The Legal Checkup Blog

Important Things to Review During Medicare Open Enrollment Period

Posted by Judith Flynn on Wed, Oct 22, 2014 @ 11:10 AM

Great article with important advice in US News and World Report, by Emily Brandon

Medicare beneficiaries will get an opportunity to make changes to their Medicare Part D coverage between Oct. 15 and Dec. 7, 2014. Many retirees will experience premium increases, changes in covered drugs and new cost-sharing requirements if they don’t switch plans. Here’s what you should review during the annual open enrollment period so you can select a new prescription drug plan if necessary.

Covered medications. Prescription drug plans are permitted to tweak the roster of medications they cover each year, and it’s important to double-check that your current medications and any new prescription drugs you expect to use in the coming year will be covered. "The first thing people should look at is whether all of their prescriptions are on the formulary,” says Casey Schwarz, policy and client services counsel at the Medicare Rights Center, an advocacy organization. “A plan can have very low premiums, but if the drug you would like to take is not on the formulary and not covered, then it is not such a good deal.”

Premium prices. The average Medicare Part D monthly premium will increase by 4 percent to $38.83 in 2014, assuming beneficiaries remain in their current plan, according to an analysis of 2015 Part D plans by researchers at Georgetown University, the University of Chicago and the Kaiser Family Foundation. However, beneficiaries in six of the most popular Part D plans will see their premiums increase by at least 10 percent, and one Part D plan increased premiums by 52 percent. About 1.5 million beneficiaries (8 percent) will experience a premium increase of $10 per month or more, while 985,000 beneficiaries (5 percent) will experience a premium decline of at least $10. “You have to weigh the amount of the change in premiums versus the inconvenience of making a shift,” says Jack Hoadley, a health policy analyst at Georgetown University and co-author of the report. “We know that some people are looking at premium increases that can be as much as $20 a month or more. In those kinds of situations, the payoff for making a switch can be substantial. If the change in your premiums is only a dollar or two, it may not be worth making a change.”

Cost-sharing changes. Prescription drug plans change the copayments and coinsurance associated with covered drugs each year. For the first time in 2015, all Part D plans will use tiered cost-sharing. Most plans have five tiers, including two for generic drugs, two for brand-name drugs and one for high-cost specialty drugs. Medications in each tier have different out-of-pocket costs, ranging from copayments to passing along a percentage of the bill to beneficiaries. “There are likely to be changes in the cost-sharing amounts that plans charge for drugs, drugs taken off the formulary and new utilization management tools like prior authorization,” says Juliette Cubanski, a policy analyst at the Kaiser Family Foundation. “Even if people are happy with the coverage that they have now, it does make sense to take a little bit of time to look at your coverage and see how it might be changing and see how your needs have changed.”

Deductibles. Most part D plans (58 percent) charge a deductible, which is typically a standard amount of $320 (44 percent). However, 14 percent of plans will charge a smaller deductible next year, up from 4 percent in 2014. “Plans that do lower or eliminate the deductible typically make other changes that might actually translate into higher costs for people,” Cubanski says. “While it might look appealing not to have that deductible, if the premium is so much more expensive that you end up paying more on an annual basis, that might not be a very good value payoff for people to be making.”

Preferred pharmacies. The majority of prescription drug plans (87 percent) now offer beneficiaries lower cost-sharing requirements if they fill their prescriptions at selected network pharmacies, up from 72 percent in 2014 and just 7 percent in 2011. For example, the AARP MedicareRx Saver Plus prescription drug plan charges a $20 copayment for a preferred brand drug at a preferred pharmacy, but the cost jumps to $45 at another in-network pharmacy that is not preferred. And beneficiaries enrolled in the Humana Walmart Rx prescription drug plan pay $1 for preferred generic drugs and $4 for non-preferred generics at a preferred pharmacy, versus $10 and $33, respectively, at other in-network pharmacies. “It’s important to understand if the pharmacy where you go to fill your prescriptions is part of the network of plans with the preferred cost-sharing,” Cubanski says.

Medication restrictions. Some Part D plans require beneficiaries to get prior authorization before they will cover certain drugs, require patients to try a lower-cost drug before paying for an expensive medication or limit the amount of medication you can buy at one time. “It may be worth paying a little bit more to get the one that doesn’t include the restrictions,” Hoadley says.

Consider other options. There will be just over 1,000 prescription drug plans offered nationwide in 2015, and Medicare beneficiaries will have a choice between an average of 30 plans. You can view the coverage options in your area using the Medicare Plan Finder at medicare.gov/find-a-plan. “Each year, plans make adjustments to their premiums, their formularies and whether they have prior authorization or other restrictions on use, and what worked for a person who was taking a particular array of drugs last year may not work for them this year,” Hoadley says. “It’s worth seeing if there is money to be saved or better coverage to be acquired.”

Tags: elder law, Legal Check Up, Medicare, nursing home

Register Now for the MassNAELA Breakfast to be held March 6, 2014

Posted by Judith Flynn on Fri, Feb 14, 2014 @ 07:02 AM

Each year, MassNAELA holds a "scattered site" breakfast that is open to non-attorneys and non-members.  It is held on the same morning in four parts of the state, and provides a wonderful opportunity for MassNAELA attorneys and other professionals who work with seniors to network. 

This year the breakfast program will be hosted at the following locations:

Armbrook Village in Westfield, The Village at Duxbury in Duxbury, Whitney Place in Natick, and Woodbridge Assisted Living Facility in Peabody.  The substantive program will be "The Affordable Care Act, Medicare, and Medicaid - Everything You Need to Know," with a panel of experts at each location. 

A special rate of $30 is available to guests of a MassNAELA member if paid by February 28th.  If you would like to attend as my guest at the Duxbury location, please download the form below, complete it, and send it with your payment as indicated on the form before the deadline. 

http://www.thelegalcheckup.com/Portals/106531/docs/140306 MassNAELA breakfast registration.pdf                                               

Please send me an email (to jflynn@thelegalcheckup.com) to let me know that you will be attending as my guest.  I hope to see you there for this important topic and great networking!

                                                     -- Judy Flynn

 

 

Tags: home care, long-term care, elder law, Legal Check Up, Medicare, Community Care, Medicaid, Estate Planning, long-term care planning

2014 MassNAELA Advocacy

Posted by Judith Flynn on Wed, Jan 01, 2014 @ 10:01 AM

Today I begin my term as President of the Massachusetts Chapter of the National Academy of Elder Law Attorneys (MassNAELA).  I look forward to a productive year of advocacy ahead and hope you will help with one of our current goals, which is to educate the public about unethical ads that prey on the vulnerabilities of seniors and people with special needs.  You've heard the ads on the radio, seen the flyers or newspaper ads.

The attorneys/companies who place these ads make false promises, create false impressions, and use scare tactics to instill fear in their intended audience.

* These ads make the nursing homes sound like money-grubbing thieves -- when the reality is that the caring staff of nursing homes provide 24/7 care to people who are unable to remain safely in the community.  Should the nursing homes provide this care for free?  You can bet that the attorneys who place such ads do not provide their services for free.  In fact, if you consider the cost of some of these ads (many thousands of dollars), it suggests that these scare tactics are having the desired effect.

* These ads give the false impression that seniors can remain in full control of their assets AND protect those same assets from the cost of long-term care (not true!).

* The ads of a few elder law attorneys place all elder law attorneys in a bad light by emphasizing "protecting assets" above all else, when the reality is that protection of the client is the paramount concern for most elder law attorneys. 

MassNAELA works hard to advocate for seniors and people with special needs, but this task is made much more difficult by offensive ads that encourage people to do whatever is necessary to make sure they won't "lose their assets to the nursing home" - in other words, let the state pay it all.

This emphasis hurts everybody because care providers, judges, and legislators have begun to see elder law attorneys as the enemy -- doing nothing more than "hiding" assets from the nursing homes.  This could NOT be further from the truth, however.  Most elder law attorneys focus on protecting the client, not the assets.  Most elder law attorneys provide comprehensive guidance and advocacy to clients, and if asset protection is part of a comprehensive plan, it is only done with full understanding that any assets that are "protected" from the cost of nursing home care are NOT fully available to the client for their future needs.  Any ads that suggest one can protect assets and retain full control of the assets are misleading at best.  

We need your help to spread the word regarding ads that use false claims and scare tactics.  Share this message with your loved ones.  If you work with seniors and their families, you have the opportunity to share MassNAELA's message with them. 

http://www.thelegalcheckup.com/blog/bid/155326/SENIORS-NEED-TO-BE-WARY-OF-LONG-TERM-CARE-ADVERTISING-USING-SCARE-TACTICS

If you or someone you know has a concern about a particular ad, feel free to send it to me at jflynn@thelegalcheckup.com

Planning is important, whether it is advance planning or crisis planning, it is important to seek professional guidance.  Just be aware that if something seems too good to be true, it probably is.  If something makes you feel rushed, anxious, or bullied, you should walk away.  Get a second opinion.  Feel free to call my office for guidance, or you can find a MassNAELA member in your area at www.massnaela.org

Happy New Year to you all!  Make 2014 the year you get your affairs in order.

Tags: long-term care, asset protection, Legal Check Up, disability planning, Medicare, Community Care, nursing home, rights, Medicaid, Estate Planning, long-term care planning

CMS announces 2014 spousal impoverishment standards

Posted by Judith Flynn on Tue, Dec 03, 2013 @ 08:12 AM

The cost of nursing home care, which is approximately $10,000 - $12,000 per month in this area, can quickly wipe out one's life savings.  In 1988, Congress enacted provisions to prevent what is known as "spousal impoverishment," or leaving the spouse who remains in the community with little or no income or resources. The provisions helped to prevent spousal impoverishment and provided some level of security for community spouses. 

Under the MassHealth regulations incorporating the spousal impoverishment provisions, a range of assets is allowed to be retained by the community spouse, and depending on factors such as income and living expenses of the community spouse.  There are additional provisions which provide for some of the institutional spouse's monthly income to be paid to the community spouse each month, or for excess assets beyond the maximum allowed to be retained to generate the needed income, in certain circumstances. 

The Centers for Medicare and Medicaid Services (CMS) have announced these and other spousal impoverishment standards for 2014, which you can see here:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Downloads/Spousal-Impoverishment-2014.pdf

 

 

 

Tags: long-term care, asset protection, elder law, Medicare, federal law, nursing home, Medicaid, Estate Planning, long-term care planning

Next Legal Check Up BOOT CAMP scheduled

Posted by Judith Flynn on Tue, Oct 22, 2013 @ 23:10 PM

SEMINARS AND WORKSHOPS

Next LEGAL CHECK UP Boot Camp to be held 

Wednesday, November 6, 2013

10 am - 12 pm

SPACE IS LIMITED - PRE-REGISTRATION IS REQUIRED 

Attendees of this free comprehensive workshop will learn the important considerations for a successful Estate and Long-Term Care Plan.  Part of the workshop will be interactive to allow attendees to discuss general problems, concerns and situations.

This workshop will cover:

*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; 

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

For more details and to sign up go to:

http://www.thelegalcheckup.com/seminars-and-workshops/

 

Tags: PACE, home care, long-term care, asset protection, elder law, Legal Check Up, Legal Documents, Durable Power of Attorney, Estate Planning, Health Care Proxy, Last Will & Testament, disability planning, Medicare, Community Care, nursing home, Program of All-Inclusive Care for the Elderly (PAC, Medicaid, Veterans Benefits, Medicaid Home Care, long-term care planning

HELP NEIGHBORHOOD LEGAL SERVICES TO CONTINUE ADVOCATING FOR SENIORS

Posted by Judith Flynn on Wed, Sep 18, 2013 @ 14:09 PM

Many of you are aware that I am very involved with the Massachusetts Chapter of the National Academy of Elder Law Attorneys (MassNAELA), and I am currently serving as the Chapter's President-Elect.  MassNAELA has approximately 500 members in the Commonwealth - attorneys who practice in the areas of Elder Law and/or Special Needs Planning.  In addition to the dedicated members of the Board of Directors, MassNAELA  has several Committees comprised of member volunteers who focus on various areas of advocacy and education to protect the rights of seniors and people with special needs in the Commonwealth. 

One of our most important efforts relates to litigation of wrongful denials of MassHealth and Medicare coverage, and several years ago we developed a Litigation Initiative to develop a cohesive approach to defend against the systemic abuses in the application process for public benefits.  One of our leaders and mentors in this effort has been Attorney John Ford and his colleagues at Neighborhood Legal Services.  John was one of the original members of MassNAELA and is a former President of the Chapter, and he has devoted his entire career to legal aid services - over 45 years!  John has brought his decades of experience in litigating issues affecting elders to provide guidance and mentorship to other MassNAELA members whose clients have been faced with wrongful Denials and a lack of Due Process.

However, John and his colleagues at Neighborhood Legal Services, like all Legal Services agencies, have been hit by hard times.  Budgets have been slashed, staff cut, and remaining staff forced to take time off without pay at times to save other positions.

Whether you realize it or not, you or your loved ones in Massachusetts have likely benefitted from the commitment and dedication of John Ford and all of the other attorneys and staff at Neighborhood Legal Services.  And, their advocacy and guidance has been invaluable to MassNAELA's public policy and litigation efforts, helping us to ensure that the rights of seniors and people with special needs are upheld.  Neighborhood Legal Services has been there for people in need, and now they need us to be there for them.

PLEASE join me in making a donation - any amount you can afford - to Neighborhood Legal Services.  They recently moved to a new location in order to cut their rent expense in half, but they had to take out a loan to pay for the up-front costs.  They need our help to pay back the loan so they can focus on what they do best - providing legal services to the poor and advocating for seniors through their Elder Law Project.

Check out their website at www.neighborhoodlaw.org, and please visit their fundraising campaign website at http://igg.me/at/Help-NLS-Move-Office/x/4646373 to make a donation.  Every little bit will help.   Thank you!

 

Tags: long-term care, elder law, Medicare, skilled services, loved ones, rights, Program of All-Inclusive Care for the Elderly (PAC, Medicaid

"Of course he was admitted -- he has been in the hospital for four nights..." (Beware "Observation Status")

Posted by Judith Flynn on Wed, Aug 21, 2013 @ 07:08 AM

Once again I have encountered the infuriating problem of "Observation Status."  A client's loved one was admitted to a Boston hospital as a result of a crisis.  I instructed my client to confirm that his father had been formally "admitted" to the hospital, and his response was a bit incredulous.  "Of course he was admitted -- he has been in the hospital for four nights!"  His response was completely logical, of course, but my concern was realized when my client confirmed that the hospital still had his father listed on "Observation Status." 

In general, Medicare will only provide coverage for skilled rehabilitation services at a nursing home if the patient had a minimum of a three-night stay and is transferred directly from the hospital to the nursing home.  My client's father could not safely return home, and would need to be placed in a skilled nursing facility, so we advocated for his status to be changed (for him to be "admitted") and ensured that he had the required three-night stay before being transferred to the nursing home.  (Just to be clear - staying at the hospital on "Observation Status" for three nights does NOT qualify as a three-night stay.  One must be "admitted" before midnight for that night to qualify.)

Unfortunately, most people are not working with an attorney and do not find out about this problem until much later when they are charged for various prescriptions and services they received in the hospital or, worse, when they receive a huge bill from the nursing home.  It is far more difficult to successfully appeal the "Observation Status" at that point, but an appeal should be pursued.

On November 3, 2011, the Center for Medicare Advocacy and the National Senior Citizens Law Center, filed a nationwide class action lawsuit to challenge this illegal practice on the basis that it violates the Medicare Act, the Freedom of Information Act, the Administrative Procedure Act, and the Due Process Clause of the Fifth Amendment to the United States Constitution. (Bagnall v. Sebelius, No. 3:11-cv-1703, D. Conn)

In the meantime, you need to know your rights and advocate for yourself.  There are a number of self-help packets (and a wealth of information on this and other topics) on the Medicare Advocacy website at http://www.medicareadvocacy.org.  Call me at 781-681-6638 if you need advocacy to protect your rights on this or a related issue, or you can find an elder law attorney in your area through the website of the Massachusetts Chapter of the National Academy of Elder Law Attorneys at www.massnaela.org

Education is the best defense!  Please share this information with your friends and family to prevent them from being the next unsuspecting victim of this illegal practice.

                           

Tags: long-term care, elder law, Legal Check Up, Medicare, skilled services, improvement standard, nursing home, rights, admission agreement, Medicaid, long-term care planning

MASSACHUSETTS ELDER LAW GROUP’S SEVEN-YEAR DRIVE FOR LONG TERM CARE INSURANCE BILL FINALLY LEADS TO PASSAGE (10/31/12)

Posted by Judith Flynn on Thu, Nov 01, 2012 @ 09:11 AM

MASSACHUSETTS CHAPTER OF THE NATIONAL ACADEMY OF ELDER LAW ATTORNEYS (MassNAELA)

CONTACT: Beth Bryant, 508.786.3013

October 31, 2012

MASSACHUSETTS ELDER LAW GROUP’S SEVEN-YEAR DRIVE FOR LONG TERM CARE INSURANCE BILL FINALLY LEADS TO PASSAGE

Governor Deval Patrick Signs Bill Protecting Seniors From Losing Their Homes, Originally Filed by the Massachusetts Chapter of the National Academy of Elder Law Attorneys (MassNAELA)

BOSTON – October 31, 2012 – The Massachusetts Chapter of the National Academy of Elder Law Attorneys (MassNAELA) today announces a legislative victory for seniors, as Governor Deval Patrick has signed into law a bill protecting individuals from losing their homes if they choose to use long-term care insurance for community-based care before entering a nursing home. Bill S.2359 grants an exemption from MassHealth estate recovery claims whether an individual uses their long-term care insurance for at-home or nursing home care. Prior to this bill, the MassHealth estate recovery exemption only applied when long-term care insurance policies were used for nursing home care.

Working with Senator Harriette L. Chandler, MassNAELA advocated for the passage of this bill, part of which was originally filed in 2005. The bill, signed into law by Governor Patrick as “An Act Establishing Standards For Long-Term Care Insurance,” also includes important consumer protection for purchasers of long-term care insurance. The Act enables MassHealth Medicaid recipients who have purchased long-term care insurance policies to use their policies for home care coverage without forfeiting estate recovery protection. This legislation allows seniors and disabled persons to seek care in their home instead of nursing home care and reinforces the incentive to purchase long-term care insurance.

“Before this new law, those who chose to use their long-term care insurance to pay for care in their home rather than a nursing home could lose their estate recovery exemption if their insurance benefits fell below qualifying levels before they entered a nursing home,” states Philip D. Murphy, Esq. President of MassNAELA. “Now, when a person buys a qualifying long-term care insurance policy, his or her home is protected from estate recovery whether the insurance is used to pay for care at home or in a nursing home. The exemption of a person’s home from estate recovery after he or she dies is a strong incentive for a person to buy qualifying long-term care insurance. More people should buy long-term care insurance under the new law, thereby saving MassHealth some long-term care costs. This is a win-win for elders and MassHealth.”

An advocate for quality of life for seniors, MassNAELA has filed several bills and been a significant force behind legislation focused on improving the ability of elders to remain financially independent and in their home while dealing with the cost of long-term care. In 2008, the organization won passage of H.975, a bill exempting MassHealth applicants from paying fees for retroactive bank records, which was signed into law by Governor Patrick as Chapter 125 of the Acts of 2008.

About MassNAELA
The National Academy of Elder Law Attorneys, the premier organization of elder and special needs law attorneys in the country, is dedicated to developing awareness of issues concerning the elderly and those with special needs. Over 500 attorneys are members of the Massachusetts Chapter, which comprises 12% of all NAELA members nationwide. They work directly with the elderly and those with special needs in areas as diverse as planning for catastrophic care costs, disability planning, age discrimination in employment and housing, benefits planning, estate planning, veterans’ benefits and more. For more information about MassNAELA, visit www.massnaela.com.

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Tags: PACE, home care, long-term care, asset protection, elder law, Legal Check Up, disability planning, Medicare, skilled services, nursing home, Program of All-Inclusive Care for the Elderly (PAC, Medicaid, Medicaid Home Care, Estate Planning, long-term care planning

"Jimmo" - An End to the Unlawful "Improvement Standard" In Sight!

Posted by Judith Flynn on Tue, Oct 23, 2012 @ 22:10 PM

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

Tags: long-term care, elder law, Legal Check Up, Medicare, termination of benefits, skilled services, federal law, improvement standard, loved ones, rights, Medicaid, long-term care planning

PACE - A program designed to keep seniors in the community

Posted by Judith Flynn on Tue, Oct 16, 2012 @ 08:10 AM

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.

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Tags: PACE, home care, long-term care, asset protection, elder law, Legal Check Up, Legal Documents, disability planning, Medicare, skilled services, Community Care, Program of All-Inclusive Care for the Elderly (PAC, Medicaid, Estate Planning, long-term care planning