Medicare, Medicaid, and a myriad of other long term care assistance programs have been enacted piecemeal over a number of years and have thus created a confusing patchwork of programs and eligibility categories. Add the various programs initiated by the states, and the numerous for profit and non-profit organizations that offer assistance and funding, and you have a system that is extremely fragmented, overlapping, and difficult to navigate.

That said, the government (state and federal) pays for more than half of the cost of long term care in this country. Medicare and Medicaid are the primary programs covering long term care, with Medicaid carrying the bulk of the load, especially when it comes to nursing home care. Medicare - the federal program funded largely by payroll taxes - plays a substantial role in funding skilled home health services, but does not cover assistance with ADLs such as dressing, bathing, toileting and eating. At roughly 13%, Medicare is a much larger payer of long term nursing home care than most people realize. Despite the fact that Medicaid has a strong institutional bias, it does – to a lesser extent - cover home health services for the financially needy.

Michigan funds some non-medical home care services for the financially and medically needy through its Home Help Program (administered by the Department of Health Services (DHS)) and the Older Americans Act and Older Michiganians Act (federal and state funded programs administered by the Area Agencies on Aging). The Veterans Administration also offers long term care benefits for veterans. The following is a summary of Medicare and Medicaid coverage for nursing home and in-home care.

MEDICARE

Medicare is the national health insurance program that covers your health care needs if you are at least 65 years of age (or younger and deemed “disabled”). Medicare may pay for help with ADLs (sometimes called “personal services”) such bathing and dressing if you require skilled nursing home care, but will not pay for such services if skilled care is not required, and does not cover help with IADLs (such as housekeeping and shopping) under any circumstances.

MEDICARE: NURSING HOME CARE

Medicare nursing home coverage is limited to skilled care in a Medicare certified facility for up to 100 days. The first twenty days are covered in full; Medicare covers days 21 through 100 to the extent the cost exceeds $114 per day.

To be covered:

• The nursing home stay must follow (within 30 days) a hospital stay of at least three consecutive days;
• The treatment received in the nursing home must be related to the hospital stay; and
• A physician must certify that skilled nursing or rehabilitative services are required on a daily basis.

During your 100-day stay, the nursing home is required to regularly review your condition to determine if you still need skilled care on a daily basis. If at any time during your first 100 days you no longer need skilled care, Medicare will terminate coverage. In that case, the nursing home must give you a written notice explaining its decision to terminate coverage and explaining your appeal rights.

See Chapter Five for a detailed discussion of Medicare nursing home coverage. Answers to your Medicare questions are available from Michigan’s Medicare Medicaid Assistance Program (MMAP), described below.

MEDICARE: IN-HOME CARE

Medicare is the primary provider of in-home skilled nursing care and other home health services for rehabilitative purposes. Home health care is covered under Medicare Part A if:

• It is prescribed by a physician;
• The services are provided by a Medicare certified home health agency (HHA);
• It follows a hospital stay of at least three consecutive days;
• The home health services are commenced within 14 days of the hospital discharge;
• It involves part time or intermittent (less than 8 hours/day, 28 hours/week) skilled nursing care, home health aide, or therapy; and
• The patient is homebound.

As with nursing home coverage, Medicare covers home care only for so long as it is determined that you need skilled services on a daily basis. Once you are eligible, the HHA bills Medicare directly much the same way as doctors bill Medicare for their services. Be careful to choose a Medicare certified home health care agency since they are the only ones eligible to receive Medicare payments. Many families find the homebound restriction burdensome since they can’t take their elder anywhere, but it’s the price for Medicare paying the home healthcare bill. Agencies that don’t take the homebound restrictions seriously can be targeted for fraud or abuse. Medicare covers only part-time home health services, not personal care, assistance with meals, or transportation.

Unfortunately, in recent years, Medicare has limited the amount of reimbursement allocated to home care. Medicare home health visits per user declined in every state between 1993 and 2002. During this same period, the average number of Medicare home visits in the U.S. declined by 47%.

Excellent information about Medicare home health care, including denials of coverage, is available from the Center for Medicare Advocacy: http://www.medicareadvocacy.org

Currently, Michigan does not license HHAs, but Medicare certified home health agencies are listed on http://www.medicare.gov (click on “Home Health Compare”) by state, county, and ZIP code.

Your hospital discharge planner or private geriatric care manager should be able to recommend a Medicare certified HHA in your area. You may check out the quality of an HHA through the Joint Commission of Accreditation of Heath-care Organizations at http://www.jcaho.org
Community Health Accreditation Program (800) 656-9656 http://www.chapinc.org; and the
National Association of Home Care http://www.nahc.org

MEDICAID

Medicaid is the government health program for the financially and medically needy. It provides long term care services to elderly and non-elderly persons with disabilities. Medicaid is basically a welfare benefit administered by the state that is federally overseen. The Michigan Department of Community Health (MDCH) runs Michigan’s Medicaid program, with the Department of Health Services (DHS) handling applications and making financial eligibility determinations. Michigan funds approximately 43% of the Medicaid budget with the federal government kicking in the remaining 57%. Medicaid began paying for nursing home costs in 1965.

MEDICAID: NURSING HOME CARE

Nationally, nearly 60% of those in nursing homes have Medicaid as their primary source of payment. Medicaid pays at least part of the bill for two out of every three nursing home residents. Of total national spending on long-term care, Medicaid accounted for 43% of spending.

In 2002, Michigan ranked 10th in the county with 41,547 nursing facility residents, 66.5 percent of whom had Medicaid as their primary payer (ranking 22nd in the county) with only 14.3 percent having Medicare as the primary payer (ranked 7th in the country).

Medicaid pays for the cost of your nursing home care if:

• You at least age 65;
• You are found medically eligible under the state’s Nursing Facility Level   of Care Criteria
• The nursing home is Medicaid certified; and
• You meet the strict income and asset tests described in Chapter Five.

Once eligible, Medicaid will pay for the full cost of your nursing home care over and above your patient pay amount (basically, all of your income, less allowance for Medicare premiums and a possible spousal stipend).

Effective November 1, 2004, Michigan adopted more stringent medical eligibility rules. The new rules replace the old eligibility requirement that a doctor’s recommendation was all that was needed to establish medical (functional) eligibility for Medicaid’s long term care benefits. Now, to qualify for Medicaid (the new rules do not apply to Medicare) long term care benefits – whether provided in a nursing home or through MI Choice – you must pass through one of seven doors. The rules establish seven separate ways to become medically eligible for Medicaid. A sufficient amount of need in any one of the following seven areas will qualify you for Medicaid: 1. Activities of Daily Living; 2. Physician Involvement; 3. Skilled Rehabilitation Therapies; 4. Service Dependency; 5. Cognitive Performance; 6. Treatments and Conditions; and 7. Behavior. If you are unable to meet any of the seven thresholds, you may seek an exception to the rules based on hardship. The state’s principal reason for passing the new rules is to keep people out of nursing homes and off the Medicaid rolls. The state estimates that the new rules will reduce the number of medically eligible nursing home applicants from eight to twelve percent. We may see more of this kind of cost cutting as Michigan attempts to balance its budget.

MEDICAID: IN-HOME CARE

Historically, Medicaid has provided only minimal access and limited funding to home health care. All states are required to provide institutional services, but not home health care. Accordingly, states have provided home care as an optional benefit or through a waiver program. Michigan provides Medicaid in-home services through its waiver program, MI Choice, discussed below. As a result of the high demand for home health care and extremely limited funding, Medicaid home health services are extremely difficult to obtain and almost always have waiting lists.

When available, Medicaid’s home health care benefit covers part-time and intermittent services similar to those provided by Medicare. Unlike Medicare, individuals need not be homebound (but they do need to meet the same functional/medical eligibility rules as required for nursing home admission), nor does the care need to follow a hospital stay. Due to limited funding, Medicaid home health benefits are subject to rigorous financial criteria – even more restrictive than Medicaid eligibility for nursing home care - and are therefore extremely difficult to obtain. Consequently, Medicaid home health benefits have dropped significantly in Michigan in recent years. Rather than in-home health services, Medicaid agencies prefer the in-home care service waiver program known as MI Choice.

MI CHOICE

All states, including Michigan, offer what are called waivered services. Essentially, the state can use Medicaid dollars to pay for certain kinds of home care without following guidelines established by the federal government. Michigan’s waiver program - Medicaid Home and Community Based Services Waiver for the Elderly and Disabled (HCBS) - is commonly known as MI Choice. It is designed for those who require nursing home level services but wish to remain in their own home. Although MI Choice providers cannot spend, on average, more than $34 (2005) per day in services for MI Choice participants, the services provided under MI Choice coupled with help from family members can make home care possible for those who would otherwise be institutionalized.

Waiver agents who, for the most part, are available through your local Area Agency on Aging, administer MI Choice. MI Choice offers a broad range of non-medical in-home and community based services including: personal care (such as bathing, dressing, and eating assistance), respite care (short-term relief for family caregivers provided at home, in an institution, or an adult day care center), homemaker and chore services, and transportation.

To be eligible, you must meet Medicaid asset eligibility requirements, the new Nursing Facility Level of Care Criteria and your monthly income cannot exceed $1,737 (2005). In practice, eligibility for the MI Choice program is more stringent than eligibility for Medicaid nursing home care.

While the state’s cost for nursing home has nearly doubled in the past decade with an average current cost of $116 per person per day, average care costs under the MI Choice program have remained at $43 per person per day ($34 allocated to patient care and $9 to administrative). Despite its obvious benefits, the MI Choice program has been crippled by budgetary cuts. With its funding currently capped at $100 million (statewide), the number of people enrolled in the program has declined from a high of 15,000 in 2001 to about 7,500 today. As a result of the current low funding levels and high demand, new applicants face waiting periods of up to two years for MI Choice services.

Despite recent cutbacks, advocates of the MI Choice program remain hopeful. Similar waiver programs in Oregon, Washington, Colorado, Vermont and Arizona have succeeded in shifting the bulk of their states’ long term care dollars to home care and assisted living. By contrast, the institutional bias remains strong in Michigan with institutional care receiving the bulk of the funding at more than 75 percent of all Medicaid long term care dollars.

MISCELLANEOUS PROGRAMS

HOME HELP PROGRAM

The Home Help Program funded by the Michigan Department of Community Health (MDCH) and administered by the Department of Health Services (DHS), pays a small stipend to service providers chosen by program participants, typically friends and family members. The applicant must be receiving Social Security Income and be eligible for Medicaid. Participants in the MI Choice program are eligible for the Home Help Program with a doctor’s certification. The Home Help Program is a very large program that covers Medicaid eligible participants with extremely low income. You apply for adult home help services at your local DHS office.

THE MICHIGAN AGING SERVICES SYSTEM (MASS)

Many in-home services programs such as home delivered meals, homemaker and home chore services, respite care and adult day care are provided through MASS. Participants are not charged for these services but are encouraged to make contributions. See http://www.miseniors.net for more details.

PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

PACE is basically an adult day care program where participants receive personal care services and limited medical care. PACE arranges for transportation to its site for activities Monday through Friday each week. Medicare and state Medicaid programs pay each site a monthly amount that must cover all participants and services. If you are already eligible for Medicaid, there is no additional charge for PACE. Unfortunately, due to limited funding, Michigan’s PACE program covers only 200 participants statewide and is available only through Henry Ford Hospital in Detroit. Contact the Center for Senior Independence at (313) 653-2020. Visit the national PACE Web site: http://www.cms.hhs.gov/pace/

VETERANS BENEFITS

If you qualify for a VA pension, the Veterans Administration will increase your monthly pension if you are homebound or need long term care. The increased pension may be used for home care, medical equipment, assisted living (called domiciliary care), and even nursing home care. See the Department of Veteran Affairs Web site: http://www.va.gov  for more information on VA programs, benefits and services.