Medicare / Medicaid

Gary Alexander, the Corbett administration official who oversees Medicaid, took a trip to Capitol Hill in December to testify on one of the most divisive issues in the country, the Affordable Care Act.  Speaking to federal legislators, he noted that Pennsylvania will delay its decision about expanding Medicaid for adults until they have the flexibility to create a program that increases affordable and cost-effective coverage.  Alexander cited "hundreds" of federal mandates that will cost money and manpower that he believes Pennsylvania does not currently have.  Alexander said the Affordable Care Act was a way for the government to micromanage the states, claiming that "We in the commonwealth have never witnessed a law so vast with such demands on state resources, and lack of federal guidance."

The hearing, in which Alexander was joined by counterparts from Louisiana and Wisconsin, was centered on Obama's plan to allow states to expand Medicaid eligibility.  All three blasted the law and its costs.  The federal government will pick up all coverage costs to start, and 90% of the tab from 2020 forward.  While Democrats say the plan will help states provide coverage to the many uninsured people with relatively low costs, Republicans say that ten percent of a huge number is still a very large number.  And given the persistent federal deficits, Corbett questioned whether Washington will be able to keep its promise.

There wasn't just negativity at the hearing.  Praise could be heard from officials from the Obama administration, Maryland and Arkansas for the expansion and its ability to offer help to people without health coverage.  Maryland Health Secretary Joshua Sharfstein said his state is projected to save nearly $2 billion because of the expansion.

Expanding Medicaid in Pennsylvania would help an estimated 542,000 new Pennsylvanians enroll, at a cost of an additional $2 to $4 billion.  By the state fiscal year 2020-2021, the estimated cost will be $883 million.  According to a study by the nonpartisan Kaiser Foundation, the federal government would pay an additional $37.8 billion over the next decade to help cover Pennsylvanians.  The expansion from the Affordable Care Act will cause for more than 40 percent of the population on a federal healthcare program, a number about the size of the total employment number in Pennsylvania.

Also at the hearing, Alexander faced sharp questions about why 89,000 children were dropped off Medicaid between August 2011 and January.  Alexander responded, saying the review was to make sure only those who are eligible were enrolled and noting that those removed were allowed to reapply.

For Alexander's full report, click here.

UPDATE: Pennsylvania still remains undecided, but other states have made their decisions.  Check out this map below for the Medicaid Expansion decisions as of January 3, 2013.

In light of the recent tragedy at Sandy Hook Elementary, people are done blaming guns and starting to talk about mental illness.  As Liza Long points out in her article that went viral, "I am Adam Lanza's Mother" (read it here), that there are very few options for people with mental illnesses.  In fact, the only option they really have is to go to prison for people to start paying attention.

This lack of options, some people say, is because of government programs, like Medicaid (known as Medical Assistance in Pennsylvania).  But services for the non-poor mentally ill patients have been hit hard by the recession, and after the Supreme Court struck the mandate requiring states to expand Medicaid programs, people are worried that the Medicaid system will suffer further cuts.  These cuts cause a decrease in coverage or providers and longer waits for appointments, which in turn causes patients to be less likely to seek the help they need.

However, in light of recent events, lawmakers are making mental health services a priority to stop future tragedies.  We have to discuss the mental health aspect and find ways to provide care for the mentally unhealthy.  We can only hope that the Medical Assistance will work to cover the mentally ill, giving them options so prison is not the solution of choice and to keep everyone safe.

Whether you have hours, weeks, or months to find a nursing home for an elderly loved one, the task is going to be daunting.  But this will be the task for a majority of the population, as two-thirds of people over 65 will need the care given by a nursing home, according to AARP.  Just as you wouldn't move into a new house without visiting and inspecting it, you should do research on nursing facilities ahead of time if possible.  And when researching, there are several key considerations you should take.

First, look at the official stats.  Medicare rates and compares nursing homes on their website (medicare.gov/nhcompare).  Some facilities are even certified by Medicare, meaning they are inspected every year and all complaints are investigated.  Read these ratings and recent inspection reports, but don't just take them at face value.  Check out the ratings for health inspections and for staffing and see if you can find why they rank as they do.  What are the citations for and how often do they occur?  One patient accident isn't a big deal, but frequent falls could be a red flag.  If you want more opinions on the nursing home, your local Area Agency on Aging (the Lancaster County Office of Aging) or a hospital discharge planner can give you referrals on nursing homes.  Furthermore, the state's ombudsman and licensing agency should be able to tell you about consumer complaints.

Check to see how staffing is at the nursing home.  How much time are residents receiving with the nurses?  The Centers for Medicare and Medicaid Services (CMS) recommends at least 2.8 hours a day of nursing aide time and 1.3 hours with an RN or licensed practical nurse.  Ask specific questions of the staff and about care, ask how personal preferences are accommodated.  Also see whether staff work with the same patients each day because when staffers know the patients better, the quality of care is higher.  Finally, make sure to ask how the staff will deal with an unexpected event, like a power loss or a situation which requires evacuation.

Visit the nursing homes you are considering, and visit more than once.  Observe lifestyle details, like do the nurses greet patients in the hall?  Are meal eaten in the dining room and are residents enjoying the meal?  Does it smell pleasant and homey and are residents smiling?  Check rooms for cheerfulness and safety, use the bathroom to check for hot water, and inspect the kitchen for cleanliness.   Ask about anything that could affect the well being and happiness of your loved one, like are there organized outings and visits?  What activities are listed on the bulletin board?  Are there stimulating offerings like exercise classes and a library?  Snoop around (and be wary of any place that objects) and try visiting unannounced on a weekend when staffing is likely to be tighter.

Another important consideration is how close the nursing home is to you.  The biggest influence on care quality is the frequency of visits by friends and family.  Make sure you're allowed to visit when you want to fit your schedule, and to monitor care at different times.  Drop by often and sometimes without notice.  Stay late sometimes after your loved one has fallen asleep.  By coming at different times, you can see how quickly a staff member respondes to a ring for assistance, whether residents are enjoying interesting activities together in the afternoon or staying cooped up in their rooms and how much your mom or dad eats at meals.

One of the biggest factors in your decision will be cost.  The median annual rate for a semi-private room in Pennsylvania last year was $89,425.  If the move is years away, consider getting long-term care insurance.  If your loved one already has long term care insurance, find out the daily rate it covers.  This could be far less than your preferred homes and most policies don't kick in until after a 60 or 90 day "elimination period."  To keep costs down, determine if it's possible to keep your loved one at home a bit longer through a combination of health aides, adult day care, and family help.  You can also consult an elder law attorney for help with nursing home planning.  The Law Office of Shawn Pierson can help with the planning and can help get you qualified for Medicaid, known as Medical Assistance in Pennsylvania.  However, not all facilities accept Medical Assistance, so make sure your preferred facilities accept payment or else you might have to move when payments switch.

If you find that your loved one is not receiving the care he or she deserves, don't hesitate to move him or her.

For more ideas on what to look for in a nursing home or long term care facility, use the checklist found here by AARP.

In our latest e-newsletter, there was an article titled "Son Liable for Mom's $93,000 Nursing Home Bill Under 'Filial Responsibility' Law."  The same day our newsletter went out, local attorney Patti Spencer had an article in the Lancaster newspaper regarding the same topic, that a son was responsible for his mother's nursing home bill.  Because of these, we've had some questions regarding filial responsibility, namely what is it and what does it mean?  Well, here's a quick run down on what Pennsylvania's filial responsibility law entails.

Pennsylvania, as well as 29 other states, has a filial responsibility law.  Although these laws vary from state to state, they all say generally the same thing; they require adult children to provide financial support for their indigent or poor parents.  In Pennsylvania, not only do the children have the responsibility of maintaining their mother or father, but the spouse of and the parents of the indigent person hold the responsibility as well.  Caring for a person also includes financially assisting him or her, however there is an exception in the case that an individual does not have the ability to support the person financially.  Additionally, A child shall not be liable for the support of “a parent who abandoned the child and persisted in the abandonment for a period of ten years during the child's minority,” meaning a child who was abandoned for 10 years while under the age of 18 is not responsible for his or her parents' care.

In order for the filial responsibility law to be enforced, a civil lawsuit must be filed to get court-ordered judgment. The amount of the liability will then be determined by the judgment from the lawsuit.  Civil action may be taken by the indigent person or any other person, public body or agency who has interest in the care and well-being of the indigent person.  Most commonly, it is the nursing home who takes civil action.

If you are found liable and fail to comply with the order, the court will schedule a contempt hearing.  If the court determines that the individual found liable has intentionally failed to comply with the order, that individual could face 6 months of jail time.

In the past 30 years, there have been only 3 cases discussing the filial responsibility law.  However, in wake of the recession and budget woes affecting state-funded nursing home programs, nursing homes and other care facilities may turn to filial law to recover the lost funding.  You can protect yourself and your parents now through estate planning, long-term care insurance and knowing home Medical Assistance works.  Legal action for filial responsibility isn't all that common now, but the trend may change.  If you are at all concerned about this, or have more questions, call our office at (717) 560-4966 or email us at questions@piersonelderlaw.com and we will be more than happy to help.

Want to read more?  You can find our newsletter article here or the article by Patti Spencer here.  Additionally, to read the current Pennsylvania statute on filial responsibility, click here.

The current age for Medicare eligibility is 65 and has been 65 ever since the program was created.  However, there are currently debates over raising it in two month increments each year until 2027, when the eligibility age will reach 67.  According to a report released by the Congressional Budget Office (which can be found here) this would reduce the federal budget deficit by $148 billion over the next 10 years.  Compared to the $15 trillion of government debt, it's not a whole lot, but it is definitely quite a bit of money.

However, the cost for the 65- and 66-year-olds, their employers, and the states would be $220 billion, quite a bit more than the savings by the government.  Additionally, an estimated 25% of 65- and 66-year-olds would find themselves uninsured.  So is this really a good idea?

There are arguments for both sides.  As seen, the total costs in the long run would be higher, but it would lower the federal budget deficit, which at $15 trillion needs to happen.  It could also encourage more people to work and to keep their job until they're older so that they still have health insurance, however the CBO expects this effect to be small.  Still, this can contribute to a more thriving economy, but would also give college graduates a harder time finding a job as people are taking longer to retire and less replacements are needed in the work force.  Medicare premiums might go up because the program would lose its healthiest beneficiares (the 65- and 66-year-olds) and private insurers would suddenly be getting more older beneficiaries, increasing their premiums as well.  And not everyone would be able to turn to private insurance; an estimated 5 percent would become uninsured.

There are obviously other effects and considerations as well, including changing the early eligibility age and the full retirment age.  I really recommend that you read the full report from the Congressional Budget Office yourself as it includes a lot of good information as well as different scenarios.  I do, however, leave you with this thought, should we decrease the federal budget deficit or should we guarantee that our 65- and 66-year-olds are insured?  Both decisions affect our future.