Share of Cost. from a Social Work Perspective

Transcription

1 Share of Cost from a Social Work Perspective

2 Benefit Results, LLC Jill A. Preston, Owner Years dedicated to helping facilities and families maneuver through complicated policy Formerly with JacksonWhite Elder Law National Consulting firm dedicated to reduce the Medicaid BAD DEBT that facilities face

3 What are the issues/frustrations that you currently see regarding Share of Cost in your facility?

4 Share of Cost The Share of Cost (SOC) is a monthly amount a customer must pay toward the cost of long term care services. AHCCCS Eligibility Policy Manual- Chapter 1200 Customer Costs 1201 Share of Cost

5 Share of Cost The SOC amount is based on the customer s: Counted income; Living arrangement; SOC deductions; SOC deductions for which the customer is entitled. The maximum SOC is limited to the monthly capitation rate for the customer

6 Share of Cost- Implication to Facility Your facility payment is the Contract Rate minus the residents share of cost If the share of cost is not paid, ALTCS still pays you only the difference It is not the state or the program contractors responsibility to enforce share of cost, AND If the resident doesn t pay it, they can not be made ineligible So burden lies with you to collect

7 Share of Cost Community Spouse Rules CSMIA Community spouse Minimum Income Allowance Currently: $1992 A calculated amount to help the community spouse pay his or her living expenses. See MA1201.C.5 for details Policy - Medical Assistance (MA) Chapter 1500 Changes >> 1502 Types of Changes

8 No SOC Why would there be NO share of cost? Community Spouse needs all of the residents income to make up minimum CSMIA No Income/SSI Garnishments/ Financial Abuse

9 SSI- Supplemental Security Income When a resident has ALTCS and is on SSI the income is reduced to $30. This is ALL the client receives, it is considered their Personal Needs Allowance. It is important to take note of this difference if the resident is wanting to utilize their SOC to pay for non-covered medical expenses. Policy 1201 SOC

10 How to handle abuse/mishandling of share of cost funds Ask the source of garnishment if it can be waived or reduced Change where income is being deposited- possibly new account so no one else has access to it ( patient trust account ) Facility can become Representative Payee Meet with family, discuss options- reiterate that the member is mandated to pay what they can for care. 30 day notice for non payment can be given but presents challenges for proper discharge

11 Share of Cost and Rep Payee status A representative payee, or substitute payee, is a person who acts as the receiver of United States Social Security Disability or Supplemental Security Income for a person who is not fully capable of managing their own benefits A representative payee is legally obligated to use the payments it receives on a resident s behalf for the resident s best interests The facility then receives the income, pays the resident their PNA, pays the facility the SOC remaining and if there is another payment How do you manage your Representative Payee process???

12 VA issues VA Aid and Attendance and Housebound Allowance VA Pension An allowance paid to veterans, spouses of disabled veterans and surviving spouses who are in regular need of the aid and attendance of another person or who are housebound. Increases in VA benefits for aid and attendance or housebound allowances are included in the pension or compensation payment. Payments made on the basis of a combination of service and an age of 65 or over, a non serviceconnected disability or death. Policy The amount attributable to Aid & Attendance is not counted towards SOC.

13 SOC- how is it calculated? ( Single) Gross Income - PNA = SOC Example: $ = $ (Married) Income PNA- CSMIA = SOC Example: $ $ $400 (ex. CSMIA) = $990.05

14 ALTERNATE SHARE OF COST When living in alternative setting such as Assisted Living Home and if the client has over the income eligibility limit they pay any overage to the Program contractor as an Alternative Share of Cost Ex: $3000 month income $ to AL, $ for PNA and $801 to state for ALT SOC???

15 Location of ALTCS member in Determining SOC If member in Skilled Nursing Facility STATE determines SOC- federal rules Eligibility Worker determines Reductions If member is in Assisted Living- the program contractor is responsible for determining ROOM AND BOARD.- state/program contractor interpretation Case Manager authorizes reductions Do you call the EI when a resident moves in from an Assisted Living?

16 Share of Cost Deductions Non-Covered Medical Expenses Costs for medically necessary services that are not covered may be allowed as a SOC deduction. The customer does not have to pay the entire cost of the service for it to qualify. A deduction may be allowed for health insurance deductibles, co-insurance, and co-payments for these costs.

17 A SOC deduction is not allowed for any service that is covered as part of the AHCCCS benefits package. Costs for the following services may qualify for a SOC deduction if not covered by other insurance: Non-emergency dental services Hearing aids, hearing aid repairs and hearing aid batteries Non-emergency eye care and prescriptive lenses Health Insurance premiums covering medically necessary services Chiropractic services, including treatment for subluxation of the spine, demonstrated by x-ray; Co-payments for Medicare Part D prescriptions; and On a case-by-case basis, other non-covered medically necessary services requested of AHCCCS and approved by the Director.

18 Reductions The federal and state rules allow for the resident to use some of this share of cost for unmet medical needs. This is done by submitting a share of cost reduction request to the State eligibility worker. ( or if in HCBS, the Case Manager can authorize reduction) Rational for reduction- per case How does this work when Facility is rep payee When there is an income only trust

19 Garnishments AHCCCS is working on language for a State Plan Amendment to change the rules on garnishment. There have been many facilities financially impacted by garnishment of residentsaffecting their Share of Cost. AHCCCS is recognizing this and proposing new language for CMS to review in our state plan. It is still in the draft stage. Other issues and fixes Child support Alimony Tax liens Insurance liens Chapter 600 Income Eligibility >> 604 Receipt of Income >> E Garnishments and Overpayments

20 One time expense - Reduction Process The facility or member needs to: 1. Obtain verification of the expense such as a bill and receipt of payment 2. Show that no other coverage existed for this expense ( just a statement) 3. Provide contact information for party who is assisting with payment/soc reduction 4. Provide this information, along with member information, to the ALTCS Eligibility Worker on record for the member The Eligibility Worker then completes the process to determine the allowable deduction. They will: * Start with the total amount of the expense billed by the provider * Subtract any amounts paid by third part liability for claim * Deduct any payments that the customer has made which do not represent the current request * The remainder is the amount that can be deducted from the share of cost income * Approve or deny deduction The eligibility worker will notify the client/facility of approved reduction amount in writing. The amount will be deducted from the Share of Cost and will be made up in the ALTCS payment to the facility for the time allocated for reduction.

21 How to handle SOC reductions successfully Remember the member is mandated to pay what they can towards their cost of care this is the share of cost assessment. Whether a portion of this amount is paying for other care ( dental, vision etc) it is still meeting the rule of using the residents money for their care. The only difference is that the amount paid to the facility is increased based on what the resident is paying for these services. The facility continues to receive the same contracted amount regardless of reduction.

22 Your Role Looking out for resident and facilities best interest Responsible for the consistent revenue stream for your facility Offering support and education regarding SOC Responsible to manage resident funds correctly Could be Responsible for ALTCS eligibility-and/or maintaining eligibility. Do not wait months to deal with non payment issue- after first non payment month start asking questions!

23 Questions???????

24 National Consulting firm dedicated to reduce the Medicaid BAD DEBT that facilities face Medicaid Loss Prevention Protocol Benefit Education and Outreach Veteran and Medicaid Prescreening Public Speaking/ Educational Sessions