan.  A Legal Check Up will enable you to fully understand the risks and benefits and pros and cons of asset protection strategies, and will enable you to make an informed decision based on your specific situation.  

Remember, if a radio or print ad seems too good to be true, it probably is. And, if an attorney offers a discount on the cost of an asset protection plan, but the price is good "today only ..."  RUN, don't walk, to another elder law attorney.  These pressure and scare tactics are not appropriate and, frankly, offensive to most elder law attorneys. Your future security must be treated with the importance and thoughtful deliberation it deserves, by you and your attorney.

Call us today at 781-681-6638 to schedule a Legal Check Up or to get a schedule of upcoming seminars, or get more information at www.thelegalcheckup.com.

The Massachusetts Bar Association invites you to participate in Court Advocacy Day on Monday, March 19 at the Grand Staircase inside the State House. Beginning at 11 a.m., the event will help reiterate the need for adequate funding to sustain the critical needs of the Massachusetts Court System. The event will open with a brief speaking program, after which attendees will be encouraged to meet with their local legislators.

The event will include speaking remarks from:

•Supreme Judicial Court Chief Justice Roderick L. Ireland;

•Chief Justice for Administration and Management Robert A. Mulligan;

•MBA President Richard P. Campbell; and

•Boston Bar Association President Lisa Goodheart

The MBA would appreciate your signing up in advance at http://www.massbar.org/cle/cle-programs?p=2709

You can sign up in advance to meet with your legislators, or just drop by their offices.  The MBA will provide informational packets at the event that include fact sheets on court funding that you can leave with your legislators.

For your convenience, you can find the list of Senators at:

http://www.malegislature.gov/People/Senate

and the list of Representatives at:

http://www.malegislature.gov/People/House.

Deb Thomson and some members of the MassNAELA Board of Directors will be at the event to offer guidance to MassNAELA members in attendance.  We hope to see many of you there to support funding for the Massachusetts courts!

Follow this link to a video and other resources to learn more about the judicial system's response to the underfunding crisis.   

http://www.massbar.org/about-the-mba/initiatives/court-funding

Hot off the press from the State House News Service:

The Patrick administration has struck a $26.75 billion deal with the Obama administration that the governor says will set the stage for a "new round of innovations" in Massachusetts's health care system and that federal officials say will serve as a precursor to sweeping changes in the way health care is delivered in the Bay State.

The deal, a three-year Medicaid pact authorized by the U.S. Department of Health and Human Services, represents a $5.69 billion, 26.2 percent increase over the last three-year deal, which was approved by the administration of President George W. Bush in 2008. The last waiver deal, a three-year pact approved in 2008 by the Bush administration, was valued at about $21.2 billion and hailed as a victory for state health programs by Gov. Deval Patrick and U.S. Sen. Edward Kennedy.

The new deal was reached last week when Patrick met with U.S. Secretary of Health and Human Services Kathleen Sebelius in Washington D.C., and details were finalized in the days since the meeting, according to an administration official.

MassHealth, the state's Medicaid program, provides 1.3 million low-income or disabled Massachusetts residents with subsidized coverage and has been a major part of the state's efforts to provide near-universal coverage.

Under the terms of the deal, also known as a Medicaid waiver, safety net hospitals in Massachusetts - including Boston Medical Center and Cambridge Health Alliance - will be required to make major changes to the way they deliver health care in order to access a $120-million-a-year pot of funds. The changes include moving away from a health care system that pays doctors based on the volume of tests they perform, rather than the health outcomes for their patients.

Gov. Patrick has pressed lawmakers to act on a bill that would make this shift the norm in the Massachusetts health care industry, but the Legislature has deferred action until next year. 

Under the waiver, Massachusetts will establish a pilot program aimed at expanding coverage for pediatric asthma services. This provision of the waiver closely mirrors a Medicaid program adopted in a state budget 18 months ago aimed at preventing unnecessary hospital admissions for pediatric asthma patients. The state will also "streamline eligibility procedures" for about 140,000 parents with children who receive food stamps, and the waiver also covers expanded "early intervention" services for children with developmental delays and disabilities.

Massachusetts officials also withdrew a number of requests, according to the federal Centers for Medicare and Medicaid Services, which sent a letter to Patrick administration health and human services chief JudyAnn Bigby. The withdrawn proposals include integrated care for residents eligible for both Medicare and Medicaid, which the Patrick administration plans to tackle independently.

The administration had also requested the ability to increase pharmacy co-pays "above allowable State plan levels" and to institute a co-pay for non-emergency medical transportation," according to the letter. The Medicaid waiver, a critical element of Massachusetts health care financing scheme, was due to be finalized in July, but negotiators sought a series of one-month extensions, unable to reach agreement as news of major pressure to cut federal spending dominated the dialogue in Washington.

Proponents of the deal said it would preserve the state's health care programs established in 2006, when Gov. Mitt Romney signed a health care law intended to guarantee access to insurance for nearly all Massachusetts residents. Since the law was signed, about 411,000 previously uninsured residents obtained health care coverage, and the Patrick administration estimates that 98 percent of all residents are insured. The cornerstone of that legislation, a health insurance exchange called Commonwealth Care, served as a model for exchanges included as part of the federal Affordable Care Act signed by President Obama nearly two years ago. Commonwealth Care helps enroll low-income residents in heavily subsidized private insurance plans. Commonwealth Care and a separate program that covers care for a diminishing pool of uninsured residents will receive $500 million a year, under the new waiver deal.

The Patrick administration has also committed to implementing all provisions of the Affordable Care Act by Jan. 1, 2014, when most major provisions of the federal law take effect. The waiver may carry some political significance heading into a presidential year, as Romney campaigns for the Republican nomination to take on President Obama. Romney has repeatedly been forced to defend the health care law he signed as an affordable plan that works for Massachusetts. But critics say the state's programs survive because of a broad lifeline provided by the federal government, a critique unlikely to be quelled by the major increase in Medicaid funding announced Tuesday.  

The holidays are a perfect time to give the gift of Peace of Mind.  PEACE of MIND gift certificates provide you with an easy way to initiate a positive conversation about estate and long-term care planning, and encourage your loved ones to get their affairs in order.

Your loved ones will not be offended by this thoughtful gift that still leaves them in control.  Best of all, it will not need to be returned because it  is the wrong size or color (although it can be returned if they choose not to use it, of course).

Exclusively from the Elder Law Office of Judith M. Flynn, PEACE of MIND Gift Certificates may be purchased in any dollar amount, or for specific services such as:  

* a Legal Check Up;

* Estate Planning Package (including Probate Avoidance and Tax Minimization);

* Asset Protection Package

* Special Needs Planning Package;

* College Student Health Care Proxy/Durable Power of Attorney Package.

Contact us today to learn more at http://www.thelegalcheckup.com/contact-us/

We all want to age in place in our own homes, on our own terms -- any place other than a nursing home.  Sometimes situations change quickly, however, and for a number of reasons it just may not be possible to remain safely in the community.  It is at these times of crisis that folks often discover that all the ideas they had about their long-term care security and how they would pay for nursing home care if needed are basically … well, wrong.  There are five major payment sources for nursing home care, each worthy of its own full-length column, but I offer the following brief summary to help dispel some of the myths on this topic. 

The most common misconception I hear from seniors is that Medicare is going to cover all of their nursing home costs.  This simply is NOT true.

MEDICARE

Medicare will only cover “skilled” care, and only if all of the following conditions are met:

• You have Medicare Part A (hospital insurance) and have days left in your benefit period;

• You have a qualifying hospital stay, which is an inpatient stay of three consecutive days or more, starting with the day of admission and not including the day of discharge. (ALERT:  If you are held for “observation” for part of your hospital stay prior to being admitted, you may not have met the minimum requirement.  This is an issue that should be promptly appealed.)

• Discharge to the rehabilitation facility either directly or within 30 days;

• Your doctor orders the services you need for SNF care, which require the skills of professional personnel such as registered nurses, LPNs, phsyical, occupational, and speech therapists, and are furnished by or under the supervision of these skilled personnel;

• You require the skilled services on a daily basis (5 days per week qualifies).

The availability of 100 days is not, however, a guaranteed coverage period of 100 days.  In fact, it is far from guaranteed with the average period of SNF care covered by Medicare being only 23 days.  You must also qualify according to the clinical criteria set forth by Medicare.  Medicare requires the facility to conduct periodic assessments of your condition and goals to determine whether you will be approved for extended skilled coverage.

Medicare will pay the full cost for days 1-20, and you will be responsible for a significant daily copayment from days 21-100.  Medicare does not pay beyond the 100-day period, unless you have a break in your coverage for at least 60 days.  In that case, with the above conditions met again, you would have a new 100-day period available.

(ALERT:  If you receive a Notice of Medicare Provider Non-Coverage informing you that your Medicare coverage will terminate because you have “reached a plateau,” “are stable,” “custodial care” or not improving, consider filing an immediate appeal.  If you need continued skilled services in order to maintain your present condition, then you are entitled to continued coverage under the Medicare Act and federal law.)

VETERANS BENEFITS

Nursing home care is not automatically available to all veterans enrolled in the VA health plan.  Only the following veterans automatically qualify for unlimited nursing home care:

• Veterans who are seeking nursing home care for a service-related condition;

• Veterans with a service-connected disability rating of 70 percent or more;

• Veterans who have a service-connected disability of 60 percent and are unemployable;

• A service-connected disability is a disability that the VA has officially ruled was incurred or aggravated while on active duty in the military and in the line of duty. The VA must rule that your illness/condition is directly related to your active military service, and it assigns each disability a rating. The ratings are established by VA regional offices around the country;

• The VA may provide nursing home care to other veterans if space permits. Veterans with service-connected disabilities receive priority.

LONG-TERM CARE INSURANCE

The popularity of long-term care insurance is growing, for obvious reasons.  The problem with this payment option, however, is that many people don’t consider purchasing long-term care insurance until they need it.  When they need it, they simply will not qualify for it.  If you have not had a diagnosis that would affect your ability to obtain long-term care insurance, look into it today.  Even if you pay more for it based on your age, the statistics show that your investment will be well worth it down the road.  In addition, there are tax incentives available for purchasing long-term care insurance, and certain qualifying policies can make your home a non-countable asset for Medicaid/MassHealth purposes.  Call my office if you would like a referral to a trusted insurance professional. 

PRIVATE PAYMENT

This is the most non-desirable payment option for extended nursing home payment, but most folks do not do adequate pre-planning.  Let me be clear.  Facilities provide care, and facilities need to be paid for their services.  Pre-planning is critical, however, to ensure that you take advantage of laws that allow you to protect your spouse and protect your own quality of care for the future.  Private payment can average from $10,000-$12,000 per month – could you afford to pay this expense for an extended period of time without putting your spouse or your security at risk?  Have you taken the necessary steps to ensure that your security will not be left to chance?

MEDICAID

Medicaid is the federal program that is known as MassHealth inMassachusetts.  When you run out of funds to pay for your nursing home care, you can apply for MassHealth coverage.  An individual may only have $2,000 in assets, and a married couple may have a combined $111,560.  There are some assets that are “non-countable” in that limit, such as the marital home, life insurance with a face value of $1,500 or less, a car, life insurance that you can not access or surrender (such as a group or term policy).  There are a myriad of regulations that apply to specific situations, and penalties imposed if you give your funds away within the five years prior to applying for MassHealth.  It is imperative to do advance planning to ensure that you apply the regulations to your particular situation in a manner that will maximize your future security without jeopardizing your eligibility for this important benefit.

This summary is far from comprehensive, but I hope it causes you to reflect on your own situation.  If you would like more information on long-term care payment options or to schedule a Legal Check Up, contact us today.