April 2016

Ohio Medicaid changes “Aged Blind Disabled” Eligibility

Posted on April 28, 2016 by Jim Koewler — No Comments ↓

Ohio Medicaid will change its rules on who can participate in the Medicaid Aged, Blind, and Disabled (“ABD”) program. The change will take effect in July 2016 for new applicants and will take effect with the annual renewals for existing Medicaid enrollees starting in January 2017. (The dates are subject to federal approval.) Ohio’s aim is to spend less on Medicaid. (It is a HUGE part of the state budget.)

Under federal Medicaid law, states can choose from two different ABD eligibility systems (meaning that the states can choose from two different SPENDING systems for their ABD programs.) The Ohio Department of Medicaid and the Ohio Department of Health Transformation, with a supporting change in the law by the state legislature, will change Ohio’s ABD Medicaid program from following section 209(b) of the federal Medicaid law to following section 1634 of the federal Medicaid law. Under the 209(b) system (the one that Ohio is leaving,) the states can make certain of their own choices on who is eligible for ABD coverage. Under the 1634 system (the one into which Ohio is moving,) the states must follow federal guidelines on eligibility.

The biggest differences between most states’ (including Ohio’s) 209(b) eligibility rules and the federal rules were in financial eligibility. States that followed 209(b) could have limits on income and assets that were tighter than the federal standards. That gave the appearance of keeping more people off of Medicaid ABD coverage than federal rules would have allowed.

Ohio’s rules under its 209(b) sy(tem (the old system) allowed people who had medical expenses to reduce their countable income by the amount of those medical expenses. This is called a “monthly spend down.” That spend down measurement allowed some people who had too much income “back” into Medicaid coverage. (A future installment will discuss the spend down in more detail.) The new system (under section 1634) will not allow spend downs to reduce countable income.

People with too much income won’t be left without coverage. People who have too much income to qualify for Ohio’s ABD Medicaid will be eligible for private insurance under the Affordable Care Act. Most anyone who would have qualified for ABD coverage through a spend down under Ohio’s old system will probably qualify for a highly subsidized, cost-controlled insurance policy through HealthCare.gov.

Many states followed 209(b) before the Affordable Care Act and its subsidy and cost control requirements made commercial policies affordable to more people. Many of those states have made the switch to 1634 since the Affordable Care Act has been implemented. Ohio is now following that trend.

In the installments ahead, we will discuss some of the details of this switch.

I Want to Stay in my Home – When to Move to a Care Community

Posted on April 21, 2016 by Jim Koewler — No Comments ↓

Sorry about last week, my friends. I wasn’t able to get a blog post done. I had to do my taxes.

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home. The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home. The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home. The February 25, 2016 installment discussed medication management. The March 3, 2016 installment discussed hiring someone to help with activities of daily living. The March 10, 2016 installment discussed whether aging in place is an appropriate choice for someone suffering cognitive issues. The March 17, 2016 installment discussed services that can make it easier for an aging adult to stay home. The March 24, 2016 installment discussed the aging parent moving into an adult child’s home. The March 31, 2016 installment discussed an adult child moving into the home with his or her aging parent. The April 7, 2016 installment discussed whether aging in place is an appropriate choice for someone suffering cognitive issues. Today’s installment will discuss signs that it is time to move out of the home into a care community.

An older adult who is trying to stay home does not want to come to the realization that staying home is no longer appropriate. Unfortunately, for some older adults, the time comes to stop trying to stay home and to move into a care community that can provide more services. There are, though, very few hard and fast rules on how to identify when it is time to move a loved one out of the home and into a more structured residence, like a senior apartment, assisted living, or a nursing home. The lack of a bright line test might be fortunate, and it might be unfortunate, and it might be both. Nonetheless, just as everything else in life that you don’t buy at a store, there is no “owner’s manual” for aging adults.

Now, if we’re looking at a rehabilitation stay (rather than long term care,) there pretty much is a bright line test. It starts with the need for some medical service (like a fall) that causes a trip to the hospital. Then, the doctor orders rehab after the hospital visit. (Who pays for the rehab is a different question that we’re not discussing here.) When deciding that it’s time for rehab, that’s a pretty bright line.

Long term care is different than rehab, at least when deciding between home and a care community. If a doctor says that it is time, then it’s probably time. If a social worker or a geriatric care manager says that it is time, then it’s probably time. If the family does not receive input (or doesn’t want to heed input) from these professionals, the family should at least consider some signs that might indicate that it is time.

IS THE FAMILY CAREGIVER’S HEALTH FAILING? There is almost always one family member who carries most of the caregiving burden. If that family caregiver is starting to suffer medically, then it’s probably time to consider moving the older adult into a residential care community. If the family delay’s much longer, there might be two people who need care.

IS THE TV THE ONLY SOCIALIZATION? If the aging family member does little other than watch TV, it is time to consider a senior living community of some kind. Senior apartments, assisted living communities, and nursing homes have a variety of activities in addition to the TV. (Even TV watching is a communal activity rather than a solitary activity in a nursing home.) There are other activities as well, such as Bingo (a staple,) Wii Bowling (a favorite that grew quickly as well as other Wii activities, singing, religious services, card games, field trips, and many other, varied activities. Loneliness and isolation are huge issues among older adults, Staying home and watching TV adds to loneliness and isolation.

HAS THE OLDER ADULT’S HEALTH DECLINED? A significant health decline signals that it might be time to move out of the house. The decline doesn’t need to be sudden, and it doesn’t need to be “caused” by the home environment. A significant decline (no matter the speed or the cause) indicates that the home care may not be enough anymore.

DOES THE OLDER ADULT HAVE BED SORES? Bed sores (aka pressure wounds) indicate that the person is not moving around or being moved around enough. A professional care setting may avoid pressure wounds better than a home environment.

IS THE HOME FALLING INTO DISREPAIR? A home that isn’t being maintained indicates that the residents are overwhelmed by other concerns. There simply is too much to do. While the condition of the house is certainly less important than the health of the residents, an inability of the residents to keep themselves and the house in order shows that perhaps it is time to allow someone else to pick up some of the burden.

IS THE PRIMARY CAREGIVER EMOTIONALLY OVERWHELMED? Many family caregivers feel as though they are “at the end of their rope.” That is probably an indication that it’s time to consider moving out of the house. If the caregiver loses hold of the end of the rope, then two people will need care.

DOES THE OLDER ADULT SOMETIMES FAIL TO RECOGNIZE THAT HE OR SHE IS HOME? Older adults with cognitive issues sometimes decline to the point that they do not recognize their own homes. When that happens, the older adult can become increasingly agitated because of a constant feeling of being lost. (Do you know that anxious feeling you get when you have lost your way? Imagine feeling that way all the time.) I feel as though the older adult should move into a senior living community before he or she declines to the point of not recognizing his or her own home. If he or she moves into a new place before losing all connection with the old place, I feel as though there is at least some chance at developing a recognition of the new place so that the anxious feeling of being lost may not be constant at the new place. (Please note: I have no data to back up this conclusion. It’s just something that seems logical to me and passes my “gut feeling” test.)

This list of indicators that it is time to consider moving into a senior living community is certainly not exhaustive. Yet, it might help give some families a place to start when facing this difficult decision.

I want to Stay in my Home – Cognitive Difficulties

Posted on April 7, 2016 by Jim Koewler — No Comments ↓

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home. The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home. The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home. The February 25, 2016 installment discussed medication management. The March 3, 2016 installment discussed hiring someone to help with activities of daily living. The March 10, 2016 installment discussed whether aging in place is an appropriate choice for someone suffering cognitive issues. The March 17, 2016 installment discussed services that can make it easier for an aging adult to stay home. The March 24, 2016 installment discussed the aging parent moving into an adult child’s home. The March 31, 2016 installment discussed an adult child moving into the home with his or her aging parent. Today’s installment will discuss whether aging in place is an appropriate choice for someone suffering cognitive issues.

Someone with a physical ailment can make changes to his or her physical environment to make aging in place workable. As we’ve discussed over the last several installments, physical limitations can be overcome. Cognitive issues are a different story, however. Home adaptations and in-home care may not be enough to allow someone with memory loss or cognitive decline to stay at home.

First, the safety issues are different. Someone with cognitive difficulties probably cannot stay live alone. He or she may not be able to stay home alone even for short periods of time.

Wandering is a huge risk. Someone with cognitive difficulties might leave the home and get lost in just a few minutes. Unless the family wishes to keep the home’s doors locked, like the exit from a secured memory care community, the loved one suffering cognitive decline can easily walk out.

Even without wandering, homes have many risks for someone with cognitive impairment. Someone with dementia might not recognize the risk of lighting a cigarette from the flame of a gas stove right after using hair spray. Someone with dementia and an unsteady gait might not remember to use his or her walker, creating a risk of falling. Someone with dementia might not remember how hot the hot water is as it comes out of the tap.

There are safety risks to the home caregivers as well. Someone with dementia might not recognize a family member or professional home caregiver and react violently, for example. As the dementia sufferer becomes less connected to his or her surroundings, a constant anxiety or even a paranoia might set in. (Do you know that anxious feeling you get when you get lost in the car? Imagine feeling that way all the time.)

None of this is meant to imply that aging in place is impossible for someone in cognitive decline. While the cognitive decline is mild, aging in place is likely very possible. The issues surrounding the attempt to age in place are very different, however, when the aging senior has cognitive issues rather than physical issues.