By Sara Duris
Q. I’ve had the same chore provider for three years and now I found out they won’t get paid anymore. What is happening?
A. I’m going to speculate that you have both Medicare and Medicaid insurance coverage, or in other words you are dually eligible. Individuals who are dually eligible can have original Medicaid and original Medicare or have a special type of Medicare Advantage plan that is known as dual special needs plan or D-SNP. In the past, dual eligible individuals who were receiving their Medicaid coverage in either of these forms could be eligible for help in the home paid for by Michigan Department of Health and Human Services (DHHS) Adult Services, or Adult Home Help, program. This has changed for some dually eligible individuals as of January 1st.
Many individuals were automatically enrolled in a new program called the MI Coordinated Health (MICH) plan, which is a highly integrated dual eligible special needs plan (HIDE-SNP). This specific type of Medicare Advantage Plan is designed to meet the needs of those who are dual eligible for Medicare and Medicaid. However, due to this insurance change, those enrolled will no longer be eligible for Adult Home Help services through MDHHS. Instead, home help options are covered through the HIDE-SNPs.
It is recommended that you speak with your insurance plan directly to discuss the benefits of the new insurance program and whether you are eligible for any in-home care through that insurance plan and if you can retain the same chore provider. This call should be made before opting out to straight Medicaid as this can affect your Medicare coverage and additional benefits, such as benefit cards or transportation.
If you wish to change or switch plans, you must contact your insurance plan directly or call Medicare at 1-800-633-4227.
If you are unsure about which plan best meets your needs, you should contact a trained State Health Insurance Programs (SHIP) counselor who will provide free, unbiased, high quality and accessible health benefit information. SHIP counselors are certified and have been trained in health care benefits counseling. This includes Medicare, Medicaid and other insurance products. SHIP counselors are unbiased. They are not connected with any insurance company, and they are not licensed to sell insurance. To schedule an appointment, call 269-408-4354 to reach a local SHIP counselor or 1-800-803-7174 to reach the state MI Options program. SHIP counselors do not discuss home care in detail but can review the options of how you can get your Medicare and Medicaid coverage.
Q. We are concerned about a relative’s treatment in a nursing facility. What is the best way to approach this problem?
A. If there is a specific instance or staff person involved, you could register your concerns with the appropriate person at the facility, such as a nursing supervisor or the nursing home administrator. For broader concerns about care, most nursing facilities have either a Resident Council and/or a Family Council for advocacy on quality and care issues.
A Resident Council is an independent group of nursing home residents who meet on a regular basis to discuss concerns and suggestions and to plan activities that are important to them. Michigan and Federal laws give residents the right to meet as a council. The nursing home is required to inform new residents of the right to create a council or participate in an existing council. The home must also provide space for meetings and give assistance to residents who need help getting to the meetings. These meetings can be private, or residents can invite staff members, family, friends, or members of community organizations to attend.
A Family Council is a group of family members, as defined by the resident, of the same nursing home that meet on a regular basis to discuss issues and concerns regarding the home and plan activities for residents. The council is independent; it is organized by family members, not by the nursing home. Nursing homes that get payments from Medicare or Medicaid must allow family councils to operate and must provide space in the facility for council meetings and activities. Michigan law also gives family members of nursing home residents the right to present concerns without retaliation. Any family member has the right to participate in the family council unless the resident does not want the family member to participate. Nursing home staff, visitors, local ombudsmen, and other guests can attend family council meetings only at the group’s invitation.
If these are not existing options, or these have been tried without successful response from the facility, consider contacting the local Long Term Care Ombudsman or filing a complaint with the State.
The Long-Term Care Ombudsman program is available toll free at 1-866-485-9393 for concerned relatives to investigate complaints, suggest remedies, and assist with resident rights, payments, guardianship, and nursing home placement. Residents and families can receive information, learn how to resolve problems or begin the complaint process for concerns in licensed nursing homes, homes for the aged, and adult foster care homes. This is a free and confidential service.
If you decide to file a complaint with the State, the Ombudsman office can help you with that. Individuals can also call toll free 800-882-6006 to make a report to the Michigan Department of Licensing and Regulatory Affairs (LARA) or file an online complaint at https://apps.lara.state.mi.us/BscComplaintIntakeForm
Sara Duris is the Professional Referral Specialist on the Information & Access Team at Region IV Area Agency on Aging. The Generations column appears each weekend in The Herald-Palladium.