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RANDY SAYS: A CALIFORNIA ELDER LAW BLOG


RESIDENTIAL CARE FACILITIES AND SSI

MEDICARE AND SKILLED NURSING IN LONG-TERM



RESIDENTIAL CARE FACILITIES AND SSI


The bulk of this article deals with Medi-Cal eligibility in a skilled nursing facility (SNF). Medi-Cal typically does not pay for a residential care facility for the elderly (RCFE).

There is, however, a program called Supplemental Security Income (SSI) that can impact payment in a RCFE.

SSI is a federal/state program which guarantees a level of minimum income to those aged 65 and above, blind or disabled, and who satisfy the resource and income requirements.

If a low income person, who is receiving SSI, lives in an RCFE, then California has put legal limits on what the facility can charge.

As of 2014, RCFE residents can receive a maximum of $ 1,133 per month from SSI. Such a person would keep his or her needs allowance of $130 per month and pay the RCFE $1,003.

What limitations does California law place on what the RCFE can charge the SSI recipient?
* The RCFE cannot charge more than the SSI monthly rate.
* Once an RCFE resident qualifies for SSI, the RCFE cannot charge more than the SSI monthly rate.
* While the RCFE may accept "voluntary" contributions from family members, the RCFE cannot charge more than the SSI monthly rate if the "voluntary" donations ever stop.
* The RCFE cannot evict a resident who become eligible for SSI and subsequently pays the SSI monthly rate.
* The RCFE is forbidden from asking or requiring a resident to waive his or her rights to receive SSI.

MEDICARE AND SKILLED NURSING IN LONG-TERM

If we think of life as a "terminal" condition, we are left with two basic conclusions: We will all die, and some of us will get very sick before we die. Our loved ones who get very sick often face financial destitution due to the high costs of long term "custodial" care in a "skilled" nursing facility (SNF).

There are really only four ways to pay SNF costs: Medicare, Medi-Cal, private pay, and long-term care insurance.

Medicare and supplemental policies will pay for "skilled" or rehab care in a SNF for up to 100 days (assuming a consecutive three day prior stay in a hospital for the condition). Few people have long-term care insurance, and if they do it often does not pay the full costs of the SNF.

At $8,000 to $12,000 a month, private pay takes most of us only so far before we are broke. Consequently, most patients in long-term "custodial" care in a SNF end up on Medi-Cal.

Medicare is federally funded health insurance for the elderly and disabled. As such, it has no income or resource requirements to meet. If you are 65, or if your disability meets certain criteria, you will qualify for Medicare. Most people also secure supplemental insurance to help pay for Medicare deductibles and co-pays.

Medicare coverage in a SNF is limited to ""skilled"" (versus "custodial") nursing or rehab services. Most of us don't get the full 100 days coverage because when we "plateau" or cease improving, care becomes "custodial" not rehab.

A recent court settlement has eliminated the necessity to show continued improvement in order to get continued rehab services. Under a case called Jimmo v. Sebelius, it is only necessary to show that continued rehab services are necessary to maintain the current condition or prevent deterioration.

If you are in a SNF getting Medicare rehab services, and someone tells you that your Medicare rehab will end before the 100 day period is up, do this:

1.Google "Jimmo v. Sebelius Summary" access the Settlement Agreement Fact Sheet, and make a copy of it.

2.Take the copy of the Fact Sheet to the SNF administrator who told you your Medicare rehab services were about to end.

3.Give them the Fact Sheet and cite the following quoted language from the Fact Sheet ... "when "skilled" services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration".

If you still need "skilled" Nursing Care to maintain your condition, or to prevent your condition from deteriorating, you should get the full 100 days!

 


 
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