An advisory issued earlier this month warns people against using a series of adult portable bed rail models after at least three people — including one in a nursing home and another in an assisted living facility — were entangled in them and died of asphyxia.

The U.S. Consumer Product Safety Commission named the following 10 models of Mobility Transfer Systems adult portable bed rails in which it says users may become trapped, resulting in serious injury or death:

• Freedom Grip (model 501)
• Freedom Grip Plus (model 502)
• Freedom Grip Travel (model 505)
• Reversible Slant Rail (model 600)
• Transfer Handle (model 2025)
• Easy Adjustable (model 2500)
• 30-Inch Security Bed Rail, single-sided (model 5075)
• 30-Inch Security Bed Rail – Extra Tall, single-sided (model 5075T)
• 30-Inch Security Bed Rail, double-sided (model 5085)
• 30-Inch Security Bed Rail – Extra Tall, double-sided (model 5085T)

The Commission’s advisory “urges consumers to immediately stop use, disassemble, and dispose of” these bed rails, which have been on the market since 1992 and available through such online retailers as Walmart.com and Amazon.com.

Users can report any incidents related to these rails at www.SaferProducts.gov.

If you are injured due to another person’s negligence and receive Medicaid benefits to pay for care, the state has a legal right to recover the funds it spends on your care from a personal injury settlement or award. Yet in a legal case involving a Floridian teen who was catastrophically injured more than a decade ago, the U.S. Supreme Court this week ruled that states have the right to recover funds that they may spend on future medical expenses, too. 

The decision affects anyone who receives medical care through Medicaid after suffering a disabling injury that results in a lawsuit.  

In 2008, a truck struck 13-year-old Gianinna Gallardo, leaving her in a vegetative state. The state’s Medicaid agency provided $862,688.77 in medical payments on Gallardo’s behalf. Her parents sued the parties responsible, and the case eventually settled for $800,000, of which about $35,000 represented payment for past medical expenses. The settlement also included funds for Gallardo’s future medical expenses, lost wages, and other damages. 

The state Medicaid agency claimed it was entitled to more than $300,000 in medical payments from this settlement, including money that had been specifically allocated for Gianinna’s future medical expenses. 

Gianinna’s parents then sued the agency in federal court, arguing that the state of Florida should be able to recover monies only from that portion of the settlement allocated for past medical expenses. 

When a U.S. district court ruled in favor of Gianinna, the Medicaid agency appealed. A court of appeals reversed the lower court’s decision. Ultimately, the U.S. Supreme Court agreed to hear the case in order to resolve the conflict. 

In a 7-2 decision, the Supreme Court agreed that the state is allowed to recover benefits for Gianinna’s past — as well as future — medical care. Justice Clarence Thomas, who wrote the majority opinion, noted that Medicaid law “distinguishes only between medical and nonmedical care, not between past (paid) medical care payments and future (un-paid) medical care payments.”  

Justices Sonia Sotomayor and Stephen Breyer dissented. They argued that accepting Medicaid shouldn’t leave a beneficiary indebted to the state for future care that may or may not be needed. 

To read the full decision, click here.

While Medicaid helps pay for nursing home care, getting into a nursing home as a Medicaid recipient is not always easy. There are several ways to navigate the process, depending on your situation. 

With the median cost of a nursing home room being more than $250 a day, most families need help paying for long-term care. Medicaid is the primary method of covering the costs for nursing home care in the United States, but in order to qualify for Medicaid, an applicant must have limited income and assets. 

Generally, nursing homes will only accept patients who can pay for their care, while Medicaid will not pay for nursing home care unless an applicant is already living in a nursing home. This creates a predicament: How to get a loved one into a nursing home in order to receive Medicaid? The following are some of the methods you can use to find a nursing home that will accept your loved one:

• Private Pay. The easiest way to get into a nursing home is to be able to pay for care while the resident’s assets are spent down in order to qualify for Medicaid. Residents who can pay privately for a few months can file a Medicaid application once they are in the nursing home and start receiving benefits when the resident’s funds are below their state’s threshold for “countable assets.” Make sure the nursing home accepts Medicaid patients — and get the timing right so that the resident doesn’t run out of funds before the Medicaid application is approved. 

If the resident lacks the funds to pay for his or her own care, the resident’s family could pay. However, this is risky. The family will not be reimbursed if the resident eventually qualifies for Medicaid. It may be possible for the family to lend the money to the nursing home under a written agreement stating that the funds will be returned when the resident qualifies for Medicaid. 

• Medicare. Medicare provides nursing home coverage for up to 100 days of “skilled nursing care” per illness. The patient must enter the nursing home no more than 30 days after a hospital stay that had lasted for at least three days (not counting the day of discharge). The care provided in the nursing home also must be for the same condition that caused the hospitalization (or a condition medically related to it). In addition, the patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. And finally, Medicare covers care only for people who are likely to recover from their conditions. If a loved one meets these conditions, it is possible for them to enter a nursing home and immediately apply for Medicaid while Medicare pays in the meantime. 
   
• Medicaid Pending. There are some nursing homes that will accept a resident who has applied for Medicaid and is awaiting a response. Unfortunately, there are only a few nursing homes that accept Medicaid pending residents without some type of payment guarantee in the event the application is denied. The nursing homes that accept Medicaid pending residents tend to be those with lower ratings for nursing home quality.  

When moving into a nursing home, be careful about signing a nursing home admission agreement. Nursing homes may try to get families to agree to pay their loved one’s bills if a Medicaid application is denied. Read any agreement thoroughly and have it reviewed by your attorney. 

Navigating the Medicaid process is complicated. If possible, consult with an attorney before entering a nursing home and applying for Medicaid. To find an attorney near you, click here.

If you need a lot of cash on hand upon retirement, Social Security offers a lump-sum payment option that’s worth six months of benefits. However, it comes at a cost. It is important to understand the details before agreeing to the payment.

If you have waited beyond your full retirement age (66 for those born between 1943 and 1954) to begin collecting Social Security benefits, you have the option of asking for back payments. The maximum that Social Security offers is six months’ worth of retroactive payments in a lump sum. The downside is that by taking the lump sum, your retirement date and the amount of your monthly benefit are rolled back six months. 

When you delay taking retirement beyond your full retirement age, you amass “delayed retirement credits” that increase your benefits by 8 percent for every year that you wait, over and above annual inflation adjustments. By taking the lump-sum payment, you lose the delayed credits that you had accumulated over the previous six months, so your monthly benefit will be lower than if you did not take the lump sum — forever.  So, for example, if by taking the six months of retroactive benefits your regular monthly benefit is reduced by $150 and you live another 25 years, you're foregoing $45,000 over that span.  

Whether you should take the lump sum payment depends on a number of factors, including your life expectancy, your spouse’s needs, and what you will do with the new money. Taking the lump-sum payment makes more sense if your life expectancy is shorter. In this case, the immediate cash infusion will be more beneficial than bigger monthly payments. However, if you are married and are the higher earner, you will want to consider your spouse’s needs. If you die, your spouse will receive spousal benefits equal to the monthly amount of your benefits. The higher your benefit, the more your spouse will receive. 

You also need to consider what you will do with the lump-sum payment. If you are paying off high-interest debt or investing in something with a good rate of return, the lump sum might be better than having the higher monthly payment. 

For more information about Social Security, click here.

Medicare is part of the Social Security Administration (SSA), so if you need to enroll in Medicare, that’s whom you contact. But in recent months, phone lines at the SSA were experiencing major technical issues, preventing some individuals from being able to reach the SSA via telephone in a timely manner. These issues affected the SSA’s national 800 number as well as its field office general inquiry phone lines. At the same time, because of the pandemic, SSA offices had not been permitting in-person appointments until early April.

Certain beneficiaries — particularly those without Internet access — were therefore unable to reach the SSA before the end of Medicare’s annual general enrollment period, which typically closes March 31.

As a result, the Centers for Medicare and Medicaid Services (CMS) has announced it will provide what is known as equitable relief to anyone who, due to these challenges, was unable to submit their Medicare enrollment or disenrollment requests after January 1, 2022. These individuals will now have extra time — through Friday, December 30, 2022 — to submit Medicare Part A or Part B enrollment or disenrollment requests without penalty. This relief from penalties also applies to the 2022 Initial Enrollment Period and Special Enrollment Periods.

Individuals who were eligible to be on Medicare and incurred medical care costs during this time period can request retroactive Medicare coverage going back to January 1, 2022. Note, however, that premiums must be paid as a lump sum or else can be deducted from any Social Security benefits the individual currently receives.

Contact the SSA’s national 800 number at 1-800-772-1213 for more information, or find an SSA office near you via the SSA’s online office locator.

For more on Medicare, click here. 

The COVID-19 pandemic has caused nursing home staffing shortages across the United States, even forcing some nursing homes to close, but some states have been hit harder than others. A new analysis looks at which states are confronting the worst staffing problems. 

Overwhelmed by the stress of long hours, low pay and exposure to the COVID-19 virus, nursing home workers have been quitting in record numbers. According to the Service Employees International Union, more than 420,000 workers — nearly 10 percent of the workforce — left the long-term care industry between the start of the pandemic and January 2022. The labor hemorrhage has turned what was already a chronic staffing problem into a full-blown crisis as understaffed facilities struggle to care for patients, accommodate family visitation, and admit new patients waiting in hospitals to be discharged.

The online platform Seniorly, which helps families find senior living facilities, recently analyzed staffing data in all 50 states and identified which ones have been hardest hit. Overall, one-quarter of nursing homes in the United States had staff shortages as of the end of February 2022, but Minnesota was reporting the most, with 41 percent of facilities experiencing a scarcity of workers. Washington and Maine also had large numbers of facilities with insufficient staff (close to 38 percent in both states). 

According to Seniorly, the biggest shortages are among nursing workers (registered nurses, licensed practical nurses, and vocational nurses) and aides (certified nursing assistants, nurse aides, medication aides, and medication technicians). These are the employees who provide the most direct care to nursing home residents. Although fewer facilities (an average of 3.5 percent) are experiencing shortages of higher paid workers, such as physicians, physician’s assistants, and advanced nurse practitioners, the number of facilities with a dearth of even these types of workers has jumped almost a percentage point since 2020.   

While most states are enduring huge staffing problems, a few states are actually trending in the right direction. Arkansas, Connecticut, and Texas have fewer facilities reporting staffing shortages than in 2020. And California has the fewest percentage of facilities with staffing issues (about 2 percent). 

To read the full analysis and see how your state is doing, click here.  

In an alarming number of instances, private Medicare Advantage plans are denying coverage for medical services that would be covered under original Medicare, according to a federal investigation.  These denials are likely preventing or delaying medically necessary care for tens of thousands of Medicare Advantage beneficiaries each year.

The investigation by the Department of Health and Human Services’ Office of Inspector General found that 13 percent of Medicare Advantage plan denials should have been covered under Medicare.  The findings were based on a review by doctors and coding experts of service denials by 15 of the largest Medicare Advantage plans during the first week of June 2019.   Extrapolating from their findings, investigators estimate that nearly 85,000 beneficiary requests for medical care — everything from MRIs to skilled nursing facility care — could have been wrongly denied in 2019.

In an even higher proportion of cases, plans are incorrectly refusing to pay claims. Nearly one-fifth of claims that Medicare Adantage plans initially declined to pay were for services that met Medicare coverage and plan billing rules.  This translates to an estimated 1.5 million refused payments for all of 2019, which delayed or prevented payments for services that providers had already delivered.

Hidden Barriers to Care

Some 26 million Medicare beneficiares were in Medicare Advantage plans as of 2021, more than double the figure a decade ago.  The Congressional Budget Office projects that by 2030 more than half of Medicare beneficiaries will be in a private Medicare plan. Unlike original Medicare, where the federal government is the insurer, Medicare Advantage plans are run by private insurance companies. The government pays the plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The less money the plans spend on patient care, the more they and their investors make. In this way, plans have an incentive to keep costs down.

For many beneficiaries, Medicare Advantage plans’ most disagreeable cost-cutting strategy is “preauthorization” — the common requirement that doctors and other medical providers obtain the plan's approval before a beneficiary can receive certain medical services. If the plan administrators disagree that a procedure is medically necessary, the plan may refuse to pay for it.

Medicare Advantage plans often look attractive because they offer the same basic coverage as original Medicare at a seemingly lower cost, plus some additional benefits and services like vision and dental care that traditional Medicare doesn't offer. (One reason Medicare Advantage plans can offer such enhanced services is because the federal government gives them additional payments compared to original Medicare.) The inspector general’s report highlights one of Mediccare Advantage’s downsides.

“[B]eneficiaries enrolled in Medicare Advantage may not be aware that there may be greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare,” the report states.

One example highlighted in the report tells of a Medicare Advantage plan that refused to approve a followup MRI to find out whether an adrenal lesion was malignant because the lesion was allegedly too small. In fact, Medicare’s rules do not restrict the use of followup MRIs based on the the size of a lesion. (The plan reversed its initial denial on appeal.)

Denial Appeals Can Work

The report identified two common causes of service denials. First, even though Medicare Advantage plans’ clinical criteria cannot be “more restrictive” than Medicare’s coverage rules, plans often used tighter clinical criteria, such as requiring an x-ray before approving more advanced imaging. Second, plans often claimed that the request for services lacked sufficient documentation, even though investigators who reviewed the denied claims found that the existing medical records were sufficient to support the request.

When a Medicare Advantage plan denies a preauthorization or payment request, the beneficiary can file an appeal with the plan.  The inspector general found that when a beneficiary or provider appealed or disputed the denial of a service that met Medicare’s coverage rules, plans sometimes reversed the denial.  And in certain cases, Medicare Advantage plans corrected their own errors.

The inspector general’s report offers several recommendations for the Centers for Medicare and Medicare Services, which oversees Medicare Advantage plans, including better auditing of plans.   

To read the inspector general’s report, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” click here.  

For more on Medicare Advantage plans, click here.

 

 

If you apply for long-term care assistance through Medicaid and your application is denied, it may feel hopeless. The good news is that you can appeal the decision. 

Medicaid is a program for low-income individuals, so it has strict income and asset eligibility requirements. Qualifying for Medicaid requires navigating the complicated application process, which has many potential stumbling blocks. However, a Medicaid denial does not mean you will not eventually qualify for benefits. 

The Medicaid agency may deny a Medicaid application for a number of reasons, including the following: 

• Missing documentation. You need to show proof that you are eligible for benefits, which usually means providing Social Security statements, bank records, property deeds, retirement accounts, and insurance records, among other things. 
• Excess assets. In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in “countable” assets (in most states). 
• Transferred assets. If you transferred assets for less than market value within five years before applying for benefits, you may be subject to a penalty period before you become eligible for benefits. 

The Medicaid agency is required to issue the denial notice with 45 days of the application (or 90 days if you filed for benefits on the basis of a disability). When you get a denial notice, read it carefully. The notice will explain why the application was denied and specify how to file an appeal. 

Before filing a formal appeal, you can try informally asking the agency to reverse the decision. If you made a mistake on the application, this is the easiest and quickest way to proceed. If the caseworker made a mistake, it may be more complicated and require escalation to a supervisor or a formal appeal. 

Appealing a Decision
The denial notice will tell how long you have to file an appeal—the deadline may be as short as 30 days or as long as 90 days after the denial notice. It is important to file the appeal before the deadline. Whether the denial notice requires it or not, you should submit your request for an appeal in writing, so that there is a record of it.

Once your appeal is submitted, the Medicaid agency will set a hearing date. Applicants must attend the hearing or their cases will be dismissed. You have a right to have witnesses testify at the hearing and to question the Medicaid agency’s witnesses. It is a good idea to have an attorney to help you through the appeal process. An attorney can make sure you have all the correct documentation and information to present at the hearing. 

If you win the appeal, your benefits will be retroactive to the date of your eligibility—usually the date of your application. If you lose the appeal, the notice will explain how to appeal the decision. The next step in the appeal process usually involves submitting written arguments. If the next appeal is unsuccessful, then you will have to appeal to court. It is crucial to have the assistance of an attorney for this. 

Reapplying for Benefits
If your application was denied correctly due to excess assets or income, there are steps you can take to spend down your assets or put your income in a trust. Contact an attorney to find out what actions you can take to qualify for benefits. Once you do this, you can then reapply for benefits. Note that when you reapply for benefits, your eligibility date will change to the date of the new application. 

Leaving a nursing home to return home is a goal for many residents and their families, but it requires careful consideration. While returning home is a good move for some, it won't work for everyone.

A nursing home stay does not have to be permanent. Many residents enter a facility temporarily to recover from an illness or accident and are able to easily transition back to living at home. For residents who continue to need care but would rather be at home, moving out of a nursing home is more complicated. 

Before considering moving out of a nursing home, here are some questions to bear in mind:

• Can you receive the care you need at home? Some patients require help with eating, dressing, and going to the bathroom. You need to consider whether you can adequately get that care at home. 
• Who will be providing the care? The care can come from family members or hiring in-home health care. If family members aren’t available, is there money to hire help? All 50 states have Medicaid programs that offer at least some home care. You will need to check with your state to see if you qualify.  
• Will you be able to take the medications you need at home? 
• How is your physical and emotional stamina? Moving back home requires determination and an ability to manage problems, since not everything will be taken care of as in a facility. 
• Is the house set up to safely accommodate you? Are there a lot of stairs? Does the bathroom have rails? If the patient has dementia, there may be other considerations to take into account. 
• Is there transportation available to get to doctor’s or other appointments? 

If you determine that moving back home is the best option, then you can begin to craft a plan based on where you will live and who will provide care. Contact your local Area Agency on Aging to get help finding and coordinating services. 

There is a federal program called Money Follows the Person that is designed to make it easier for nursing home residents who qualify for Medicaid to move out. Currently, 34 states and the District of Columbia participate in the program, which provides personal and financial support to help eligible nursing home residents live on their own or in group settings.

For tips on transitioning from a nursing home to the community, click here.