Medicaid and Long-Term Care Services
Federal and State Partnership
Financial Eligibility Rules for Aged and Disabled in Institutions or Receiving Community Care Waivers
Table of State Long-Term Care, Medicaid Financial Eligibility Rules
Medicaid Level of Care Eligibility for Nursing Homes
Medicaid Reimbursement of Nursing Homes
Medicaid Estate Recovery
Table of State Medicaid Estate Recovery Programs
Insurance Partnerships
Medicare and Medicaid Long-Term Care Test Programs for The Aged

 

Medicaid and Long-Term Care Services
Medicaid was established as Title IX of the 1965 Amendment to the Social Security Act while Medicare was established at the same time as Title VIII of the Act. Medicaid is a health insurance program for certain low-income people. These include: certain low-income families with children; aged, (65 and older) blind, or disabled people on Supplemental Security Income; certain low-income pregnant women and children; and people who have very high medical bills.

Medicaid is funded and administered through a state-federal partnership. Although there are broad federal requirements for Medicaid, states have a wide degree of flexibility to design their program. States have authority to establish eligibility standards, determine what benefits and services to cover, and set payment rates. All states, however, must cover these basic services: inpatient and outpatient hospital services, laboratory and X-ray services, skilled nursing and home health services, doctor’s services, family planning, and periodic health checkups, diagnosis and treatment for children.

Long-term care recipients of Medicaid come almost exclusively from the aged, blind and disabled group of eligible beneficiaries but very few of those are actually receiving SSI (Supplemental Security Income). SSI is a welfare payment for certain disabled or handicapped individuals who are unable to work, have no assets and have no extended family financial support. Certain provisions of the enabling Act, as well as congressional amendments since 1965 have allowed the aged, blind and disabled who don't qualify for SSI to receive Medicaid under an alternate set of eligibility rules.

Medicaid enrollment almost doubled over the period of 1990 to 1998 from about 25 million U.S. recipients to about 40 million in 1998. Today, 47 million people--a little over 1 in 7 of all Americans--are receiving Medicaid. In 1998 about 10.6 million aged, blind and disabled were receiving Medicaid assistance, in the form of medical and long-term care services. Although this group only represented 1 in 4 of all Medicaid recipients in 1998, the group accounted for a large portion of the budget. For the group receiving old age (65+) long term care, Medicaid spends more per recipient than for any other group.

During the 1990's there was a large one-time influx of younger Medicaid enrollees due to changes in governing Federal law. This skewed the picture such that growth of long-term care services was hidden.  But in the future, a growing larger proportion of aged and disabled are expected to receive benefits. 

The number of long-term care enrollees went up by 80% between 1990 and 1998. As impressive as that may appear, actual spending on long-term care increased 3 times faster than enrollment.  From 1990 to 1998, Medicaid spending for long-term care skyrocketed an astronomical 225%.

Federal Medicaid grants to States now account for the fifth largest federal budget item, after Social Security, defense, federal debt and Medicare, but Federal Medicaid is growing at such a fast rate it will soon overtake Medicare and move into fourth place.  State Medicaid budgets in most states account for the second or third largest budget item expenditures after education and transportation.

A doubling in expenditures every 7 years, which we experienced this last decade, would eventually bankrupt government budgets. The growth of Medicaid spending, including long-term care, cannot go unchecked without some sort of offsetting reduction in services.

 

Federal and State Partnership
Congress determines the rules under which Medicaid operates but the States have broad discretion in determining who gets covered and how they qualify financially. States also determine reimbursement rules under Federal guidelines and disperse funds to providers. In order to receive Federal grant money, certain groups must be covered. These are mentioned above. The Feds may also withhold funds if mandatory provisions in the form of occasional Congressional amendments are not followed.

Federal reimbursement for Medicaid is in the form of block grants to States. The Federal Medical Assistance Percentage (FMAP) is determined annually for each State by a formula that compares the State's average per capita income with the national average. By law, the FMAP can be no higher than 83% nor lower than 50%. As an example, in 2000, Connecticut, Massachusetts, New Jersey, New York and Maryland had the highest per capita income in that order. Federal matching funds for Connecticut will be 50% and the other 50% will come from its state budget. On the other hand, Mississippi, West Virginia, Arkansas, New Mexico, Montana and Utah had the lowest per capita income in that order. In this case, the Federal grant for Mississippi will 83% of its Medicaid costs and the other 17% will come from its state budget. All other states fall somewhere between 50% and 83% for FMAP.

Overall the Federal Government provides about 70% of total Medicaid costs and the States provide the other 30%. From 1990 to 1998, Federal outlays for Medicaid rose about 12% a year. Estimates for the longer period from 1990 to 2001 put the average annual increase at about 11%. Total combined State and Federal Medicaid costs from 1990 to 1998 went up about 10.2% per year. The higher Federal spending increase compared to a lower combined increase means the Federal Government has been shouldering an ever-increasing share of costs whereas the States' portion has been decreasing. Total Medicaid spending is estimated to be a little over $200 billion for 2002. Medicaid costs will soon surpass those of Medicare, since Medicaid is going up at a much faster rate.

Congress is concerned about rising Medicaid costs and over the years, attempts have been made to curtail spending. In 1988, legislation was directed at tightening financial eligibility. This mostly affected the elderly population receiving long-term care since this is the fastest growing segment of expenses. In 1993, legislation directed States to implement a mandatory estate recovery program for recipients over age 55, who are receiving nursing home and community waiver care. And in 1998 Congress mandated that States set up recovery service agencies.  Again the targeted group was primarily the elderly long-term care beneficiaries. Apparently Congress is concerned that some recipients are qualifying for Medicaid by shifting assets that could be used for care, to their children, thus forcing tax payers to pick up the cost.

States, on the other hand, are not so anxious to tighten up payment rules for long-term care recipients. States feel that most elderly long-term care recipients are truly impoverished by long-term care costs and attempts to "squeeze" these people only create a greater burden for overextended family members. West Virginia most recently lost a lawsuit over this issue.

The West Virginia State Medicaid refused to enforce estate recovery rules and subsequently the Feds withheld matching funds. The state sued over withheld funds and lost the suit. West Virginia is probably representative of many states. The feeling is that elderly recipients are truly deserving and shouldn't be punished. Besides, state governors and legislators are well aware of the political power of elderly Americans and the politicians probably tone down programs like estate recovery in order to avoid offending this group. Even states like California that seem to be more aggressive at weeding out undeserving Medicaid coverage, appear to exhibit more bark than bite.

The only state that has an effective recovery program is Oregon.  As of 2004, a few states had no functiong recovery program and it's estimated that all states recover about 0.3 % of state Medicaid budgets nationwide.  So far recovery is a dismal failure.

 

Financial Eligibility Rules for Aged (65+) and Disabled in Institutions or Receiving Community Care Waivers

Income and Resource Rules for Institutions (Nursing Homes)
Financial eligibility for Medicaid nursing home and community waiver requires the recipient to be receiving SSI payments. If the recipient is not receiving SSI but is qualifying under alternate income rules, he or she must have less than $2,000 in resources. ($3,000 if a couple needs care) A few states use lower limits.

Resources are defined as any asset that can be utilized to produce income. There are numerous rules as well as gifting lookback provisions that define what a resource is and what a so-called "disregard" resource is. Some important resources that often aren't required to be counted are a personal residence and a car. If the recipient is married, the spouse keeps the residence and a vehicle worth any value. Also if the recipient is single but plans on returning home, the residence is not included. Disabled dependents living at home also "disregard" the residence. Also money invested in an income annuity is a disregard. Only the income counts. Assets that don't produce cash are subject to estate recovery at the death of the recipient.

Lookback provisions require any gift or so-called transfer-for-less than- value within 36 months of a community waiver or nursing home stay to be counted as a resource and any irrevocable trust assets created in the prior 60 months to be counted. Revocable trusts or any other arrangements in which the beneficiary has a "life interest" are counted as resource. Counting these transferred resources, even though they haven't been spent down on medical care or become subject to recovery, requires adding the equivalent dollar amount to a nursing home or waiver stay before Medicaid starts to pay for care.

Here's how it works. Suppose Mary gives her daughter her $120,000 dollar residence, 2 years before entering a nursing home. It takes Mary 5 months in a nursing home before she has spent her remaining liquid resources down to less than $2,000 at which point she would normally become eligible for Medicaid. But she still must incur a penalty period or sanction because the $120,000 transfer occurred within 3 years. The sanction period is determined by dividing the sanctioned resources by the average Medicaid reimbursement rate in the state which in this example is $3,000 per month. The result, in this case, is a period of 40 months in which someone other than Medicaid pays for care. In this case it may be Mary's daughter. Her daughter can also transfer the title to the house back to Mary and avoid a sanction. The sanction period starts on the date of transfer and runs concurrently with a spend down so that Mary or her daughter have to pay for 11 months of care before Medicaid takes over. (40 months minus the 29 months since the gift)  Mary is single but if she had a husband, the community spouse resource protection which we will discuss next still applies even during a sanction period.

Also note that the sanction is longer by four months, then the three year look back. This is a paradox. If Mary had given the gift exactly three years before entering a nursing home, she would have only had to wait 36 months before Medicaid paid for care as opposed to 40 months before Medicaid would pay with a sanction. With a large gift, penalty periods could last up to five to ten years or more. A shorter look back provides a planning opportunity for gifting prior to receiving Medicaid. Look in the Medicaid planning section for more details.

Most recipients in nursing homes or on community waivers are not receiving SSI payments. Special rules allow aged (over 65) and disabled people in nursing homes or receiving waivers and who are not receiving SSI to meet alternate income tests. Most states have a "Medically Needy Program" that allows individuals to deduct the cost of care from their income. This spend down allows them to meet the alternate income test levels typically set at 100% of SSI.

States that do not follow Federal guidelines for Medicaid eligibility and that apply stricter rules, are called 209(b) states. Eleven states are 209(b) but most of them have a medically needy program. Federal law requires 209(b) states without medically needy to allow spend down to trigger Medicaid eligibility. Spend down means that all nursing home and medical costs not covered by Medicare, are deducted from a person's income until the person meets the income test. In some 209(b) states this is set at the state dictated level and in others there is no level. The difference between what a person can afford and what care costs determines eligibility.

States that are not 209(b) and who don't have a medically needy program are called income test states. Twelve of these states set income eligibility for Medicaid nursing home coverage at 300% of SSI--$1,692 per month in 2004. Delaware, the 13th of these states, sets income at 250% SSI. A person who makes more than the income level is not eligible for Medicaid in these states. Income is gross income, not medically adjusted income. Federal law requires these states to allow a person to establish a Miller Trust in order to circumvent the income test.

A Miller Trust is a legal document that transfers all of a person's income to another individual--the trust. The trust must be set up to pay the long-term care costs for its beneficiary--the person transferring income. Thus the person transferring income, has no income and comes in below the state income eligibility trigger. A Miller Trust must be set up so that the State can recover money at the death of the Medicaid beneficiary.

After meeting the income, resource and level of care (need for care assessment) tests and qualifying for Medicaid, a recipient is required to share Medicaid costs by contributing all of his or her total income to the total cost of care and Medicaid picks up the balance, if any. An allowance is added back in to provide monthly personal care. (a Federal minimum of $45 per month but as much as $75 in some states) Also, an allowance for medical costs and insurance premiums not covered by Medicare is added back in.

Income and Resource Rules for Medicaid Community Waivers
Medicaid Home Based and Community Services (HBCS) waivers are an attempt to provide services not originally dictated by Federal law. Federal Medicaid rules originally required only nursing home coverage for eligible long-term care recipients and thereby did not allow for other long-term care options. Rules do allow, however, for the Centers for Medicare and Medicaid Services (CMS) to grant waivers from Medicaid nursing care. The waiver is a state plan approved by CMS to provide community services such as home care or assisted living to a certain number of qualifying people.

Eligibility requirements for waivers are determined by the States, sometimes varying among different waiver types. Waivers might be designed to cover recipients who are: aged (over 65) or disabled, mentally retarded or developmentally disabled, children, AIDs infected, mentally disturbed and so on. The number of participants is controlled, probably due to funding and administrative constraints. Federal rules require that waiver participants meet State Medicaid level of care eligibility rules for nursing homes and that the cost for waivers be neutral, meaning they can't exceed equivalent nursing home costs.

Medicaid community waiver care is often a more desirable alternative to nursing homes and generally those receiving care prefer to stay at home or use community programs, but the availability of such care is still widely restricted. There are at least 4 reasons for this:

The 1999 Supreme Court, Olmstead decision, will have a great impact on the availability of Medicaid community care. Olmstead requires that care for the disabled under ADA be provided in the most suitable setting not just nursing homes, regardless of cost. Since most Medicaid nursing home recipients are also disabled--requiring help with ADLs--States will have to find ways to offer alternative care through community programs. All the states and the CMS are now grappling with the solutions to Olmstead compliance.

Many states have programs already in place. If you want to see what's happening in your state, go to National Conference of State Legislatures.

Community Spouse Protected Resource Standard for Institutions
Realizing that resource spend down for a couple might put an undue hardship on the spouse at home and not needing care--the so-called community spouse--Congress authorized the community spouse to retain some assets. A minimum allowable retention amount and a maximum amount are set each year by the CMS and indexed to inflation. The States can set their own protected resource amounts between the minimum and maximum. Most states choose the extreme at either end. Either the minimum or the maximum.

Here's how it works. The resource spend down rule requires the couple's liquidable assets to be lumped together. The resources are then divided in half. The resulting amount is compared to the State's resource standard. If the amount is less than the resource standard, the community spouse keeps it all. If the amount is between the community standard and the maximum Federal allowable, the community spouse keeps the larger of the two--the amount or the standard. If the amount is more than the maximum Federal standard, the community spouse may only keep an amount equal to the maximum. Whatever portion is attributed to the spouse needing care must be spent down.  (Spend down does not necessarily have to be spent on care, it just needs to be spent.)

Money invested in qualified accounts--IRA, 401(k), 401(a ), 403(b), 457, SEPP, SIMPLE, etc.--is not subject to spend down if the owner is older than 70 1/2. Instead, the IRS required minimum withdrawal or larger withdrawals are treated as income.

Federal minimum standard for 2004 is $18,554. Federal maximum standard for 2004 is $92,760.

Here are some examples: 1) John and Jane have $200,000 combined resources. The State standard is $24,000. Dividing $200,000 in half yields $100,000. Jane keeps $92,760 and John must spend down $107,240 to $1,999. 2) George and Ann have $80,000. State resource standard is the maximum, $92,760. Half of $80,000 is $40,000. Ann keeps $80,000. No spend down required. 3) Same as #2 except State resource is the minimum allowable, $18,554. Ann keeps $40,000 and George spends down $40,000. 4) Same as #2 but State resource standard is $56,000. Ann keeps $56,000 and George spends down $24,000. Click here for current resource limits.

Community Spouse Protected Resource Standard for Waivers
Federal rules don't require community spouse resource protection for waivers. Most states extend this protection but 12 states do not.

Spouse Income Protection for Institution
Income protection prevents a community spouse from being impoverished and having to go on welfare when the other spouse needs expensive long-term care. Here's how it works:

Income rules for Medicaid eligibility require each spouse in a couple to claim the amount of income that actually belongs to that person. Shared income is divided in half. For example, suppose Henrie gets $3,500 a month in Social Security and pension income. His wife Frieda gets $750 in Social Security. Together they get $800 a month in rental income from property in both of their names. Henrie has a disabling stroke and will go in a nursing home, probably for many years since he is otherwise healthy. His State allows income spend down to qualify for Medicaid. He and Frieda apply for Medicaid even though he doesn't yet qualify. Medicaid determines that his income is $3,900 ($3,500 plus $400 of the rental income--his half). Frieda keeps $1,150, her Social Security plus $400--half the rental income. Henrie also must spend down $20,000 of their liquid assets before becoming eligible for Medicaid. His nursing home costs $4,000 a month. Subtracting the $4,000 a month from his income allows Henrie to meet the income test for Medicaid. Once having spent down to below $2,000 in remaining resources (He doesn't have to necessarily spend it on care.) , Medicaid should cover $145 of Henrie's costs. He pays the other $3,855 and keeps $45 for a personal needs allowance. The problem is Frieda can't maintain the rental property and pay the rest of her bills with $1,150 a month and her remaining community spouse allowable resources.

Federal Medicaid rules have spousal impoverishment provisions for situations like this. The community spouse is allowed to take back enough of the couple's income to bring his or her income to the minimum state impoverishment standard. Federal rules set a minimum and maximum standard and States can choose an amount between the two standards. The CMS sets the amounts each year based on inflation. The minimum impoverishment standard for 2004 is $1,515 a month and the maximum is $2,319 a month.

From the previous example, suppose Henrie's State sets its standard at the Federal minimum of $1,515 a month. Instead of getting $1,150 a month, Frieda now gets $1,515 a month. Henrie now pays $3,531 a month of his nursing home cost and Medicaid pays the balance of $469. Click here for current income protection limits.

Spouse Income Protection for Community Waiver
Federal Rules for spousal impoverishment don't apply to waivers; however, most states allow extension of these benefits for waivers. A number of states don't offer it.

Protected and Spouse Maintenance Incomes for Community Waivers
Medicaid reimbursement for nursing homes also includes room and board as well as care services. Reimbursement for community services is generally only for care. The recipient must still cover rent, food, utilities, taxes and so on out-of-pocket. Most states recognize this dilemma and allow the beneficiary as well as a spouse to retain some income to pay for room and board. However, allowances are either too small or lacking in some states. This forces many who could rely on waivers to go to a nursing home instead.

Table of State Long-Term Care, Medicaid Financial Eligibility Rules

	(1) Income and Resource Rule for Institution	(2) Income and Resource Rule for Community Waiver	(3) Community Spouse Protected Resource Standard Institution	(4) Community Spouse Protected Resource Standard Waiver	(5) Spouse Income Protection for Institution	(6) Spouse Income Protection for Community Waiver	(7) Individual's Protected Income Community Waiver (2001)	(8 Spouse Maintenance Needs Allowance Community Waiver (2001)
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Col Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachus Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hamp New Jers New Mex New York North Car North Dak Ohio Oklahoma Oregon Pennsylva Rhode Isl South Car South Dak Tennessee Texas Utah Vermont Virginia Washington West Virg Wisconsin Wyoming	3 3 3 1 1 3 1 3 1 1 1 1 3 1 2 1 1 1 1 1 1 1 1 1 3 2 1 1 3 1 1 3 1 1 1 2 1 1 1 1 3 3 1 3 1 1 1 1 1 1 3	4 5 5 5 6 5 4 6 4 5 4 6 5 6 6 5 6 4 4 6 4 6 6 6 5 6 6 4 5 6 4 6 6 6 6 6 5 5 4 6 5 5 6 5 6 6 6 4 4 6 5	$25,000 max min max max max min max min max max max min max min $24,000 min max max max max max max $24,247 max min min min max min min $31,290 $74,820 min max min min min min min $66,480 $20,000 min min min max max max max $50,000 max	none max min none max max min max min none max max min max none $24,000 min max max none none none max $24,247 none max none min max none min $31,290 $74,820 min max min min min none min $66,480 $20,000 min min min max max max none $50,000 max	min max max max max max max max max max max max max max max max max max max max max max max max max max max min max max max max max max max max max min max max 75%max max max max max max max max max max max	none max max none max max max max max none max max max max none none max max none none none none max max none none none min max none max max max none max max max min none max 75%max max max none max max max max none max max	300%SSI 300%SSI 300%SSI keep all varies 300%SSI 200%FPL 250%SSI none varies 100%SSI 100%FPL $796/$530 $2175 100%SSI 300%SSI $696 100%SSI 300%SSI 125%FPL varies none 300%SSI $722 300%SSI $953 $525 SSP 300%SSI varies 300%SSI keep all $625 none $475 $1036 $259 SSI+SSP none 100%FPL 100%SSI $551 max CSMI 300%SSI varies $733 varies 100%FPL none $711 300%SSI	none $2175 $531 none varies $1452 none none none none none none $796/$530 none none $2175 none $2175 none 100%SSI none none none none none none AFDC none none none none none $900 cple none $475 none $325 $1452 up to $223 2 MNIL none $551 none 100%SSI max$2175 $1452 none 100%FPL none $711 none

Source: National Association of Medicaid Directors

Explanation of Table:

(1) Income and Resource Rules for Institutions--Eplanation of Code

1=States that have a medically needy program to allow spend down for nursing home eligibility. With the exception of a few states with different income rules, for the majority of states, the spend down triggers Medicaid eligibility when income reaches 100% of SSI.

2=States that don't have a medically needy program and don't follow Federal guidelines for Medicaid nursing home eligibility, so-called 209(b) states. Eleven states are 209(b) but most of them have a medically needy program. Federal law requires 209(b) states without medically needy to allow spend down to trigger Medicaid eligibility.

3=States that are not 209(b) and who don't have a medically needy program. These 13 states are the so-called income test states. Twelve of these states set income eligibility for Medicaid nursing home coverage at 300% of SSI--$1,692 per month in 2004. Delaware sets income at 250% SSI--$1,410 per month in 2004. A person who makes more than the income level is not eligible for Medicaid. Income is gross income, not medically adjusted income. Federal law requires these states to allow a person to establish a Miller Trust in order to circumvent the income test.

(2) Eligibility for Community Waivers--Explanation of Code

4=State does not allow spend down to qualify and does not allow use of a Miller Trust to circumvent lack of spend down. An income test pegged at 300% SSI is used in 8 of the 11 states in this category. Of the other 3, Alabama uses 100% SSI. (It would be pretty tough to get a waiver in Alabama), the District of Columbia and Nevada use 100% FPL (Federal Poverty Level, which is for 2002, $8,860 per year in 48 states & D.C. and $11,080 in Alaska and $10,200 in Hawaii.)

5=State does not allow spend down but does allow a Miller Trust.

6=State does allow spend down similar to a medically needy program for nursing home eligibility.

(3) Community Spouse Protected Resource Standard for Institutions--Explanation of Code

max=State uses maximum allowable Federal standard. $92,760 for 2004.

min=State uses minimum allowable Federal standard. $18,552 for 2004.

($ amount)=State uses stated amount for a standard.

(4) Community Spouse Protected Resource Standard for Waivers--Explanation of Code

max=State uses maximum allowable Federal standard. $92,760 for 2004.

min=State uses minimum allowable Federal standard. $18,552 for 2004.

($ amount)=State uses stated amount for a standard.

none=State provides no resource protection

(5) Spouse Income (Impoverishment) Protection for Institutions--Explanation of Code:

max=State uses maximum allowable standard. $2,319 for 2004

min=State uses minimum allowable standard. $1,515 for 2004

(6) Spouse Income (Impoverishment) Protection for Community Waivers--Explanation of Code:

max=State uses maximum allowable standard. $2,319 for 2004

min=State uses minimum allowable standard. $1,515 for 2004

none=State has no spouse impoverishment program

(7) Individual's Protected Income for Community Waivers and
(8) Spouse Maintenance Needs Allowance for Community Waivers--Explanation of Code

SSI=Supplemental Security Income. $564 per month for 2004.

FPL=Federal Poverty Level. For 2002, $8,860 per year in 48 states & D.C. and $11,080 in Alaska and $10,200 in Hawaii.

MNIL=Medical Needs Income Limit

 

Medicaid Level of Care Eligibility for Nursing Homes
After meeting financial eligibility criteria, an individual must go through an devaluation with a state Medicaid assessment specialist in order to determine a need for care. If the individual fails to meet the minimum level of care needed to qualify for that State's Medicaid coverage, then no Medicaid help is forthcoming.

A need for skilled nursing care will automatically qualify a person in any state. It's also likely that a candidate already in a nursing home but not needing skilled care will still qualify. Skilled care must be needed on a frequent basis. Examples of skilled care might include the need for: frequent monitoring of vital signs, wound dressing changes, maintenance of mechanical ventilation equipment, maintenance of a catheter, help with elimination problems, maintenance of IV administrations, careful monitoring of medication usage, managing colostomy problems, careful supervision of severe diabetes, frequent injections, maintaining a feeding tube and many more problems requiring the skill of a nurse or doctor.

People who are otherwise able to manage their own health problems or who are healthy but mentally impaired must meet the minimum level of care defined by the State Medicaid regulations. These regulations define whether a person qualifies for a minimum level of care provided by a nursing home. Even if Medicaid intends on providing a qualifying candidate with home care through a community waiver, a candidate must still meet the minimum level of care for a nursing home.

The minimum level is tied to a person's ability to perform a certain number of activities of daily living (ADLs) without assistance. Consideration is also given to people with mental impairment such as dementia, Alzheimer's or disabling mental illness, who may be able to perform ADLs but nevertheless require supervision. The mentally ill disabled may be provided services in special Medicaid intermediate care facilities licensed for this type of care. The most commonly used ADLs are transferring, dressing, bathing, toileting and eating. Some states define more ADLs such as wandering or medicating. Some states give consideration to instrumental activities of daily living (IADLs) such as: meal preparation, medication management, shopping, housework, doing laundry, using the telephone and handling finances.

Assistance or supervision required to manage a care recipient with ADLs and IADLs is defined differently by the States. Some states allow only a presence or verbal coaching for some ADLs. Some states require hands-on assistance for some ADLs. A person needing care in one state may not qualify under that state's rules but might qualify under the rules of a neighboring state. Of particular concern are candidates suffering from dementia or Alzheimer's. It's difficult to quantify their need for care and in some states, those people who are cognitively impaired might not get help with Medicaid even though their needs might be greater than the needs of those who are physically disabled.

Some states use a scoring system based on verbal tests and questions. Meeting a minimum score qualifies. Most states determine the minimum number of eligibility rules met in order to qualify a person.

A person might meet the ADL and supervision criteria from one state but not those of another state. Families should consider moving loved ones who have been declined in one state, to live with a member of the family in another state and possibly qualifying in that state.

 

Medicaid Reimbursement of Nursing Homes
About 62% of all nursing home costs are paid by Medicare or Medicaid so it's not surprising that most facilities would want to be certified by either or both of these government programs. Out of approximately 1,850,000 nursing home beds in this country, 3.4% are certified for Medicare only, 45.6% are certified for Medicaid only, 44.9% are certified for both and 6% are not certified. Non-certified facilities either do not meet government standards or they have deliberately chosen to avoid government red tape and only service private-pay residents. Medicaid is administered by each state and because of a desire to shift long-term care services away from nursing homes, some states choose to restrict the number of Medicaid beds. However, Federal mandates will not allow States to restrict supply of beds such that access to Medicaid is impeded. In areas of high demand the State may not bring new beds on-line fast enough and potential Medicaid residents in high-demand areas may have to go on a waiting list for a Medicaid bed or find a vacant bed hundreds of miles away from family or friends.

It's estimated that in 2002, Medicaid will pay about 44% of all nursing home costs. Medicaid is also paying part or all of the costs of about 70% of all elderly and functionally disabled nursing home residents. Decisions and reimbursement policies of State Medicaid Departments have a profound impact on the operations of U.S. nursing homes.

Medicaid reimbursement is carried out at a state level. Generally the States employ some rather convoluted and arcane rules to reimburse nursing homes. Most states reimburse with a prospective payment system like Medicare but a few states reimburse actual costs up to certain predetermined statewide maximum amounts. Some states pay directly, others pay through privately-contracted managed care administrators. Medicaid reimbursement to nursing homes is not uniform from state to state. In many states, nursing homes are not given enough money to cover their actual costs. One state nursing home association claims that 85% of its member nursing homes are not meeting costs with Medicaid. In other states nursing homes may be faring better.

Medicaid reimbursement has a direct impact on the daily bed rates of private-pay residents. These are residents who are paying out-of-pocket for their own care. They may be spending money from their own income and assets or their family may be pitching in as well. Many of these people are going through Medicaid spend down--depleting assets until they qualify for Medicaid. If the nursing home is losing money on government Medicaid reimbursement it may be charging private-pay residents higher daily rates to make up the difference. But one should not assume this is always the case. At least 2 states, Minnesota and North Dakota, prohibit nursing homes from charging more than the Medicaid reimbursement rate. In addition, not all homes lose money on government reimbursement. These facilities may be charging the same for all residents. Finally, although most states prohibit nursing homes from charging private-pay less than the Medicaid reimbursement rate, in those states that allow it, private-pay residents may be paying less than with Medicaid.

 

Medicaid Estate Recovery
Federal legislation in 1993 made it mandatory for States to attempt to recover Medicaid payments for recipients from their estates after they die. Since most tangible assets are spent through Medicaid spend down, estate recovery focuses on real property, personal property or business ownership that the deceased had an interest in just prior to receiving Medicaid. Recovery applies to individuals who were age 55 or older when they received Medicaid or to permanently institutionalized adults under 55. Recovery can also occur from the estate of living recipients who are in a nursing home and who have been certified that they cannot reasonably be expected to be discharged and return home. If it's a house, as an example, Medicaid can force the sale of the property.

The property is exempt from estate recovery if: 1) the recipient's spouse is living there 2) A blind or permanently disabled child lives there or 3) If as a result of a state lien, additional protection for siblings and adult children can be satisfied. If all of these conditions cease to exist then the property becomes subject to recovery.

Interestingly, if a person had a spouse living in the home at the time of Medicaid qualification, the home didn't have to be counted as a resource for the qualifying beneficiary. Yet at the death or Medicaid confinement of the surviving spouse, the home becomes subject to recovery.

For recovery purposes, Federal law gives States the directive to go after property that would be subject to probate. Probate is a court process by which title to a deceased's property is changed and creditors of the estate--in this case, Medicaid--can get their claims satisfied. This property may include real property not in joint tenancy with survivorship, vehicles and equipment (however most states employ a simplified ownership change avoiding the courts), and noncorporate business ownership. Contractual arrangements of assets with beneficiary provisions are not subject to probate and might include: life insurance death benefits, IRA's, 401(k)s, profit sharing, deferred annuities, trusts, and bank accounts or securities with written provisions that transfer assets at death. Also, property held as joint tenancy with rights of survivorship, transfers to the living tenant(s) at death, avoiding probate. It should be noted that even though many of the cash accounts listed above are not subject to probate they are subject to Medicaid resource spend down requirements and transfer lookback rules. Also, any assets retained by the community spouse under resource protection standards are not subject to her husband's Medicaid estate recovery. This boils down the list of nonprobate assets, not subject to spend down or estate recovery to: joint tenancy, trusts, community spouse protected resources, life insurance and retirement contracts such as IRA's, 401(k)'s etc..

Based on the lists above, about the only assets Medicaid might commonly claim for recovery would be a home or land held solely in the name of the deceased or the deceased's spouse when she dies. If the surviving spouse sets up a trust or joint tenancy with a family member prior to her death or the Medicaid beneficiary does the same, Medicaid would have no claim on the property. Or transferring assets to an income annuity would also avoid probate. An income annuity works this way: all liquid assets must be spent down; and transferred assets are subject to lookback rules, but an income annuity simply converts those assets to income which then falls under Medicaid income rules and helps pay for Medicaid costs. In the case of income annuities, the probate avoidance process exempts any residual value in the annuity at the death of the annuitant which could then pass to heirs, avoiding estate recovery.

Congress recognized the flaw in just limiting recovery to probate and so the 1993 legislation for estate recovery allowed the States, at their discretion, to expand their definition of estate to include the other nonprobate assets listed. In addition, allowance was made for States to place a lien against real property preventing a sale until the lien is satisfied. These are called TEFRA liens after the law authorizing them. Most States, probably for political reasons, have not been enthusiastic about estate recovery so only a few States have an expanded definition of probate estate and less than a third of States do TEFRA liens. Only a handful of states have expanded their estate definitions to go after such assets as funded trusts, joint tenancy property, life insurance proceeds or residual annuity value.

Congress also recognized the dire effects of encumbering a farm or business with the additional financial burden of recovery, thus jeopardizing the ability of children or siblings to make a living. Also considered were the effects a lien may have on the use of property by spouses, siblings and dependent children. As a result, provisions were included which gave the states authority to exempt property where recovery might cause undue hardship. A number of protective exemptions were also granted in the use of liens. Finally, States were allowed to exempt property below a state-established minimum value.

The chart below was derived from a North Carolina Department of Health and Human Services survey. The survey was done in 1997-1998 by intern Beth Kidder under the direction of Susan Harmuth. An attempt was made to see how other states are fairing with estate recovery. Data are from 1997. It's interesting to note that four years after OBR 93, the mandatory Federal enabling legislation, four states--Alaska, Georgia, Texas and Michigan--still had no recovery program. It's also interesting to note the total recovery rate for all responding states of 0.26% of all 1997 Medicaid expenditures. That's virtually a drop in the bucket. Either there are very few assets available for recovery or the States are doing a poor job or both. However, at the time of the survey, about 16 states were considering strengthening their programs. Click Here for the Full text of the Survey

Table of State Medicaid Estate Recovery Programs

	(1) Type of Estate Recovery	(2) Assets Subject to Recovery	(3) Use of TEFRA Liens	(4) Surviving Spouse Dependent in Home	(5) Undue Hardship Criteria	(6) Amount Collected As Percent of Total 1997 Medicaid Expenditures
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	probate none probate probate expanded probate expanded probate probate none probate probate probate probate expanded probate expanded probate probate expanded probate none expanded probate probate expanded probate expanded probate expanded probate NR probate probate probate NR expanded probate expanded probate expanded probate none probate probate NR expanded probate expanded probate	--- --- --- --- 1,2,3,5,6 --- 4 --- --- --- --- --- --- --- 1,2,3,4 --- --- --- --- 1,2 --- --- NR --- --- 1,2,4 --- 1,2,3,4 --- 7 --- --- --- --- --- --- 1,5 --- 1,2 --- 1,2,3 --- --- --- --- --- 1,2,3 --- 1,8 ---	yes NR no no yes yes yes yes no NR yes yes yes no no no no no no yes yes NR yes no yes yes no no no no no yes no no no NR no no no no no no NR no no NR no yes yes no	2 NR 1 1 4 1 1 4 1 NR 1 2 2 1 4 4 1 2 1 1, 2, 3 2 NR 2 2 1, 2 1 1 2 2 1 2 1 1 4 1 NR 4 1, 4 1 1 4 1 NR 1 4 NR 4 2, 3, 4 2 3	1,2,3 NR 1,4 1 4 1 None 4 1,3 NR 1 1,2,3 NR 1,2,3 1 1 1 1 1,4 1 1 NR 1,2,3 1 1 1,2,3 1,3 2,3,4 1 1 1,3 NR 1 1,2,3,4 1 NR 1,2,3 1,2,3 2 1 1 1 NR 1,2,3 1 NR 1,3 1,2,3 1 1	.13% --- --- .02% .02% .19% .74% .02% .09% --- .01% .54% .34% --- .52% .26% --- .00% .45% --- .39% --- .83% .03% .11% .3% .09% .14% .78% .05% --- --- .01% .49% .04% --- .74% --- .05% .12% .20% .00% --- .36% --- --- --- --- .52% .23%

(1) Type of Estate Recovery

probate=State restricts recovery to property defined in probate code

expanded=State goes after assets in addition to probate

none=State had no recovery program as of 1997

NR=State did not respond to this portion of the survey

(2) Assets Subject to Recovery--Assets the States, who have an expanded definition of probate, go after

1=cash (the $2,000 retainable spend down or burial money not used)

2=other personal property of recipient that might have avoided probate

3=property transferred under joint tenancy with rights of survivorship

4=property in which recipient had a life estate interest (might be a trust)

5=trust (usually inter vivos)

6=annuity

7=all allowed by OBRA 93

8=other not defined

NR=not reported or no recovery program

(3) Use of TEFRA Liens

yes=State uses TEFRA liens

no=State does not use TEFRA liens

NR=not reported or no recovery program

(4) Surviving Spouse Dependent in Home--State's procedure in going after a home when the surviving spouse lives there.

1=State may waive its right to go after the home when the surviving spouse dies

2=State may defer recovery to death of surviving spouse

3=State negotiates amount of waiver or recovery

4=State uses some method other than above

NR=not reported or no recovery program

(5) Undue Hardship Criteria--Related to (4) above but these are State procedures towards going after all assets when it may cause undue hardship

1=State may waive recovery

2=State may defer recovery until death of eligible exempt dependents

3=State may negotiate amount of recovery

4=State may use some method other than above

NR=not reported or no recovery program

 

Insurance Partnerships
Currently four states offer a long-term care insurance partnership policy: New York, Connecticut, Indiana and California. State medicaid waivers to Federal Medicaid rules allow someone with one of these policies to be exempt from resource spend down and estate recovery should the benefits in the policy become exhausted and Medicaid has to step in. Naturally the policy owner must use the benefits in the partnership state in order to get the Medicaid exemption. There is current Federal legislation pending that would allow all states to receive partnership waivers. Here are links to the four partnership states: New York, Connecticut, Indiana and California

The following information was copied from the New York site:

About the NYSPLTC
The New York State Partnership for Long-Term Care (the Partnership) is a unique and innovative program that combines private long-term care insurance and Medicaid to help New Yorkers prepare financially for the possibility of needing nursing home or home care. The program allows New Yorkers to protect their assets while remaining eligible for Medicaid if their long-term care needs exceed the period covered by their private insurance policy.

SAY THAT AGAIN?
If you buy a long-term care insurance policy under the Partnership program, and you use 3 years of nursing home care, or 6 years of home care, or some combination of the two, you may apply for New York State Medicaid benefits AND STILL RETAIN ALL YOUR ASSETS. You will, however, have to contribute your income to the cost of your long-term care.

WHY WAS THE PARTNERSHIP CREATED?
The Partnership was created to help New Yorkers finance long-term care without impoverishing themselves or signing over their life's savings, with the accompanying loss of dignity. In the long run, the program will help reduce New York's massive Medicaid tax expenditure - over $7 billion in 1998 and growing. The Partnership offers New Yorkers and New York a better alternative.

WHAT ARE THE BASIC BENEFITS?
All participating insurance companies are required to offer a basic policy which contains the following minimum benefits:

• Coverage for at least 3 years of nursing home care, 6 years of home care or a combination of the two (where 2 home care days equal 1 nursing home day).
• $155/day coverage for nursing home care; $77/day coverage for home care.
• Inflation protection equal to 5% compounded annually.
• Care management: information, referrals, consultation on service needs and benefits.
• 14 days of respite care, renewable annually, to give the at-home caregiver some needed rest.
• 30 extra grace days to pay the premium IF you have designated someone to be notified if you don't pay your premium on time.
• Special consideration for adjustment of premiums/benefits in the event of a national long-term care program.
• Review of denied requests for benefit authorization on a case-by-case basis.

You can also select richer policy benefits. However, all Partnership policies have, at least, the above-listed basic benefits.

WHY SHOULD I CONSIDER A POLICY?

• To stay in control of your own assets.
• To increase your chance of getting the long-term care of your choice -- whether in a nursing home or in your home -- when you need it.
• To continue to feel like a dignified, independent human being.

More than 2 out of 5 Americans 65 and over face going into a nursing home at some point in their remaining lifetimes. Think about it.

Who Is The Partnership For
While the policies are not a solution for everyone, they may be for you. The state recommends that New Yorkers of middle age and older consider these policies if they:

• are generally healthy.
• are married with a total income minimally in the $40,000-$50,000 range, and assets, not including the home, of at least $140,000.
• are single with a total income of at least $30,000 and assets, not including the home, of at least $60,000.

You should be able to pay for the premiums without diminishing your life-style -- the Partnership was set up to help you protect your assets.

WHERE DO I FIND THESE POLICIES?
Insurance companies sell the Partnership policies. Only a policy with the logo you see on the home page is an approved Partnership policy.

WHAT IF I MOVE?
During the period covered by your private insurance coverage, you may use the policy benefits anywhere indicated in your policy. However, if you leave New York State, you must return to receive the Medicaid Extended Coverage portion. Therefore, if you know you are going to move out of state and you know you will not be coming back, these policies are not for you! Consider, then, purchasing a comprehensive, non-Partnership long term care insurance policy.

HOW MUCH DOES IT COST?
The cost of your premiums will depend on your age, and the policy and coverage options you choose. Whatever the cost, the premiums will not change based on changes in your health status or your advancing age.

HOW CAN I FIND OUT MORE ABOUT THE PARTNERSHIP POLICIES?

1. Ask your financial advisor, insurance agent, or call a participating insurance company.
2. Call the state's toll-free hotline for basic questions about the Partnership policies and find out which insurance companies offer them:

1-888-NYS-PLTC (697-7582): toll-free in New York State only
or (518) 473-8083 from anywhere. 3. Write:
New York State Partnership for Long-Term Care
NYS Department of Health
1 Commerce Plaza, Room 726
99 Washington Ave.
Albany, NY 12260
4. E-mail:
or e-mail: pltc@health.state.ny.us

HOW CAN I FIND OUT MORE ABOUT MEDICAID?
You can access theMedicaid Reference Guide at the NYS Department of Health Web Site. Call your local Department of Social Services (see Government Listings in the telephone directory blue pages or consult Access to County Government.) Learn more about the Partnership and Medicaid eligibility rules.

Getting More Information about the Partnership Program
You can get much of the information you need on the Partnership by browsing this web site. You can also download some program information you need. However, if you wish to receive a general information package which contains a program pamphlet, a Consumer Booklet, an informational document called Medicaid Eligibility and the Treatment of Income and Assets under the New York State Partnership for Long Term Care, and a list of participating insurance companies with their 800 numbers, you can:

1. Call the state's toll-free hotline (inside New York State) and leave your name and address:
1-888-NYSPLTC (697-7582) or call
(518) 473-8083 from anywhere and leave your name and address 2. Or write to request a package:
New York State Partnership for Long-Term Care
NYS Department of Health
1 Commerce Plaza, Room 726
99 Washington Ave.
Albany, NY 12260 3. E-mail:
or e-mail: pltc@health.state.ny.us

How to Purchase a Partnership Policy
The State office does not sell Partnership insurance. The State administers and monitors the Partnership program. If you wish to purchase a Partnership policy, please contact your financial advisor, insurance agent, insurance broker, and/or attorney. Currently, Partnership insurance is available from the participating insurance companies which are authorized by the New York State Department of Insurance to market and sell these policies.

Some Tips from the Partnership Office:

1. Be a smart consumer: Just as in making any major purchase, shop around and compare policies and prices based on your needs, where you live, and what you can afford to purchase.
2. Make sure the Partnership logo appears on your policy: All Partnership policies should have the Partnership logo on the front page of the insurance policy and other materials related to it.
3. Make sure you sign the Consumer Participation Agreement and keep your copy: When you purchase a Partnership policy, you are required to sign the Consumer Participation Agreement in order to be enrolled in the program. The Consumer Participation Agreement is a legal contract between you and the State of New York. The Partnership office in Delmar, NY receives the copy with your original signature; please keep your copy in a safe place.
4. Bookmark our web site and visit here often: We will announce program-related news and updates, legislation affecting the program, events, and more as the Partnership program evolves. Visit our WWW site regularly to keep yourself up-to-date about Partnership program developments and information.

Awards
The New York State Partnership for Long Term Care has won two national awards since 1994. These include:

The Ford Foundation/John F. Kennedy School of Government at Harvard University Innovations in State and Local Government Award (1994)

The Rutgers University National Center for Public Productivity Exemplary State and Local Award (1995)

The Partnership also has won two regional awards since 1994. These include:

The Council of State Governments Innovations Award (1994)

An Éclait Gold Award for Best Newsletter 1996 for The Partnership Press by The Hudson Valley Area Marketing Association

Questions & Answers

I am planning to move out of New York State. Can my Partnership policy cover me in other states?
Your Partnership policy has two components: a private insurance component (the first 3 years of nursing home care/6 years of home care) and the Medicaid Extended Coverage component. During the private component, you can use your policy wherever you choose (in accordance with the policy contract conditions).

Can I use Medicaid Extended Coverage in other states, including other Partnership states (Connecticut, Indiana, or California)?
At the present time and in the foreseeable future, to enjoy the benefits of lifetime long term care and asset protection under the New York State Partnership program's link with the Medicaid program, it is necessary to use the Medicaid Extended Coverage services in New York State.

I am planning to move to a non-Partnership state and have no plan to come back to New York. Is a Partnership policy good for me?
If you are planning to relocate out of New York State with no intention of returning, you would not be eligible for the Medicaid Extended Coverage afforded by your policy. Under these circumstances, you might want to consider buying a comprehensive non-Partnership policy. However, you should keep two important considerations in mind:
a) New Yorkers who become ill or disabled often return to New York State (even if they had no intention of doing so) for a variety of reasons, including the circumstance that they often have relatives in New York whom they wish to be near;

b) if you buy a non-Partnership policy, you must think about the issue of benefit duration. If you buy a traditional policy with a coverage term less than lifetime, you run the risk of paying out of pocket for any period of care beyond the coverage term. (For example, if you buy a 5-year coverage term and need a 7-year nursing home stay, you will be paying out of pocket for the last 2 years of care). Therefore, comprehensive long term care insurance coverage to protect you outside New York State would be a policy which includes a lifetime benefit duration, inflation protection and nursing home and home care benefits.

How can I tell if my insurance company is solvent?
All insurance companies who have filed to sell long-term care insurance in New York State must submit contract and fiscal information to the New York State Department of Insurance which thoroughly reviews policy filings and regulates the insurance industry. You can review the financial ratings of insurance companies by checking the evaluations of financial rating companies such as Moody's Investors Service, A.M. Best, Duff and Phelps Credit Rating Co., Standard and Poor's, and Weiss Research, Inc., to ascertain the financial viability of an insurance company. Publications of these companies may be found in the reference section of your public library.

I purchased a group long-term care insurance certificate through my company's group policy that is not a Partnership policy. Can I change it to a Partnership policy?
You must check with your benefits coordinator to see if a Partnership policy is one of the purchase or replacement options available to you under the group contract. If so, and if the Partnership policy is now being offered for the first time under the group plan, you will have an opportunity to convert to a Partnership policy. Your benefits coordinator is in the best position to provide details to you.

If a Partnership policy is not one of the purchase options available under the group contract, you cannot convert to a group Partnership policy. You might want to contact your benefits coordinator to ask about the future possibility of a Partnership policy offering under the group plan. You also might wish to contact your insurer about purchasing an individual Partnership policy. In general, however, you should not cancel any existing coverage you have before clarifying your situation and being approved for any new coverage for which you have applied.

As the owner of a Partnership insurance policy, am I able to receive care in any nursing home facility in New York State? In other words, do all nursing facilities accept Medicaid?
As a reminder, your insurance contract entitles you to use your private insurance benefits anywhere your contract permits, whether in New York State or elsewhere. That being said, it is important for you to know that a small number of nursing facilities in New York State do not accept Medicaid. These facilities accept only Medicare reimbursement and/or private payments, including private insurance. Consequently, while Partnership program participants may receive care in these facilities as Medicare/private pay/private insurance patients, Medicaid Extended Coverage will not be accepted as reimbursement for services in one of these facilities after the Partnership insurance coverage period ends.

In addition, there are a few New York State nursing facilities which only accept Medicaid, or only accept Medicare. The Medicare-only facilities do not accept private payments or Medicaid; the Medicaid-only facilities would not be able to accept private insurance payments from Partnership participants.

Therefore, it is important for Partnership program participants to be knowledgeable about such circumstances when choosing the nursing facilities in which they wish to receive care. In other words, it is recommended that you know beforehand which methods of payment and/or reimbursement are accepted by a particular nursing facility in order to make an informed decision about your care.

New York State Partnership for Long Term Care
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Medicare and Medicaid Long-Term Care Test Programs for The Aged
The text below was copied from the Medicare home page of the Centers for Medicare and Medicaid Services it can be found online at: http://www.medicare.gov/Nursing/Alternatives.asp

Social Health Maintenance Organizations (S/HMO)
A Social HMO is an organization that provides the full range of Medicare benefits offered by standard HMO's plus additional services which include care coordination, prescription drug benefits, chronic care benefits covering short term nursing home care, a full range of home and community based services such as homemaker, personal care services, adult day care, respite care, and medical transportation. Other services that may be provided include eyeglasses, hearing aids, and dental benefits. These plans offer the full range of medical benefits that are offered by standard HMO's plus chronic care/ extended care services. Membership offers other health benefits that are not provided through Medicare alone or most other senior health plans.

Current S/HMO Sites
There are currently four S/HMO's participating in Medicare and each S/HMO has eligibility criteria. These S/HMO plans are located in: Portland, Oregon; Long Beach, California; Brooklyn, New York; and Las Vegas, Nevada. Listed below are the four plans and the criteria for joining each plan.

* Kaiser Permanente, Portland Oregon
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Kaiser Permanente's S/HMO service area. The enrollee cannot have end-stage renal disease, or reside in an institutional setting. In order to receive the long-term care benefit, an expanded care resource coordinator will visit you at home to determine if you qualify for nursing home certification based on criteria established by the State of Oregon Senior and Disabled Services. These criteria may include needing daily ongoing assistance from another person with one of the following activities of daily living: walking or transferring indoors, eating, managing medications, controlling difficult or dangerous behavior, controlling your bowels or bladder, or the need for protection and supervision because of confusion or frailty.

* SCAN, Long Beach California
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in SCAN's service area. The enrollee cannot have end-stage renal disease. In addition, in order to receive extended home care services, members must have a Nursing Home Certificate which indicates that the members informal support system , such as a family member or care giver, is not sufficient to keep the member out of a nursing home.

* Elderplan, Brooklyn, New York
The enrollee must be 65 years of age or older, must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Elderplan's service area. The enrollee cannot have end-stage renal disease. In order to receive chronic care benefits, the enrollee must meet state nursing home certifiable criteria.

* Health Plan of Nevada, Las Vegas, Nevada
The enrollee must be at least 65 years of age, or may under 65 if they are disabled. The enrollee must have Medicare Part A and Part B, must continue to pay the Part B premium and must live in Health Plan of Nevada's service area. The enrollee cannot have end-stage renal disease. For the long-term care benefit, the beneficiary must meet certain criteria based on established medical, psychological, functional, and social criteria as well as needing to be medically necessary.

Your Cost
Each plan has different requirements for premiums. All plans have co-payments for certain services. To obtain cost and benefit information, please visit our Medicare Health Plan Compare tool for specific details. Before making any health plan decisions, you should contact the plan directly using the phone number listed in the site.

Program of All Inclusive Care for the Elderly (PACE)
PACE is unique. It is an optional benefit under both Medicare and Medicaid that focuses entirely on older people, who are frail enough to meet their State's standards for nursing home care. It features comprehensive medical and social services that can be provided at an adult day health center, home, and/or inpatient facilities. For most patients, the comprehensive service package permits them to continue living at home while receiving services, rather than be institutionalized. A team of doctors, nurses and other health professionals assess participant needs, develop care plans, and deliver all services which are integrated into a complete health care plan. PACE is available only in States which have chosen to offer PACE under Medicaid.

Eligibility
Eligible individuals who wish to participate must voluntarily enroll. PACE enrollees also must:

* Be at least 55 years of age.

* Live in the PACE service area.

* Be screened by a team of doctors, nurses, and other health professionals.

* Sign and agree to the terms of the enrollment agreements.

Services
PACE offers and manages all of the medical, social and rehabilitative services their enrollees need to preserve or restore their independence, to remain in their homes and communities, and to maintain their quality of life. The PACE service package must include all Medicare and Medicaid services provided by that State. At a minimum, there are an additional 16 services that a PACE organization must provide, e.g., social work, drugs, nursing facility care. Minimum services that must be provided in the PACE center include primary care services, social services, restorative therapies, personal care and supportive services, nutritional counseling, recreational therapy, and meals. When an enrollee is receiving adult day care services, these services also include meals and transportation. Services are available 24 hours a day, 7 days a week, 365 days a year.

Generally, these services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need. This includes such services as medical specialists, laboratory and other diagnostic services, hospital and nursing home care.

An enrollee's need is determined by PACE's medical team of care providers. PACE teams include:

* Primary care physicians and nurses.

* Physical, occupational, and recreational therapists.

* Social workers.

* Personal care attendants.

* Dietitians.

* Drivers.

Generally, the PACE team has daily contact with their enrollees. This helps them to detect subtle changes in their enrollee's condition and they can react quickly to changing medical, functional, and psycho-social problems.

Payment
PACE receives a fixed monthly payment per enrollee from Medicare and Medicaid. The amounts are the same during the contract year, regardless of the services an enrollee may need.

Persons enrolled in PACE also may have to pay a monthly premium, depending on their eligibility for Medicare and Medicaid.

Current Sites
There are 25 PACE sites and each site has about 200 enrollees. Limited new sites may be added each year. Sites are available in the following states. Select a state from the list below for a list of sites available in that state and the contact phone number and address for each site.

California

Colorado

Maryland

Massachusetts

Michigan

Missouri

New York

Ohio

Oregon

South Carolina

Tennessee

Texas

Washington

Wisconsin