For Medi-Cal, You May Have to ‘Spend Down’
Question: My grandmother, who is 85, needs 24-hour care. She is paying $120 a day for her care at home. She owns her home completely and has a small savings account. But soon she will run out of money and have to go into a nursing home [where the government will pay for her care]. What kind of formula does Medi-Cal use to decide if someone qualifies for her nursing home bills to be paid? Will the state take the equity in her home?
Answer: Medi-Cal is the joint program run by the federal government and the state to help pay the medical bills of poor people. The eligibility requirements have general limits of $640 a month for income and $2,000 for financial assets (stocks, bonds, mutual funds, CDs, savings and checking accounts). Houses, furniture and a car are usually exempt from being counted as assets. However, the state has the right to seek recovery of moneythrough the sale of a house after a person dies. When your grandmother applies for Medi-Cal, she should state that she intends to return to her home. She can make this declaration regardless of her physical condition. The declaration will assure that the state will not count her home as an asset to help pay Medi-Cal costs. However, she is still obligated to “spend down,” or use her financial assets such as the savings account, until she has reduced them to the $2,000 level.
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Q: When I acquired individual coverage through an HMO, the company refused to cover my 7-year-old daughter, who had heart surgery as an infant. Her surgery was a complete repair, and she is not on any medication. So now I pay $330 a month for the rest of my family and $115 extra for my daughter through the California state risk plan. Wasn’t legislation passed forcing companies to accept patients with preexisting conditions?
A: The federal Health Insurance Portability and Accountability Act was designed to protect workers and their families when they switch jobs. It forbids group health plans offered through businesses from discriminating against individuals on the basis of their health conditions. But under your individual policy, the HMO is allowed to refuse to cover your daughter according to the federal Health Care Financing Administration.
The best advice is for you to check other HMOs and see if you can find one that will cover your daughter. Also, if you go to work for a company offering health insurance for workers and dependents, your daughter would be automatically covered.
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Q: My sister had a severe heart attack and left her job. She continued health insurance through COBRA (the law allowing workers to keep group coverage after leaving a job), but her COBRA benefits will expire soon. What can she do about insurance?
A: Some group plans allow conversion of group health insurance to individual policies. Tell your sister to look at the documents from her former employer describing the health coverage. It would be called either “evidence of coverage” or “summary plan description.” If she does have conversion rights, her former employer must notify her before her COBRA coverage expires. If she hasn’t kept her records, or isn’t certain, have her call the former employer and ask for a copy of the health documents and about her rights to convert to individual coverage. If the policy doesn’t allow conversion, she can check with the California high risk pool, which guarantees coverage, at (800) 289-6574.
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Q: My uncle has some serious health problems, including arthritis and high blood pressure, which require him to take lots of drugs. He has big prescription bills, and Medicare doesn’t pay for them. He has a very modest income, and it is a hardship for him to pay for the drugs. Is there any way he can get some help?
A: Your uncle has several choices. He can consider getting a supplemental Medi-gap policy, which provides prescription drug coverage. Three of the 10 government-approved supplemental polices, H, I, and J, include drug coverage, but can be costly, ranging from about $1,200 to more than $2,000 a year. He should take a close look at the variety of Medicare HMOs offering drug coverage, usually with a small co-payment. Drugs and other expanded benefits beyond Medicare’s regular coverage are available in return for joining an HMO. But the beneficiary must agree to stay within the HMO’s network of hospitals and doctors.
A third possibility, if your uncle is very poor, is the free drug program operated by pharmaceutical companies. Your uncle’s doctor must fill out an application. For a list of the companies, and the free prescriptions they offer, call Pharma (the industry trade association) at (800) 762-4636.
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Q: My company is thinking about changing to different HMO choices. Where can we get information about the quality of these plans?
A: Medical quality measurement is still in its infancy as a science. But you can start by looking for plans accredited by the National Committee for Quality Assurance. “While it is far from perfect, accreditation shows that the plan is willing to let an independent third party review its operations,” according to “Managed Care Made Easy,” a new book from the People’s Medical Society. “By securing accreditation, a plan is also creating a yardstick by which it can be measured against its competitors,” the book said.
The NCQA looks at HMOs for issues such as physician credentials, preventive services, quality improvement and member rights. Call (800) 839-6487 to find out if an HMO has been accredited. Reports are also available on the NCQA’S Web site at https://www.ncqa.org.
The Joint Commission on Accreditation of Healthcare Organizations looks at hospitals, nursing homes, home health care agencies, and drug and alcohol treatment facilities. Call (630) 792-5800. The Web site is https://www.jcaho.org.
Tips of the Month
* Best wishes in this season for Christmas, Hanukkah and Kwanzaa.
* In Los Angeles, anyone with HIV-benefits issues can get free help from AIDS Project Los Angeles.
The program provides information on health and life insurance and on applying for Supplemental Security Income, Social Security Disability Insurance and Medi-Cal. Public workshops will be held at 6:30 p.m. Tuesday at 1313 N. Vine St. For insurance inquiries, contact Jacques Chambers at (213) 993-1473 or jchambers@apla.org. For public benefits, contact Phil Curtis at (213) 993-1475 or pcurtis@apla.org.
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This column appears every second Monday in Health. Send your questions, worries, tips, successes or failures in living with the health insurance revolution to Benefits Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail: Bob.Rosenblatt@latimes.com.