Nursing Home Social Services Reference/Flow of Care/Changes in Benefits

There can be situations that cause a change in benefits eligibility. Benefits that can change include Social Security retirement, SSI and SSDI, and Medicaid. Medicare usual changes only for those who surrender their disability or for lack of payment of the Part B premium. Part D benefits can be changed by the insurer when they alter their formulary leaving some of a resident's drugs unreimbursed or unpaid. There may also be state benefits that are affected. Some benefit changes such as COLA increases in social security and other statutory changes to state benefits can increase the benefit. For Medicaid insured residents, increases change the resident obligation and decrease the Medicaid reimbursement. This results in no change to the resident's monthly income. Some benefit changes decrease the amount of money the resident receives. This could expose the facility or resident to debts and fees. Some of these changes can be retroactive and can cause "clawbacks" where the insurer insists on being repaid for a reimbursement that was not allowed in the past. Benefits might decrease in the following situations: Residents who while receiving social sercuity retirement or disability benefits were in jail for a period of more than 30 days Disabled residents who did not file their disability certification after the third year of disability (not required for all residents receiving SSI or SSDI) or gave up their disability benefits Medicaid residents who receive an inheritance or large gift, win the lottery, or do not use a social security or other government lump sum award within the required period of time or used their award improperly (see Improper Uses of Funds) Residents who have some social security garnished (limit is $250) to pay a federal tax lien or school loan. Social services may be required to help the resident find ways to pay the facility or file some paperwork for a compensating benefit. Managing these changes in benefits can require some effort. Compensating benefits may require reassessment by Medicaid. Medicaid may cover some changes in social security or disability payments for example insuring the resident's bill is paid at the facility. The Federal school loan program includes a forgiveness for permanently disabled debtors. This requires filling out a form, providing proof of the permanent disability and sending this to the proper agency withint the Dept of Education. Other grant and private benefit charities may also be able to help in difficult cases. A payment plan using the resident's Medicaid cash allotment is also possible.