Are You Considering Nursing Facility Care?

Are You Considering Nursing Facility Care?
July 2007

Answers to some common questions about:
    Medicare & Medicaid (Title 19)
    Admissions
    Your Legal Rights

Medicare and Medicaid (Title 19)
What is Medicare?
What is Medicaid and what coverage does it provide for nursing facility care?
What is the application process to a nursing facility in Connecticut?
Can the nursing facility ask me for a security deposit or advance payment?
Can I be moved from one room to another in the same facility?
Can I be transferred or discharged from one nursing facility to another?
What is the Patient's Bill of Rights?
Is there an alternative to nursing home placement?
Regional Ombudsmen
For more information

Introduction

If you are reading this pamphlet, then you are probably facing a very difficult period in your life. Seeking admission to a nursing facility is stressful for the patient and his or her family because of the many questions that can arise.

This pamphlet will answer some of the common questions people have regarding the nursing facility admission process, a nursing facility resident’s rights following admission, and the government programs that help to pay for nursing facility care.

Medicare and Medicaid (Title 19)

The government programs that help to pay for nursing facility care are Medicare and Medicaid (also known as Title 19). Medicare and Medicaid are two different programs. Medicare will provide limited nursing facility coverage in some circumstances. Only Medicaid, available to those who meet specific income and asset guidelines, will pay for most long-term nursing facility costs. However, neither Medicare nor Medicaid will pay for telephone, television, or other personal comfort items. For more information on nursing facility costs, see our pamphlet, Paying for Nursing Home Care with Medicaid (Title 19).

What is Medicare?

Medicare is a federal health insurance program. Anyone at least 65 or disabled and eligible for Social Security or Railroad Retirement benefits is eligible for Medicare. Medicare beneficiaries can receive their Medicare benefits through the Original Medicare Program or through a Medicare Advantage (formerly Medicare+Choice) health plan.

Original Medicare
The Original Medicare Program has two parts -- Part A and Part B.

Part A covers inpatient hospital care, skilled nursing facility care, hospice care and some home health services.

Part B covers doctor and diagnostic services, some home health services, durable medical equipment, medical supplies and other miscellaneous medical expenses.

Medicare Supplement Insurance policies, also called "Medigap" policies, cover medical costs that Original Medicare does not cover. Private insurance companies offer several different policies, all of which must include core benefits. Medicare beneficiaries must pay a monthly premium for these policies. For information about Medigap policies that can be purchased in Connecticut, contact the CHOICES program at 1-800-994-9422.

Medicare Advantage (formerly Medicare+Choice)
Medicare Advantage health plans were created to provide beneficiaries additional choices for the delivery of their Medicare benefits. These additional choices include:

Managed Care plans (Health Maintenance Organizations, Provider Sponsored Organizations, Preferred Provider Organizations),
Private Fee For Service plans
Medical Savings Accounts

Currently, the Health Maintenance Organization (HMO) is the most common Medicare Advantage plan available. Medicare Advantage plans must provide at least the same benefits that the Original Medicare Program provides. Beneficiaries enrolling in a Medicare Advantage plan must also have Medicare Part B coverage.

Medicare Part D

Medicare Part D is the new voluntary prescription drug benefit that helps Medicare beneficiaries pay for their prescriptions. Private insurance companies offer several different Medicare Part D Prescription Drug Plans (PDP's), all of which must include a standard drug benefit package. A person must be eligible for Medicare Part A or enrolled in Part B to in enroll in a Medicare PDP. There are several costs associated with Medicare PDP's: deductibles, co-payments and monthly premiums. For those who need extra help with these costs, Medicare offers low-income subsidies. Nursing home residents with both Medicare and Medicaid (called dually eligible) do not have drug co-payments. For more information about Medicare Part D and Medicare in general, call the Center for Medicare Advocacy at 1-800-262-4414 or visit the web site at www.MedicareAdvocacy.org.

What coverage does Medicare provide for nursing facility care?

Medicare coverage for nursing facility care is limited to up to 100 days of care per spell of illness. In order to receive coverage by Medicare, the patient must:

have been in the hospital receiving Medicare-covered services for at least 3 days before entering the nursing facility;
generally, be admitted to the facility within 30 days of discharge from the hospital; and
require and receive daily skilled nursing care or skilled rehabilitation at least 5 days per week, for a condition that was treated in the hospital.

Original Medicare: The Original Medicare Program will pay the first 20 days completely, but the patient is required to pay a co-insurance for days 21 through 100. Some, but not all, Medigap policies will cover the cost of co-insurance for days 21 through 100 in a nursing facility.

Medicare Advantage: If you are enrolled in a Medicare Advantage health plan, you are not responsible for paying a co-insurance. However, some Medicare Advantage plans may charge a monthly premium.

Medicare will not pay for nursing facility care for those who need only custodial care. Custodial care is dressing, bathing, feeding, and similar care that can be provided by non-medical persons.

How will I know if Medicare will pay for my nursing facility stay?

You must be given a written notice (called a "Notice of Medicare Non-Coverage") whenever a determination is made that your nursing facility stay will not be covered. The notice must advise you of your right to appeal.

If you are denied coverage of your nursing facility stay, you have the right to appeal (contest) that decision. An appeal can sometimes win additional nursing facility coverage. Call the Center for Medicare Advocacy at 1-800-262-4414 for more information about Medicare appeals.

What is Medicaid and what coverage does it provide for nursing facility care?

Medicaid (Title 19) is a medical assistance program run by the Department of Social Services (DSS). Medicaid will pay for custodial care, as well as skilled care, as long as you continue to qualify under Medicaid’s specific income and asset guidelines. For more information on Medicaid, see our pamphlet, Paying for Nursing Home Care with Medicaid (Title 19).

Unless otherwise indicated, the following questions and answers apply whether your payment source for nursing facility care is Medicare OR Medicaid OR you pay privately for your own care.

What is the application process to a nursing facility in Connecticut?

The first thing you will need to do is obtain applications from the nursing facilities you are interested in. If you are living at home, you, or a relative or friend should call or write to a nursing facility for an application. If you are hospitalized, the hospital social worker or discharge planner is responsible for requesting applications on your behalf and assisting you, your family, guardian or conservator in completing the application.

When an application is requested, the nursing facility must send you an application and dated receipt within two days. At this time, the nursing facility will place your name on the dated list of applicants. This list only shows that you have requested an application and that it has been mailed to you.

Upon receipt of the application, you, or the person assisting you, must fill out the application and return it to the nursing facility. When the application is received by the nursing facility, your name will be placed on the nursing facility waiting list for admission. It is not until you are placed on the waiting list that you will be considered for a bed in the nursing facility. The nursing facility will not place your name on the waiting list unless your application is substantially completed (see below for definition).

What does "substantially completed" mean?

There is no clear definition of "substantially completed." Generally, you should fill out as much of the application as you can. If a nursing facility will not place your name on its waiting list because your application is not substantially completed, contact your Regional Ombudsman or Legal Services office to find out if the nursing facility’s decision can be challenged. (See "Regional Ombudsmen in Connecticut" at the end of this pamphlet for phone numbers).

What financial information can a nursing facility request?

A nursing facility may ask if you currently have private insurance, Medicare or Medicaid to pay the facility. It may not ask for financial information in person, over the phone, or in writing that would assure the facility that you are not eligible for Medicaid or will not apply for Medicaid in the future.

Once I am on the waiting list, when will I be admitted to the facility?

Connecticut law states that a nursing facility must keep a waiting list of all applicants whose applications are substantially completed. Generally, a nursing facility must admit applicants in the order in which they appear on the waiting list. However, Connecticut law provides that if a nursing facility has a certain percentage of beds occupied by Medicaid recipients, or the only room available is a private room, the facility may refuse to admit applicants receiving Medicaid benefits. If a nursing facility denies you admission for this reason, contact your Regional Ombudsman. (See "Regional Ombudsmen in Connecticut" below for phone numbers).

Are there exceptions to the waiting list law?

Yes. There are many exceptions to the waiting list law. Certain circumstances may entitle you to an earlier admission. For example, if:

your spouse is already a resident in the nursing facility,
you require short term rehabilitation,
you require protective services, or
you are a resident of a facility that is closing.

How do I check whether I am on a nursing facility's waiting list?

State law requires that the nursing facility keep a written record of the waiting list and inform you of your place on the waiting list whenever you or your representative requests such information.

When can my name be removed from the waiting list?

Once your name is placed on the admission waiting list, it may not be removed until:

you have been admitted to the nursing facility, OR
after you have been on the waiting list at least 90 days, the nursing facility writes to you asking if you wish to remain on the list, and you do not respond to the letter within 30 days.

Can the nursing facility ask me for a security deposit or advance payment?

Generally, a nursing facility may not require you, a family member or others, to pay a deposit or advance payment if your stay will be covered by Medicare or Medicaid.

MEDICARE:

If any part of your stay will be covered by Medicare, a nursing facility may not ask you for a deposit or advance payment for any services or supplies that will be covered by Medicare, or to cover your co-insurance for days 21 through 100.
The nursing facility can request a deposit only if it is clear that your entire stay will not be covered by Medicare. (Also see, "How will I know if Medicare will pay for my nursing facility stay?" above).
The nursing facility must refund any money incorrectly collected.

MEDICAID:

If you are already receiving Medicaid, the nursing facility may not request any deposit or advance payment from you.
In Connecticut, if you have applied for Medicaid but have not yet been found eligible, and your stay will not be covered by Medicare, the nursing facility may request a deposit or advance payment of no more than $1,500. If a deposit is paid, it must be held in an account for your benefit and must be returned to you when your Medicaid eligibility has been established.
The nursing facility may not charge, ask for, accept or receive any gift, money or donation in addition to Medicaid payment as a condition of admission or as a way to expedite admission.

NOTE: All nursing facilities in Connecticut must post a notice in a prominent location that displays the limitations on deposits or advance payments under Medicare and Medicaid, as listed above. All nursing facilities must also obtain a statement in writing from you prior to admission showing you understand the limitations on the nursing facility’s ability to request deposits or advance payments.

Can I be moved from one room to another in the same facility?

A nursing facility cannot move you from one room to another without your consent if it is medically harmful to you. If a facility wishes to move you to another room, the purpose for the move must be to promote your well-being. In making any room-to-room transfer, the facility must make sure you are disrupted as little as possible.

If you do not consent to a room change, the facility must consult with you, your family, or other representative and medical staff to discuss the proposed move, the risks and benefits, and any alternatives to the room change.

If, after the consultative process, the facility still wants to move you to another room and you still do not wish to be moved, the facility can move you only if the move is necessary:

to make repairs or renovations that otherwise could not be made,
to separate you and your roommate where there is a threat of harm to you if you are not separated,
to place you in a room with a person of the same sex in order to vacate a room to allow admission to a person of the opposite sex,
to allow another resident to use specialized medical equipment that you no longer use, or
because you no longer need the specialized service offered in the area of the facility in which you are located.

Following the consultative process, the facility must give you written notice at least 15 days before any move based on the last four reasons stated above. The notice must include the reason for the transfer, the location to which you are being moved, and the name, address and telephone number of the Regional Ombudsman. In the case of an involuntary move because of repairs or renovations, you must be given at least 30 days written notice and returned to your original room if you so desire. Finally, if you are moved, the facility must then assess, monitor and adjust your care as necessary.

In a few limited circumstances, a facility can move you immediately without your consent:

to protect you or others from physical harm,
to control the spread of infectious disease,
to respond to a physical plant or environmental emergency that threatens your health or safety, or
to respond to a situation that puts you in immediate danger of death or serious physical harm.

If you are moved for one of these four reasons, the facility must give you a written notice within 24 hours of the move and, if practical, you must be returned to your room when the problem has been eliminated.

In addition, if Medicaid is paying for your nursing facility care and you are in a private room, the facility may move you to a semi-private room unless the move is medically harmful. The facility must give you at least 30 days written notice of this move and provide a consultative process as described in the previous section.

You also have the right to refuse a move from one room to another if the move is from a Medicare part of the facility to a non-Medicare part, or from a non-Medicare part to a Medicare part. Your refusal to move for this reason will not affect your eligibility or entitlement to Medicare or Medicaid.

IMPORTANT: If you receive notice of a room change and you do not want to change rooms, or if you are moved without your consent, contact your Regional Ombudsman or Legal Services office.

Can I be transferred or discharged from the facility if I go on Medicaid?

If you are a resident of a nursing facility that accepts both Medicare and Medicaid, a transfer or discharge solely because you go on Medicaid is unlawful. If the nursing facility does not accept Medicaid, you may be transferred to a nursing facility that does accept Medicaid.

Can I be transferred or discharged from one nursing facility to another?

You may be transferred or discharged from one nursing facility to another only under the following limited circumstances:

you no longer need the nursing facility services because your health has improved,
for your own welfare, if the facility cannot meet your needs,
you endanger the health or safety of the other residents,
you are a self-paying resident and do not pay your bill within 15 days after the facility has given you notice to pay your bill, or
the nursing facility closes.

NOTE: A transfer or discharge from one nursing facility to another nursing facility may include your being moved from one building, floor, or ward to another, if the portion of the facility to which you are being moved is certified as a separate nursing facility.

IMPORTANT:
In Connecticut, a nursing facility can never transfer or discharge you from one facility to another if the transfer or discharge is medically inappropriate.

What must the facility do before it can transfer or discharge me?

Generally, the nursing facility must give you, your guardian, conservator or legally liable relative a notice in writing, at least 30 days, and no more than 60 days, before a transfer or discharge from one facility to another.

The notice must include:

the reason for transfer or discharge;
the date of the proposed transfer or discharge;
the location to which the nursing facility proposes to transfer or discharge you;
your right to a hearing administered by DSS to contest the transfer or discharge,
the procedures you must follow to request a hearing;
the date by which you must request a hearing in order to prevent the transfer or discharge from occurring before the hearing is held. The date given must be at least 10 days from your receipt of the notice from the facility.
your right to represent yourself or have legal counsel, a relative, friend or other person represent you at the hearing;
if you are being transferred to a hospital, information regarding holding your bed and readmission to the facility; and
the name, mailing address and phone number of the State Long Term Care Ombudsman; or, if you are mentally ill or developmentally disabled, the Office of Protection & Advocacy.

Also, the facility is responsible for assisting you in finding appropriate placement.

Should the facility prepare a discharge plan for me?

If the nursing facility wishes to transfer or discharge you to another nursing facility, it must first develop a proper discharge plan.

The discharge plan must:

be developed by your doctor or the nursing facility’s medical director together with other medical staff;
consider the possibility of placement near your relatives, spouse, guardian or conservator;
include a written evaluation of the effects of the transfer or discharge on you and a statement of how the nursing facility will make the transfer or discharge less disturbing; and
outline the care and kinds of services which you will receive upon transfer or discharge.

Except in an emergency, the nursing facility must give you, your doctor, guardian, conservator or legally liable relative a copy of the discharge plan at least 30 days prior to the transfer or discharge.

Will Medicare or Medicaid pay the facility to reserve my bed when I am temporarily absent from the facility?

MEDICARE will not make any payment to the nursing facility to reserve a bed for a Medicare beneficiary. However, if you are also a Medicaid recipient, Medicaid bed-hold payments can be made.

MEDICAID will pay to reserve your bed for up to 15 days if you are hospitalized; and for up to 21 days per year if you are temporarily absent for other reasons, such as short visits to family or friends on holidays.

Can the nursing facility charge me or my family to reserve my bed?

Under Medicare, you cannot be charged to reserve a bed during a temporary absence if the services you will receive on your return will be covered by Medicare and you will be returning on a predictable date. If you do not meet this criteria, you may voluntarily pay to reserve your bed to assure that you can return to it.

Under Medicaid, once bed-hold payments have been exhausted, you, your family members, or others cannot be required to pay to continue to reserve your bed, but you may do so voluntarily to assure that you can return to your bed. The facility cannot charge you more than the per diem Medicaid rate.

NOTE: If payment to hold your bed has not been made or has been exhausted, but you wish to return to the same nursing facility, you will be entitled to the first available bed at that facility.

Can the nursing facility require someone else to agree to pay for my care?

The law states that a nursing facility may not require anyone else (such as a family member) to agree to personally pay for your nursing facility stay.

What is the Patients' Bill of Rights?

When you are admitted to a nursing facility, you will be given a copy of the Connecticut Patients' Bill of Rights. If a nursing facility denies you any right under the Patients' Bill of Rights, you can sue the facility. If you have questions or complaints, contact your Regional Ombudsman. (See "Regional Ombudsmen in Connecticut" below for phone numbers).

Is there an alternative to nursing home placement?

The Connecticut Home Care Program for Elders (CHCPE) provides services in the home to seniors who would otherwise be eligible for nursing home placement. To find out if you qualify for the CHCPE, call the Department of Social Services Alternate Care Unit at 1-800-445-5394. Also, if you have been living in a nursing home for at least six months, you may qualify for a new nursing home transition program called Money Follows the Person, which provides payment for goods and services that will help you return safely to the community. Contact DSS for more information.

Regional Ombudsmen in Connecticut

The State Long Term Care Ombudsman program advocates for the needs of residents in assisted living facilities, nursing homes and residential care homes.

State Ombudsman: 1-866-388-1888 or 860-424-5200

Regional Ombudsmen:
Western: 203-597-4181
Southern: 860-823-3366
Northern: 860-424-5221

For more information

Statewide Legal Services: (860) 344-0380 (Central CT & Middletown) 1-800-453-3320 (All other regions)

This pamphlet was produced by the Legal Assistance Resource Center of CT in cooperation with Connecticut Legal Services, Greater Hartford Legal Aid, New Haven Legal Assistance Association, and Statewide Legal Services.

The information in this pamphlet is based on the laws in CT as of July 2007. We hope that the information is helpful. It is not intended as legal advice for an individual situation. If you need further help and have not done so already, please call Statewide Legal Services (see above) or contact an attorney.