Long Term Care

Table of Contents


    WHAT IS LONG TERM CARE?

    Long-term care is a range of services and supports you may need to meet your personal care needs. [1]

    Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life, sometimes called Activities of Daily Living (ADLs). These tasks include bathing, dressing, eating, using the toilet, caring for incontinence, and transferring to or from your bed or a chair. Other common long-term care services and supports are assistance with everyday tasks, sometimes called Instrumental Activities of Daily Living (IADLs). These tasks include housework, preparing and cleaning up after meals, shopping for groceries or clothes, using the telephone or other communication devices, taking medication, and managing money.

    WHERE WOULD I RECEIVE LONG TERM CARE?

    There are three general settings in which you can receive long-term care: a nursing home, an assisted living facility, or in your home or community.

    The settings that may be appropriate for you depend on the level of assistance you need and your own personal preferences.

    Nursing Home

    Nursing homes are also sometimes called “nursing care facilities.”

    Nursing homes have someone available to provide nursing care 24 hours per day. They are therefore usually for people who need extensive or complex assistance.

    Assisted Living

    Michigan does not use the term “assisted living” legally. Instead, these types of facilities are called Homes for the Aged (HFA) or Adult Foster Care (AFC).

    Homes for the aged are specifically for adults who are 60 years old and older. Adult foster care is available to adults who are 60 years old and older but is also available to other adults who need long-term care. Most adult foster care homes are relatively small, providing care to 20 or fewer adults. By contrast, most homes for the aged are larger, providing care to 21 or more people.

    An operation needs to be licensed by the State of Michigan as an adult foster care (AFC) facility if it provides personal caresupervision, and protection in addition to room and board to 20 or fewer unrelated persons who are aged, mentally ill, developmentally disabled, or physically disabled, for 24 hours a day, 5 or more days a week, for 2 or more consecutive weeks for compensation.[2]

    An operation needs to be licensed by the State of Michigan as a home for the aged (HFA) if it provides room and board and supervised personal care to 21 or more unrelated people who are 60 years of age or older; or if operated as a distinct part of a licensed nursing home, can be provided to fewer than 21 residents.[3]

    Here is an explanation of some of these terms:[4]

    Personal care means personal assistance with dressing, personal hygiene, grooming, maintenance of a medication schedule, or the development of those personal and social skills required to live in the least restrictive environment.

    Supervision means guidance of a resident in the activities of daily living, including reminding a resident of important activities and appointments and to take medication, and being aware of a resident's general whereabouts even if the resident may travel independently in the community.

    Protection means actions taken to insure the health, safety, and well-being of a resident, including protection from physical harm, humiliation, intimidation, and social, moral, financial, and personal exploitation.

    Room and board means the provision of housing and meals. Under this definition, a "room" could be a bedroom, an apartment, a suite, etc. Board generally means the provision of one or more meals/food as part of a "package" that includes room or lodging.

    Supervised personal care means guidance (cuing, prompting, reminding) or assistance with eating, toileting, bathing, grooming, dressing, transferring, mobility, medication management, reminding resident of important activities to be carried out, assisting a resident to keep appointments, supporting a resident's personal and social needs, and being aware of a resident's general whereabouts even if the resident is capable of independent travel about the community.

    More information about Adult Foster Care and Homes for the Aged is available here

    Home or Community-Based Services

    Increasingly, long-term care is being provided in a person’s home or community. If you receive long-term care in their home or community, you are said to be receiving “home and community-based services.” These services allow you to maintain your independence by remaining in your home or community rather than moving into a long-term care facility.

    There are a wide range of home and community-based services. Depending on your needs and preferences, you can receive one or more of these services. Just some of the many types of home and community-based services are:

    Assistance with tasks like bathing, dressing, eating, and toileting

    Assistance with chores like cleaning, shopping, laundry, and preparing meals

    Some types of nursing care

    Home-delivered meals

    Adult Day programs offering care, social and recreational services, and/or therapies

    Respite care when your caregiver(s) cannot be with you or needs a break

    Adaptations or modifications to your home like the installation of ramps and grab-bars, the widening of doorways, and the modification of bathrooms

    Transportation to allow you to access activities, services, and resources in your community

    In Michigan, there are two Medicaid-funded programs that provide home and community-based care – the MI Choice Waiver program and the Program of All-Inclusive Care for the Elderly (PACE). You can read more about these below under “What Is the MI Choice Waiver Program All About?” and “What is the Program of All-Inclusive Care for the Elderly (PACE) All About?”. 

    There is also another, more limited program in Michigan called Home Help that can help people who are eligible for Medicaid with some daily tasks. You can read more about Home Help below under “Can You Tell Me About the Home Help Program In a Nutshell?”


    WHAT RIGHTS DO I HAVE IN THESE LONG TERM CARE SETTINGS?

    Nursing Home

    When you live in a nursing home, you have a lot of important rights that are established by federal law. (If you have a guardian, some of these rights may be for your guardian, not for you.) While there are some exceptions to these rights, some of the rights you have are:

    • The right to be a part of planning your care and treatment

    • The right to pick your doctor

    • The right to refuse treatment

    • The right to sign an advance directive

    • The right to see all of your records

    • The right to keep and use your personal possessions (unless doing so would harm the rights, health, or safety of other residents)

    • The right to talk with and have people visit you, including your family members, your doctor, and the state long-term care ombudsman

    • The right to handle your own finances, including the right not to deposit your money with the nursing home

    • The right to refuse to perform work or services for the facility

    • The right to personal privacy and confidentiality of your records

    • The right to see the results of the most recent federal survey of the nursing home

    • The right to voice grievances without discrimination or reprisal, and the right to have the facility make prompt efforts to resolve your grievances

    • The right not to be transferred or discharged from the nursing home unless one of these situations applies:

      • The transfer or discharge is necessary for your welfare and your needs can’t be met in the nursing home

      • Your health has improved so you don’t need the nursing home’s services

      • The health or safety of other residents at the nursing home is at risk

      • After getting notice, you haven’t paid for your nursing home stay

      • The nursing home is closing

    You can read about other federal rights of nursing home residents here.

    Many of the rights that are protected by federal law are also protected by state law. Your nursing home might also guarantee you additional rights and protections. You can look at your contract with the nursing home or ask the staff or administration for a list of the rights that you have in that nursing home.

    For some options you may have if any of your rights are being violated, see “What Do I Do If I Have a Problem With My Long-Term Care Provider?” below.

    Adult Foster Care Home or Home for the Aged[5]

    When you live in an adult foster care home or a home for the aged, you have a number of important rights that are established by state law. (If you have a guardian, some of these rights may be for your guardian, not for you.) While there are some exceptions to these rights, some of the rights you have are:

    • The right to get adequate and appropriate care

    • The right to refuse treatment

    • The right to communicate privately with your doctor, lawyer, or any other person that you want

    • The right to privacy in treatment and caring for your needs, to the extent feasible

    • The right to see a copy of your medical record

    • The right to have your records kept confidential

    • The right to get an explanation of your bill, regardless of who is paying for it

    • The right to present grievances to the staff without restraint, interference, coercion, discrimination, or reprisal

    If you live in a home for the aged, you also have some additional rights (again, with some exceptions) under state law, including:

    • The right to participate in the planning of your medical care

    • The right to keep and use personal clothing and possessions as space permits (unless doing so would harm the rights of other residents or your own health)

    • The right to handle your own finances

    • The right to be transferred or discharged only for medical reasons, for your or other residents’ welfare, or if you don’t pay for your home for the aged stay

    • The right to reasonable advance notice if the home for the aged is going to transfer or discharge you

    Your adult foster care home or home for the aged might also guarantee you additional rights and protections. You can look at your contract with the home or ask the staff or administration for a list of the rights that you have there.

    For some options you may have if any of your rights are being violated, see “What Do I Do If I Have a Problem With My Long-Term Care Provider?” below.

    Unlicensed Assisted Living Facility

    Because unlicensed assisted living facilities are not regulated by the state, there aren’t any specific rights guaranteed to residents in these facilities. You should look at your contract with the facility to see if it says what rights you have as a resident of that facility.  You can also ask the staff or administration at the facility if they have a resident rights policy, and if so, if you can have a copy of it.

    For some options you may have if any of your rights are being violated, see “What Do I Do If I Have a Problem With My Long-Term Care Provider?” below.


    MI Choice

    When you are a MI Choice participant, you have a number of important rights.  (If you have a guardian, some of these rights may be for your guardian, not for you.) Some of the rights you have are[6]:

    • The right to always be treated with respect and dignity by people who are helping you

    • The right to choose the services included in your plan and help develop that plan

    • The right to involve anyone you want in the process to plan your services

    • The right to talk about ideas you have to replace suggested services that you don’t want

    • The right to choose where in the community you want to receive your services

    • The right to receive services from any provider who is willing and qualified

    • The right to have your cultural and religious choices respected and addressed

    • The right to be free from abuse and the misuse of your property

    • The right to refuse to provide any information you don’t want to share (although if you refuse to provide information that is needed to see if you qualify for MI Choice, you might not be able to be in the program)

    • The right to contact your supports coordinator with questions or complaints

    • The right to receive a complete copy of your plan for services and supports

    • The right to have your records kept confidential

    • The right to appeal a decision that you are ineligible for MI Choice, or reductions, suspensions, or terminations of any of your MI Choice services

    These rights and others are spelled out in the MI Choice Waiver Participant Handbook. You can download a copy of this Handbook here.

    For some options you may have if any of your rights are being violated, see “What Do I Do If I Have a Problem With My Long-Term Care Provider?” below.


    HOW DO I PAY FOR LONG TERM CARE?

    Medicare[7]

    (For more information about Medicare, including who qualifies for Medicare and how you can apply for it, see the Topic on Medicare).

    Medicare does not pay for very much long-term care. For example, Medicare does not pay for 24-hour-a-day care at home, meals delivered to your home, or homemaker and personal care services when these are the only services you need. When Medicare does pay for long-term care, there are many requirements and caveats, and you may be required to pay for a portion or a percentage of your care.

    Medicare covers three general types of long-term care:

    #1: Home Health Care.[8]

    Medicare will pay for home health care only if:

    1. You are under the care of a doctor and you are getting services under a plan of care established and reviewed regularly by a doctor; and

    • You need, and a doctor certifies you need, part-time or intermittent skilled nursing care and/or therapies (physical, occupational, speech-language); and

    • The home health agency caring for you is Medicare-certified; and

    • You are, and a doctor certifies that you are, home-bound.

    Here is an explanation of some of these terms:

    • Part-time or intermittent nursing care means skilled nursing care you need or get less than 7 days each week or less than 8 hours each day over a period of 21 days (or less) (with some exceptions in special circumstances).

    • Examples of skilled nursing care include giving intravenous drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes.

    • Home-bound means that you have trouble leaving your home without help (like a cane, wheelchair, walker, crutches, special transportation, or help from someone else) because of an illness or injury; or leaving your home isn’t recommended because of your condition and you’re normally unable to leave your home because it is a major effort. You can leave home for medical treatment or short and infrequent absences for non-medical reasons like attending religious services.

    In addition to skilled nursing care and/or therapies, Medicare home health care also includes:

    • Home health aide services, such as services to help you with activities of daily living like getting up, bathing, getting dressed, or making meals. Medicare will not pay for home health aide services if that is all you need. You must also require skilled nursing care and/or therapies to qualify for coverage.

    • Medical supplies.

    • Durable medical equipment that is ordered by your doctor for use in your home, such as a walker, wheelchair, or hospital bed. Medicare usually pays for only 80% of the Medicare-approved amount for durable medical equipment.

    #2 Skilled Nursing Facility Care.[9]

    Medicare will pay for skilled nursing facility care only if:


    1. You have Medicare Part A and have days left in your benefit period; and

    2. You have a qualifying hospital stay; and

    3. Your doctor decided you need daily skilled care given by or under the direct supervision of skilled nursing or rehabilitation staff; and

    4. You get skilled services in a Medicare-certified skilled nursing facility; and

    5. You need these skilled services for a medical condition that was either a hospital-related medical condition, or a condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.

    Here is an explanation of some of these terms:



    • Your benefit period begins the day you are admitted as an inpatient in a hospital or skilled nursing facility and ends when you have not received any inpatient hospital care or skilled care in a skilled nursing facility for 60 days in a row.

    • A qualifying hospital stay is 3 days as an inpatient. Time that you spend in a hospital as an outpatient before you are admitted does not count toward the 3 inpatient days, and observation services are not covered as part of the inpatient stay. You must enter the skilled nursing facility within a short time (generally 30 days) of leaving the hospital. (After you leave the skilled nursing facility, if you re-enter a skilled nursing facility within 30 days, you do not need another 3 day qualifying hospital stay to get additional skilled nursing facility benefits. This is also true if you stop getting skilled care while in the skilled nursing facility and then start getting skilled care again with 30 days.)

    • A hospital-related medical condition is a condition that was treated during your qualifying hospital stay, even if it was not the reason you were admitted to the hospital.

    Even if you meet the five requirements listed above, Medicare will not pay 100% of your nursing home stay. 



    • For Days 1-20, Medicare will completely cover the cost of your nursing home stay for each benefit period. 

    • For Days 21-100, Medicare will pay a portion of the cost of your care if you continue to require skilled services. You must pay part of the cost of your stay. As of May 2014, the coinsurance was $152 per day of each benefit period. 

    • After Day 100, Medicare does not pay for any of your nursing home stay.

    Medicare coverage ends when you no longer need skilled nursing care or therapy.



    #3 Hospice Care.[10]



    Medicare will pay for hospice care only if:





    1. You are eligible for Medicare Part A; and

    2. Your doctor certifies that you are terminally ill and are expected to have 6 months or less to live; and

    3. You accept palliative care (for comfort) instead of care to cure your illness; and

    4. You sign a statement choosing hospice care instead of routine Medicare-covered benefits for your terminal illness.

    Once you choose hospice care, Medicare will generally not cover any of the following services:







    • Treatment intended to cure your terminal illness

    • Prescription drugs to cure your illness (rather than for symptom control or pain relief)

    • Care from any hospice provider that was not set up by the hospice medical team

    • Room and board when you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility

    • Care in an emergency room, inpatient facility care, or ambulance transportation (unless it is either arranged by your hospice team or is unrelated to your terminal illness)

    Medicare will pay for 100% of your hospice care. However, you may need to pay a small copayment for each prescription drug and other similar products for pain relief and symptom control while you are at home.






    Medicaid

    Medicaid in Michigan will pay for long-term care in a nursing home, or for home and community-based services through the MI Choice Waiver program or the Program of All Inclusive Care for the Elderly (PACE), if you meet certain medical and financial eligibility criteria.







     






    Financial Eligibility








    Financial eligibility for Medicaid and Medicaid-funded long-term care (including nursing home care, MI Choice, and PACE) is determined by the Michigan Department of Human Services (DHS). You will need to apply to DHS for Medicaid and Medicaid-funded long-term care, and you should talk to DHS if you have any financial eligibility questions or problems. You can find contact information for your local DHS office here: http://www.michigan.gov/dhs/0,4562,7-124-5459_5461---,00.html






    Medical Eligibility








    The same medical eligibility criteria apply regardless of whether you are seeking long-term care in a nursing home or home and community-based services through PACE or the MI Choice Waiver.






    To qualify for Medicaid-covered long-term care, you must qualify for what is referred to as “nursing facility level of care.” 







    A nursing facility or the organization providing PACE or MI Choice Waiver services will meet with you and perform an assessment to see if you need nursing facility level of care. The tool that they will use to assess you is called the Level of Care Determination (LOCD) (or sometimes the Nursing Facility Level of Care Determination).






    The LOCD tool has seven “doors”; if you meet the criteria for any one of the seven doors, you will meet nursing facility level of care (and therefore be medically eligible for Medicaid-covered long-term care in a nursing facility or through the MI Choice Waiver or PACE programs). The seven doors look at your needs, circumstances, and abilities in the following areas:[11]






    1. Activities of Daily Living. This door looks at, in the last 7 days, how much help you needed with bed mobility, transfers, toilet use, and eating.

       

    2. Cognitive Performance. This door looks at your short-term memory, your cognitive skills for daily decisionmaking, and your ability to make yourself understood.

       

    3. Physician Involvement. This door looks at how many doctors’ visits you have had and how many changes to your doctors’ orders there have been in the last 14 days.

       

    4. Treatments and Conditions. This door looks at whether, in the last 14 days, you have or need stage 3-4 pressure sores, IV or parenteral feedings, IV medications, end-stage care, daily tracheostomy care, daily respiratory care, daily suctioning, pneumonia, daily oxygen therapy, daily insulin with two order changes, or peritoneal or hemodialysis.

       

    5. Skilled Rehabilitation Therapies. This door looks at how much speech, occupational, and/or physical therapy you have received or been scheduled for in the last 14 days.

       

    6. Behavior. This door looks at whether, in the last 7 days, you wandered, were verbally abusive, were physically abusive, were socially inappropriate or disruptive, resisted care, or experienced delusions or hallucinations.

       

    7. Service Dependency. This door looks at whether you are currently receiving and have been receiving for at least one year Medicaid-covered long-term care and whether you “require[] ongoing services to maintain [your] current functional status.”

       


     




    Other Eligibility Requirements






    Nursing Facility[12]




    In addition to needing nursing facility level of care, there are two more medical requirements for you to be eligible for Medicaid-covered nursing home care:




    1. A doctor must certify that you need continuous nursing facility care.

    2. You must pass the Preadmission Screening/Annual Resident Review (PASARR) Level I screening. This screening looks at whether you have any mental illness or intellectual disabilities or conditions related to such an illness or disability. 

    If you meet all of the eligibility requirements for Medicaid-funded nursing facility care, Medicaid may not pay for 100% of your nursing home care. You may have to pay a certain amount each month towards your care, which is called your patient pay amount. Your patient pay amount is based on your excess income (any remaining income after deducting your allowable expenses), and it can change if your financial eligibility changes.




    Your nursing facility will probably want to find out what your patient pay amount is as quickly as possible so it can make sure it gets paid for all of the services it provides. Your facility and the local DHS office will probably communicate so the facility can find out what your patient pay amount is. If your local DHS office can’t determine for sure whether you are eligible within 5 days of receiving your application, it is supposed to send the facility a Tentative Patient Pay Amount Notice (form DHS-3227), with the tentative patient pay amount that the facility can collect from you until your local DHS office has made a final determination.




    If you have a monthly patient pay amount, you can’t legally be charged more than the Medicaid rate for a short stay in a nursing facility. For example, if you are only in the facility for 5 days, the facility can only collect 5 days from your patient pay amount. The facility has to return the rest of the monthly patient pay amount to you or your family.




    If you need medical or remedial care recognized under the State law but not covered by Medicaid, federal law allows you [nursing facility beneficiaries] to use your patient pay amount to get these services.




    MI Choice




    In addition to needing nursing facility level of care, there are two more requirements that you must meet to be eligible for MI Choice:




    1. You must need at least one covered MI Choice service.




    2. You cannot be enrolled in MI Choice if your needs can be fully met with State Plan or other available services.




    This means that to be a MI Choice participant, you must need MI Choice services and you must not be able to get these services in any other way.






    PACE




    In addition to needing nursing facility level of care, there are a few more requirements that you must meet to be eligible for PACE:




    1. You must be at least 55 years old.




    2. You must live in the PACE organization’s service area.




    3. You must be capable of safely residing in the community without jeopardizing health or safety while receiving services offered by the PACE organization.




    4. You must not be concurrently enrolled in the MI Choice program or in an HMO.





    WHAT IS THE MI CHOICE WAIVER PROGRAM ALL ABOUT?[13]

     

    The MI Choice Waiver program is for people who need the kind of care that one would get in a nursing home but provides this care in someone’s home or in a community-setting rather than in a nursing home.




    The MI Choice Waiver program is run by organizations called waiver agencies. To determine if you are eligible for MI Choice services, a team from a waiver agency made up of at least a registered nurse and a social worker will perform an initial assessment of your needs and circumstances. 




    If you are found eligible for MI Choice and when there is room in the MI Choice program, someone from the waiver agency called a supports coordinator will work with you to make a plan of service that meets your needs and preferences. This plan of service includes lots of information that is specific to you, including the problems and concerns that you have, your goals, how you plan to meet those goals, the services that you will be receiving, how often you will get each service, how long you will get each service for, and the type of provider that will provide you with each service.




    The supports coordinator is supposed to use a person-centered planning process.  This means that the supports coordinator should work with you and any friends or family members you want involved in the process. The supports coordinator should explain the variety of options you have and help you pick and choose which services you want to meet your needs, goals, and preferences.




    There are many different services that are available through the MI Choice Waiver program. Your supports coordinator should help you to understand these services and which might work for you. The services offered through the MI Choice Waiver program are:




    • Adult Day Health. These services include health and social services provided in a community-based setting to help you reach your highest level of functioning. These services are provided four or more hours per day on a regularly scheduled basis for one or more days per week.

    • Homemaker services. This includes performing household tasks like preparing meals and household cleaning.

    • Personal Care services. These services help you do things that you would normally do for yourself if you did not have a disability. These services include help with activities like eating, bathing, dressing, and personal hygiene.

    • Respite Care services. This is care provided when you cannot care for yourself, and is provided on a short-term basis when the people normally providing your care can’t be there or need a break.

    • Specialized Medical Equipment and Supplies. These are devices, controls, or appliances that help your ability to perform activities of daily living or to perceive, control, or communicate with your environment. It also includes things that you need for life support or to address physical conditions.

    • Fiscal Intermediary. This service is for people who choose self-determination (you can read more about self-determination below). The Fiscal Intermediary helps with managing and distributing funds from your budget and helping you hire and pay your caregivers.

    • Goods and Services. These are services, equipment, or supplies for people who choose self-determination (you can read more about self-determination below), and are things that you can’t get any other way. The goods and services have to help you with certain things for them to be covered.

    • Chore Services. These are services to keep you home clean, sanitary, and safe. This includes chores like washing floors and windows, moving heavy items of furniture, yard work, and snow plowing.

    • Community Living Supports. This is one of the most common MI Choice services. These supports are designed to preserve your health and safety and allow you to stay independent and reasonably participate in your community. These supports can include help with tasks like bathing, eating, dressing, personal hygiene, meal preparation, laundry, household care, shopping for food and necessities, managing your money, and non-medical transportation to allow you to go to community activities.

    • Counseling. This service is for people who are experiencing emotional problems or form whom it is harder to function. These services are usually provided on a short-term basis only.

    • Environmental Accessibility Adaptations. These are changes to your home to keep you healthy, independent, and able to continue living in your home. These adaptations include installing ramps and grab-bars, widening doorways, modifying bathrooms, or installing special electric and plumbing systems that will work with your medical equipment and supplies.

    • Home Delivered Meals. This is a service like Meals on Wheels that provides you with one or two nutritious meals per day, if you cannot care for your own nutrition.

    • Non-Medical Transportation. This service is to allow you to get services and resources and go to activities that are in your plan of services.

    • Nursing Facility Transition. This is a one-time service for people who are moving from a nursing home into the community to help you get settled in your new home. It provides funds to help you with things like housing or security deposits, setting up utilities, furniture, moving expenses, and cleaning.

    • Personal Emergency Response System (PERS). This is an electronic device that allows you to call for help in an emergency.

    • Private Duty Nursing. This is individual and continuous nursing care provided by licensed nurses. This is not for people who only need care from a nurse part of the time or from time-to-time.

    • Residential Services. This is for people living in a licensed, home-like setting that is not a hospital or a nursing home. These services provide extra help with things that are not provided by the place where you live.

    • Training. This service teaches you skills you need to learn to be able to live independently.

    Once the waiver agency has worked with you to create a plan of service and approved you for a combination of these services, you will need to choose a provider. This is the person or organization that will actually provide you with the services for which you have been approved.




    There are two main types of providers. You can have your services provided by an agency. The agency’s business is to provide these kinds of services, and they have a lot of people on-staff who can be assigned to be provide you with the services in your plan of service. Depending on where you live, there might be only one agency that provides these services or there might be more than one agency. If there is more than one agency, you get to choose which agency to use.




    Instead of using an agency provider, you can choose to hire your own caregivers. If you want to choose your own caregivers, you would do so through an option called self-determination.




    Self-determination is an option where you get to direct and control your services, including choosing and hiring the people that will be providing your services and caring for you. You could choose to hire professional caregivers that you find yourself or you could choose to hire family members or friends to care for you. When you choose self-determination, the waiver agency will work with you to develop a budget. Then you get to choose how to manage that budget to meet your plan of service. Among other things, you will use your budget to pay your caregivers, including family members or friends that you have hired to be your caregivers. You can get help managing your budget and distributing money from a “fiscal intermediary,” which you can read a little more about above.




    It is your choice whether to have your services through an agency or whether to hire your own caregivers through self-determination. There are pros and cons to each option, so you will need to decide what makes the most sense for you. Here are a few things to think about:




    • With an agency, if your caregiver is sick, on vacation, or for some reason can’t come one day to help you, the agency can easily assign someone else to provide your services for the day(s). When you hire your own caregiver, you are responsible for finding a replacement caregiver if your regular caregiver can’t be there.

    • With self-determination, you get to control exactly who is providing your care and can choose someone you trust and feel comfortable with. With an agency, you may not get a say as to which staff are assigned to care for you (although you may be able to request a different caregiver if you have a problem with your current caregiver).

    • With self-determination, you always know who will be providing your care. With an agency, the agency may change the person that is providing your care. Depending on the agency, you may have different caregivers every day, or you may have the same caregivers most of the time.

    • Provider agencies usually work with waiver agencies all the time, so with an agency, you probably will not have to worry about a lot of the administrative tasks and paperwork. With self-determination, you (or you with your fiscal intermediary) are responsible for handling all of the administrative and paperwork issues.

    You can read more about what to do if you are interested in becoming a MI Choice participant under “How Do I Find Long-Term Care Options?” below.





    WHAT IS THE PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) ALL ABOUT?[14]

     

    The Program of All-Inclusive Care for the Elderly (PACE) is a program for people over age 55 who need nursing facility level of care. The goals of this program are to enhance your quality of life and autonomy, maximize your dignity, enable you to live in the community for as long as possible, and preserve and support your family unit.




    When you are a PACE participant, you have an interdisciplinary team that coordinates all of your services, including Medicare, Medicaid, and other services. Your team will assess your needs, develop a plan of care, and monitor how your services are being provided. Usually, PACE organizations provide social and medical services in an adult day health center and also provide necessary home and other services.




    Services must include, but are not limited to:




    • Adult day care that offers nursing, physical, occupational and recreational therapies, meals, nutritional counseling, social work and personal care

    • All primary medical care provided by a PACE physician familiar with the history, needs and preferences of each beneficiary

    • All specialty medical care

    • All mental health care

    • Interdisciplinary assessment and treatment planning

    • Home health care, personal care, homemaker and chore services

    • Restorative therapies

    • Diagnostic services (including laboratory, x-rays, and other necessary tests and procedures)

    • Transportation for medical needs

    • All necessary prescription drugs and any authorized over-the-counter medications included in the plan of care

    • Social services

    • All ancillary health services (such as audiology, dentistry, optometry, podiatry, speech therapy, prosthetics, durable medical equipment, and medical supplies)

    • Respite care

    • Emergency room services, acute inpatient hospital and nursing facility care when necessary

    • End-of-Life care


    HOW DO I FIND AND CHOOSE A LONG TERM CARE OPTION?

    Nursing Homes

    Depending on the community, there may be only one nursing home or there may be a number of nursing homes. If you want Medicare or Medicaid to pay for your nursing home stay, you will need to look for facilities that have Medicare-certified beds or Medicaid-certified beds. Keep in mind that even if a facility has Medicare- and Medicaid-certified beds, the facility might not have any of these beds available for you to move in immediately.




    To learn about the nursing homes in your community, click here to use Medicare.gov’s Nursing Home Compare tool.  This tool allows you to see a list of the nursing homes in your community and provides information about each nursing home, including how many beds they have and whether they participate in Medicare and/or Medicaid. This tool also provides, for each nursing home, overall ratings and ratings for specific measures, as well as information from recent inspections and the full text of recent inspection reports. This information can help you assess the quality of the nursing homes in your community and whether they are likely to be able to meet your needs and preferences.




    You can also look at state surveys of the nursing homes you are considering and documents related to complaints about the nursing home that have been filed with the Michigan Department of Licensing and Regulatory Affairs. You can access that information here




    You can also ask the state or your local long-term care ombudsman questions about specific nursing homes. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. They are usually very familiar with each nursing home and will most likely be able to answer your questions about nursing homes you are considering. 




    Once you have identified some nursing homes that might be a good fit for you, it is often a good idea to visit the nursing home, look around, and talk with the residents and staff. If possible, it’s often helpful to visit more than once and at least once during non-business hours to get a good sense of what living in the nursing home is like.




    For more information about and considerations involved in choosing a nursing home, you can look at the following resources:




    Assisted Living (Adult Foster Care homes and Homes for the Aged)

    In Michigan, “assisted living” facilities only have to be licensed if they house a certain number of people and provide certain services. You can read more about when places have to be licensed as adult foster care (AFC) facilities and homes for the aged (HFAs) above, under “Where Would I Receive Long-Term Care?”.




    It can be harder to learn about facilities that aren’t licensed. Facilities that are not licensed are also not regulated by the state. You should consider whether it is important to you to live in a place that is licensed and regulated by the state.




    To learn about the licensed Adult Foster Care homes and Homes for the Aged in your community, click here to search the Michigan Department of Human Services’ database.  This website allows you to see a list of the Adult Foster Care homes and/or Homes for the Aged in your community and provides basic information about each home, including what its capacity is and what services it offers. This database also provides, for each home, copies of inspection reports, study reports, and/or special investigation reports. For some homes, there is a copy of the Original Licensing Study Report, which provides a description of the home and its program. All of this information can provide a starting place to help you assess the Adult Foster Care homes and Homes for the Aged in your community and whether they are likely to be able to meet your needs and preferences.




    Adult Foster Care homes and Homes for the Aged are licensed by the Michigan Department of Human Services, Bureau of Children and Adult Licensing. If the database discussed above does not include inspection and licensing documents, you can contact the Bureau to get this information. Contact information is available here




    You can also ask the state or your local long-term care ombudsman questions about specific Adult Foster Care homes or Homes for the Aged. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. They are often very familiar with a particular facility and may be able to answer your questions about facilities you are considering. 




    Once you have identified some facilities that might be a good fit for you, it is often a good idea to visit them, look around, and talk with the residents and staff. If possible, it’s often helpful to visit more than once and at least once during non-business hours to get a good sense of what living in the facility is like.




    For more information about and considerations involved in choosing an assisted living option, you can look at the following resources:




    MI Choice

    There are 20 waiver agencies in Michigan. Waiver agencies serve certain regions of the state; depending on where you live, there will be either one or two waiver agencies from which you can receive MI Choice Waiver services.




    If you are interested in becoming a MI Choice participant, you should contact the waiver agency(ies) in your region. To determine which region you live in and which waiver agency(ies) serve that region, click here.  




    You can also ask your doctor or hospital discharge planner about referring you to MI Choice instead of a nursing home. If you currently live in a nursing home, you can ask staff at the nursing home about “nursing facility transition,” a program that helps you transition out of the nursing home and into the community, including into the MI Choice program.




    Many waiver agencies have a long wait list for MI Choice services, so if you think you are eligible for and want MI Choice services, it is a good idea to call the waiver agencies in your region as early as possible. There are a number of factors that influence where on the waiting list you will be placed.




    As discussed above under “What Is the MI Choice Waiver Program All About?”, once you become a MI Choice participant, you get to choose whether you want an agency or someone you hire yourself to provide your MI Choice services.




    For more information about and considerations involved in choosing who you want to provide your MI Choice services, you can look at this resource:




    PACE

    There are currently seven PACE organizations in Michigan, each of which serves a different area of the state. You must live within a PACE organization’s service area to be a PACE participant with that organization. As of 2014, there are areas of the state that are not served by a PACE organization; people living in these areas are therefore not eligible for PACE.




    If you are interested in becoming a PACE participant, you should contact the PACE organization in your community. To determine if there is a PACE organization serving the area where you live and how to contact that organization, click here and scroll towards the bottom of the page.    




    You can also ask your doctor or hospital discharge planner about referring you to PACE instead of a nursing home. If you currently live in a nursing home, you can ask staff at the nursing home about “nursing facility transition,” a program that helps you transition out of the nursing home and into the community, including into programs like PACE.





    WHAT DO I DO IF I HAVE A PROBLEM WITH MY LONG TERM CARE PROVIDER?

    Problems in a Nursing Home

    If you have a problem with the staff, other residents, or visitors in your nursing home – or any other problem – you have a number of options available to you. Depending on the problem you have, some of the options discussed here may be more appropriate than others. You can also consider doing more than one of the things listed here at the same time.




    1. Document the problem and any specific incidents. This will make a record of what happened and could be helpful if you’re taking some of the other actions listed below.




    2. Talk to the state or local long-term care ombudsman. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. They can help you with many if not all of the other actions listed below. 




    3. Talk with a staff member at the nursing home or someone in the nursing home’s administration to try to fix the problem. The nursing home may be willing to work with you to fix the problem.




    4. File a formal complaint or grievance with the nursing home. You have a right under federal law to present your grievances and have the nursing home take prompt actions to resolve your grievances. Some nursing homes take this obligation of theirs more seriously than others.




    5. File a complaint with the Bureau of Health Care Services at the Michigan Department of Licensing and Regulatory Affairs. This is the agency that regulates nursing homes. They have a process for receiving and investigating complaints about nursing homes from residents. You can ask that the Bureau not disclose your name during its investigation. For more information about the Bureau and how to file a complaint, click here




    6. Report anything illegal to the police or other law enforcement. If the problem you are having involves something illegal or if it is putting your safety at risk, you can report the problem to the police. They will investigate your report just like any other report they get.




    7. Move out of the nursing home. If the problem you are having makes you not want to live at the nursing home anymore, you can move out of the nursing home and into another nursing home or into some other long-term care setting. The ombudsman may be able to help you find another long-term care option and move out of the nursing home.​




    Problems in an Adult Foster Care Home or Home for the Aged

    If you have a problem with the staff, other residents, or visitors in your adult foster care home or home for the aged – or any other problem – you have a number of options available to you. Depending on the problem you have, some of the options discussed here may be more appropriate than others. You can also consider doing more than one of the things listed here at the same time.




    1. Document the problem and any specific incidents. This will make a record of what happened and could be helpful if you’re taking some of the other actions listed below.




    2. Talk to the state or local long-term care ombudsman. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. They can help you with many if not all of the other actions listed below. 




    3. Talk with a staff member at the adult foster care home or home for the aged, or someone in the home’s administration to try to fix the problem. The home may be willing to work with you to fix the problem.




    4. File a complaint or grievance with the adult foster care home or home for the aged. You have a right under state law to present your grievances to the staff at your adult foster care home or home for the aged.




    5. File a complaint with the Bureau of Children and Adult Licensing at the Michigan Department of Human Services. This is the agency that regulates adult foster care homes and homes for the aged. They have a process for receiving and investigating complaints about adult foster care homes or homes for the aged. If you make a complaint, your name will be kept confidential and will not be released unless ordered by a court. You can also make an anonymous complaint, but this may make it harder or impossible for the agency to investigate your complaint. For more information about how to file a complaint with the Bureau, click here.  




    6. Report anything illegal to the police or other law enforcement. If the problem you are having involves something illegal or if it is putting your safety at risk, you can report the problem to the police. They will investigate your report just like any other report they get.




    7. Move out of the adult foster care home or home for the aged. If the problem you are having makes you not want to live at the home anymore, you can move out and into another adult foster care home or home for the aged, or into some other long-term care setting. The ombudsman may be able to help you find another long-term care option and move out of the adult foster care home or home for the aged.




    Problems in an Unlicensed Assisted Living Facility

    If you have a problem with the staff, other residents, or visitors in your unlicensed assisted living facility – or any other problem – you have a number of options available to you. Depending on the problem you have, some of the options discussed here may be more appropriate than others. You can also consider doing more than one of the things listed here at the same time.




    1. Document the problem and any specific incidents. This will make a record of what happened and could be helpful if you’re taking some of the other actions listed below.




    2. Talk to the state or local long-term care ombudsman. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. While they don’t usually make regular visits to unlicensed assisted living facilities, they can work with you to resolve problems. They may be able to help you with many if not all of the other actions listed below. 




    3. Talk with a staff member at the assisted living facility, or someone in the facility’s administration to try to fix the problem. The assisted living facility may be willing to work with you to fix the problem.




    4. File a complaint or grievance with the assisted living facility, if it has a process for you to do so. Depending on the facility, it may or may not have a formal process for you to file a complaint. You can ask staff at the facility or read your contract with the facility to find out if it does have a complaint process and how it works.




    5. Report anything illegal to the police or other law enforcement. If the problem you are having involves something illegal or if it is putting your safety at risk, you can report the problem to the police. They will investigate your report just like any other report they get.




    6. Move out of the unlicensed assisted living facility. If the problem you are having makes you not want to live at the assisted living facility anymore, you can move out and into another assisted living facility, or into some other long-term care setting. The ombudsman may be able to help you find another long-term care option and move out of the facility.




    Problems in MI Choice

    If you are a MI Choice participant and have a problem with your waiver agency or caregivers, you have a number of options available to you. Depending on the problem you have, some of the options discussed here may be more appropriate than others. You can also consider doing more than one of the things listed here at the same time.




    1. Document the problem and any specific incidents. This will make a record of what happened and could be helpful if you’re taking some of the other actions listed below.




    2. If you are having a problem with the person who is providing your care, talk with that person to try to fix the problem informally. Your caregiver may be willing to work with you to fix the problem.




    3. Talk with your supports coordinator to try to fix the problem. Part of your supports coordinator’s job is to make sure the MI Choice Waiver program is working for you and that you have an appropriate plan of service and are getting the services included in that plan. 




    4. If you are having a problem with the person providing your care and that person works for an agency, file a complaint or grievance with the agency, if it has a process for you to do so. You may be able to file a formal complaint with the agency (your caregiver’s employer). If there is a way for you to do this, the agency should investigate and respond to your complaint.




    5. If you are having a problem with your waiver agency, file a complaint or grievance with the waiver agency. The waiver agency is required to have its own process for you to file a complaint, and the waiver agency is required to tell you about this process. If you don’t already know about it, you can ask your supports coordinator for information about filing a complaint with the waiver agency.




    6. If you are having a problem with the person providing your care, request or hire a new caregiver. If your caregiver works for an agency, the agency should be able to assign you a new caregiver. If you participate in self-direction, you have the right to fire your current caregiver and hire a new one.




    7. If you are having a problem with the person or agency providing your care, choose a new agency to provide your care or hire your own caregiver through self-direction. Under the MI Choice program, you have the right to choose who provides your services. In most communities, there is more than one agency that provides MI Choice services, so you could switch to the other or one of the other agencies. You could also choose not to have an agency provide your services and to hire your own caregiver(s) through self-determination instead. You can read more about this under “What is the MI Choice Waiver Program All About?” above.




    8. If you are having a problem with your waiver agency, try to switch to a different waiver agency. If there is another waiver agency in your region, you can apply to be a MI Choice participant with that waiver agency instead, although there might be a waiting list to sign up with that waiver agency. If there is not another waiver agency in your region, you can ask the Michigan Department of Community Health for an exception to let you choose a waiver agency from a nearby region. To do this, you should contact the Medical Services Administration, Bureau of Medicaid Policy and Health System Innovation, Long Term Care Services Division.




    9. Report anything illegal or unsafe to the police, other law enforcement, or Adult Protective Services. If the problem you are having involves something illegal or if it is putting your safety at risk, you can report the problem to the police. They will investigate your report just like any other report they get. You can also report a problem involving abuse, neglect, or exploitation to Adult Protective Services. They will investigate your report and take steps to get you out of the bad situation.




    10. Leave the MI Choice Waiver program. If the problem you are having makes you not want to be part of the MI Choice Waiver program anymore, you can leave and find some other long-term care setting. The state or local long-term care ombudsman may be able to help you find another long-term care option. Long-term care ombudsmen are advocates for residents of long-term care facilities and help them deal with any problems that arise in long-term care facilities. 





    WHAT CAN I DO IF A NURSING HOME OR WAIVER AGENCY DECIDES THAT I'M NOT MEDICALLY ELIGIBLE FOR MEDICAID-FUNDED NURSING HOME CARE OR FOR MI CHOICE?

    If you are found medically ineligible for Medicaid-funded nursing home care or for MI Choice because you didn’t pass the LOCD (level of care determination), there are three ways that this decision can be challenged. (You can read more about the LOCD under “How Do I Pay for Long-Term Care?” above.)




    Exception Review

    The first kind of challenge is called an Exception Review, which is for people who have already been found financially eligible for Medicaid or who have applied for financial eligibility and the decision is pending. The nursing home or waiver agency that conducted the LOCD has to request an Exception Review – you can’t request one yourself. If the nursing home or waiver agency decides to ask for this review, it has to make the request on the day it conducted the LOCD. 





    Exception Reviews are performed by the Michigan Peer Review Organization (MPRO). During this review, MPRO does not look at the LOCD to decide whether you qualify for nursing home care or MI Choice. Instead, MPRO looks at a different set of criteria to decide whether you qualify for an “exception” to the LOCD. (These criteria are sometimes also called the “frailty criteria,” because many of them look at how frail you are.)






    The exception criteria are[15]:




    • You can move in bed, toilet, transfer, and eat independently but need an unreasonable amount of time to do these things

    • Your performance of any activity is impacted by consistent shortness of breath, pain, or debilitating weakness

    • You have fallen at least twice in your home in the last month

    • You have trouble managing medications even after getting medication set-up services

    • You show signs of poor nutrition even after getting meal preparation services

    • You meet the criteria for Door 3 of the LOCD (which looks at how many doctors’ visits and changes to your doctors’ orders there have been in the last 14 days) when emergency room visits for clearly unstable conditions are taken into account

    • You have at least a one month history of and in the last seven days have had two or more instances of wandering, verbal or physical abuse, socially inappropriate behavior, and/or resisting care

    • You have a demonstrated need for complex treatments or nursing care

    You only need to meet one of the many criteria to be found eligible for Medicaid-funded nursing home care or for MI Choice. Once MPRO receives the request for an Exception Review, MPRO will call the nursing home or waiver agency and ask questions about you to see if you meet any of the frailty criteria. 




    MPRO will make a decision within 24 hours of receiving the Exception Review request. If MPRO decides that you qualify for an exception, you are now medically eligible for Medicaid-funded nursing home care or MI Chioce. If MPRO decides that you do not qualify for an exception, MPRO will issue you a notice informing you that you have been found medically ineligible and explaining how you can appeal that decision. (See “Appeal to the Michigan Administrative Hearing System for the Department of Community Health” and “How Do Appeals to the Michigan Administrative Hearing System for the Department of Community Health Work?” below for more information on the appeals process.)





    You have the right to either an Exception Review or an Immediate Review (see “Immediate Review” below), but not both.





     




    Immediate Review

    The second kind of challenge is called an Immediate Review. An Immediate Review is like an Exception Review (see “Exception Review” above), except you (not the nursing home or waiver agency) request that MPRO perform this review, and MPRO has a little more time to make a decision.






    If the nursing home or waiver agency decides that you don’t pass the LOCD and it does not request an Exception Review, the nursing home or waiver agency will give you an action notice informing you that you have been found medically ineligible for Medicaid-funded nursing home care or MI Choice and explaining your right to request an Immediate Review and/or appeal the decision. If you want to request an Immediate Review, you have to do so by noon of the first business day after getting the action notice from the nursing home or waiver agency.




    Once MPRO receives your request for an Immediate Review, MPRO will call the nursing home or waiver agency and request your medical/case record. MPRO then has three business days to look at your record and decide whether you qualify for an exception. They use the same criteria that they use in an Exception Review (see “Exception Review” above for more information). 




    Just like with an Exception Review, if MPRO finds that you are medically ineligible, you can appeal that decision.




    You have the right to either an Exception Review or an Immediate Review, but not both.





     




    Appeal to the Michigan Administrative Hearing System for the Department of Community Health

    The third kind of challenge is an appeal to the Michigan Administrative Hearing System for the Department of Community Health (MAHS). You can appeal a decision of medical ineligibility regardless of whether you had an Exception or Immediate Review.




    When you are found medically ineligible for Medicaid-funded nursing home care or MI Choice, you will be issued an action notice. If you are not currently getting Medicaid-funded nursing home care or MI Choice services but are applying for one of them and you are found ineligible, you will receive an Adequate Action Notice. If you are currently getting Medicaid-funded nursing home care or MI Choice services but are found no longer medically eligible, you will receive an Advance Action Notice. These notices need to explain the procedure for requesting a hearing to appeal the decision that you are medically ineligible.




    If you are in a nursing home, the nursing home and/or MPRO has to issue an Advance Action Notice at least 90 days before your nursing home care will be stopped. If you are getting MI Choice services, the waiver agency and/or MPRO has to issue an Advance Action Notice at least 12 days before your MI Choice services will be stopped. If you request a hearing before the date that your nursing home care or MI Choice services are supposed to stop, the nursing home or waiver agency has to keep providing your care until after the judge makes a decision in your case. However, if the judge decides that you are medically ineligible, you may be required to pay for the services that were provided to you while the hearing was pending. 





    During the appeal to the Michigan Administrative Hearing System, a judge called an Administrative Law Judge (ALJ) looks at the decisions that were made by the nursing home, waiver agency, and/or MPRO to see if they made the right decision. If you had an Exception or Immediate Review, the ALJ will look at a) whether the LOCD was performed properly and b) whether the Exception or Immediate Review was performed properly. If you did not have an Exception or Immediate Review, the ALJ will only look at whether the LOCD was performed properly; this means the ALJ will not look at whether you qualify for an exception to the LOCD. If you want to be considered for an exception to the LOCD criteria, you should make sure to have MPRO conduct an Exception or Immediate Review.




    If the ALJ ultimately decides that you are medically ineligible for nursing home care or MI Choice and you think that your needs or circumstances have changed since the nursing home or waiver agency last assessed you and decided you didn’t qualify, you can ask the nursing home or waiver agency to reassess you to see if you now pass the LOCD.




    You can read more about appeals under “How Do Appeals to the Michigan Administrative Hearing System for the Department of Community Health Work?” below.







    WHAT DO I DO IF SOMEONE IS TRYING TO TERMINATE OR REDUCE PAYMENT FOR MY LONG TERM CARE?

    Medicare: Skilled Nursing Facility Care and Home Health Services[16]

     

    Your nursing home will give you a notice called a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) if it thinks Medicare may not cover your care or stay because it isn’t reasonable or necessary or is considered custodial care.




    Your home health agency will give you a notice called a Home Health Advance Beneficiary Notice (HHABN) if the home health agency reduces or stops providing any of your home health services for business-related reasons or because your doctor changed your orders, or if the agency plans to give you a service or supply that Medicare probably won’t pay for. The Notice will explain what service or supply is going to be reduced or stopped. The Notice will also tell you what you can do if you want to keep getting it.




    You have the right to have your nursing home or home health agency send your claim to Medicare so Medicare will make a decision about payment. You can also keep getting the services, but you may have to pay the nursing home or home health agency for them.




    When your nursing home care or all of your covered home health services are ending, your nursing home or home health agency will give you a written notice called the Notice of Medicare Provider Non-Coverage at least 2 days before your services end. (You can ask for this notice if the nursing home or agency doesn’t give it to you.) This Notice tells you the date your services will end, how to ask for a fast appeal, and your right to get a detailed notice about why your services are ending.




    You may have the right to a fast appeal if you think your services are ending too soon. The deadline for requesting a fast appeal is noon of the day after you get the Notice of Medicare Provider Non-Coverage. (If you miss the deadline, you can still ask the Quality Improvement Organization (QIO) to review your case, but different rules and timeframes apply.)   




    You request a fast appeal from an independent reviewer called a Quality Improvement Organization (QIO). (The QIO is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.) 




    When the QIO gets your request, it will notify the nursing home or home health agency. By the end of the day that the nursing home or home health agency gets the notice from the QIO, the nursing home or home health agency will give you a Detailed Explanation of Non-Coverage. This notice tells you why your services are no longer reasonable and necessary or why they are no longer covered. This notice also includes the relevant Medicare coverage rule or policy and explains how it applies to your situation. 




    The QIO looks at your case and decides if you need the nursing home care or home health services to continue. The QIO will ask for your opinion about why you think coverage should continue, and it will look at your medical information and talk to your doctor. The QIO will notify you of its decision as soon as possible, generally no later than 2 days after your services are supposed to end.




    If the QIO decides your services should continue, Medicare may continue to cover your care or services (except for any applicable coinsurance or deductibles). If the QIO decides that your coverage should end, you may have to pay for any services you got after (but not before) the date given on the Notice of Medicare Provider Non-Coverage for when your nursing home care or covered home health services should end.




    After Medicare makes a decision on a claim, you have the right to appeal. You can appeal if a service or item you got isn’t covered and you think it should be, or if a service or item is denied and you think it should be paid. If you appeal, you can ask your doctor and/or people providing your health care or supplies for any information that might help your case.




    The company that handles claims for Medicare will send you a list of your claims, called the Medicare Summary Notice (MSN), every 3 months. This notice tells you if your claim is approved or denied. If the claim is denied, the reason for the denial will be included on the notice. The notice will also include information about how to file an appeal.





     




    Medicaid

    If your nursing home care or MI Choice services are being terminated because of a finding that you no longer qualify financially for Medicaid-funded long-term care, you should contact your local Michigan Department of Human Services office. The Department of Human Services is the agency that decides whether you are financially eligible for Medicaid, including Medicaid-funded nursing home care and MI Choice. You can find contact information for local DHS offices here





    If your nursing home or waiver agency is terminating your care because it has found that you no longer pass the LOCD and qualify medically for Medicaid-funded long-term care, see “What Can I Do If A Nursing Home or Waiver Agency Decides That I’m Not Medically Eligible for Medicaid-Funded Nursing Home Care or for MI Choice?” above.





    MI Choice




    If your waiver agency is terminating your services for a reason other than the reasons discussed immediately above, or if your waiver agency is reducing or suspending your services (but not terminating them), the waiver agency is required to give you advance notice of this action and you have the right to a hearing to appeal the action.




    The waiver agency is required to give you a notice called an Advance Action Notice if it wants to reduce, suspend, or terminate your services. The notice must be provided at least 12 days before the date they want the reduction, suspension, or termination to start. The notice must clearly explain how your services are to be reduced, suspended, or terminated and it must tell you why your services are going to be changed. 




    The notice must also tell you that you have the right to a hearing to explain to a judge why you think your services should not be changed or should not be changed in the way the waiver agency has proposed. The notice has to explain that if you request a hearing before the date the waiver agency wants the reduction, suspension, or termination to start, then your services will not be changed until after the judge holds your hearing and makes a decision about your services. The notice may also explain that if the judge decides that your services should be reduced, suspended, or terminated, you may be required to pay for the services that were provided to you while the hearing was pending. The notice needs to explain the procedure for requesting a hearing.





    If the ALJ ultimately decides that your services should be reduced, suspended, or terminated and you think that your needs or circumstances have changed since the waiver agency last assessed you, you can ask the waiver agency to reassess you to see if you now qualify for services or more services.




    You can read more about appeals under “How Do Appeals to the Michigan Administrative Hearing System for the Department of Community Health Work?” below.







    HOW DO APPEALS TO THE MICHIGAN ADMINISTRATIVE HEARING SYSTEM (MAHS) FOR THE DEPARTMENT OF COMMUNITY HEALTH WORK?

    If a nursing home or waiver agency decides that you are no longer medically eligible for Medicaid-funded nursing home care or MI Choice, or if a waiver agency wants to reduce or suspend your MI Choice services, you have the right to appeal those decisions to the Michigan Administrative Hearing System (MAHS) for the Department of Community Health. If a nursing home or waiver agency wants to do any of these things, it has to issue you an action notice. More information about these action notices is discussed under the relevant sections above. The action notice will tell you how you can request a hearing to appeal the decision. You will have to fill out a Request for Hearing form, which you can find online here.  




    Once you have requested a hearing, you will receive a Notice of Hearing from MAHS. You are allowed to have a lawyer during your hearing, or have someone you trust be your “authorized representative” and speak for you during the hearing.




    Most hearings are scheduled as phone hearings. This means that on the day and time of your hearing, the judge will call you, your authorized representative if you have one, representatives from the nursing home or waiver agency, and sometimes a representative from the Michigan Department of Community Health. Everyone will be on the same phone line for the hearing. If you would prefer to have a hearing where everyone is all in the same room, you have the right to and can request an in-person hearing. In-person hearings are sometimes held in state office buildings so you might have to travel to get to the place where the hearing is being held.




    A judge called an Administrative Law Judge (ALJ) will hear your case. You can have witnesses or you yourself can testify, and you can also present any documents or other evidence that helps your case. The nursing home or waiver agency will also have a chance to have witnesses testify and present documents or other evidence. You have a chance to cross-examine or ask questions of the nursing home’s or waiver agency’s witnesses, and the nursing home or waiver agency has a chance to do the same for your witnesses. The judge may also ask you, the nursing home, and/or the waiver agency questions. The judge won’t usually make a decision about your case during the hearing; he or she will issue an order with his or her decision sometime after the hearing.





    CAN YOU TELL ME ABOUT THE HOME HELP PROGRAM IN A NUTSHELL?[17]

     

    The Home Help program provides unskilled personal care services to help people who have certain limitations to function as independently as possible.




    The Home Help program is run by the Michigan Department of Human Services. If you are interested in and/or enrolled in Home Help, you will be working with a DHS employee called an “adult services specialist.”




    To be eligible for Home Help, you must:




    • Be eligible for Medicaid

    • Have a certification of medical need for personal care services from a Medicaid-enrolled doctor, nurse practitioner, or therapist

    • Need at least some direct assistance with one or more of the following things:

      • Eating

      • Toileting

      • Bathing

      • Grooming

      • Dressing

      • Transferring

      • Mobility

    • Have an appropriate level of care status

    You are not eligible for Home Help services if you have a spouse who is able and available to provide the services. Your spouse is considered unable if he or she has his or her own disabilities that prevent him or her from caring for you. Your spouse is considered unavailable if he or she is away from your home for an extended period because of something like work or school. 





    There are other programs in Michigan that also help people who need help with everyday tasks, such as community mental health services programs (CMHSPs), prepaid inpatient health plan (PIHPs), home health services through Medicaid, MI Choice, PACE, the Nursing Facility Transition program, and hospice. If you are eligible for or already enrolled in or getting help from any of these programs, that might affect your eligibility for Home Help or what Home Help can help you with.




    Your




    DHS adult services specialist will come meet with you in your home to assess whether and how much help you need with the things listed above.




    If the DHS specialist finds that you qualify for Home Help, he or she will assess how much help you need and then use a person-centered process to develop a Home Help service plan that includes things like what specific services you will get and who will provide them. Person-centered means that the supports coordinator should listen to you and work with you and any friends or family members you want involved to develop your service plan. After you’ve started receiving Home Help services, your DHS specialist will come and meet with you in your home every six months to see how everything is going, whether your service plan needs to be adjusted, and whether you still qualify for Home Help.




    Home Help can help you with the following things:




     Eating




    Toileting




     Bathing




     Grooming




     Dressing




     Transferring




     Mobility




     Taking medication




     Meal preparation




     Laundry




     Light housework




     Shopping and errands




    While there are limits on how much help you can get through Home Help, if you have extensive needs that can’t be met within these limits, you might be eligible for expanded home help services.




    There are some things Home Help cannot help you with, including:






    • Transportation

    • Money management

    • Home-delivered meals

    • Adult day care

    You can choose to use a professional agency or hire a friend, family member, or someone else you know to provide your Home Help services. However, you’re not allowed to hire your spouse. If you choose to use someone you know, in 2014 he or she will be paid between $8 and $11 an hour to be your Home Help caregiver. The amount your caregiver will be paid depends on the county in which you live. In most counties, (including Wayne, Oakland, Macomb, and Kent) in 2014 your Home Help caregiver will be paid $8.00 per hour.




    Finding Out About and Appealing Negative Actions[18]

     

    If DHS evaluates you for Home Help and decides you don’t qualify, they will send you an Adequate Negative Action Notice which must explain why you don’t qualify.




    If DHS plans to reduce, suspend, or terminate your Home Help services, it generally has to give you an Advance Negative Action Notice at least 10 days before your services will be changed. The notice has to explain why your services are going to be changed.  




    If you get any kind of negative action notice, you have a right to a hearing before an Administrative Law Judge. DHS should send you a Request for Hearing form along with the negative action notice that you can fill out to request a hearing. During your hearing, you can present evidence, testify yourself, or have others testify about why your services should not be reduced, suspended, or terminated.




    If you are already receiving services and DHS plans to reduce, suspend, or terminate them, and you request a hearing before the date that your services are supposed to change, DHS has to keep paying for your Home Help services until after the judge makes a decision in your case. However, if the judge decides that your services should be changed, you may have to pay for the services that were provided to you while the hearing was pending.





    RESOURCES

    Many of these resources are also mentioned in the relevant discussions above. They are compiled here, with some additional resources, for your convenience.




    General Resources

    Here are some general resources on long-term care:




    • What is Long-Term Care? U.S. Department of Health and Human Services.  

    • Piecing Together Quality Long-Term Care: A Consumer’s Guide to Choices and Advocacy in New York. Long Term Care Community Coalition.  

      • A guide for consumers and their families and caregivers on long-term care, with information about, descriptions of, and considerations regarding a wide variety of long-term care options in all three long-term care settings; also includes information on how to assess the care and services that an individual needs, the cost of long-term care and how to pay for it, nursing home transition, and other helpful resources for consumers.

    • Long-Term Care Resources on the Internet. National Citizens’ Coalition for Nursing Home Reform. 

      • A consumer factsheet that includes questions to ask when visiting long-term care websites to assess their information appropriately and a list, with brief descriptions/key features, of relevant websites.

    • Your Guide to Choosing a Nursing Home or Other Long-Term Care. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

      • A booklet that discusses alternatives to nursing facilities, how to find and compare nursing homes, what to consider when visiting nursing homes, how to pay for nursing home care and other health care costs, and living in a nursing home (including care plans, reporting and resolving problems, and resident rights and protections); also includes a short glossary.

    Nursing Homes

    For information about laws and regulations related to nursing homes, see the following resources:




    • An Ombudsman’s Guide to the Nursing Home Reform Law. The National Consumer Voice for Quality Long-Term Care. 

      • A document that discusses important provisions and aspects of the Nursing Home Reform Law, the legislative process to enact the law, the law’s subsequent implementation, and the current challenges with the law; and provides a summary of the major provisions of the law.

    • Residents’ Rights: An Overview. The National Consumer Voice for Quality Long-Term Care.

      • An information sheet that discusses and outlines the resident rights protected by the federal Nursing Home Reform Law.

    • NH Regulations Plus, Federal Regulations. University of Minnesota. 

      • A webpage with links to the federal regulations on nursing homes (located at 42 CFR § 483), broken down by subpart and/or subsection; also includes a link to CMS Survey Resources.

    • NH Regulations Plus, Regulations by Topic. University of Minnesota. 

      • A webpage with links to nursing home regulations, organized by topics that mirror the F-tag categories in the federal nursing home regulations; each topic page includes a description of the federal requirements, a comparison of state requirements, a table comparing states, and a complete transcript of state requirements on the topic.

    • NH Regulations Plus, Regulations by State: Michigan. University of Minnesota. 

    For information about evaluating and choosing a nursing home, see the following resources:




    • Nursing Home Compare. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

      • An online tool to evaluate nursing homes; allows users to, e.g., view basic information on facilities, compare facilities, view both overall ratings and ratings on specific factors, get information on staffing and quality measures, see the nature and extent of any deficiencies discovered during recent inspections, and view inspection reports.

    • Facility Search. Michigan Department of Licensing and Regulatory Affairs. 

      • An online tool to evaluate nursing homes; allows users to, e.g., search for and/or browse nursing facilities and view state surveys and documents related to complaints about particular facilities.

    • A Consumer Guide to Choosing A Nursing Home. The National Consumer Voice for Quality Long-Term Care.                                     

    • Your Guide to Choosing a Nursing Home or Other Long-Term Care. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

      • A booklet that discusses alternatives to nursing facilities, how to find and compare nursing homes, what to consider when visiting nursing homes, how to pay for nursing home care and other health care costs, and living in a nursing home (including care plans, reporting and resolving problems, and resident rights and protections); also includes a short glossary.

    •  Fact Sheet: When Looking for a Nursing Home. Michigan Long Term Care Ombudsman. 


    For information about getting good care in nursing homes, see the following resources:




    For information about addressing problems in a nursing home, see the following resources:




    • How to File a Complaint Against Health Facilities, Agencies and Programs. Michigan Department of Licensing and Regulatory Affairs, Bureau of Health Care Services.  

      • The Bureau of Health Care Services at the Michigan Department of Licensing and Regulatory Affairs is the agency that regulates nursing homes. This webpage has more information about the Bureau and how to file a complaint about nursing homes.

    • 20 Common Nursing Home Problems – and How to Resolve Them. Eric Carlson, National Senior Citizens Law Center.                                           

      • A publication that identifies twenty common problems with nursing homes and provides information related to and suggestions for resolving each problem; among the problems discussed are those related to care planning, physical and chemical restraints, feeding tubes, the admission process, Medicare and Medicaid, and eviction.

    • Consumer Concerns for Older Americans: When You Can’t Go Home Again: Using Consumer Law to Protect Nursing Facility Residents. National Consumer Law Center.

      • A publication that discusses common problems with nursing facilities and tools to challenge abusive nursing facility practices, and suggests a variety of consumer law remedies/causes of action, with an in-depth discussion of Unfair and Deceptive Acts and Practices (UDAP) statutes.

    Homes for the Aged, Adult Foster Care Homes, and Unlicensed Assisted Living Facilities

    For information about homes for the aged and adult foster care homes in Michigan, see the following resource:




    Adult Foster Care and Homes for the Aged. Michigan Department of Human Services, Adult Foster Care and Homes for the Aged Licensing Division. 





    For information about evaluating and choosing a home for the aged, adult foster care home, or unlicensed assisted living facility, see the following resources:




    Statewide Search for Adult Foster Care / Homes for the Aged Facilities. Michigan Department of Human Services. An online database that allows users to find a list of the adult foster care homes and/or homes for the aged in a particular community and provides basic information about each home, including what its capacity is and what services it offers. This database also provides, for each home, copies of inspection reports, study reports, and/or special investigation reports. For some homes, there is a copy of the Original Licensing Study Report, which provides a description of the home and its program.




    Contact Information for the Bureau of Children and Adult Licensing. Michigan Department of Human Services.                             




    Fact Sheet: How to Choose a Residence That is Right for You.  Michigan Long Term Care Ombudsman.




    Consumer Expectations Checklist. Washington Long-Term Care Ombudsman Program. 




    For information about addressing problems in a home for the aged, adult foster care home, or unlicensed assisted living facility, see the following resources:




    File a Complaint. Michigan Department of Human Services, Bureau of Children and Adult Licensing. The Bureau of Children and Adult Licensing at the Michigan Department of Licensing and Regulatory Affairs is the agency that regulates adult foster care homes and homes for the aged. This webpage has information about how to file a complaint about these facilities with the Bureau.




    Home and Community-Based Services Generally

    For general information about home and community-based services, see the following resources:




    • Home and Community-Based Services. National Association of Area Agencies on Aging (n4).

      • A list and brief descriptions of the types of home and community-based services available.

    • Services Available. Administration on Aging, Eldercare Locator.

      • An informational webpage listing and providing brief descriptions of the types of home and community-based services available.

    • LTSS Options at Home and in the Community. The National Consumer Voice for Quality Long-Term Care.  See p. 3-5 of the pdf.

      • A factsheet for consumers that explains what long-term services and supports are, discusses the difference between and examples of activities of daily living and instrumental activities of daily living, gives examples of some of the most common home and community-based services, gives case examples of how home and community-based services can allow people to stay in their homes, and lists and describes a few resources to contact to find out what services are available in a given community.

    For information about evaluating and choosing a home a home and community-based services provider, see the following resource:




    • Medicare and Home Health Care. U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. See Section 2, Choosing a Home Health Agency.

    MI Choice

    • Medicaid Provider Manual (July 1, 2014). Michigan Department of Community Health. See the MI Choice Waiver Chapter, starting at p. 983 of the pdf.

    • MI Choice. Michigan Department of Community Health.  

      • This webpage provides links to a number of documents relevant to MI Choice, including a link to download the MI Choice Waiver Participant Handbook.

    • Choices for older or disabled persons who may need help caring for themselves. Michigan Department of Community Health.      

      • This webpage provides information about the MI Choice program and a Waiver Agency Region Map and list of Waiver Agents.

    PACE

    Home Help

    • Map of DHS County Offices. Michigan Department of Human Services. 

      • This webpage provides a map with links to the contact information for local DHS offices. The Home Help program is run by the Department of Human Services; contact your local DHS office to apply or with questions or concerns.

    Medicare and Long-Term Care

    • See the many resources about Medicare in the topic on Medicare.

    • Medicare and Home Health Care. U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. 

      • A booklet that discusses who is eligible for Medicare home health benefits, Medicare coverage of home health care, what services Medicare does and does not cover, Home Health Advance Beneficiary Notices, appeal rights, choosing a home health agency, care plans, Medicare recipients’ rights, and other programs to help with health-related expenses; also includes a short glossary.

    • Your Medicare Coverage: Home health services. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

    • Your Medicare Coverage: Skilled nursing facility (SNF) care. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.  

    • Your Medicare Coverage: Hospice & respite care. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

    Medicaid and Long-Term Care

    • Medicaid Provider Manual (July 1, 2014). Michigan Department of Community Health. See especially the following chapters: Nursing Facility Coverages, starting at p. 1213 of the pdf; MI Choice Waiver, starting at p. 983 of the pdf; and PACE, starting at p. 1850 of the pdf.

    • Medicaid and Long Term Care. Michigan State Long Term Care Ombudsman Program.  

    Contesting Adverse Decisions by Medicare

    • Medicare Appeals. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                           

      • This handbook, written in easy-to-understand language, includes detailed information about the process to contest or appeal Medicare decisions with which you disagree.

    • Self Help Packets. Center for Medicare Advocacy.  

      • The Center for Medicare Advocacy’s self help packets are fantastic resources to help you to handle your own Medicare appeals.

    Contesting Adverse Decisions by Medicaid

    • Beneficiary Support: Administrative Hearing. Michigan Department of Community Health.                                                                           

      • This webpage provides contact information for the Michigan Administrative Hearing System and a link to download the Request for Hearing Form to request an administrative hearing to challenge an adverse decision by the Michigan Department of Community Health.

    • Medicaid Fair Hearings: Rights & Responsibilities. State Office of Administrative Hearings & Rules for the Department of Community Health.  

      • This brochure provides information about Medicaid Fair Hearings.

    • Michigan Medicaid Nursing Facility Level of Care Determination: Long Term Care Adverse Action Notices. Michigan Department of Community Health.  

      • This section of this webpage includes information about and sample adverse action notices.

    • Map of DHS County Offices. Michigan Department of Human Services. 

      • This webpage provides a map with links to the contact information for local DHS offices. The Department of Human Services handles the determination of one’s financial eligibility for Medicaid and Medicaid programs; contact your local DHS office to apply for Medicaid or with questions or concerns or to challenge a finding about your financial eligibility.


    [1]U.S. Department of Health and Human Services. What is Long-Term Care? http://longtermcare.gov/the-basics/what-is-long-term-care/

    [2] Michigan Department of Human Services. What Needs to be Licensed. http://www.michigan.gov/dhs/0,4562,7-124-5455_27716_27717-245180--,00.html.

    [3] Id.

    [4] Id.

    [6] MI Choice Waiver Participant Handbook. Michigan Department of Community Health. Downloadable at: https://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42549_42592-151693--,00.html

    [7]The National Consumer Voice for Quality Long-Term Care. Paying for Long-Term Care. http://www.theconsumervoice.org/sites/default/files/about/16.%20Paying%20for%20Long-Term%20Care.pdf; The National Consumer Voice for Quality Long-Term Care. Piecing Together Quality Long-Term Care. http://www.theconsumervoice.org/pdf/piecing-together-quality-long-term-care.pdf; Centers for Medicare & Medicaid Services. Medicare and Home Health Care. http://www.medicare.gov/Publications/Pubs/pdf/10969.pdf

    [9] Medicare.gov. Skilled nursing facility (SNF) care. http://www.medicare.gov/coverage/skilled-nursing-facility-care.html.

    [10] Medicare.gov. Hospice & respite care. http://www.medicare.gov/coverage/hospice-and-respite-care.html

    [11] Michigan Department of Community Health. Michigan Medicaid Nursing Facility Level of Care Determination. http://www.michigan.gov/documents/AttachA__NF_LOC_Criteria_Form-WEB-BLANK_107510_7.pdf

    [12] Medicaid Provider Manual (April 1, 2014). Beneficiary Eligibility Chapter. p. 54-55 [re: patient pay amount]

    [13] Michigan Department of Community Health. Medicaid Provider Manual, MI Choice Waiver Chapter. http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

    [14] Michigan Department of Community Health. Medicaid Provider Manual, Program of All-Inclusive Care for the Elderly Chapter. http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

    [15] See Michigan Department of Community Health. Michigan Medicaid Nursing Facility Level of Care Determination Nursing Facility Level of Care Exception Process. http://www.michigan.gov/documents/AttachD_Exception_Criteria_pc-WEB_107347_7.pdf

    [16] Centers for Medicare & Medicaid Services. Medicare and Home Health Care. http://www.medicare.gov/Publications/Pubs/pdf/10969.pdf (p. 11-14); Centers for Medicare & Medicaid Services. Medicare Appeals. http://www.medicare.gov/Pubs/pdf/11525.pdf (p. 7-22, especially p. 18-22).

    [17] Medicaid Provider Manual. Home Health Chapter. p. 22; Adult Services Manual 101 (Available Services), 102 (Person Centered Planning and Advocacy), 105 (Eligibility Criteria), 115 (Adult Services Requirements), 120 (Adult Services Comprehensive Assessment), 125 (Coordination with Other Services), Service Plan (130), Home Help Providers (135), Reviews (155).

    [18] Adult Services Manual 150 (Notification of Eligibility Determination) http://www.mfia.state.mi.us/olmweb/ex/AS/Public/ASM/150.pdf