PROVIDENCE, R.I. — The proposed $9.6 billion state budget headed for a House vote later this week has elicited both sighs of relief – and groans – since its piece-by-piece unveiling late Friday night.
A blog dedicated to the challenges facing people with developmental disabilities carried this headline: “Crisis appears averted in RI DD Services.”
But nursing homes cried foul over a “devastating” 8.5 percent cut in their state Medicaid reimbursements to offset the millions they won in a court case, that is currently in limbo, because a state lawyer, who has since resigned, missed the appeal deadline. The Raimondo administration is currently begging the Supreme Court for a reprieve.
Here’s what the bill says: “Beginning July 1, 2018, the rates paid to nursing facilities will be reduced by eight and one-half percent (8.5%) from the rates approved by the Centers for Medicare and Medicaid Services and in effect on October 1, 2017 for nine (9) months until March 2019, at which time the rates will revert to the October 1, 2017 level and be increased by one percent (1%).”
Mattiello told reporters the wording is aimed at reinforcing the funding level lawmakers intended all along, in the face of winning arguments by the nursing homes that the state had improperly shortchanged $8 million a year – and a potential $24 million overall – in its calculations.
James Nyberg, the director of one of the two nursing home advocacy groups – LeadingAge RI – issued a statement over the weekend that said the proposed new budget “will have immediate and devastating consequences for nursing homes and their residents.”
“Tucked into the budget is a cut of 8.5 percent for nursing homes that will go into effect July 1st, in just 21 days. How can we, as an industry, be prepared to react responsibly when we are already significantly underfunded?” he asked.
Denial of Medicaid Benefits based on Income-Only Trust Overturned
A Massachusetts Superior Court has overturned a MassHealth denial of coverage for a nursing home resident who MassHealth found had countable assets available from a trust she had created.
MassHealth who administers the Medicaid program for Massachusetts residents has been aggressively challenging and contesting applications where the applicant was the beneficiary of an Income-Only trust. MassHealth would take the position that assets held in an Income-Only trust are considered available to the applicant to be used on their own care and thus would disqualify them from Medicaid eligibility.
An Income-Only Trust used for Medicaid purposes states that the grantor of the trust shall, as the name indicates, only be entitled to receive income from the trust. If the terms of the trust also state that the grantor shall never be able to receive principal from the trust, the assets in the trust will not be deemed an available resource for the Medicaid applicant. Massachusetts has not followed this rule and denied Medicaid benefits to applicants despite these terms in the trust. With this new decision, MassHealth has been told that it was improper to deny applicants Medicaid benefits of the the basis of Income-Only Trusts.
This decision is welcome news for many estate planners seeking to clarify the role Income-Only trusts play in the estate planning process.
The usage of Trusts in Estate Planning is a critical component. The rules and terms contained in the trust dictate how various governmental agencies will view the trust. Having a clear understanding as to interpretation of language as to important benefits such as tax treatment, control issues or Medicaid qualification is required. This decision with MassHealth brings clarity to language that prior was in flux.
Want to learn more about Irrevocable Income-Only trusts? Contact our office for a no-cost consultation to see if they fit into your estate plan.
Alzheimer’s disease and estate planning
When caring for and planning for an individual, we address the financial and legal aspects of caring for a loved elderly one. These planning considerations do not happen in a vacuum. The decisions we make rely on the medical issues, complications and opportunities available to us. Knowing about treatment options and emerging science is critical in planning for future needs. Alzheimer’s disease robs cognitive ability and causes those who are afflicted to need long-term skilled nursing care.
When medical breakthroughs are occurring on diseases the are often require long term nursing care, we must share and learn as to their success and progress. Such studies and advancements are occurring at Butler Hospital in Providence, Rhode Island as evidenced by the attached link to an article published by the Providence Journal.
Co-Pays and Not Changes to Eligibility Proposed
Gov. Gina Raimondo has proposed balancing next year’s $9.38-billion budget with nearly $166 million in cuts to Medicaid. None of the changes will affect eligibility or benefits, officials said. Co-Pays and other cost reducing strategies will be implemented.
A plan to “rebalance” long-term care and nursing home services would account for another $18.2 million in savings. That includes “modernizing” the eligibility process for long-term care. The budget also calls for a 1-percent increase to nursing home reimbursement rates. In recent years, those rates have seen as much as a 3-percent increase.
Asked if he expected backlash from the nursing homes, Beane said, “I think, frankly, the nursing homes will be pleased to see that some part of the COLA is going to be included here. That’s the first time the governor’s proposed budget has included an increase. She has said in her cover letter to this budget that if revenues are up, this is an area she’d like to see more investment.”
As the long term care insurance market continues to struggle with its future, knowledge as to the rules of Medicaid eligibility that will pay for long term skilled nursing is critical. Individuals can only have $4,000 of countable resources to qualify for Medicaid. Your home, car and personal property is not a countable resource and is protected. Under the proposed budget, those rules appear to remain unchanged. However, what are you to do with savings, investment accounts, a second home or investment property? Will you be forced to liquidate those assets and spend them down on my long term nursing care below $4,000 before I qualify for Medicaid? Without a plan and proper advice, the answer is likely yes for most. However, with a proper plan, these assets can be protected for yourself, your spouse and your heirs. Contact us to discuss how.
Health Costs May Gobble Up Social Security Benefits
Healthcare for the average woman means they could spend an estimated 70 percent of her retirement check on health care costs, according to a recent study by the Nationwide Retirement Institute. The average man fares better, but still uses nearly half of his benefits to cover medical expenses.
Here’s how the Nationwide analysis reached its disturbing healthcare estimates: It assumed a woman with a life expectancy of 88 married a man who would live to 85 and they both claimed Social Security at 62, which is the earliest and most popular age to file for retirement benefits, regardless of gender. More than half of elderly married couples and nearly 75 percent single retirees depend on Social Security for the majority of their income in retirement. “Women disproportionately rely on Social Security in retirement,” said Nancy Altman, co-director of Social Security Works, which advocates for the expansion of the program. In fact, roughly two-thirds of Social Security beneficiaries age 85 and older are women. In the Nationwide’s bleak scenario, the man collects a monthly benefit of $1,543 and the woman collects $1,171 per month. (The average monthly benefit for a retired worker is $1,350, according to the Social Security Administration.)
Nationwide projects hefty health costs for the hypothetical couple. The man would pay $214,278 in medical costs in retirement and the woman would pay more than $289,682, because of her longer lifespan. The forecast includes what the couple would have to spend on long-term care at a nursing home or in an assisted living center.
Want to protect your life savings from possible long term care costs?
We have advised hundreds of people on the steps they must take today to protect their assets from the possible catastrophic costs associated with long term care and nursing home care. Contact our office today for a no-cost consultation to discuss your estate planning options.
Promising new research on Alzheimer’s at Butler Hospital and Brown University begins with a simple swab of the cheek
Cognitive impairment such as Alzheimer’s is a prevalent cause for needing long-term care. As the disease progresses, it undermines a persons ability to live independently in the community. Families who are faced with this disease, are a loss as to how to care for their loved ones. Estate Planning is a critical step in this process. Another, is learning and understanding more about the disease and what research is being done around it.
PROVIDENCE, R.I. — The weather one recent evening reflected the nature of the topic when a small crowd gathered at Butler Hospital to learn more about Alzheimer’s disease. It was cold and dark — in a word, gloomy.
Such is the illness, which erases memory and personality while burdening relatives and caregivers on its path to inevitable death. As yet, there is no cure.
But the man who drew these people from the comfort of home preaches hope, in the form of groundbreaking research he conducts with other scientists around the world.
On this evening, Dr. Stephen P. Salloway did more than preach.
Using the military metaphor he favors, he sought to enlist recruits in a new phase of a campaign he likens to the Second World War, when, against great odds, Allied forces defeated a mighty foe.
“I’m very excited that we are building an infrastructure worldwide to fight Alzheimer’s disease,” Salloway said as he began his presentation. “Many of our same allies in World War II are allies in this fight against Alzheimer’s.”
The scientist projected a slide describing research efforts around the planet, with Europe, Australia, North America and parts of Asia pinpointed as strategic centers.
“We are making progress, and there are other initiatives and consortiums, here and abroad, moving this forward,” Salloway said.
On he went, through slides of diseased brains, of German neuropathologist Alois Alzheimer’s first, historic patient, and of the APOE gene, which may indicate increased risk of the disease, depending on which of six possible variants an individual carries. Other factors, including age, diet, lifestyle and overall health, also influence risk.
With researchers elsewhere, Salloway and his team at Butler’s Memory and Aging Program are seeking volunteers to enlist in the so-called Generation Study, for men and women age 60 to 75 who are cognitively normal — but may be at risk, depending on their genetic makeup.
Screening begins with a swab of the cheek, which is analyzed for the APOE gene; eligible candidates may then decide to enroll in clinical studies of new medications, including a drug known as CNP520, which has just entered a trial sponsored by Novartis Pharmaceuticals in collaboration with Amgen and Banner Alzheimer’s Institute.
“Not only can you find out your genetic risk by having the APOE test,” Salloway said, “but then if you’re the right age group and meet the criteria and you’re interested, you could also participate in a prevention trial to try to lower the risk. We’re very excited about that.”
Many in the audience were as well. Eighteen would sign the necessary papers and have their cheeks swabbed. They would become the latest recruits in Salloway’s citizen army — which, when all studies and the Butler prevention registry are counted, now numbers more than 800.
Salloway’s aim is much higher.
Sandra Robinson Gandsman, a Pawtucket resident who spent most of her career in health-care marketing, was among those who enlisted with a swab and her signature. She was motivated, in part, by her knowledge of disease.
“Very honestly, this is more frightening than cancer,” Gandsman told The Journal. “If you get a diagnosis of cancer, there’s a possibility you can be cured. Certainly there are treatments that you can take. But Alzheimer’s — it’s kind of like, ‘Wow, there’s not much there.’”
The work of Salloway and others, she said, could put something there. Lives could be transformed for the better. New generations could escape the threat altogether if promising avenues prove true.
Sentiment also motivates Gandsman. She related the experience of a 73-year-old friend diagnosed with early-stage Alzheimer’s — that “mild” first of three phases of the disease characterized by “challenges performing tasks in social or work settings” and “forgetting material that one has just read,” among other symptoms, according to the Alzheimer’s Association.
“I noticed for a couple of years a lot of forgetfulness and repetition,” Gandsman said of her friend.
One day, she stepped on the tennis court with the woman, who had played the game for decades and was skilled at it.
“She didn’t know where she was,” Gandsman said. “She couldn’t keep score, but she didn’t know she couldn’t. She hit the ball and wasn’t sure where she was supposed to stand. I immediately called her husband. I thought she’d had a small stroke.”
“Her husband had been covering for her,” Gandsman said. “I didn’t realize it at the time.”
It was not hyperbole.
The prevalence of the disease doubles every five years after age 65, reaching as high as half of all people 85 and older. Lacking major advances, by 2050 an estimated 125 million people worldwide will have dementia, a broad category of brain afflictions that includes Alzheimer’s. Health-care costs for U.S. Alzheimer’s patients was estimated at $259 billion in 2017, a figure that does not include the billions of hours of free care, typically accompanied by significant emotional and other stresses, that family and friends provide.
Beyond the statistics is the reality of becoming one, as Salloway’s audience — mostly middle-age and older — acknowledged.
“If you ask older people what disease they fear most, what’s number one?” Salloway said.
“Alzheimer’s,” was the collective response.
But optimism co-exists with alarm, which is another theme Salloway strikes when he speaks to the public, as he does regularly. Building an army is more than a desk job.
“In order to make a difference, we need to find better treatment,” he said. “Congress is getting older and they’re worried about Alzheimer’s, too. That’s one of the few things that Democrats and Republicans agree on: that Alzheimer’s is bad. And so there is now a national plan to fight Alzheimer’s, with a major goal of developing breakthrough treatments by 2025. And we’re working hard to meet that goal.”
Congress has done more than pay lip service, Salloway said, and his slide confirmed it: National Institutes of Health funding for Alzheimer’s research rose from $448 million in 2011 to $991 million in 2016, surpassing the billion-dollar mark last year, when it reached $1.39 billion. This year, research funding is projected to reach $1.8 billion.
“Cancer is $6 billion, so we’re still well below that, but we’re making progress,” said Salloway, a professor at Warren Alpert Medical School of Brown University. “You might have heard that Bill Gates announced he was investing $100 million in Alzheimer’s research. That’s terrific. We’re so excited about that. I think that’s going to stimulate others to donate as well.”
Special-education teacher Donna de Chauny doesn’t have millions to invest; like Gandsman, she answered Salloway’s call out of noble purpose.
“If some of the research that we participate in helps further the information that helps find a cure, then I am happy to participate,” de Chauny said.
“When you watch somebody you love go through it, it’s just terrible,” de Chauny said.
Before moving from her home in North Carolina to Warren, Collene’s symptoms had become increasingly pronounced, even as she endeavored to hide them.
“She knew she couldn’t remember things,” her daughter said. “Every time you’d talk to her on the phone, the same things would repeat themselves because she was trying to have a conversation. And she couldn’t really gather the words to react to what you were saying in an appropriate way.”
But she kept trying to maintain a veneer of normalcy, even after relocating to Rhode Island.
“She would pour her coffee on her cereal in the morning and think nothing of it,” de Chauny said. “We’d say, ‘I don’t think that’s going to taste too good, Mom.’ And she’d say, ‘Oh, that’s always the way I have it.’”
Collene was not the only family member to suffer from Alzheimer’s, de Chauny said; all three of her mother’s siblings also died of the disease.
Salloway spoke to that during the swabbing event, the second held at Butler, saying that remaining mentally and physically active and socially engaged appear to reduce risk, as do “eating a balanced, Mediterranean-type diet,” sleeping well, quitting smoking, maintaining healthy weight and blood pressure, and other measures. All are encapsulated in the mantra: “What’s good for the heart is good for the brain.”
But more than lifestyle is involved in Alzheimer’s, which is characterized by buildups of two proteins in the brain: tau, which forms tangles inside neurons, and amyloid, which forms damaging plaque in connections between nerve cells. The precise mechanism of these protein buildups is not entirely understood, but research has brought advances.
One recent development has been a type of Positron Emission Tomography, or PET, technology that can reveal the presence of plaque years before symptoms of Alzheimer’s appear; previously, a diagnosis could be confirmed only at autopsy, with a microscopic examination of the brain.
Another has been clinical trials of Aducanumab, a drug made by Biogen that has demonstrated success in reducing amyloid plaque. The drug holds such promise that the paper describing the research behind it made the cover of the Sept. 1, 2016, edition of Nature, one of the world’s leading science publications. Salloway was one of the paper’s authors.
A third is a technique being developed by Salloway’s group and a team led by Peter J. Snyder, professor of neurology at the Alpert Medical School and Lifespan’s chief research officer, that could be used to diagnose Alzheimer’s by retinal imaging, a relatively simple and inexpensive procedure that an ophthalmologist could perform.
And there is more promising research elsewhere in the state, including that conducted by University of Rhode Island neuroscientist Paula Grammas, whose work focuses on the role the vascular system plays in Alzheimer’s. Grammas is the inaugural director of the George and Anne Ryan Institute for Neuroscience.
Salloway projected a slide, “Rhode Island as an incubator for innovation in AD research,” that included a photo of Grammas with Governor Gina Raimondo, URI president David M. Dooley, and former CVS Health Chairman and CEO Thomas M. Ryan, who established URI’s Ryan Institute.
“Rhode Island — because of our small size, everybody knows everybody,” Salloway said, to laughter.
But proximity and determination have more than comic value. With both, collaboration can flourish.
“We could really be an innovation center for Alzheimer’s research and prevention studies,” Salloway said.
Without volunteers, innovation would slow. And so, Salloway urged his latest recruits to encourage others to join the army.
“You’re already doing a lot to fight Alzheimer’s,” he said, “but I want you to take the Alzheimer’s challenge. I want you to tell five other people that you came here tonight to find out about Alzheimer’s research. We hope you will spread the word around.”
And also, host “swabbing parties” at homes or civic organizations, with the Butler team handling the logistics.
To learn more about Alzheimer’s research at Butler and how to enroll in a study, call (401) 455-6402 or visit butler.org/memory
Alzheimer’s disease research funding
National Institutes of Health spending in 2011
NIH spending in 2017
NIH projected spending in 2018
NIH spending on cancer research in fiscal 2017
Sources: NIH, U.S. Senate Committee on Appropriations
How is Medicaid funded and what are the funding rules?
States are not required to accept federal funding for Medicaid; however, if they chose to participate in the Medicaid program, they are required to comply with federal statutory and regulatory requirements. Camacho v. Texas Workforce Com’n., [326 F.Supp. 2d 794 (W.D.Tx. 2008)].
States must submit their proposed Medicaid plans for approval from the Centers for Medicare and Medicaid Services (CMS). CMS does not automatically approve state Med
icaid plans and has the final say in approving or denying a proposed amendment to a state Medicaid plan. For instance, in Md. Dept. of Health and Mental Hygiene v. CMS, [592 F.3d 424, 427 (4th Cir. 2008)], the CMS rejected Maryland’s proposed amendments to its state Medicaid plan because those amendments would have unreasonably limited the deductibility of medical expenses incurred by Medicaid enrollees after being determined eligible for Medicaid in contravention of federal requirements.
The CMS may approve a state’s waiver application through a section 1115 waiver application. The 2017 National Academy Elder Law Attorneys Summit highlighted a current trend of CMS allowing a state to forgo the three months of retroactive Medicaid coverage. Recently, Arkansas and Maine have submitted 1115 demonstration waiver applications doing away with the three months of retroactivity and Iowa is also seeking to forgo this option. It is anticipated that CMS will continue to relax the three month retroactive coverage in future state demonstration waiver applications.
Understanding how the funding for the Medicaid program works is a step in understanding the rules to qualifying for Medicaid and where those rules originate. The State of Rhode Island has the Department of Human Services as overseeing the administration of the Medicaid program. Applications for Medicaid are submitted to DHS where they review and advise as to the applicants approval for the program.
A wrinkle in Medicaid’s complex funding formula gives nursing homes owned or leased by city or county governments a funding boost of 30 percent per Medicaid resident. The money is sent to the hospitals, which negotiate with the nursing homes over how to divvy it up.
Westminster Village North, a nursing home and retirement community in Indianapolis, recently added 25 beds as well as two kitchens to speed food delivery to its residents. It redesigned patient rooms to ease wheelchair use and added WiFi and flat-screen televisions. This fall, it’s opening a new assisted-living unit.
The nursing home can afford these multimillion-dollar improvements partly because it has, for the past five years, been collecting significantly higher reimbursement rates from Medicaid, the state-federal health insurance program for the poor.
The changes began when Hancock Regional, a county-owned hospital 15 miles away, began leasing Westminster Village North. A wrinkle in Medicaid’s complex funding formula gives nursing homes owned or leased by city or county governments a funding boost of 30 percent per Medicaid resident. The money is sent to the hospitals, which negotiate with the nursing homes over how to divvy it up.
About half of Westminster’s residents are on Medicaid, so the new funding was substantial.
“We have seen amazing changes and created a more homelike environment for our residents,” said Shelley Rauch, executive director of the home.
Nearly 90 percent of Indiana’s 554 nursing homes have been leased or sold to county hospitals in the past 14 years, state records show, bringing in hundreds of millions in extra federal payments to the state.
Even though Indiana’s nursing home population has remained steady at about 39,000 people over the past five years, Medicaid spending for the homes has increased by $900 million, to $2.2 billion in 2016, according to state data.
Today, more than two-thirds of Indiana’s Medicaid long-term care dollars go to nursing homes. The U.S. average is 47 percent.
The funding enhancements were pioneered in Indiana, but hospitals in Pennsylvania and Michigan also have used the process. Advocates say it has been a key factor in helping to keep Indiana’s city and county hospitals economically vital at a time when many rural hospitals nationwide are facing serious financial difficulties.
Critics contend that the money flow has not significantly improved nursing home quality. Furthermore, they say, it has provided incentives to steer patients to nursing homes rather than lower-cost options, such as home health care or community-based daycare centers.
Joe Moser, who until May was Indiana’s Medicaid director, acknowledged while in office that more people were moving to nursing homes rather than staying in their homes, and said it was due in part to the hospital-nursing home marriages. “It is a factor that has contributed to our imbalance” in care choices, he said.
Daniel Hatcher, a law professor at the University of Baltimore and author of “The Poverty Industry,” a book published last year, said this funding arrangement is a bad deal for the poor because it takes a large portion of Medicaid dollars targeted for services for low-income nursing home residents and sends it instead to hospitals to use as they please.
That undercuts the purpose of the Medicaid program, he said.
“The state is using an illusory practice and taking away money from low-income elderly individuals who are living in poor-performing nursing homes,” he said. He noted Indiana is ranked near the bottom of states for nursing-home quality by several government and private reports. Among them is a scorecard from Families for Better Care and the AARP scorecard.
But proponents of the practice say that even when hospitals get most of the money, it is well spent.
Marion County Hospital and Health Corp., the large safety-net hospital system in Indianapolis, owns or leases 78 nursing homes across the state, more than any other county hospital.
Sheila Guenin, vice president of long-term care there, said the hospital keeps 75 percent of the additional Medicaid dollars and the nursing homes get the rest. Still, the additional money has improved care. The transfer of the license to the hospital has kept several nursing homes from closing and increased staffing rates at many others, she said.
About 40 percent of the county hospital’s nursing homes have five-star ratings from the federal government, up substantially from 10 years ago, Guenin said. Among the improvements at the nursing homes were the addition of electronic health records and of high-capacity emergency generators to provide power in a natural disaster.
Still, some patient advocates said the extra funding is flowing to hospitals and nursing homes with little public accounting. Ron Flickinger, a regional long-term-care ombudsman in Indiana, said, “A lot of extra money is being spent here, but I’m not sure patients have seen it benefit them.”
Medicaid, which typically covers about two-thirds of nursing home residents, is jointly financed by the federal and state governments. States pay no more than half the costs, although the federal match varies based on a state’s wealth. In Indiana, the federal government pays about 65 percent of the costs.
The enhanced nursing home payments began in 2003 when a county-owned Indianapolis hospital decided to take advantage of Medicaid rules to bolster its bottom line. In this case, the hospital purchased a nursing home, then provided the money for the state to increase what it spent on the home to the federally allowed maximum.
That increase, in turn, drew down more federal matching funds. Since the federal remittance was larger than the hospital’s contribution, the hospital got back its initial investment and divided the extra money with the nursing home.
Other county-owned hospitals in Indiana slowly followed suit.
All the Medicaid funding for nursing homes should be going to those homes to care for the poor, not shared with hospitals to use as they choose, he said.
The strategy, promoted by consultants advising hospitals and nursing homes in Indiana, is used heavily there because of the plethora of county-owned hospitals. But the federal government is tightening the rules about such payments.
Texas has secured Medicaid approval for a similar strategy starting this month, but federal officials have made the extra funding dependent on nursing homes meeting quality measures, such as reducing falls. Oklahoma is seeking to get federal approval as well.
And in a rule released last year, the federal Centers for Medicare and Medicaid Services announced that it would gradually force states to shift to payment systems that tie such reimbursements to quality of care. Michael Grubbs, an Indiana health consultant, said that rule does not stop the Indiana hospital funding program, but it’s unclear that it will last.
Nursing-home operators in Indiana say the financing arrangement has helped them keep up with rising costs and improve care for residents.
Zach Cattell, president of the Indiana Health Care Association, a nursing-home trade group, noted the number of nursing homes in the state earning Medicare’s top, five-star rating has increased 9 percentage points since 2011. He said the percentage of high-risk residents with pressure ulcers and those who are physically restrained also dropped significantly.
“The money has meant a great deal to us,” said Gregg Malot, director of business development at Pulaski Memorial Hospital in northern Indiana. “I don’t see this as a loophole but see it as an opportunity for small, rural community hospitals to improve our quality and access to care.”
His hospital is the only one in Pulaski County. The extra Medicaid revenue from having acquired 10 nursing homes statewide — about $2 million a year — has helped finance the purchase of the hospital’s first MRI machine, so doctors don’t have to rely on a mobile unit that used to come twice a week, he said. The hospital also spent some of the money to add a computerized system to monitor patients’ vital signs.
Steve Long, chief executive of Hancock Regional Hospital in Greenfield, said his hospital recently built two fitness centers in the county with help from the extra Medicaid dollars that resulted from its acquisition of Westminster Village.
He rejects the notion that additional Medicaid money reduces the hospital’s incentive to add home- and community-based care in the community. He said new Medicare financing arrangements, such as accountable care organizations, give the hospital motivation to find the most efficient ways to care for patients after they leave the hospital.
But he acknowledged the hospital benefits from seeing more patients go to nursing homes licensed under its name.
“Welcome to health care — it’s a complex and confusing environment where we have all different competing incentives,” Long said.