It can happen to anyone.  Our health declines and we need some help taking care of ourselves so our family pitches in to help.  They don't want us to have to move to a nursing home.  They want us to remain at home where we are most comfortable, surrounded by the people we love.

Families do amazing things to care for a spouse or parent who needs long term care.  But sometimes the need for medical and personal care becomes too much for the family to handle without outside help. Unfortunately, the price tag for that extra assistance with in-home care can be tremendous - way beyond the family's means.

Families who find themselves in this situation may be able to benefit from a program called the PDA 60+ waiver.  This program can help keep seniors who need a lot care at home for as long as possible. For those who qualify, the PDA 60+ waiver can pay for things like personal care, home health aides, nurses, medical supplies, home modifications, therapy and transportation.  The person in need of care must qualify both medically and financially, but this can frequently be accomplished with a little planning.     Currently almost 13,000 Pennsylvania seniors benefit from this waiver program. And this number is expected to increase substantially over the next year since funding for more "slots" will be available. 

In the past, one big limitation of the waiver program is that the state would not provide funding in excess of 80% of what it would have to pay if the person needing care resided in a nursing facility.  While this meant that the program could pay more than $3,000 a month to help with home care, individuals with more costly needs would have to enter a nursing home, although they could have remained at home with just a few more services. 

Now Pennsylvania is going to change the rules so that people with even greater needs will be able take advantage of the waiver program and remain at home.  It is anticipated that on July 1^st, the 80% cap on the cost of individual services will be lifted.  Pennsylvania will still have an 80% ceiling on the cost of waiver services, but that cap will be applied on an aggregate basis, state-wide, rather than on an individual basis.

Many people who receive waiver services don't come close to using their entire 80%.  As a result, on an aggregate basis, Pennsylvania has only been spending 40% of what nursing facility services would cost for all of the individuals in the program.  Some of those excess funds will now become available to pay for extra services for people with more severe needs.             

The change from an individual cap to an aggregate cap is just one of the initiatives the Pennsylvania Department of Aging is pursuing to allow more people to receive the care they need at home.

If you want to find out if the waiver program can help you and your family, call one of our geriatric planning specialists at 1-800-401-4552.

"Paperless, Electronic, and Online"

 The Make Over of U.S. Savings Bonds

Written By: Geriatric Planning Specialist, Michael Rentko                           

  In recent months the U.S. Treasury has taken steps to reduce the costs of their U.S. Savings Bonds Program and make it more efficient and accessible for individuals.  One of the biggest changes made by the Treasury is the phasing out of paper U.S. Savings Bonds.  The Treasury has already reduced the purchase of new paper bonds through the use of Savings Bonds Direct, a website that investors can use to purchase bonds directly from the Treasury.  The only remaining issuing sources of paper bonds are through a financial institution or through a payroll savings plan with an employer.  It is anticipated that both of these remaining sources will be phased out by the end of 2005.

"Paperless" U.S. Savings Bonds must be purchased through Treasury Direct http://www.savingsbonds.gov/. This is an online electronic account that allows users to track their bond investments. Currently the system does not permit a legal representative, legal guardian, or trustee to establish an account on behalf of an estate, decedent, trust, or incompetent person.  In order to create an account a person must link an existing banking account for purchases and redemptions.  An individual is given the option to purchase series EE or series I bonds ranging in value from $25.00 - $30,000 in penny increments.  This is a big change from paper EE and I Bonds which have fixed increments (and a minimum investment of $50 for I bonds).

Purchases are generally posted to your account within one business day of purchase.  An electronic bond must be held for a minimum of 12 months before it can be redeemed.  If the bond is redeemed prior to five years from the issue date, there is a 3 month interest penalty on the redemption value.  An individual can decide to make full redemption or partial redemption of the security. If a partial redemption is made, the individual must leave a minimum of $25 in the security. Bonds still mature in 30 years from issue; upon maturity, they will be liquidated and paid directly to the linked banking account.

For more information on U.S. Savings Bonds, please go to the website at www.savingsbonds.gov.

Does Your Club Or Organization Need A Speaker?

If you are interested in having an attorney or geriatric planning specialist from

The Elder Law Firm of Marshall, Parker & Associates' speak to your group, or at an upcoming event, please contact

our Director of Public Education, Melissa Bottorf

at mbottorf@paelderlaw.com or 1-800-401-4552

An Alphabet Soup for Saving on Medicare Costs: QMB, SLMB and QI

Written By: Jeffrey A. Marshall, CELA*

  There are a number of government programs that can help low income Medicare beneficiaries pay their Medicare premiums, deductibles and co-payments.  These programs are sometimes referred to as Medicare Savings Programs because they help people on Medicare save.  More frequently the programs are referred to by their acronyms (QMB and SLMB). QMB stands for the Qualified Medicare Beneficiary Program and SLMB for the Specified Low-Income Medicare Beneficiary Program.  In order to qualify, Medicare beneficiaries must be eligible to enroll in Medicare Part A, be within the program's asset limits, and meet the program's income guidelines (which change annually on April 1^st). 

QMBs are individuals who are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less ($776 for individuals and $1,041 for couples in 2004) and have resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples).  States are required to pay the deductibles, co-insurance and premiums for Medicare Part A and Part B for QMBs. The state's obligation also applies to beneficiaries who enroll in a Medicare Advantage (HMO or PPO managed care) plan.

SLMBs are individuals who would qualify as QMBs except that their incomes are higher - between 100% and 120% of the federal poverty level. States are required to pay only the Part B premiums for SLMBs. 

As part of the Balanced Bud get Act of 1997, special block grant funding was provided to pay the Part B premiums for beneficiaries with even higher incomes of between 120% and 135% of the federal poverty level. These higher income individuals are known as "Qualified Individuals" (QI-1s).  The QI benefit has been set to expire at various times, but has been extended several times. Since these are block grant federal funds (rather than a Medicaid cost sharing program), there is a limit to the amount of funds available to the state, and thus a limit on the number of QI participants each year. 

Individuals age 65 or older who are not eligible for Medicare Part A without a premium may conditionally enroll in Part A, provided they meet the requirements (at least age 65 and a legal U.S. resident for the past five consecutive years). They can then apply for a Medicare Savings Program. Once eligible for the QMB program, the state will pay both the Part A and Part B premiums. If eligible for the SLMB or QI program, the state will pay only the Part B premium.

Medigap (Medicare Supplement) insurance premiums are not covered by any of these programs. Note, however, that if an individual qualifies for the QMB program, Medigap insurance may be unnecessary, unless the Medigap policy covers services beyond those which are subject to Medicare cost sharing. 

Definitions of Medicare Savings Program Beneficiaries

1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less ($776 for individuals and $1,041 for couples in 2004) and resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples), and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and co-insurance for Medicare services provided by Medicare providers.

2. QMBs with full Medicaid (QMB Plus) - These individuals are entitled to Medicare Part A, have income of 100% FPL or less ($776 for individuals and $1,041 for couples in 2004) and resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples), and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance, and also provides full Medicaid benefits.

3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL ($931 for individuals and $1,249 for couples in 2004) and resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples), and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.

4. SLMBs with full Medicaid (SLMB Plus) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL ($931 for individuals and $1,249 for couples in 2004) and resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples), and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits.

5. Qualifying Individuals (QI-1s) - There is an annual cap on the amount of money available, which may limit the number of individuals in this group. These individuals are entitled to Medicare Part A, have income of at least 120% FPL, but less than 135% FPL, ($1,048 for individuals and $1,406 for couples in 2004), resources that do not exceed twice the limit for SSI eligibility ($4,000 for individuals and $6,000 for couples), and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.

Pennsylvania also has a "Healthy Horizons Categorically Needy Program" for the elderly and disabled which not only pays Part A and B premiums, deductibles and coinsurance, but also provides medical benefits including prescription drug coverage (that is better than PACE), doctor or clinic visits, dental and eye care. For the Healthy Horizons Categorically Needy Program, resources may not exceed the SSI resource standards ($2,000 for individuals and $3,000 for couples) and income may not be greater than 100 percent of the Federal Poverty Income Guidelines.  

Where to Apply

To apply for these programs individuals should contact their local Department of Public  Welfare County Assistance Office.  A listing of County Assistance Offices is available at:

http://www.dpw.state.pa.us/general/dpwcao.asp

Seniors may also inquire at their local Area Agency on Aging.  A listing of Area Agencies on Aging is available at:

http://www.aging.state.pa.us/aging/cwp/view.asp?a=275&Q=177124

Federal Court Says Medicaid Beneficiaries Can

 Sue to Enforce Rights

Written By: Jeffrey A. Marshall, CELA*

  On May 11th, the Federal 3^rd Circuit Court of Appeals issued its opinion in Sabree v. Richman.  In a victory for individuals seeking to enforce their rights under the Medicaid laws, the court held that four MR individuals have the right to sue Pennsylvania for services to which they are entitled under Medicaid. 

The plaintiffs sued under 42 U.S.C. §1983 claiming that Pennsylvania was in violation of 42 U.S.C. §1396a(a)(8) which requires Pennsylvania to provide assistance with reasonable promptness to all eligible individuals.  The Department of Public Welfare (DPW) did not deny that it was in violation of this Medicaid requirement. Instead, DPW claimed that the individuals who were being denied benefits had no right to sue the state to force it to comply.  DPW claimed that only the Secretary of Health and Human Services was allowed to enforce the rules.

The Court disagreed with DPW.  It held that the sections of the Medicaid laws under consideration clearly and unambiguously conferred rights on the plaintiffs and did not preclude them from pursuing those rights in court.  The 3^rd Circuit distinguished the U.S. Supreme Court's decision in the Gonzaga University case. 

The court also noted that the plaintiffs did not have to rely solely on the administrative appeal procedures DPW had established.  They could go to federal court and sue under the federal law - §1983.  Unfortunately, the Sabree case may be more representative of the past than the future.  In a concurring opinion, Judge Alito noted that the direction of the law is towards narrowing the individual right to sue the state in situations like this.   

Here is a link to the case. http://caselaw.lp.findlaw.com/data2/circs/3rd/031226p.pdf

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*Attorney Marshall is certified as an Elder Law Attorney by the National Elder Law Foundation under authorization from the Pennsylvania Supreme Court

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