ALABAMA MEDICAID HOT TOPICS AND ISSUES Presented by: Healthcare Compensation Solutions P.O. Box 240515 Montgomery, AL 36124-0515 866-271-1359 LONG TERM CARE ISSUES -Discharge Notices- -Bed Hold- -Therapeutic Leave- -Outpatient Observation- -Patient Accounts At Death- DISCHARGE NOTICES (ACM 560-X-25-10-.26) 1
Allowable Reasons For Discharge a. Resident s welfare/needs cannot be met b. Resident s health has improved-no longer needs services of facility c. Safety of others is endangered d. Health of others is endangered e. Failure to pay for stay in facility f. Facility ceases to operate Documentation Clinical records must be documented. Also, must be documented by: By resident s physician if transfer is due to discharge reason (a) or (b) By a physician under (d) 2
Notice Before Transfer Notify resident/sponsor of discharge AND reasons Record reasons in clinical record Notice must include all required information Required Contents of Notice Reason for discharge Effective date of discharge Location to which resident is to be discharged Name/Address of Alabama Medicaid Agency and statement of appeal rights Contents of Notice: continued For residents with developmental disabilities, the mailing address and phone number of the Agency responsible for protection of developmentally disabled For residents who are mentally ill, the mailing address and phone number of Agency responsible for protection of mentally ill 3
Notice may be made as soon as practicable before discharge or transfer when: (1) safety/health of others in facility would be endangered (2) resident s health improves to allow more timely discharge (3) resident s urgent medial need required immediate discharge (4) resident in facility less than 30 days BED HOLD (ACM 560-X-10-.05) Medicaid residents or sponsors cannot be charged for the first four days of any period during which resident is absent due to hospital admission. Arrangements should be made with resident/sponsor for reservation of bed beyond bed hold days BEFORE discharge to hospital 4
In situations of both discharge to hospital or therapeutic leave, facility must provide resident/sponsor with written notice which specifies duration for the bed hold/tl policy. Facility must readmit resident upon discharge from hospital unless facility can no longer meet resident s needs. THERAPEUTIC LEAVE (ACM 560-X-10-.07) Limited to six days per calendar quarter One TL visit may not exceed 3 days Visits may not be combined to exceed the three day limit Must be authorized by patient s physician Facility must provide written notice to resident/sponsor of Medicaid s TL policy prior to TL visit 5
OUTPATIENT OBSERVATION (ACM 560-X-10-.05) 24 Hour Hospital Stay: If resident goes out to hospital and receives outpatient observation services, the resident does not have to be discharged from the facility UNLESS he/she is retained longer than 24 hours. After 24 hours discharge is necessary PATIENT ACCOUNTS AT DEATH OF RESIDENT ACM 560-x-10-.14(3) ACM 560-X-22-.25(5)(e) SSA Guide For Organizational Rep. Payees 6
What Does Medicaid Say? 560-X-10-.14(3)f (f) Conveyance upon death. Upon the death of a resident with a personal fund deposited with the facility, the facility must convey promptly the resident's funds, and a final accounting of those funds, to the individual administering the resident's estate. 560-X-22-.25(5)(e) (e) In case of death, all remaining funds shall be returned by check to the patient's estate. If there are no known heirs or estate, the facility may turn over these funds under the provisions of the Uniform Disposition of Unclaimed Property Act Alabama Code Section 35-12-20 through 35-12-48) by filing the appropriate forms (UP-1, UP-2), along with the properly identified funds to the Alabama Department of Revenue, Unclaimed Property Section. The forms may be obtained from the Alabama State Revenue Department. Proper delivery of funds under the terms of the above statute relieves the facility of liability for such funds. What Does Social Security Say? Upon the death of the beneficiary, any conserved or other funds you have belonging to the beneficiary become the property of his or her estate. You must immediately turn over conserved funds to the legal representative of the beneficiary s estate for disposition under State law. If there is no legal representative, you must contact the State probate court for instructions on what to do with remaining funds. If you need information about State law, contact the probate court or an attorney. Important: Do not return conserved funds to SSA after the death of the beneficiary. 7
ELIGIBILITY ISSUES -Income Offset- -Qualifying Income Trusts- -Alabama Family Trusts- -Requests For Hardship- -New POA Law- -Long Term Care Insurance- INCOME OFFSET ACM 560-X-25-.10(4)(d) Definition: amounts of income for incurred necessary medical or remedial care recognized under state law but not covered under the State s Medicaid Plan, nor subject to payment by Medicare or any other third party health insurance including Medicare premiums, deductibles and coinsurance. (ACM-560-X-25-.10 (4)(d)) 8
Allowable Post Eligibility Deductions: In determining the amount of income an individual has to apply to his cost of care in an institution, the following are deducted: 1. Personal Needs Allowance ($30/$90) 2. Spousal/Family Allocation 3. Health Insurance Premiums 4. Non-covered medical expenses Requirements for Income Offset Must be determined to be medically necessary. Must be submitted to Medicaid within 6 months of the date of service or award. Deduction (offset) will be allowed based on the lesser of the Medicaid rate, the Medicare rate, or reasonable and customary charges. Requirements cont d Deduction is available for the three months prior to the month of application, even if the patient was ineligible during that time. No deduction is allowed if patient is under a transfer penalty. Deduction allowed for initial/replacement dentures (Medicaid Criteria must be met) Deduction allowed for hearing aids (Medicaid criteria must be met) 9
Other Things To Note: Resident must have a liability amount. Requests can be sent in before the services are rendered. If approved, resident will then have 3 months to have the service performed and submit the receipts for offset. This is an income offset. The resident will be allowed to keep the money to pay for the service from his/her available income. No payment will be made directly to the facility from Medicaid. QUALIFYING INCOME TRUSTS QIT Facts And Issues For Nursing Home residents who have income over the established limit. QIT is an income trust only. Only income can be part of the QIT. Only resources that can be part of QIT are a result of accumulated income (except for minimal amount used to open QIT account). 10
If resident receives more than one source of income he/she is not required to put all of his/her income into the QIT.he/she may place only one source of income into QIT if placing that particular amount into QIT will bring other income below the income limit, but must place ALL of that source of income into QIT. Effective date of eligibility is the first day of the month the trust was established and funds deposited into the QIT. Must provide proof that trustee has requested, in writing, that t direct deposit of income into the QIT has been requested. Prior to direct deposit beginning, sponsor must place ALL of check/checks into the QIT each month. If there is a build-up of funds in the QIT there is no penalty. Any build-up of funds in the QIT must be used for the resident. Money can be used to pay mortgage payments on the claimant s home, attorney fees, normal living expenses of resident, etc. 11
Medicaid will require past 12 months of bank statements on QIT, at review. Using funds in QIT inappropriately or placing resources into the QTI will render the QIT inoperative. Termination of trust occurs when resident is discharged from the facility, dies or information is received that the trust has been or will be terminated. Burial/Funeral expenses cannot be paid from QIT. At resident s death or termination of the trust, ALL REMAINING FUNDS IN THE QIT ARE DUE THE STATE OF ALABAMA, UP TO WHAT MEDICAID HAS PAID ON BEHALF OF THE RESIDENT. Sponsor will be contacted by Medicaid re: sending funds to the State Medicaid Agency ALABAMA FAMILY TRUST 12
AFT Facts: AFT administers (1) Third Party Special Needs Trusts, established by a third party for the benefit of a loved one with a disability and (2) First Party Special Needs Trusts, established by the beneficiary, guardian/conservator or with the beneficiary s own funds. Only Cash Deposits are accepted. Funds are placed in a sub account then pooled together and invested and managed by BankCorpSouth Bank. Special needs distributions are made for items not provided by government support or private health plans (preneed burial, dental, rehab therapy, medical equipment, pharmacy, etc.) AFT can also be used for clothing, phone, cable, internet, mileage, books/tuition/tutoring, travel, etc. AFT is a d(4)(c) trust.funds placed in the trust are excluded resources by Medicaid and SSI. All funds remaining in the AFT at the time of the beneficiary s death are subject to recovery by Medicaid. 13
Costs for setting up trust are currently $750 (set up fee) Minimum initial contribution to establish trust is $1500 Contact Information: Alabama Family Trust 101 Oslo Circle Birmingham, AL 35211 800-711-1301 or 205-944-3987 www.alabamafamilytrust.com How Can AFT Help NH Residents? Pay NH bill during transfer penalty period Pay private room differential Phone, cable, TV Clothing, personal hygiene items Computers, televisions, video games Examples of Items Not Covered: Food, drinks Mortgage Payments, residence insurance Final expenses upon death Mileage for general visitation by sponsor 14
REQUESTS FOR HARDSHIP (ACM 560-X-25-.09) Undue Hardship Facts/Suggestions: NH can request undue hardship on behalf of beneficiary. Begin work on UH requests EARLY Medicaid says UH exists when individual has admitted assets were transferred for Medicaid eligibility purposes. Circumstances Medicaid Will Consider: Individual in need of protective services Has exhausted all efforts to have asset returned, including voiding transfer under State law or criminal or civil action Individual was deprived of asset by fraud or misrepresentation. Individual has exhausted all reasonable efforts to meet his/her needs from other available resources 15
Undue Hardship Packet: Suggest NH have appt. of rep. form Letter requesting UH goes to DO Attachments should include: -Copy of Medicaid Notice of Penalty -Physician s Statement -DHR Statement -Police Reports -Proof of Court Actions -Other related documentations PROTECTING ALABAMA S ELDERS ACT (New POA Law) Effective Date 9-1-2013 Gives law enforcement the ability to arrest individuals with POA if they are exploiting a senior citizen over the age of 60. Penalties range from misdemeanor to Class B Felony (2 to 20 years) Misuse of POA prior to 9-1-2013 falls under OLD LAW 16
LONG TERM CARE INSURANCE (ACM 560-X-25-.06 (f) and (g)) Resource Protection Is Available To Individuals Who Have Long Term Care Insurance. Two different rules apply: Policies purchased prior to 3-1-2009 Policies purchased after 3-1-2009, LTC Policies Purchased Before 3-1-2009: Medicaid will not consider resources of a person equal to the amount of long term care insurance benefit payments if the policy has paid for the first three years of NH care and/or home health care services. 17
Exclusion applies for life of purchaser LTC Insurance Proceeds must have been spent on:. Services Medicaid approves or covers for its recipients. In amount not in excess of charges of the service provider. For NH and/or home health care. For services delivered after 10-1-97 Resources protected under LTC provision are protected in addition to resources which are protected for the community spouse. Resources protected under this rule are subject to estate recovery. LTC Policies Purchased After March 1, 2009 Medicaid will not consider resources equal to the amount of benefits paid (dollar for dollar) by an Alabama Long- Term Care Insurance Partnership Policy (Partnership Policy) for long term care services received. Does not have to pay for three years as in policy prior to 3-1-09. 18
Individual must be covered under a Partnership Policy that has been certified by the Alabama Department of Insurance as meeting the following criteria:. Covers a person who was a resident of Alabama when coverage is effective. Policy meets specific requirements of IRS Code of 1986.. Policy meets specific requirements of DRA of 2005. Policy includes inflation protection factors noted in Admin. Code Resources protected under this provision are not subject to estate recovery. Policies issued prior to 3-1-2009 can be converted to LTC Partnership Policies (resource exclusion will apply only with respect to insurance benefits received under the new Partnership Policy). Other Notes Re: LTC Insurance Premiums are an allowable deduction in post-eligibility. If LTC insurance payments are not If LTC insurance payments are not sufficient and resident must apply for Medicaid, LTC insurance payments should be assigned to NH; otherwise, payments will be counted as income to resident. 19