MEDICARE Part A Benefits in Long Term Care

MEDICARE Part B Benefits in Long Term Care

Services Medicare Does Not Cover

MEDI-CAL Long Term Care Benefits

HMO Benefits in Long Term Care

Long Term Care and Taxes

MEDI-CAL – Qualifying and Applying:

Comparison of Senior Living Options

Explanation of Various Living Arrangements

Medicare Part A Benefits in Long Term Care

Medicare Part A is a federally funded medical program intended to take care of an acute illness. As it relates to long term care services, the following must have happened prior to receiving any Medicare Part A services:

Medicare will pay for 100% of the costs for care in a skilled nursing facility for the first 20 days per spell of illness. From the 21st day up to the 100th day, they will pay all but a co-insurance, which is billed either privately, or to a secondary insurance such as Medi-Cal. A patient is NOT guaranteed coverage for a full 100 days. Coverage only lasts as long as there is a skilled need such as physical therapy. Typically, coverage can last from two to five weeks at a time, but it can last up to the full 100 days.

What is a spell of illness? It starts when a person is hospitalized over three consecutive midnights, then transferred for skilled nursing care. As long as there is at least a 60-day time period since their last skilled need, the person will be able to start a NEW spell of illness and receive another 100 days of Medicare Part A coverage, contingent upon a qualifying hospital stay. It is important to note if there is no break in a skilled need, such as a patient receiving food through a tube and a pump, they will receive 100 days of coverage. After this time, they would never be eligible for Medicare Part A skilled nursing coverage again because there would not be a break in the spell of illness to start a new 100-day period.

If you have questions on how to enroll in Medicare, call Social Security's toll-free number, 1-800-772-1213, any business day between 7:00 a.m. and 7:00 p.m. When you call, have your Social Security number handy. The lines are busiest early in the week and early in the month so it is best to call at other times.

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Medicare Part B Benefits in Long Term Care

Medicare Part B is a federally funded medical program intended to take care of outpatient medical needs. In a long term care facility, Medicare Part B is seen as supplemental insurance. It is used to pay for some equipment needs and skilled therapies when there is a change of condition, which warrants such. Medicare part B can only be given when:

Medicare Part B pays for ancillary services such as X-ray, Laboratory, Physical Therapy, Occupational Therapy, Speech Therapy or specialty beds. Other services may be available depending on the need, and current Medicare guidelines. Medicare Part B will only pay for 80% of the cost of the service. The remaining 20% is billed privately or to a secondary insurance such as Medi-Cal.

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Services Medicare Does Not Cover

Medicare Part A does not pay for convenience items such as telephones and televisions provided by hospitals or skilled nursing facilities, private rooms (unless medically necessary), or private duty nurses.

The only type of nursing home care Medicare pays for is skilled nursing facility care for rehabilitation, such as recovery time after a hospital discharge. Medicare does not pay if you need only custodial services (help with daily living activities like bathing, eating or getting dressed).

Medicare Part B usually does not pay for most prescription drugs, routine physical examinations, or services not related to treatment of illness or injury. Medicare Part B does not pay for dental care or dentures, cosmetic surgery, routine foot care, hearing aids, eye examinations, or eyeglasses. Except for certain limited cases in Canada and Mexico, Medicare does not cover treatment outside the United States.

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Medi-Cal Long Term Care Benefits

Medi-Cal is a program funded by both state and federal funds. The program is intended to care for the medical needs of individuals with limited funds and income. An individual who is eligible for Medi-Cal would receive medical services from a physician or facility that accepts Medi-Cal patients. The facility or doctor bills the patient for the patient’s portion of the medical bill, as determined by the state, and the balance is billed to Medi-Cal directly.

One important aspect of Medi-Cal is the cost for services to the recipient is the same regardless of where they receive that service. For example: if a Medi-Cal patient went to a Medi-Cal participating hospital in Beverly Hills (if there was one), their out of pocket costs would be the same as if they went to a county general hospital. This is also true for Physician services.

Medi-Cal sets their rates based on regional averages for given services. Though these regional costs may fluctuate, the cost to the individual is constant throughout the state. Medi-Cal eligibility is verified at the time of service for each service rendered. This is because situations can arise that would make an individual ineligible for Medi-Cal such as receiving winnings from the lottery, which would place them outside the income and funds limits.

The aspects involved in calculating Medi-Cal eligibility are continually changing and revised on an ongoing basis. If an individual believes they may be eligible for the Medi-Cal program, they should see their local Medi-Cal Field Office.

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HMO Benefits in Long Term Care

With the variety of HMO plans and services it is impossible to accurately discuss coverage and services available. One thing that is important to note:

HMO plans that are in place of Medicare Part A and B coverage must at least cover those services that Medicare covers. HMO's usually have lower out of pocket costs than the same coverage under Medicare. In fact, HMO's often cover items without cost, or for a small co-payment, which Medicare would not normally cover. This often includes services such as the cost of medications or a doctor’s visit. If you have any specific questions regarding a particular HMO plan or the coverage they offer, please contact the Plan Administrator directly for explanation of coverage.

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Long Term Care and Taxes

As of January 1, 1997, individuals may now deduct out-of-pocket long-term care service expenses (including nursing home care and long-term care insurance premiums) from their taxes as medical expenses.

In order to qualify for deductions, the medical expenses or insurance premiums must total over 7.5% of adjusted gross income and be paid for someone who is chronically ill, and is defined as:

A person unable to perform (without substantial assistance) two out of any five activities of daily living (dressing, toileting, eating, bathing, transferring and continence), or certified within the previous 12 months by a licensed health care practitioner as having such a level of disability, based on criteria outlined by the Department of Health and Human Services regulations.

Adult children who are paying for their parents' care can also deduct long-term care costs if they claim their parent or parents as dependents and their parent is "certified." The amount of allowable insurance premium deductions is capped by age. People over 71 may take up to $2,500; those 61 to 70 may deduct $2,000; 51 to 60, $750; 41 to 50, $375; and 40 or under, $200. Most policy benefits are also non-taxable income, and per-diem payments up to $175 are excluded from gross income. (Tax laws are constantly changing. Please consult with a qualified accountant before proceeding).

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HOW TO APPLY FOR AND USE MEDI-CAL BENEFITS

LONG TERM CARE MEDI-CAL is a special Medi-Cal program designed to help pay for nursing home care. Medi-Cal regulations are complex and change frequently. This guide provides an overview of the program only. Current information should be obtained from your local office. Refer to your local phone book under the Government Offices – COUNTY section, for the listing under the Public Social Services Department or call the main information number and request the office for Medi-Cal.

BECOMING ELIGIBLE:
To be eligible for Long Term Care Medi-Cal, you must:

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SPENDING DOWN ASSETS:
As an individual, your assets should be reduced or "spent down" to $2,000 or less. You may only spend your money on items and services for your own benefit. The date your assets are $2,000 or less, you may apply for Medi-Cal. The same applies to a married couple who must reduce their assets to $92,000 or less.

SSI RECIPIENTS:
When you are in a nursing home and plan to remain for an extended period of time, you will no longer be eligible for SSI benefits. You will need to terminate your SSI and apply for LONG TERM Medi-Cal. You will receive $35 per month for your personal needs.

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PAYING YOUR SHARE:
If you have income (Social Security, pension, V.A., or retirement), you will be required to pay for a part of your care. This payment is called your SHARE OF COST. Most of your income will go toward paying your share of cost. Medi-Cal allows you to keep $35 a month for personal needs while in a skilled nursing facility.

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EXEMPT ASSETS:
Assets include any resources with a cash value, such as savings, checking accounts, stocks, real property (land and buildings), etc. Medi-Cal allows you to keep some assets that are not counted in determining Medi-Cal eligibility.
You may keep the following:

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EXEMPTING YOUR HOME
A home that has served as your principal residence (the place you lived) may be exempted for any of the following reasons:

There are other special circumstances for exempting the home. Check with your Legal Services agency or Medi-Cal office

CAUTION!!!
Giving away any nonexempt assets or selling them for less than the fair market value within two and a half years (this is going to three years in the near future) of applying for Medi-Cal may result in ineligibility. An exemption is when one spouse transfers interest in the home to the other.

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SPOUSAL ALLOWANCE
When an Aged, Blind or Disabled patient is married and has a spouse at home, the at-home spouse is entitled to a "Spousal Allowance" set by the State of their combined monthly income. Where the at-home spouse's own income is less than this amount, the patient may choose to give his/her available income to the home spouse up to the recognized need as set by the State per month. This of course reduces the patient's share-of-cost by the amount given. In no case does the at-home spouse contribute any of his/her own income to meet the needs of the patient.

MEDI-CAL RIGHTS

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RESPONSIBLE PARTY & AGENT
As of January 1,1987, a skilled nursing facility may no longer require that a Medi-Cal resident have a "responsible party" sign the admission agreement and assume full financial responsibility .A facility however, may require that an agent sign or co-sign with the resident. Your agent is only responsible for using your income to pay your share-of-cost and other expenses not paid for by Medi-Cal. Agents who withhold a resident's money are committing a misdemeanor and may be prosecuted by the law.

NON-COVERED MEDICAL COSTS:
Necessary (ordered by the doctor) non-covered medical treatment or supplies may be paid for from the share-of-cost. There are two ways of doing this:

IMPORTANT!!! You must submit bills or paid receipts no later than two months after the expenses were incurred.
Please note: These amounts change periodically, please contact your local Medi-Cal office for current information.

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VARIOUS LIVING ARRANGEMENTS:

SKILLED NURSING FACILITIES: Provide long term care to residents who are usually in need of specific skilled nursing services under the direction of a physician. Their condition often does not allow them to stay in lower levels of care. Those who need only custodial type care are also accepted. They will also accept many forms of payment and insurance.

ASSISTED LIVING FACILITIES: Provide extended residence for people who need assistance with activities of daily living but not necessarily licensed nursing care. They often cannot adequately care for their own personal needs without assistance or supervision. Facility staff provides minimal care.

INDEPENDENT LIVING: Simply a place of residence. Often they provide meal service as well as maid services at an additional charge. The facility staff gives no care, but independent arrangements can be made between residents and independent care givers.

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