Financial Eligibility

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1 MassHealth Long Term Care Jan Stiefel, J.D. Community Legal Aid Financial Eligibility A. Assets: $2,000 limit 1. Excess assets may be offset by outstanding medical bills 2. Inaccessible assets: additional time to seek appointment of conservator 3. Non-countable assets (ex. burial account $1,500 or less/burial contract of any amount) 4. The home is non-countable, if equity interest less than $858,000 2

2 Penalty for transfer of assets B. Penalty for Transfers 1. Look back period: 5 years 2. Penalty start date for transfers 3. Penalty is calculated at $354/day; $10,620 for 30-day month 3 Penalty for transfer of assets 4. A transfer penalty can be cured 5. A transfer penalty may be waived a. If ineligibility will cause nursing home resident undue hardship b. Nursing facility must notify resident of its intent to initiate a discharge due to nonpayment for stay 4

3 Permissible transfers C. Permissible transfers 1. Spouse to spouse (of all assets) 2. Caretaker child residing in elder s home 2 years, child under age 21, sibling residing in home at least 1 year with interest in home (of primary residence) 3. Disabled child of any age (of all assets) 4. Pooled trust for nursing home resident 5. Pooled, special needs trust for permanently disabled child and/or disabled person under 65 when trust created 5 Income D. Income 1. One month deductible/spenddown E. Deductions from income 1. Personal needs allowance (PNA) of $ Minimum monthly maintenance needs allowance (MMMNA) for spouse in community 6

4 Deductions from Income 3. Family maintenance needs deduction for minor child or dependent child, parent and/or sibling 4. Home maintenance allowance 5. Health insurance 6. Medical/remedial expenses incurred and not covered (ex. dental) 7 Medical Eligibility F. Medical eligibility 1. ASAP medical assessment of need for nursing home care 2. Short versus long term admission 3. Score Three level of care criteria 8

5 Rights of Community Spouses G. Rights of community spouse 1. Asset assessment (snapshot) on date of nursing home admission 2. Community Spouse Resource Allowance (CSRA) 9 Rights of Community Spouses a. First $123,600 deemed to community spouse; b. Minimum monthly maintenance needs allowance: (MMMNA)$2,030/month minimum and $3,090/month maximum c. Can be increased by appeal 10

6 Liens and Estate Recovery H. Liens 1. Notice lien is placed on home of resident not reasonably expected to return home unless: 2. Exceptions to lien placement 11 Liens and Estate Recovery I. Estate recovery 1. Estate recovery unit will file claim against an estate for reimbursement of all payment made by MassHealth on behalf of resident a. for all services provided while member was 55 or older; and b. on or after March 22, 1991, regardless of age, if client is institutionalized and could not be reasonably expected to return home 12

7 Liens and Estate Recovery 2. Sale of home post lien 3. Exceptions to estate recovery 4. Deferral of or waiver of estate recovery 13 Transfers and Discharges J. Transfers and Discharges 1. Transfer of resident between beds with different certifications or discharge to another facility or to the community trigger right to appeal a. Requirement of written 30-day notice specifying location to which resident is to be transferred/discharged 14

8 b. Permissible grounds for transfer/discharge: care i. Resident requires higher level of ii. Resident s health improved and no longer needs level of care provided 15 iii. Safety/health of other individuals in facility endangered iv. Non-payment v. Facility going out of business 16

9 Transfers and Discharges 2. Can only appeal transfers between beds within same facility with same certification to medical director of facility new state law limits rights previously afforded by regulations pursuant to Consumer Protection Act (93A) 17 Bed Holds in Facility 3. Bed Hold a. 10 days per hospitalization b. 10 days per 12-month period for nonmedical leave 18

10 Transfers and Discharges 4. Transfer to hospital triggers right to be re-admitted (Brunelle case) a. Must re-admit to same bed if within bedhold period b. Must re-admit to first available bed in semiprivate room if beyond bedhold period c. Refusal to re-admit considered discharge/transfer to which appeal rights apply 19 Appeals Fair Hearing K. Appeals 1. Applicants and recipients have right to appeal any appealable claim 2. Actions denying, reducing, suspending, terminating, recovering, or restricting assistance 3. Coercive or otherwise improper conduct by a MassHealth employee 20

11 Appeals Fair Hearings 4. Division of Hearings must provide an adequate and timely written notice of any appealable decision 5. Determine the legal basis of the appeal 6. Complete the appeal form, including all information and statement of disagreement with the action 21 Appeals Fair Hearings 7. Request an interpreter if needed and 8. Request expedited hearing if appellant is not receiving benefits 9. Designate Authorized Representative if desired 22

12 Appeals Fair Hearings 10. Appeal must be received by the Office of Medicaid Board of Hearings no later than thirty days from receipt of the notice day appeal limit for continuing benefits 23 Appeals Fair Hearings 12. Rescheduling for specified good cause 13. Grounds for dismissal 24

13 Appeals Fair Hearings L. Fair hearings 1. Right to examine and copy file 2. Pre-hearing resolution 3. Hearing preparation 25 Appeals Fair Hearings 4. Hearing conducted by impartial and independent hearing officer 5. Submission of evidence 6. Decision within 45 days if deciding on an application; 90 days otherwise 26

14 Appeals Fair Hearings 7. Appellant may request a rehearing (within 14 days) or 8. Appeal adverse decision to Superior Court under Massachusetts General Laws, chapter 30A, within 30 days of decision 27 Rest Homes M. Rest homes 1. EAEDC payment for care a. Income less than rest home payment b. Asset limit $250 c. PNA $

15 Rest Homes 2. SSI payment for care a. Income less than $1,028 (SSI payment amount) b. Asset limits same as MassHealth c. PNA $

Financial Eligibility

MassHealth Long Term Care Jan Stiefel, J.D. Community Legal Aid Financial Eligibility A. Assets: $2,000 limit 1. Excess assets may be offset by outstanding medical bills 2. Inaccessible assets: additional