The Legal Checkup Blog

MASS IN LINE FOR 26 PERCENT MEDICAID FUNDING HIKE IN NEW FEDERAL PACT

Posted by Judith Flynn on Wed, Dec 21, 2011 @ 09:12 AM

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.  

Tags: PACE, home care, long-term care, elder law, Legal Check Up, Estate Planning, Medicare, Community Care, priorities, Medicaid, Medicaid Home Care, termination of benefits, skilled services, federal law, rights, nursing home, Program of All-Inclusive Care for the Elderly (PAC, Personal Care Assistance Program

RED CARPET PREMIERE of guardianship training video ...

Posted by Judith Flynn on Tue, Nov 01, 2011 @ 17:11 PM

Sign up now for the annual dinner meeting of the Massachusetts Guardianship Association (MGA), featuring the “RED CARPET PREMIERE” of the new training video for family guardians and conservators.

December 6, 2011 at 5 pm

Newbridge on the Charles

6000 Great Meadow Road

Dedham, MA  02026

The video was produced by Northnode, Inc. in collaboration with the MGA and the Office of the Chief Justice of the Probate Court, Paula M. Carey.  The video, "Stepping In When Help Is Needed," was made possible through funds provided by the MGA and a generous grant from the Office of the Attorney General, Martha Coakley.  If you are a family guardian or conservator or a professional who deals with people who need guardians or serve as guardians, we welcome you to this premiere. Spread the word - all are welcome, but RSVP is required as outlined below.

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Seating is limited -- registration is required no later than November 28th:  call the MGA at 617-350-6500 or e-mail jflynn@thelegalcheckup.com. 

 

Tags: elder law, Legal Check Up, Estate Planning, disability planning, Community Care, family, loved ones, Durable Power of Attorney, Health Care Proxy, Last Will & Testament, parents

Medicare "Improvement Standard" is a Barrier to Skilled Services

Posted by Judith Flynn on Sun, Sep 25, 2011 @ 21:09 PM

I frequently deal with wrongful termination of Medicare benefits for my clients, assisting them through the appeals process or advocating directly with the facilities for some additional coverage. 

The typical scenario involves an elder who has suffered a crisis in the community, whether a fall, a stroke, or some other acute condition that brings her to the hospital.  After a few nights in the hospital, she is discharged to a rehabilitation facility for skilled therapy.  After a short period of time, perhaps a few days or a week, her spouse is notified that her Medicare coverage will be terminated in a day or two, and that she will be discharged home or they will be responsible to pay privately for her continued stay at the facility at a cost of $350-400 per day!

I assist my clients to immediately request an appeal of the termination of benefits because the basis of the termination of benefits is almost always illegal.  The basis for the termination of coverage is usually described as “medically stable," "custodial level of care,” or "plateaud." These bases for termination of Medicare coverage are in violation of the Medicare Act and federal law.

42 CFR §409.44(c)(2)(iii) provides for maintenance health care and therapy.  It states that “The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed.  Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”  In addition, the regulations support coverage if the condition will improve OR the skills of a therapist are necessary to perform a safe and effective maintenance program.

Application of an “improvement standard” to justify termination of benefits to a patient is illegal, as the only reference to a requirement for improvement potential in the law pertains to a “malformed body member.”  The imposition of an improvement standard in the typical rehab setting described above results in wrongful termination of skilled services which patients require to maintain their present condition, and often results in further harm and deterioration when the skilled services are terminated prematurely.

If you or your loved one receives a Notice of Medicare Provider Non-Coverage for any of the reasons listed above, call us right away to assist you in appealing the wrongful decision.  781-681-6638.

Tags: elder law, Medicare, Community Care, termination of benefits, skilled services, federal law, improvement standard