Many people confuse Medicare and Medicaid and most seniors assume that Medicare covers long term care costs. Unfortunately that is generally not the case.
Most individuals who have reached the age of 65 are eligible for Medicare coverage and there is automatic enrollment for Part A for those who are receiving Social Security at age 65. There are several parts to Medicare: Part A (hospitalization), Part B (major medical), Part C (HMOs) and Part D (pharmaceutical coverage).
Part A is the basic Medicare hospital insurance. For most individuals there is no premium for this coverage. It covers inpatient care in hospitals, skilled nursing facilities, hospice and home health care. However, it only covers skilled care, not assistance with basic activities of daily living or supervision, known as custodial care. It is this custodial care that comprises the essence of long term care and is not covered by Medicare or other health insurance.
Advocacy for the patient is essential to maximize coverage under the Medicare program. For example, a common pitfall is where a patient’s rehabilitation stay is not authorized because their three day hospital stay was not considered an admission as the patient was merely on “observation status.” Another situation our clients commonly face is termination of rehabilitation coverage for “failure to progress” despite a recent class action lawsuit prohibiting such action.
We educate and advocate for our clients facing these and other Medicare coverage issues. We also provide advice on when seniors should enroll in Part B and choosing between traditional Medicare and Part C Advantage plans.
Many people are confused about which public benefits they are eligible to receive and how those benefits work. Medicaid may be one of these benefits and we are experienced at working with clients to navigate the Medicaid system.
Medicaid is a needs-based, means-tested program originally conceived as a way to provide health care for the poor. Over the years it has come to be a major payer of long-term care costs for the middle class.
Payment of long-term care costs is one of biggest medical expenses that anyone will ever pay. Many individuals find that they cannot afford to pay on their own and need to explore Medicaid. Without sound advice, seniors often make costly mistakes – either by taking actions which inadvertently result in penalties or delayed eligibility or by not preserving assets and maximizing income legally. We help our clients plan for and apply for Medicaid guiding them through the complex rules and policies so they get the benefits they need while protecting their families to the greatest extent possible.
New Jersey Medicaid has gone through dramatic change in the last couple of years. Until recently, Medicaid had an income cap for home care and assisted living eligibility of about $2,200 per month. However, over the last two years several programs were merged so that now there is effectively no income cap for those needing long term care. With the exception of certain exempt resources, assets in excess of $2,000 have to be spent or otherwise be unavailable at the time of application in order for an individual to be eligible for Medicaid. There are opportunities to preserve assets and maximize income for spouses and other family members, but it is dangerous for families to make their way through the minefields of Medicaid regulations, policies and caselaw without experienced and knowledgeable counsel.
We guide our clients through this complex process. Under Managed Long Term Support & Services (MLTSS), there is also a new medical screening. This is another important opportunity for advocacy as the screening determines eligibility as well as number of hours and services for applicants at home.
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