How does the look-back period affect a person’s eligibility for Medi-Cal benefits?

Tuesday, Jan. 25th 2022 3:26 PM

In California, any transfer of a non-exempt asset (also called “countable”) within 30 months of an individual’s application for Medi-Cal for nursing facility level of care may result in a period of ineligibility. This period of ineligibility will only apply to the nursing facility level of care and, if
otherwise eligible, the individual would be eligible for all other Medi-Cal covered services. Remember, the look-back period does not apply to those assets that are exempt (also called “not countable”). The most common exempt asset is the individual’s principal residence. The period of ineligibility is determined by dividing the average private pay rate (APPR) in California, currently $4,322, into the value of the transferred non-exempt asset. Let us take a look at the following example:

Ten months prior to Ms. Peabody’s (a single individual) application to Medi-Cal to pay for her stay at Sunnyside Nursing Facility, she transferred $200,000 from her bank account to her son John. She meets all other eligibility requirements for Medi-Cal. Would Ms. Peabody have a period of ineligibility for payment to the nursing facility as determined by her eligibility worker? If so, what would be the period of ineligibility?

Yes, Ms. Peabody would have a period of ineligibility of 21 months. Here is how it is calculated:

The first step taken by the eligibility worker would be to determine the maximum period of ineligibility. This is accomplished by dividing the value of the $200,000 non-exempt transfer by the APPR for 2002, which is $4,322. For this example, the calculation results in 46 months. OBRA 93 (Omnibus Budget Reconciliation Act) lifted the ceiling on the maximum period of ineligibility. Remember, however, that the maximum period of ineligibility in California is still 30 months. In this example, the transfer took place 10 months prior to Ms. Peabody’s application for Medi-Cal. In determining the actual period of ineligibility, the eligibility worker would start counting beginning with the 10th month and continue through the 30th month. The ineligibility period would thus be 21 months. Medi-Cal would not begin to
pay for Ms. Peabody’s nursing facility costs until another 21 months had passed.

The period of ineligibility is always the lesser of one of the following: – 30 months; or – the number of months obtained by dividing the value of the transfer by the APPR; or – the difference between 30 months from the date of the transfer and the date of application for Medi-Cal benefits, inclusive. In other states, the look-back period and the period of ineligibility may differ from that used in California.

Posted on Tuesday, Jan. 25th 2022 3:26 PM | by Share of Cost | in Medi-Cal, Share of Cost | No Comments »

Does Medi-Cal pay for Residential Care Facilities for the Elderly

Saturday, Jan. 22nd 2022 5:21 AM

Currently, Medi-Cal does not pay for board and care in a RCFE, since RCFE care is not considered to be medical care. In addition, RCFE’s are not licensed as medical care providers. Medi-Cal does, however, allow an individual to retain income each month, up to the amount of the monthly charge of the facility, as long as the person requires and is receiving custodial care within the facility. If an individual is residing in an RCFE simply because the individual enjoys the luxury of not having to cook, clean and do laundry, Medi-Cal does not allow the individual to retain the additional income. If the individual is residing in the facility, however, because he or she requires assistance and needs custodial care, MediCal allows the individual to retain more of his or her income.

For example, a single individual residing in a RCFE receives $1,000 a month from Social Security and the RCFE charges $1,000 per month.

This individual would normally only be able to retain $600 per month because he or she is not residing in a hospital or intermediate or skilled nursing facility. Because he or she requires custodial care in an RCFE, the county allows the individual to retain $600 per month and considers the remaining $400 per month “unavailable” (similar to an income deduction) because the facility charge is $1,000 per month. This individual, then, has a zero share of cost and Medi-Cal pays all of the individual’s medical expenses
in that month for Medi-Cal covered services. If, however, the facility charges only $900 per month, the county will consider only $300 per month (in addition to the $600) as “unavailable”. In this case, the individual has a share of cost of $100 per month that he or she pays or obligates him or her to pay on medical expenses before Medi-Cal pays the remainder of Medi-Cal covered services.

Posted on Saturday, Jan. 22nd 2022 5:21 AM | by Share of Cost | in Medi-Cal, Share of Cost | No Comments »

ShareofCost.com – Acid Reflux Disease

Monday, Jan. 17th 2022 3:12 PM

The risk of esophageal cancer among patients who suffer from gastroesophageal reflux disease (GERD) is not as high as many may think, according to new research from University of Michigan gastroenterologists. GERD is considered a relative risk for developing esophageal adenocarcinoma, but the absolute risk is not known, says Joel Rubenstein, M.D., M.Sc.

Posted on Monday, Jan. 17th 2022 3:12 PM | by Share of Cost | in Medi-Cal, Share of Cost | No Comments »

Share of Cost: Spanish Medicare Fraud; Prevention PSA is on Youtube

Wednesday, Nov. 9th 2011 3:29 PM

The National Hispanic Senior Medicare Patrol (NHSMP) has launched a new outreach and communications campaign, which includes a Spanish language public service announcement (PSA).  The PSA is currently being aired in South Florida through mid-September.

The PSA, titled El Fraude al Medicare es un Delito. Denúncielo. (Medicare Fraud is a Crime. Report It.), is part of the NHSMP’s Spanish language communications toolkit.  It was developed based on a needs assessment conducted to gauge the perceptions of the community and understand why they were underreporting Medicare fraud. NHSMP found that although a majority of seniors could identify Medicare fraud, they didn’t know how to report it or felt overwhelmed by their lack of English skills to communicate effectively.

The PSA is posted on Youtube. We encourage you to share it, post it on your webpage and help get the word out on how to stop and prevent Medicare fraud and abuse. For additional Spanish resources, see the available educational outreach and communications tools on the NHSMP webpage. You can also see our Medicare Fraud resources section for additional Spanish materials.

Posted on Wednesday, Nov. 9th 2011 3:29 PM | by Share of Cost | in Social Security | No Comments »

Share of Cost: Medigap Cost-Sharing Changes Meet Diverse Opposition

Monday, Nov. 7th 2011 6:29 AM

A provision in the 2010 federal health care reform law calls for changes in Medigap policies that essentially shift the burden of health care costs more onto the hands of beneficiaries. Several members in Congress have come to the unsubstantiated conclusion that because some Medigap plans (the most popular ones, C and F) cover most of the costs Medicare doesn’t — hence this insurance is referred to as MediGAP, beneficiaries use more services than they need. Therefore, they claim that Medicare pays more health care costs for these beneficiaries than others. To to help reduce these costs and hence the federal deficit, Congress has asked the National Association of Insurance Commissioners (NAIC) to propose changes to these Medigap plans so that beneficiaries pay more out-of-pocket for their health care.  The Congressional Budget Office estimated in March that such changes could save the government $53 billion in Medicare spending over a decade by strengthening incentives “for more prudent use of medical services.”

Yet despite this request, as written in the health care reform law, an unlikely group of health insurance regulators, insurers and consumer advocates are raising opposition to these Medigap changes. In several interviews with reporters, Bonnie Burns, our Training and Policy Specialist who also serves on the NAIC, points out some substantial flaws or blind spots in Congress’ thinking. First, she strongly questions the idea that beneficiaries need an incentive not to use services. After all, physicians are the ones who order services, not the beneficiaries. Also, although some studies have found that seniors with Medigap policies use more Medicare services, they may be sicker than the average Medicare beneficiary, which is why they bought Medigap coverage in the first place.

“To suggest that Medicare beneficiaries overutilize services on a whim because they don’t have ‘skin in the game,’ is pretty disturbing,” says Burns, as quoted in a recent article on Kaiser Health News.

Second, Mary Beth Senkewicz, Florida’s deputy insurance commissioner, who chairs the NAIC’s senior issues committee, which includes the Medigap group, questions the legality of making changes that apply to Medigap policies beneficiaries have already purchased. The policies are contracts between the insurer and the beneficiary which contain certain promises of coverage. When state regulators require changes in insurance, those typically apply to future policies only, not to existing ones as well.

Similar to Burns’ point of Medicare beneficiaries not being directly responsible for their higher health costs noted above, several members of this group have also suggested that Medigap policies are not responsible for Medicare’s growing costs. These carriers, the Medigap plans, only pay for services that Medicare deems to be medically necessary. Those determinations are not made by the Medigap insurance company.

In Conclusion

Some of Congress’ proposed Medigap changes dramatically shift costs onto seniors, leaving members of diverse interest groups concerned for good reasons. Medigap insurance has long been a product that has worked well for many benficiaires, currently 7 million, which comprise about 1/6 of the population with Original Medicare. These policies have helped maintain beneficiaries’ peace of mind, knowing that they have coverage for the gaps in Medicare. Putting this coverage in jeapordy may not be the best or even a mediocre move to help save some money to help the federal budget deficit, especially when savings aren’t even a guaranteed outcome.

For more information on this issue, see the following articles:

  • Changes to Medigap Plans Meet Resistance
  • Lawmakers Propose Cuts to Medicare and Medigap Coverage
Posted on Monday, Nov. 7th 2011 6:29 AM | by Share of Cost | in Social Security | No Comments »

Share of Cost: Watch Out for the American Opportunity Act Scam

Saturday, Nov. 5th 2011 6:29 AM

Did you know that by calling a special 1-800 number you may qualify to receive $500 from the American Opportunity Act?  By providing your Social Security number, date of birth and other personal information, in just 4 weeks you will receive a Visa Check card ready to be loaded with money.  Sound too good to be true?  Well it is!

Scam artists are continually misusing real information in an effort to steal beneficiaries’ money and their personal information.  There is no program called the American Opportunity Act that just gives away money.  But as part of the American Recovery and Reinvestment Act, parents and students can qualify under the American Opportunity Tax Credit to pay for college expenses.

We encourage people to never give their personal information out to strangers.  This type of information is used to not only commit identity theft but also to commit medical identity theft as well as stealing money from the health care system in the form of Medicare fraud. To learn more about our California SMP and how you can prevent Medicare fraud and abuse, see our Medicare Fraud section.

Posted on Saturday, Nov. 5th 2011 6:29 AM | by Share of Cost | in Social Security | No Comments »

Share of Cost: Consumers Beware of Medicare Advantage Marketing Fraud

Thursday, Nov. 3rd 2011 6:29 AM

Last week Julie Schoen, our California Senior Medicare Patrol (SMP) Project Director, spoke on Medicare fraud on a statewide press teleconference hosted by California’s Department of Managed Health Care (DMHC). Both agencies, DMHC and SMP, are committed to protecting beneficiairies from the sometimes malicious and fraudulent practices of a few insurance agents. While most agents may be trustworthy, DMHC has reports of several who are trying to persuade seniors to switch from their current health plan to the Medicare Advantage (MA) plan they are selling even though it is not in their best interest, and sometimes even without their consent.

DMHC put together a helpful 2-page consumer alert (PDF) that summarizes 7 red flags to watch out for when being approached by an insurance agent, and 10 actions to take before signing up for any new health plan. See Medicare Fraud for more info on fraud. Also see Medicare’s Fall Open Enrollment to learn about your rights to switch MA and Part D plans or return to Original Medicare during Oct 15 through Dec 7.

Posted on Thursday, Nov. 3rd 2011 6:29 AM | by Share of Cost | in Social Security | No Comments »

Share of Cost: Medicare’s Fall Open Enrollment Has Begun ~ Oct 15 – Dec 7

Tuesday, Nov. 1st 2011 6:29 AM

Medicare’s Fall Open Enrollment, officially known as the Annual Enrollment Period (AEP) starts and ends earlier now. From October 15 – December 7, beneficiaries can change their Medicare health plan and Part D coverage and/or return to Original Medicare. Coverage changes become effective January 1, 2012.

Learn more about the AEP and other enrollment periods. Beneficiaries can also contact their local Health Insurance Counseling and Advocacy Program (HICAP) for free counseling and information on their health care options in their area.

Posted on Tuesday, Nov. 1st 2011 6:29 AM | by Share of Cost | in Social Security | No Comments »

Share of Cost: California Beneficiaries Hit Hard by Medicare Advantage Plan Pull-outs

Sunday, Oct. 30th 2011 6:29 AM

Almost 151,000 beneficiaries in California are in a Medicare Advantage plan that is pulling out of Medicare in 2012. This means these plans are not renewing their Medicare contracts, their plans are terminating by the end of the year, and beneficiaries enrolled in these plans need to choose a new coverage option for 2012. With a total of 301,912 beneficiaries nationwide affected by such terminations, 50% are in California.  Anthem Blue Cross is the reason for this high percentage of affected beneficiaries. They decided not to renew two regional PPO plans, the Freedom Blue plans, which have 113,709 enrollees or 75% of affected beneficiaries statewide.

Anthem Blue’s explanation for not renewing these popular regional PPO plans is “to ensure that we manage our operational and financial stability so that we can continue to support our member’s needs today and in the future.”  Other Medicare Advantage plans that are not renewing account for the remaining 25% of affected beneficiaries.  Some of these plans may be terminating because of low enrollment.

What can beneficiaries in this situation do?

Beneficiaries who are affected by these non-renewals should have received a notice from their plan on or before Oct 2nd informing them about their upcoming termination and that they have a Special Election Period (SEP) to join another plan.  They also have the option to return to Original Medicare, enroll in a stand-alone Part D prescription drug plan, and use a Guaranteed Issue right to purchase a Medigap policy without a health screening, a form of Medicare supplemental insurance. See When MA Plans Terminate for more info.

Beneficiaries who want to use their SEP to join another Medicare health plan may or may not have many plan options to choose from depending on which county they live in. Generally, beneficiaries in southern California have many Medicare Advantage plan options, especially HMOs, whereas beneficiaries in northern California have fewer Medicare Advantage plan options.  In urban areas in northern California, some counties have a few HMO plans, and in rural areas, some counties have private fee-for-service (PFFS) plans only.

Although there are no counties without any Medicare Advantage plan options, a few counties have options that are not affordable or suitable.  For example, four counties – Marin, Nevada, Sutter and Yuba – each have only one Medicare Advantage plan in 2012, and the premiums of these plans range from $79.60 to $99, much higher than the current Freedom Blue PPO which has a $0 premium.  Another example is Santa Cruz county which will have two Medicare Advantage plans next year, but the premiums are high: one HMO with prescription drug coverage at $192 and one HMO without prescription drug coverage at $89. Beneficiaries who want a Medicare Advantage plan and prescription drug coverage have to choose the HMO with prescription drug coverage because of a rule that a beneficiary cannot combine an HMO with a stand-alone Part D plan.

Three counties – San Benito, Tehema and Tuolumne – illustrate another problem. Each county has only a private fee-for-service plan; they have no local HMO or PPO plans.  Many doctors do not accept the payment terms and conditions of these private fee-for-service plans.  Thus a private fee-for-service plan enrollee may have coverage but no access to his or her doctor.

Sponsors of plans that are not renewing are trying to get affected beneficiaries to enroll in the sponsor’s other plans, such as other MA plans or stand-alone Part D plans.  Anthem Blue, for instance, is offering local PPO plans in 13 counties and three Part D plans statewide.  Insurance companies that sell Medigap policies, including some sponsors of Medicare Advantage plans, are also targeting affected beneficiaries since these beneficiaries have a guaranteed issue right to buy a Medigap policy.  Beneficiaries should look at all their options and not just the plans offered by one sponsor.  To find out about their options, beneficiaries’ best bet is to contact their local HICAP (Health Insurance Counseling & Advocacy Program) at 1-800-434-0222.  Local HICAPs provide objective Medicare benefits counseling at no cost, such as helping a beneficiary compare the difference between Medicare Advantage plans and Medigap, or finding and comparing Part D prescription drug plans.

All Medicare beneficiaries can make changes involving a Medicare Advantage or Part D plan during the Annual Election Period, also called Fall Open Enrollment, which is earlier this year, from October 15 to December 7.  A beneficiary who is in a non-renewing plan also has a Special Election Period from Dec 8 to Feb 29, which gives them more time to make a change.

See our website for more information on the AEP and your rights if your Medicare health plan is terminating coverage.

Posted on Sunday, Oct. 30th 2011 6:29 AM | by Share of Cost | in Social Security | No Comments »

Share of Cost is calculated independently for CMSP and Medi-Cal

Tuesday, Oct. 25th 2011 6:03 AM

SOC policy also applies to County Medical Services Program (CMSP) providers and subscribers. Share of Cost is calculated independently for CMSP and Medi-Cal, however, the same subscriber income is included in both calculations. Therefore, the same medical expenses may be used to clear SOC for both programs.  Providers may apply the same services used to clear a Medi-Cal SOC obligation to clear a CMSP SOC obligation.  Two separate transactions are required.  Clearing Share of Cost for one program does not automatically clear SOC for the other program.

Posted on Tuesday, Oct. 25th 2011 6:03 AM | by Share of Cost | in Share of Cost | No Comments »

Share of Cost Case Summary

Sunday, Oct. 23rd 2011 6:01 AM

Your Medi-Cal case has been affected by a lawsuit called Sneede v. Kizer.  This lawsuit limits which family members may use medical expenses that are not billed to Medi-Cal to meet their family’s Share of Cost. If you are a spouse or a parent, you have the choice of listing your medical expenses in any case number on the reverse side of this form in which your name appears.  You may list all your medical expenses in a single case number, or you may divide up the expense and list it in two or more case numbers in which your name appears.  However, the total being reported for the single service cannot be more than the original bill.

If you are a caretaker relative such as a grandparent, aunt, uncle, etc., your medical expenses may only be listed in the case number in which your name appears. If you are a minor mother, a mother under the age of 21 years who lives in the home with her parent(s), you may list your medical expenses in both the case number with your parent(s) and again in the case number where you are in an aid code “IE” with your child.  The same medical expense for minor mothers should be listed TWICE IN FULL.  The medical expense is never divided up. IMPORTANT:  A person listed as “IE” or “RR” in the aid code section on the reverse side of this form will not receive Medi-Cal benefits when the Share of Cost for that case number has been met.  In order to receive Medi-Cal benefits, this person must meet the Share of Cost for a case number where the person is not listed as an “IE” or “RR.” This summary does not guarantee Medi-Cal eligibility.  This summary only shows which members of the family have a Share of Cost for Medi-Cal. Note:    “IE” means ineligible and “RR” means Responsible Relative.

According to the Sneede v. Kizer lawsuit, a subscriber’s eligibility and SOC must be determined using his/her own property.  Children and spouses within the same family may have varying SOCs and, therefore, multiple case numbers listed on the Share of Cost Case Summary form. Sneede v. Kizer cases may result in the following scenarios: 1.    A mother has medical expenses totaling $75 that have not been billed to Medi-Cal.  The mother has a Share of Cost Case Summary form that lists her in two separate cases.  She is listed with an “RR” code with her child and she is listed by herself with aid code 37.  She may do one of the following: •    Apply the entire $75 to her own $100 SOC. •    Apply the entire $75 to her child’s $125 SOC. •    Apply any amount less than $75 to her SOC and the balance of the $75 to her child’s SOC.  The total amount reported cannot exceed the original $75. 2.

The Smith family consists of a stepfather (husband), a mother (wife) and the mother’s separate child.  The wife and her husband are listed together on the Share of Cost Case Summary form as eligible subscribers with a $100 SOC.  The mother is listed as an “RR” with her child in the second case with a $125 SOC. The mother has medical expenses totaling $100 that have not been billed to Medi-Cal.  She may do one of the following: •    Apply the entire $100 to her own $100 SOC. •    Apply the entire $100 to her child’s $125 SOC. •    Apply any amount less than $100 to her SOC and the balance of the $100 to her child’s SOC.  The total amount reported cannot exceed the original $100. In all other cases that do not involve a natural or adoptive parent, Share of Cost can be cleared only for a person’s own medical expenses.  Examples: •    Caretaker relatives (such as a grandparent, aunt or uncle) can use their medical expenses to clear only their own Share of Cost. •    Children can use their medical expenses to clear only their own Share of Cost.

A minor mother is listed on the Share of Cost Case Summary form with an “IE” (ineligible) or “RR” aid code in the same case with her child.  In addition, the minor mother also may be in a second case, either listed with her parent(s) or in her own case.  In this situation only, full medical expenses may be used to clear SOC in both cases.  Two separate transactions are required. A minor mother is defined as a mother under the age of 21 who resides in the home of her parent(s).

Posted on Sunday, Oct. 23rd 2011 6:01 AM | by Share of Cost | in Share of Cost | No Comments »

Reversing Share of Cost Transaction

Friday, Oct. 21st 2011 6:57 AM

To reverse SOC transactions, providers enter the same information as for a clearance but specify that the entry is a reversal transaction.  After the SOC file is updated, providers receive confirmation that the reversal is completed.  Once a subscriber has been certified as having met the Share of Cost, reversal transactions can no longer be performed.  Reversals may only be performed for partial clearance prior to the time the subscriber is certified as eligible.

Posted on Friday, Oct. 21st 2011 6:57 AM | by Share of Cost | in Share of Cost | No Comments »

Share of Cost, Medi-Cal, NICE Consults On Draft Guideline On Food Allergies In Children

Sunday, Oct. 3rd 2010 6:32 AM

NICE has opened the consultation on its draft clinical guideline on the diagnosis and assessment of food allergies in children and young people. Its aim is to support GPs and other health professionals in primary care and community settings in recognising the signs and symptoms of food allergy, by giving clear recommendations on taking allergy-focussed histories to assess the condition.

Posted on Sunday, Oct. 3rd 2010 6:32 AM | by Share of Cost | in Share of Cost | No Comments »

Share of Cost, Medi-Cal, Link Between Acetaminophen Use In Adolescents And Doubled Risk Of Asthma

Saturday, Oct. 2nd 2010 6:32 AM

New evidence linking the use of acetaminophen to development of asthma and eczema suggests that even monthly use of the drug in adolescents may more than double risk of asthma in adolescents compared to those who used none at all; yearly use was associated with a 50 percent increase in the risk of asthma.

Posted on Saturday, Oct. 2nd 2010 6:32 AM | by Share of Cost | in Share of Cost | No Comments »

Share of Cost, Medi-Cal, Also In Global Health News: HIV In Cities; NIH Director’s Role In Global Health; Access To Healthcare In Kenya; Food Aid In Ethiopia; More

Saturday, Oct. 2nd 2010 6:32 AM

UNAIDS Calls On Cities To Enhance Response To HIV; China Vows To Step Up Prevention UNAIDS has “issued a call for cities to ‘take the lead in making HIV history’ by enhancing their response to the epidemic,” UN News Centre reports.

Posted on Saturday, Oct. 2nd 2010 6:32 AM | by Share of Cost | in Share of Cost | No Comments »

Hello world! Share of Cost …

Monday, Jul. 26th 2010 2:39 AM

Welcome to ShareofCost.com which provides a consumer forum for helping Medi-Cal, Medicaid, Medicare, and other beneficiaries find a dental insurance plan to meet their threshold for Share of Cost.

Posted on Monday, Jul. 26th 2010 2:39 AM | by Share of Cost | in Dental Insurance, Share of Cost | 1 Comment »