Nursing Care & Alternative Care

As we consider the nature of the programs we offer those individuals who can no longer provide adequate care for themselves, it’s important to remember the human side of the issue. Beyond every case number and form you have filled out requesting nursing care or other assistance, you have human beings who are very often undergoing some of the most traumatic times they have ever faced.

Don’t lose sight of that as you work with these families. It’s often no more easy for a son or daughter to place a parent in the nursing home than it is for that parent to give up his or her independence and go there.

Clients will come to you with a lot of specific concerns. They will ask what they need to do, when they need to do it, and perhaps even how they need to do it. While you are not there to counsel with them regarding the appropriateness of the action they’re taken, you do need to be aware of their unspoken concerns.

Eligibility for nursing care and alternative care requires you to make a determination of categorical relationship for each person receiving a medical service. It’s essential that you always remember the first step to serving your client will be determining which category he or she is related to. Until you do that, you cannot make a decision on eligibility, and you may not even be able to gather the correct information.

Once you’ve established categorical relationship, you can move on to examining the areas of nursing care and alternative care that your client may require.

For the categorically needy, those areas include:

• Care in a nursing facility
• Care in an intermediate-care facility for the mentally retarded
• Public or private care for persons 65 years or older in mental health hospitals
• Home and community based waiver services for the Advantage Program
• Personal care (also covered under the medically needy program)

Level of Care

Just as you need to know how to categorically relate your clients, you also have to know what level of care a client may require.

Sometimes clients will come in wanting one level of care when they really need another level. Sometimes they may not know what levels of care are available, and you will have to ask enough questions about their situation to make a recommendation.

The following nursing care and alternative care services are available at this time:

• Personal Care
• Advantage Program
• Nursing Facility Care (Intermediate Care & Skilled)
• Home & Community Based Waiver (HCBW)
• Transfer of Assets

Nursing and alternative care cases often deal with people who have accumulated a variety of resources during their lifetimes. It isn’t unusual for the issue of property to come up during interviews for health coverage in these areas. Parents wish to pass property on to their heirs, and children are interested in their potential inheritance. Many just want to make sure they don’t do anything wrong.

Remember that this is a difficult time for many of your clients. They will have apprehensions and concerns you will need to address at the same time you’re dealing with all the forms and processes involved in determining eligibility.

Some programs have specific policies covering how assets should be handled. Others, such as the personal care program for the State Supplemental Payment (SSP) program, do not have transfer of resource policies. It’s up to you to know how to work with the clients you serve so they have a good understanding of policy.

When someone enters the nursing home, the issue of transferred property must be explored. As noted above, it’s not unusual for families to want to ensure property is passed on to the next generation. This is not a problem if sufficient time has passed since the transfer or if commensurate return has been received for the property.

If this does not occur, the value of the property is divided by the cost of monthly nursing care to arrive at a penalty period. Penalty periods stay in effect until they expire or the client receives commensurate return for property that is transferred. When a penalty period is computed, partial months are dropped.

Form MA-11 (08MA011E) is designed to gather information on assets and to assist in making decisions about how assets and income will be handled according to policy. While you will probably use it when an application for nursing or alternative care has been made, you can also use it to assist those who may need such care in the future to make appropriate decisions.

When you do use the form as a planning tool, make sure you keep a copy for the county’s use when an application is filed later. You may file it in any existing cases on the client or in the county’s information only files. Always check those files when a new application is made, otherwise you may miss important information.

Income Pension Trusts (Miller Trusts)

Income pension trusts are also known as “Miller trusts.” They’re designed to handle those situations in which a client’s income exceeds the standard for nursing care. This came about because of a policy change which resulted in total ineligibility for anyone whose income exceeded the nursing care standard. It is a good example of how our policies can be changed as a result of court action.

Spousal Impoverishment

What about those left in the home? How do you handle situations in which most of the household money and assets might be used to cover the cost of nursing care? How would the remaining spouse survive?

To ensure the spouse remaining in the home maintains sufficient income and resources to survive, a special policy was developed. That policy is called “Spousal Impoverishment.”

Terminology:

• Institutional Spouse
• Community Spouse
• Spousal Impoverishment
• Maximum Resource Standard

The policies on spousal impoverishment may be found in 317:35-17-11 and 317:35-19-21.