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ObamaCare Clusterfuck: If you're 55+ and forced into Medicaid, capitation could mean you lose your estate even if you don't cost the government a dime in care

From another excellent Paul Craig Roberts article on the abomination of the estate recovery program:

Many states are choosing to move all or portions of their Medicaid populations to managed care plans. Thirty-five are expected to make changes to their managed care programs in 2014, up from 28 in 2013 and 20 in 2012. States jumping on the privatized-Medicaid bandwagon will mean more profit for corporations and less money allocated to patient care.

A Managed Care Plan is a system of health insurance which includes a network of contracted providers that are paid a fixed amount to provide health benefits to a defined population. Needless to say, this model relies on restriction and denial of care putting Medicaid patients at risk.

A Medicaid Managed Care Plan adds more charges subject to estate recovery for those who are tossed into Medicaid. The Medicaid Manual says that when an individual age 55 and older is enrolled either voluntarily or mandatorily in a managed care plan, the state must seek recovery from the individual’s estate for the premium payments. If the state plan recovers for all Medicaid services, the state must recover from the individual’s estate the total capitation rate for the period the beneficiary was enrolled in the managed care plan.

Check your own state to see if this could apply to you, but as the quotation points out, privatization means capitation, and Medicaid is increasingly privatized.

Yves has a longer post on the suck here, but I thought I'd call out this one point.

NOTE Needless to say, this only happens to you if you're poor.

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DailyPUMA's picture
Submitted by DailyPUMA on

I posted the following on N.C. but it is in moderation and probably won't make it out.

There is another side to this issue that relates to Medi-Caid versus Medi-Care. In home supportive services is supposed to assess/pay CareGivers, (many times a stay at home family member), a certain amount of hours per month to be an in home caregiver.

The big picture is paying a CareGiver anywhere from a hundred dollars up to 2,000 dollars a month (after taxes) is cheaper than assisted living that apparently costs between 5,000 to 7,500 dollars a month and probably offers inferior care for an elderly person who has suddenly been taken out of an environment they have lived in for many years.

For some bizarre reason the asset recovery aspect is pounded into the in home supportive services caregiver applicant even though it may not apply to them! For instance, if a person lives in the same home as the person they will be caregiving for, has been a caregiver for at least two years, and if their caregiving services are the only reason the parent is not in assisted living home, the asset recovery is supposed to be waived.

However, the waiver eligibility possibilities are never mentioned, but the asset recovery is. The combination of mentioning asset recovery and then assessing low hours scares people off from becoming a caregiver. The assisted living places, which apparently can't be sued for poor caregiving while getting paid top dollar (up to 3.5x times as much per month as a home caregiver would get) for what is presumably not as good services as a family caregiver could provide.

Once the parent is placed in assisted living, the charges are used by asset recovery to siphon the wealth out of the home in an accelerated fashion since they do charge up to 3.5 times as much as a in home caregiver would be paid. I have no idea if actual medical procedures are charged at full value.

As I fruitlessly navigate in home supportive services (it's been a three year path so far with no payment yet for my ongoing Caregiving services), I have now learned that they won't let my parent keep paying their 106 dollars a month for medicare. I think this is done so that they can begin to dismantle the amazing coverage my parent has, which included getting a pacemaker which may extend their life for many more years now.

Very scary stuff is going on in which it appears that health care is becoming privatized and then the government swoops in recoup the money they paid the insurance company via the assets of the elderly. Even scarier is the bullying being done to family members who would rather become a caregiver than send their parent off to assisted living but are scared off of in Home Supportive Services, which ironically might actually save EVERYBODY money while keeping the elderly's assets within the family.

As for this happening only if one is poor, keep in mind that some were not poor and only became eligible once they had exhausted their savings. So only the poor is not accurate, it can happen to anyone who had wealth and exhausted it.

Rainbow Girl's picture
Submitted by Rainbow Girl on

When you say: "I have now learned that they won't let my parent keep paying their 106 dollars a month for medicare." What reason are "they" giving, and who are "they"? This sounds absurd if the elderly person is currently on Medicare. This sounds like someone getting kicked out of Medicare into Medicaid. Where in Medicare laws does it say they can do this, if that is what is going on.

The situation sounds nightmarish. You are brave navigating these hoary waters and hope things resolve well.

DailyPUMA's picture
Submitted by DailyPUMA on

This sounds like someone getting kicked out of Medicare into Medicaid. Where in Medicare laws does it say they can do this, if that is what is going on.

The Medi-CAL rep who came to our residence was most concerned about getting us to sign documents. I will be appealing their two hour a day assessment and have spent the past several weeks attempting to fully document what I do and what our objections are.

Their assessment meant I would get zero dollars for being a full time CareGiver.

Yes, it looks like they are trying to shift my mother into medi-caid even as they assess a 600 dollar monthly "share of cost" to lower their own monthly liability.

DailyPUMA's picture
Submitted by DailyPUMA on

As was pointed out in the Roberts Article...

However, Federal law requires all states to incorporate the following protections for Medicaid recipients into the design of their estate recovery program:

— The State should notify Medicaid recipients about the estate recovery program during their initial application for Medicaid eligibility and annual re-determination process.
— The State must notify affected survivors about the initiation of estate recovery and give them an opportunity to claim an exemption based on hardship.
— The State must establish procedures and criteria to waive recovery if it would cause undue hardship.

Undue Hardship can include the loss of the home the CareGiver shares with the person they are CareGiving for.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Undue hardship as encompassing the potential loss of the home that the Care Giver shares with the elderly person. This means the ability to keep the home in the family and out of MERP's claws, right? This sounds practically humane - a shocker in this Medicare/Medicaid/ACA swamp of unrelenting cruelties.

I'd never heard about this but would not be surprised that HHS/CMS/White House would prefer that people not know about it because that would gum up MERP and reduce this vampiric rent stream.

DailyPUMA's picture
Submitted by DailyPUMA on

The problem is if I outlive my parent, I still have to report to asset recovery within thirty days of the passing and I may have to go to court and produce paperwork about hardship.

I don't understand why hardship can't be established ahead of time as long as I document the hardship aspect. I think assisted living lobbyists are pressuring the states to not mess with assisted care living payments and so the in home caregiver becomes the deer in the headlights even though home caregivers save the state money.

Unless the plan is to force parents in assisted living KNOWING the elderly would never live as long in assisted living as they would at home.

So the scam may be, push the elderly into assisted living through medicaid, thereby making the home asset up for grabs. Keep the elderly person alive long enough to suck out all the wealth of the home, then if something bad happens to the elderly, the assisted living facility can't be sued.

Alexa's picture
Submitted by Alexa on

blurb from a Pennsylvania (even if you don't reside there) elder law attorney, since he addresses federal statute.

The federal statute provides that a parent may transfer their primary residence to a child without causing an ineligibility period if the following is true: 1) That child resided in the property for at least two years prior to the parent entering a nursing care facility. 2) The child provided care for that parent that kept the parent out of the nursing home for at least the two years prior to entering the nursing home.

Legal Documentation: It is very important that proper documentation be made if this asset protection technique is used. The child to whom the gift will ultimately be made, should keep a log or journal that sets forth specific instances or events that but for the child’s care might have resulted in the parent’s institutionalization. These notations should include aspects of a parent’s behavior that would have necessitated full time nursing care. These might include gas or electric burners not being shut off, water left running in the tub or sink, or the parent wandering outside without being properly clothed and in a way that may be dangerous or medically harmful to him or her. . . .

Here's the link:

SPECIAL CAREGIVER EXCEPTIONTO SAVE THE HOME FROM NURSING CARE SPEND DOWN

I would also make sure that "Assisted Living Facilities" even come under this category.

There are many seniors who are able to even run around town with "escorts" from Assisted Living Facilities, because this group of residents are usually not in the same category (at all) as a resident of an actual "nursing home."

That is true in many states, anyway. Sometimes couples reside in them partly to be a part of "a community."

And to my knowledge, Medicaid does NOT pay for this type of facility--or at least not in some states.

The only people I know who've lived in these were relatively well-heeled, and paid the costs of the facility from their own resources.

One was a neighbor who was relatively well off, her only child had passed very prematurely, and she was widowed. She had a relatively minor heart condition and had a "knee-replacement" surgery. Otherwise, she was in decent health, and definitely sharp as a tack, mentally.

Of course, she went into the facility BEFORE the ACA was law.

So what applied to her, may or may not apply to someone, today.

Alexa's picture
Submitted by Alexa on

— The State should notify Medicaid recipients about the estate recovery program during their initial application for Medicaid eligibility and annual re-determination process.

but went on to name a state that did not do this (might have been Massachusetts?).

We've had a family member in exactly the same scenario, and found the "hardship exemption" process so onerous, they had to get an elder law attorney.

The Medicaid program in each state has a great deal of leeway, so what one state deems "hardship," another may not.

The entire point of "expanding" Medicaid by removing the "asset test" was to enable the US Government to loot more Americans.

Frankly, I would leave nothing to chance. I suppose some of my skepticism is due to my own years as a federal bureaucrat.

You learn real fast that if you don't know "exactly" the right question(s) to ask, you can put yourself at great risk.

:-)

Rainbow Girl's picture
Submitted by Rainbow Girl on

Well, perhaps if we establish that involuntary or unwitting Medicaid enrollees do, indeed, have an absolute right to refuse enrollment (or Dis=enroll - and yes, your point about it being so onerous that you have to hire a lawyer to do it is such a feature not a bug - disgusting) then we in the interspheres can simply do what we do, and make that point at all relevant opportunities. Eventually, maybe, MSM picks it up. Particularly the righter-wing and libertarian outlets who deal squarely with many of the offenses of ObamaCare/Medicaid (QED C. Roberts's anonymous source/writer.)

The butterfly effect seems to have originated here a few times already :)

Rainbow Girl's picture
Submitted by Rainbow Girl on

Apalling. This is an excellent read, as was the 2013 article.

One thing I'm confused about. When someone is deemed to fall into the poverty bracket sufficient to qualify for Medicaid, is that person able to say "No thanks. I'll pay the penalty, just like everyone else (in the non-Medicaid buckets) is able to do." Or is the mandate different for those qualifying for Medicaid, i.e., unlike everyone else, you can't extricate yourself from Medicaid by paying a penalty.

It's not clear from this article and I think it's an important point to clarify. If nothing else, so that persons who find themselves chucked into Medicaid can defend themselves and say "Whoa, hold on a minute. I don't want any and cancel me right now."

Alexa's picture
Submitted by Alexa on

but I "think" that one can disenroll.

Seems that they mentioned the possibility of one doing so when they are automatically and categorically enrolled by "program" association (SNAP), so to speak.

Problem is, will most of these people be informed of their "right" to do so?

And, if someone in this income category is critically and/or terminally ill, do they have a choice if they want to receive healthcare, now that the ACA is the law of the land?

Won't providers have the "right," now, to demand that every American citizen (foreign nationals exempted, since they cannot enroll in the ACA) present proof of insurance, or proof of the ability to pay cash, before extending health care? Good question.

I do believe that the Reagan-era law about extending health care in life-threatening situations (at ER) still pertains to some people--just not clear on who this pertains to.

I believe that this aspect of the law is murky--intentionally.

Rainbow Girl's picture
Submitted by Rainbow Girl on

On yet another dis-equality aspect of the US "public-private" system for so-called "healthcare."

"And, if someone in this income category is critically and/or terminally ill, do they have a choice if they want to receive healthcare, now that the ACA is the law of the land?"

If they've disenrolled from Medicaid and then get sick, seems to me they are in exactly the same position as the person who opted out of Exchange Care and paid a penalty. Both would go to an ER or hospital and be given care. But neither are enrolled in Medicaid. I wonder if there's a "gotcha" provision in Medicaid/ACA/OBRA that kicks in at that juncture. Presumably, the uninsured citizen who was "too rich for" Medicaid dukes it out with the ghouls at the hospital. Whereas the uninsured citizen was was "poor enough for" Medicaid -- what of him/her? Is there a law somewhere that once you've been given "free" care you are obligated (no optouts, no penalties in lieu, etc.) to enroll in Medicaid, which then pays the hospital but puts you on the hook for MERP?

As I write here, I realize how this scenario sure highlights -- also -- the strong incentives that hospitals providing care to the uninsured (assuming they didn't just shut the door in their face) have to turn into sleazy car loan salesmen and get that "free care moocher" onto Medicaid ASAP so *they* can bill and get paid -- and, conversely, to ensure that the poor citizen is none the wiser other than being pressured to "just sign these forms" in a 3 second window.

Alexa's picture
Submitted by Alexa on

the strong incentives that hospitals providing care to the uninsured (assuming they didn't just shut the door in their face) have to turn into sleazy car loan salesmen and get that "free care moocher" onto Medicaid ASAP so *they* can bill and get paid -- and, conversely, to ensure that the poor citizen is none the wiser other than being pressured to "just sign these forms" in a 3 second window.

is a possibility under the ACA. (not that I KNOW that it is)

From all that I've read here (and at other blogs and in the mainstream media), it sure seems plausible to me.

Not long ago I saw "somewhere," (think it was here) that hospitals are beginning to demand relatively hefty up-front "deposits" upon admission. (Some may have in the past, but the gist of the article was the increase in numbers which do, and the amount of prepayment required.)

If this is true, what does someone with little or no (financial) resources and very low income, do?

Would be curious to find out if anyone knows if hospitals are now equipped with computer (insurance) programs which allow them to determine if prospective patients are Medicaid-eligible, at the drop of a hat (IOW, even after hours, when the insurance department is closed).

Somehow, I find it hard to believe that people who "refuse" to insure themselves--UNLESS they receive a bona fide 'hardship exemption"--especially those who would qualify for a government provide at little or no cost, will be "allowed" to get ER Room Care under the Reagan-era law.

After all, if that were the case--"what would be the point of the "Individual Mandate?"

As I understand it, the point of enacting the individual mandate was to avoid uncompensated ER Room costs which are passed on to taxpayers and various government entities. (And/or written-off by providers.)

I really have a sinking feeling that except for those people allowed to be exempt by law for various reasons--lack of US citizenship, felons, religious exemptions, etc., the "ER Room Law" may no longer apply to those persons who deliberately "opt out" of insurance coverage.

(Not that I concur with this, just that I'm imagining that the neoliberal mindset would view it this way.)

I sure wish I could ask the author of these two excellent articles, this question--it is such a "key issue" in the healthcare law debate.

Alexa's picture
Submitted by Alexa on

What care does Medicare not cover?

Medicare does not cover custodial care, which may be required for longer periods of time following a hospitalization.

This is the type of care required when beneficiaries need assistance with daily activities, such as getting in and out of bed, dressing, bathing, eating, or using the bathroom.

This care is often given in a nursing home facility, but Medicare will not cover it.

(This sounds like what we were told by "nursing home" staff. This would not apply to an elderly person in a SNF, sometimes part of a "nursing home," who is undergoing physical therapy, and is expected to return home, or not remain institutionalized.)

DailyPUMA's picture
Submitted by DailyPUMA on

Medi-Caid can cover it if the elderly person does not make "too much" from social security every month by paying an in home supportive services CareGiver. However there is a limit of around 250 hours a month.

If the CareGiver lives in the home, has been keeping the person they caregiver for out of an instituiton for at least two years, and would face hardship if the home were sold to pay Caregiver bills, asset recovery is not supposed to kick in, otherwise the caregiver may also have to give back whatever they were paid!

Alexa's picture
Submitted by Alexa on

Estate Recovery and Liens

State Medicaid programs must recover certain Medicaid benefits paid on behalf of a Medicaid enrollee. For individuals age 55 or older, states are required to seek recovery of payments from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services. States have the option to recover payments for all other Medicaid services provided to these individuals, except Medicare cost-sharing paid on behalf of Medicare Savings Program beneficiaries.

Under certain conditions, money remaining in a trust after a Medicaid enrollee has passed away may be used to reimburse Medicaid. States may not recover from the estate of a deceased Medicaid enrollee who is survived by a spouse, child under age 21, or blind or disabled child of any age. States are also required to establish procedures for waiving estate recovery when recovery would cause an undue hardship.

States may impose liens for Medicaid benefits incorrectly paid pursuant to a court judgment. States may also impose liens on real property during the lifetime of a Medicaid enrollee who is permanently institutionalized, except when one of the following individuals resides in the home: the spouse, child under age 21, blind or disabled child of any age, or sibling who has an equity interest in the home. The states must remove the lien when the Medicaid enrollee is discharged from the facility and returns home.

Definitely sounds like the exemption that you are seeking is granted by state statute or law, since this specific category--aside from "hardship"--is not mentioned at Medicaid.gov. (Unless you are a minor, blind or disabled adult child.)

A quick 'Google' shows that some states (which grant this exemption) go by the "2-year" rule. However, the state of Texas has/had a "1-year" rule.

I'm "guessing" that you may not be able to be granted an exemption "in advance" since this criterion seems to be a state-to-state one (not federally-mandated), and is granted at the whim of your state legislature, or state HHS, or both.

IOW, the criteria could change, as a state's fiscal condition or needs change.

The ACA appears to have changed several aspects of our public health programs. It would probably behoove you to carefully monitor the MERP in your state. I imagine that as the ACA is "reformed or amended," state MERPs may also be amended.