The Administration reported today that the Affordable Care Act will save Medicare beneficiares 208 billion dollars through 2020 and save the Medicare program 200 billion dollars through 2016.

Regardless of whether those estimates are accurate, they raise the question again – ‘So What Happens Now with Health Care Reform?’

The Supreme Court is expected to hand down its decision on the constitutionality of the Affordable Care Act just prior to the July 4 congressional recess.

In brief, there are three key issues before the Court:

1) Is the Individual Mandate unconstitutional because Congress overstepped its bounds to regulate commerce?

2) Is the Medicaid expansion unconstitutional because it is coercive to the States?

3) If one piece of the bill falls, is the bill severable so that other pieces might survive?

This third issue — severability — is crucial. Should the individual mandate not survive, the Court may or may not uphold some of the “consumer protections” in the bill such as guranteed issue and community rating of insurance policies.

If the Court strikes the mandate but upholds the consumer protections, how would insurers be able to issue policies?

Most experts say that without everyone buying in to insurance through a mandate or some other mechanism, the resulting risk selection problems would make insurance cost-prohibitive for everyone. In general, healthy people wouldn’t buy it and sick people would.

Should this scenario occur, expect Congress to want to deal with this as quickly as possible to avoid the fallout from States and the public.

Spring has sprung, and like many people, I’ve spend the past few weekends sprucing up the yard and knocking off projects on my “honey do” list. All these home improvement projects got me thinking about what happens to a nursing facility resident’s house after he enters a Facility … must the home be sold in order to qualify for Medicaid benefits?

Depending on the state, nursing facility residents may not have to sell their homes in order to qualify for long term care Medicaid. In some states, like Pennsylvania and Colorado, the home will not be considered a countable asset for Medicaid eligibility purposes as long as the resident intends to return home. In other states, like Massachusetts, the resident must prove a likelihood of returning home in order to exclude the house. Because the rules vary from state to state and equity limits may apply, it is important to check the governing Medicaid regulations in your state. In all states and under the Deficit Reduction Act of 2005 (DRA), the house may be kept with no equity limit if the Medicaid applicant’s community spouse or another dependent relative lives there.

From a practical prospective, however, a resident may not be able to keep the home due to mortgage payments, property taxes, insurance and the costs of general upkeep. Thus, even though Medicaid regulations may not require the home be sold, the sheer financial reality of owning property may necessitate the home being placed for sale. Even if a home is excluded as an asset during the Medicaid eligibility process, once the home is sold, the proceeds are considered countable and must be spend down in accordance with applicable regulations. It is also crucial that any sale be for “fair market value” so as to avoid potential disqualification for Medicaid. As with so many issues, it is important to keep the lines of communication open with residents, their family members and other caregivers regarding plans for a resident’s home.

Happy Spring!

Janice works out of our Denver office with Mitchell Ronningen, Kali Backer and Sarah Thomas.

This November not only determines the next President of the United States, but also the political direction the nation will take. In addition to the presidential election, 33 Senate seats, the entirety of House of Representatives, and 11 Governorships will also face the polls. All of these races will have effects on the Affordable Health Care Act (ACA) and its integration (or lack thereof) into the heath care system.

The presidential election hinges on 12 to 15 swing states, but the deciding factor will likely boil down to just 4 to 6 key states. Should President Obama win re-election, even if the both Chambers of Congress are held by Republicans, the ACA would not be repealed. However, it is to be expected that the Senate and House would increase oversight of ACA implementation and closely scrutinize any future Obama nominees to the relevant departments implementing the ACA (Health and Human Services, Office of Management and Budget, etc)

In addition to the immediate ramifications to the ACA, the results of the upcoming elections will have great influence on the health reform environment for years to come. For instance, a Romney Administration likely would look favorably upon a “block grant” style approach to the Medicaid program and a voucher program for Medicare.

Control of the Senate in 2012 is uncertain. The Democrats currently have a 53-47 majority, but 21 Democratic seats are being contested while only 10 Republican seats and 2 Independent seats are in question.

Future healthcare legislation, including the proposed Ryan plan in the House of Representatives lives or dies by who prevails this November. The Ryan plan proposes inflation rates be held lower for health care spending than historical inflation rates in exchange for increased flexibility. Such a plan would likely have significant consequences to Medicaid and Medicare reimbursement for all providers.
By the time the general election is in full swing, the Supreme Court will have likely rendered its verdict on the constitutionality of key provisions of the Affordable Health Care Act (ACA).

While there are a variety of election permutations that could impact the health care landscape, it is worth keeping in mind that should the Supreme Court affirm the constitutionality of the ACA, it would likely take 60 votes in the Senate to repeal health reform, which is an unlikely outcome even if Republicans take control of the Senate. However, a Republican presidential administration would certainly have the ability to alter significantly the regulatory environment of health care reform.

Finally, regardless of whom controls the White House and Congress, recall that automatic cuts of $500 billion in defense and $500 billion in domestic spending are slated to go into effect in January 2013. Both Medicaid and Medicare certainly would be viable options for significant reductions as they were during consideration by the “Super Committee” late last year.

In Pennsylvania, after a facility receives a Medicaid eligibility determination for its resident, it must submit an invoice requesting payment within 180-days of services. Although 180-days seems like a long time to submit an invoice may facilities do not receive Medicaid eligibility determinations until well after 180-days have passed since the services were rendered to the resident. Many times this is due to no fault of the facility, but more often than not, a delay in processing the eligibility notice by the County Assistance Office. Luckily the “180-day invoicing,” promulgated in Section 1101.68 of the Pennsylvania Code provides an exception to the strict compliance with the 180-day invoicing

The exception states that if an invoice is submitted after the 180-day period it will be rejected unless an eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination. This means that if an eligibility determination is received after the 180-day period, as soon as the notice is received, the facility has 60 days to submit the invoice along with an exception request form. The exception request form can be found in the Medical Assistance Handbook and provides the facility with a place to document the expectation and demonstrate that the request falls within the exception category.

Keep in mind that even though there is an exception to the 180-day rule, strict compliance with the regulation is mandatory. Thus, facilities should strictly follow the regulation and fill out the forms and invoices correctly because claims that are granted an exception but denied through the claims processing system due to provider error will not granted additional exceptions!

Trisha works out of our Manhattan office with Monica Singh and Veanne Cao

The central figure in the Medicaid eligibility process is obviously the resident. However, family members and guardians of the resident also play an integral role. Much of the time they are just as committed to securing benefits as the facility. Other times, issues arise with family members and guardians that can complicate a resident’s application for Medicaid benefits. There are several issues to keep an eye out for that can make dealing with family members and residents easier and reduce complications in getting a resident qualified for Medicaid benefits:

1. Family members and guardians are sometimes wary of talking to an attorney, whose role in the Medicaid eligibility process they might not fully understand. While the attorneys at Schutjer Bogar do their best to explain their role to these third parties, reassurance from the facility that Schutjer Bogar is working on their behalf and in the best interests of the resident can go a long way to assuring family members and guardians that Schutjer Bogar is on the resident’s side.

2. When filling out an initial Medicaid application on behalf of a resident who is incapacitated, ask any family members or guardians for information they have on assets and resources, including bank accounts, life insurance policies and trusts. Listing these assets on the initial application gives the caseworker a clearer picture of the resident’s financial situation, allowing them to render an eligibility determination more quickly.

3. If a family member or guardian is dragging their feet and refusing to cooperate with the facility in filling out the initial Medicaid application or turning over a resident’s income that should be going to the facility, tell us as soon as possible so that we can begin the proper procedures, up to and including seeking the appointment of a new guardian or filing litigation to compel cooperation with the Medicaid eligibility process.

In the end, sitting down with a family member or guardian early in the process and explaining things to them can go a long way in making the resident’s Medicaid benefits application process go more smoothly. And if a family member or resident turns out to be uncooperative, Schutjer Bogar is ready to become involved and secure their compliance with the Medicaid eligibility process.

Brendan works in our Washington, DC office with Monica O’Connell, Erin Saylor and Lucretia Bailey