Today Your Legal Corner will provide information on “Illness and Medicaid.”

Medicaid presently is the main form of payment for care in a nursing home facility.

With Valentine’s Day approaching, one cannot help but think of the many kinds of love. Most special to me is witnessing the love a caregiver parent has for his or her child.

The legal definition of a caregiver is an individual who takes care of a person that has a chronic illness or a disease. However, unlike my example, the caregiver is the adult child and the inflicted person is the parent. Care may be administered within the community or within a nursing home type facility.

Long term care in a nursing type facility requires the payment of extensive funds and often begins with the happening of a traumatic event.

MEDICARE

As the story goes, a traumatic event, such as a fall, occurs which requires the injured party to enter the hospital. Thereafter, the injured party is transferred from the hospital to a skilled care facility to receive prescribed rehabilitation.

When an individual is hospitalized for at least three days and then transferred to a skilled nursing facility for care or rehabilitative purposes, Medicare will pay the first 20 days in full, so long as the individual continues to require the course of treatment.

Additionally, Medicare will continue to pay for skilled care for the next 80 days but with a deductible to be paid by the patient, unless he or she has a secondary insurance policy. Important to note is the fact that Medicare will not pay for long term care when the rehabilitation has ended and the patient is still not able to return home. It is at this time elder law attorneys are contacted by the patient’s family for help.

We all are aware of the extensive cost of long term nursing home care. That is why it is best to have a plan in place in case of a sudden illness.

In New Jersey, there are two types of programs for long-term care: Medicaid only and medically needy.

MEDICAID ONLY

This program benefits people 65 years of age or older or those who are blind or disabled who require care in a long-term facility. Additionally, their assets must be less than $2,000 and a monthly income of $2,130 or less. If the patient qualifies, the program will generally pay for the long-term care facility and associated health care costs.

MEDICALLY NEEDY

The second program provides benefits to individuals whose monthly income exceeds $2,130 and whose assets do not exceed $4,000. This program does not pay as much as the Medicaid Only program. As with the other program, the individual must be disabled and have a medical need in order to qualify for Medicaid.

Medicaid is a joint state and federal program.

In Gloucester County, the Board of Social Services is responsible for coordinating programs on aging regardless of the funding source. They can be reached at 856-582-9200.

The Center for Medicare and Medicaid Services is the coordinating office within the federal government for Medicare and Medicaid services. For detailed information on these services see www.cms.hhs.gov.

Next week, YLC will update and discuss “Living in the Community and Medicaid.” Till then, God bless, keep smiling and remember who’s in Your Legal Corner!

Victoria M. Dalton is a dedicated Family/Elder Law Attorney with the Law Offices of Hoffman Dimuzio. Call 856-845-8243 for further information. Email correspondence to vdalton@hoffmandimuzio.com or see www.ylcdirection.com.  

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By Martin Bricketto
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Law360, New York (January 23, 2014, 7:10 PM ET) — A family court order couldn’t control a New Jersey agency’s decision on the appropriate allowance for a Medicaid recipient’s wife, a state appeals court ruled Thursday in a case that pitted the conservation of Medicaid funds against the ability of beneficiaries to shelter income for spouses.

An institutionalized man identified as R.S. challenged how the state Division of Medical Assistance and Health Services calculated a “community spouse monthly income allowance” for his wife in determining the income that he could contribute toward his nursing home care….

By David Adinaro

Anyone. Anytime. 24/7/365. This is the motto that emergency physicians embrace. It is also the basis of the federal Emergency Medical Treatment & Active Labor Act that requires hospitals to provide evaluation and stabilizing care to everyone who comes to the emergency department.

As president of the New Jersey Chapter of the American College of Emergency Physicians and an emergency physician for many years, I am proud to be part of the medical safety net that Americans rely on, and that more than 300,000 patients use every day.

Emergency physicians are, however, dependent on access to other medical specialists to properly care for our patients. These on-call specialists are a vital part of the safety net and often have responsibilities to the patient far beyond their time in the ER. Access to these specialists in New Jersey is endangered by low reimbursements from Medicaid and the disastrous state of medical liability. Every day the families of children with broken bones, for example, are unable to arrange follow-up care because so few orthopedists accept Medicaid.

This week, ACEP, the national organization focused on supporting quality emergency care, released the 2014 National Report Card on the State of Emergency Medicine. This report card assesses the support each state provides their emergency care systems. New Jersey received a D-plus — a significantly lower score than the C-plus the state received in the last report in 2009. That decline is due in large part to poor access to needed specialists.

New Jersey received an F for its Medical Liability Environment, as it did in 2009. Malpractice insurance premiums in our state continue to be more than 30 percent higher than the national average. A small pool of insurers, a lack of pretrial screening, and no caps on awards for noneconomic damages are major contributors to this problem.

The report also noted that New Jersey’s Medicaid fees for physicians were only 40 percent of the national average. This ranks our state among the lowest in the country for Medicaid physician reimbursement and is a major impediment to recruiting and retaining vital specialists to the state. While recent changes from the Affordable Care Act will temporarily increase Medicaid rates for primary care, it leaves reimbursement for specialty care unreasonably low.

This combination of low reimbursement and high liability cause needed specialists to decline to be on call for ER patients. ACEP proposes that New Jersey join Florida and other states in enacting legislation that provides liability protection for physicians who provide emergency care mandated under the Emergency Medical Treatment act.
This would encourage more specialists to provide on-call service to local hospital emergency departments, helping to ensure all patients get quality, timely care and appropriate follow-up. That would mean more orthopedists to reset broken bones. More ophthalmologists to tend to eye injuries. More cardiologists to treat life-threatening heart attacks.

We also call on Gov. Chris Christie and the state Legislature to take a serious look at the very low reimbursement that Medicaid offers physicians to take care of some of the sickest patients in our state. It has been many years since New Jersey has raised the Medicaid rates for physicians. Having insurance means nothing if patients cannot obtain the care they need because doctors are unavailable.

New Jersey emergency physicians are proud of the quality care we provide our neighbors, friends and family. Along with emergency nurses and many other dedicated professionals, we look forward to providing state-of-the-art care for more than 3 million ER patients in 2014.

We will be there for our patients 24/7/365.

David Adinaro, MD, FACEP (@PatersonER), is the chief of Adult Emergency Services at St. Joseph’s Regional Medical Center in Paterson and president of New Jersey Chapter of the American College of Emergency Physicians (@NJACEP and NJEmergencyDocs.com).

Nearly 2.2 milllion Americans enrolled in private health insurance through the federal marketplace by the close of last year – with roughly 35,000 of them from New Jersey.

Additionally, another 71,000 New Jerseyans were deemed eligible for Medicaid.

The monthly update provided by Secretary of Health and Human Services Kathleen Sebelius on Monday showed the troubled healthcare.gov website finally gained traction in December.

However, both New Jersey and the country as a whole have a long way to go between now and the March 31 deadline for Americans to have health insurance, health care experts warned.

“It’s a lower number that I would expect – but not surprising given all the problems with healthcare.gov,” said Joel Cantor, director of the Center for State Health Policy and Professor of Public Policy at Rutgers University.

One bright light, said Cantor, was Medicaid: 71,000 New Jersey applicants on the website were eligible for insurance under Medicaid, whose income guidelines have been loosened to cover more people.

He saw that as an impressive dent in the 300,000 uninsured New Jerseyans who earn so little they now qualify for Medicaid. “This is a good down-payment on that,” he said.

View full size 

But a problematic area remains the enrollment of the “young invincibles,” those young adults who don’t feel any need to buy health insurance. Without sufficient young, healthy people paying premiums, no insurance pool can afford to cover the sickly.

Nationally, just 24 percent of the enrollees have been in the 18-34 age bracket, even though that group accounts for roughly a third of the uninsured. New Jersey’s number is slightly lower, at 23 percent.

Adults 45 and over have been the quickest to buy insurance through the federal marketplace, accounting for 55 percent of the enrollees. That number is slightly higher – 58 percent – in New Jersey.

“We’re going better,’”said David Knowlton of the New Jersey Health Care Quality Institute, of the enrollment process. “But the big question is, ‘Where are the young invincibles?’”

Obama administration officials said they were pleased with the number of young people enrolling, noting it matched the experience of Massachusetts when that state mandated health insurance. The younger applicants were the last to sign up there, and federal officials expect the same thing will happen with Obamacare.

Until they sign up, however, the risk remains they’ll simply choose to pay the fine to remain uninsured.

“That’s still a concern,” said Jeff Brown, of the New Jersey Health Care Quality Institute.

One pleasant surprise to health care experts is that 60 percent of enrollees around the country chose a so-called “Silver” plan – a middle-tier plan that costs more than a “Bronze” plan but has lower out-of-pocket expenses.

While younger, healthier applicants might be tempted by the lower premiums of a Bronze plan, they could be in for an unpleasant surprise should they get a serious illness, said Cantor.

“That number’s a little reassuring, because if more people picked a Bronze plan, then we would see a large portion of people getting into financial trouble because of health costs,” he said.

Knowlton said he doubted people were pouring over insurance plans, then picking a plan by balancing premiums versus coverage. Instead, he said, they were behaving more like typical consumers of any product. “It’s like how people pick wine,” he said. “They go to the middle of the menu.”

Meanwhile, New Jersey’s Medicaid program, New Jersey FamilyCare, reported the glitches that have stymied the transfer of enrollment data from the federal website have been fixed. As of late last week, the state was finally receiving “workable information” from the federal website and was processing those applications, said Nicole Brossoie, spokeswoman for the New Jersey Department of Human Services.

Anyone ruled eligible will have their coverage backdated to Jan. 1.

In the meantime, hospitals and federally qualified health centers will assume someone who has applied for Medicaid is eligible, and an interim application will be taken so the provider can be reimbursed.

Some of the update’s highlights:

• The administration continues to play catch-up. Originally, officials hoped to sign up more than 3.3 million people through the end of 2013, nearly halfway to the goal of 7 million enrollments by the end of March. Instead, enrollment as of Dec. 31 was not quite 2.2 million.

• Fifty-four percent of those who signed up were women, a slightly higher proportion of females than in the population.

• Nearly four out of five who signed up got financial help with their premiums.

• A few states accounted for a huge share of the enrollment. California alone had 23 percent of the signups. That state, along with New York, Florida, Texas and North Carolina accounted for nearly half the total.

The Associated Press contributed to this report.

Nearly 2.2 milllion Americans enrolled in private health insurance through the federal marketplace by the close of last year – with roughly 35,000 of them from New Jersey.

Additionally, another 71,000 New Jerseyans were deemed eligible for Medicaid.

The monthly update provided by Secretary of Health and Human Services Kathleen Sebelius on Monday showed the troubled healthcare.gov website finally gained traction in December.

However, both New Jersey and the country as a whole have a long way to go between now and the March 31 deadline for Americans to have health insurance, health care experts warned.

“It’s a lower number that I would expect – but not surprising given all the problems with healthcare.gov,” said Joel Cantor, director of the Center for State Health Policy and Professor of Public Policy at Rutgers University.

One bright light, said Cantor, was Medicaid: 71,000 New Jersey applicants on the website were eligible for insurance under Medicaid, whose income guidelines have been loosened to cover more people.

He saw that as an impressive dent in the 300,000 uninsured New Jerseyans who earn so little they now qualify for Medicaid. “This is a good down-payment on that,” he said.

View full size 

But a problematic area remains the enrollment of the “young invincibles,” those young adults who don’t feel any need to buy health insurance. Without sufficient young, healthy people paying premiums, no insurance pool can afford to cover the sickly.

Nationally, just 24 percent of the enrollees have been in the 18-34 age bracket, even though that group accounts for roughly a third of the uninsured. New Jersey’s number is slightly lower, at 23 percent.

Adults 45 and over have been the quickest to buy insurance through the federal marketplace, accounting for 55 percent of the enrollees. That number is slightly higher – 58 percent – in New Jersey.

“We’re going better,’”said David Knowlton of the New Jersey Health Care Quality Institute, of the enrollment process. “But the big question is, ‘Where are the young invincibles?’”

Obama administration officials said they were pleased with the number of young people enrolling, noting it matched the experience of Massachusetts when that state mandated health insurance. The younger applicants were the last to sign up there, and federal officials expect the same thing will happen with Obamacare.

Until they sign up, however, the risk remains they’ll simply choose to pay the fine to remain uninsured.

“That’s still a concern,” said Jeff Brown, of the New Jersey Health Care Quality Institute.

One pleasant surprise to health care experts is that 60 percent of enrollees around the country chose a so-called “Silver” plan – a middle-tier plan that costs more than a “Bronze” plan but has lower out-of-pocket expenses.

While younger, healthier applicants might be tempted by the lower premiums of a Bronze plan, they could be in for an unpleasant surprise should they get a serious illness, said Cantor.

“That number’s a little reassuring, because if more people picked a Bronze plan, then we would see a large portion of people getting into financial trouble because of health costs,” he said.

Knowlton said he doubted people were pouring over insurance plans, then picking a plan by balancing premiums versus coverage. Instead, he said, they were behaving more like typical consumers of any product. “It’s like how people pick wine,” he said. “They go to the middle of the menu.”

Meanwhile, New Jersey’s Medicaid program, New Jersey FamilyCare, reported the glitches that have stymied the transfer of enrollment data from the federal website have been fixed. As of late last week, the state was finally receiving “workable information” from the federal website and was processing those applications, said Nicole Brossoie, spokeswoman for the New Jersey Department of Human Services.

Anyone ruled eligible will have their coverage backdated to Jan. 1.

In the meantime, hospitals and federally qualified health centers will assume someone who has applied for Medicaid is eligible, and an interim application will be taken so the provider can be reimbursed.

Some of the update’s highlights:

• The administration continues to play catch-up. Originally, officials hoped to sign up more than 3.3 million people through the end of 2013, nearly halfway to the goal of 7 million enrollments by the end of March. Instead, enrollment as of Dec. 31 was not quite 2.2 million.

• Fifty-four percent of those who signed up were women, a slightly higher proportion of females than in the population.

• Nearly four out of five who signed up got financial help with their premiums.

• A few states accounted for a huge share of the enrollment. California alone had 23 percent of the signups. That state, along with New York, Florida, Texas and North Carolina accounted for nearly half the total.

The Associated Press contributed to this report.