Six months after her mother died in 2014, Karen Craig opened her mailbox to find a bill for $9,530.06.
It came from Medi-Cal, the state’s version of the Medicaid program for low-income people, which was seeking repayment for her mother’s medical care even though she had used her coverage just once, for a routine wellness exam. (Her mother’s medical costs were primarily covered by Medicare, the federal program for seniors, Craig says.)
“I was just shocked and panicked,” says Craig, a Central Coast resident.
In the ensuing months, Craig learned that Medi-Cal’s “Estate Recovery Program” can demand posthumous payback from enrollees 55 and over for a broad range of medical costs. For many people, including Craig’s mother, these costs include the monthly payments that Medi-Cal makes to managed care plans to cover its enrollees, even if they didn’t use any medical services.
“We couldn’t believe it,” Craig says. “Other than her house, my mother had no possessions. Heirs should certainly be protected.”Ask Emily
A series of columns answering consumers’ questions about California’s changing medical landscape.
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Disbelief and anxiety over the estate recovery program are widely shared among Medi-Cal enrollees and their families.
Now, to their relief, the program is changing: If you die on or after Jan. 1, new rules will dramatically reduce what can be collected from your estate after your death.
“People who are 55 and over don’t have to worry nearly as much about Medi-Cal recovery now,” says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.
Today, I’ll explain how the new rules will affect you and your heirs. I also have a warning: An unresolved question could end up exposing hundreds of thousands of enrollees — those who use In-Home Supportive Services — to new posthumous Medi-Cal claims.
How It Works
The federal government requires states to recoup specific medical costs — mostly related to nursing home care — from the estates of certain Medicaid beneficiaries after they die. California is among a minority of states that seeks repayment beyond the federal mandate.
Under current rules, the state can collect for nearly all Medi-Cal coverage you receive after you turn 55. In some cases, the state also can recover costs from Medi-Cal members under 55 who are patients in nursing homes.
For fiscal year 2015-2016, California’s estate recovery program collected close to $70 million, says Tony Cava, spokesman for the state Department of Health Care Services, which administers Medi-Cal. That’s up from roughly $53 million in 2011-2012.
Enrollees, legislators and advocates assert that the program unfairly targets older and poor Californians.
“It is an equity issue,” says Linda Nguy, a policy advocate for the Western Center on Law and Poverty.
Sen. Ed Hernandez, D-West Covina, points to other federally subsidized health programs, such as Covered California and Medicare, which don’t go after members’ assets posthumously.
“When Covered California enrollees get subsidies, we don’t say you have to pay it back when you die and we’re going to take your home away from you,” says Hernandez, who championed the changes in the state Legislature.
The new rules adopted by lawmakers limit recovery to the federal minimum. That means the state can only make claims for costs primarily related to nursing home care and “home- and community-based services,” such as adult day health care and a pilot program testing the use of assisted living as a Medi-Cal benefit.
However, one critical question looms: The state does not currently recover costs related to In-Home Supportive Services (IHSS), which helps elderly and disabled people who are eligible for Medi-Cal receive assistance at home.
Advocates like McGinnis and Nguy don’t think that policy should change under the new rules.
However, state officials believe the federal government will require California to recover certain IHSS benefits, and they are waiting for official guidance, Cava says.
About three-quarters of the 574,000 Medi-Cal members who used IHSS in the last fiscal year were 55 or over at the time, Cava notes.
That’s a huge group of people who will be exposed to new estate recovery claims if the state changes its policy, McGinnis says.
If it does, she promises a lawsuit.
“Under the current federal guidelines and federal law, they can’t do this,” she says. “If they want to go to court, fine.”
I’ll update you after the state issues its decision.
What Is Changing?
LIMITS ON RECOVERY: As I mentioned, recovery will be limited to federal guidelines. That means Medi-Cal can no longer recover the monthly payments it makes to managed care plans on your behalf unless you’re in a nursing home, receiving home- and community-based services or related hospital and prescription drug services, Cava says. Even then, the state will only recover the portion of the monthly payment that’s related to those services, he says.
Also, the new rules protect a “homestead of modest value” from recovery, which means that a home whose fair market value is 50 percent or less of the average home price in the enrollee’s county at the time of death will be exempt.
SPOUSES: Right now, the state can’t go after your assets after you die if your spouse or registered domestic partner is alive. But it can after that person dies.
The new rules forbid the state to go after your assets if you have a surviving spouse or domestic partner— even after that person dies.
“Whether the Medi-Cal beneficiary died before or after Jan. 1, 2017, there’s no more recovery from surviving spouses and registered domestic partners,” McGinnis says. “That’s major.”
MORE WAYS TO PROTECT YOUR PROPERTY: The new rules also limit recovery to assets that are subject to probate, which is a legal process that takes place after someone dies.
There are ways to shield your property from probate, including the use of living trusts, joint tenancies, naming beneficiaries on retirement accounts and other legal arrangements, says Dustin MacFarlane, an elder law attorney in the Sacramento area.
Please note that wills are subject to probate, he says.
“Every account should have a named successor,” MacFarlane says. “If you don’t have that, then a court proceeding may be required and Medi-Cal may make a claim in that proceeding.”
INTEREST ON LIENS: The state may ask your heirs to sign a “voluntary lien” on your home if they can’t afford to pay the estate recovery claim. Right now, the state charges 7 percent interest on those liens, McGinnis says. Under the new rules, people in this situation will usually face a significantly lower interest rate, she says.
If you’re a Medi-Cal enrollee and want a list of medical expenses to date that may be subject to an estate recovery claim, you can submit a request once a year to the state by filling out Form 4017, which will cost $5 after Jan. 1.
And if you’re 55 or over, please talk with a lawyer who specializes in estate planning or elder law and is familiar with Medi-Cal estate recovery. Or reach out to groups like McGinnis’ for guidance (www.canhr.org or 800-474-1116).
Craig, whose mother passed away in 2014, is grateful that the rules are changing for other families. After negotiating with the state, she was able to reduce the amount she owed Medi-Cal but still had to cough up thousands of dollars.
“That completely strapped us,” she says. “We don’t have that kind of money.”
Rep. Tom Price, the physician and Georgia Republican tapped for the nation’s leading health care job, has long criticized federal spending as excessive. Yet during his years in Congress, he’s worked hard to keep federal dollars flowing to his most generous campaign donors.
Price has been a go-to congressman, a review of his records show, for medical special interests hotly sparring with regulators or facing budget cuts. Over the past decade, he has waded into issues related to specific drugs and medical devices, making 38 inquiries with the federal Food and Drug Administration, according to federal records obtained through the Freedom of Information Act. He questioned the FDA on his constituents’ behalf about matters as minute as a device for fertility treatment and an ingredient in pain creams.
In other cases, he has gone to bat for companies whose executives and employees have generously contributed to his campaigns and political action committees.This KHN story also ran in BuzzFeed. It can be republished for free (details).
“It looks like he’s somebody who could throw the store open to a lot of niche special interests,” said Ross Baker, a political science professor at Rutgers University who specializes in Congress. “These are things that fly under the radar. If you take a meat ax to Medicare, for example, everybody would know about it. But this kind of stuff is done in the dark of night.”
Just a few weeks before Trump tapped Price to lead the Department of Health & Human Services in November, the congressman took the stage at an Atlanta conference for vendors who sell canes, hospital beds and power wheelchairs. Price was the star of the show — a conference with 5,000 attendees. He spoke to the gathered crowd about the Medicare cuts plaguing the industry and pledged to fight them. The leaders of the Medtrade conference honored Price with an award for his stalwart advocacy and convened a $100-per-person fundraiser in his honor.
Price, 62, a tea party Republican and orthopedic surgeon from the northern Atlanta suburbs, was elected to Congress in 2004 after four terms in the Georgia state Legislature. A third-generation physician, he has said he entered politics on a quest to limit government meddling in health care. He has won significant campaign support over the years from drug firms and physician groups.
Records obtained through a public records request show that Price has taken an interest in his constituents’ struggles with the FDA. He hand-signed a letter of concern over the availability of heart valves used in pediatric surgeries in 2005. Four years later, he urged review of a local company’s sperm-analysis device. He dubbed the company a “pillar of the community” and said it should be exempted from a clinical trial that would be “impossible to pass.” Earlier this year, his staffer pressed the FDA on behalf of a constituent trying to get capsaicin palmitate, a hot-pepper ingredient similar to one available over the counter — on a list of approved products for specialized pain creams.Letter to FDA (p. 8) Rep. Tom Price has been a go-to congressman for medical special interests hotly sparring with regulators or facing budget cuts. View entire document on DocumentCloud Signed Letter (p. 11) Records obtained through a public records request show that Price hand-signed letters on behalf of his constituents’ struggles with the FDA. View entire document on DocumentCloud
A staunch opponent to President Barack Obama’s Affordable Care Act, or Obamacare, which he says destroys “the sacred doctor-patient relationship,” Price has offered several plans, including the Empowering Patients First Act, to repeal and replace the president’s health reforms. He favors instead offering patients health savings accounts which they may tap to pay for coverage and care, and tax credits to help people buy health insurance on their own.
Price’s office did not respond to interview requests or to detailed written questions about his relationships with contributors or his legislative record. His confirmation hearing could come before President-elect Trump’s inauguration on Jan. 20, and Senate Minority Leader Chuck Schumer has said Price is among the top targets for Democrats — and whose nomination they are trying to derail. The Office of Government Ethics will review Price’s financial disclosure report, which contains information about his assets, income and other personal financial information and then advise the Senate Finance Committee on whether Price needs to take steps to avoid conflicts of interest.
In recent weeks, Price has come under criticism for his stock trading in drug companies, including an Australian firm that plans to seek U.S. approval for a promising drug.
Phil Blando, a Trump transition spokesman, said Price has complied with the law and ethics rules. Blando said that Price “takes his obligation to uphold the public trust very seriously” and, if confirmed by the Senate, will work with ethics officials to “ensure his continued compliance and transparency.”
Champion of Medical Equipment
When thousands gathered at the Medtrade meeting to learn about the latest home medical equipment in the fall, Price pledged to help them.
The industry has battled widespread changes in government payment mandated by Congress in 2003 and implemented by the Obama administration. The reforms came after a decade of Justice Department prosecutions that targeted fraudsters who bought wheelchairs at wholesale prices, allegedly gave them to seniors who didn’t need or want them and billed Medicare at a premium.
The most recent reforms have included budget cuts and a competitive bidding program meant to limit medical supply profitability, including the wheelchairs. Providers of home medical equipment have ranked as key Price backers, contributing $52,600 to his campaign since 2013, according to a Kaiser Health News analysis of federal contributions.
Despite his longtime stance as a budget hawk, Price has sided with industry leaders who say the cuts harm rural medical suppliers who face higher costs delivering equipment. Price said in a press release that the cuts jeopardize seniors’ access to life-saving medical equipment, including scooters and oxygen tanks. “Georgia’s seniors ought to have access to quality health care,” Price said in a statement in May.
Price introduced a bill that month to delay cuts in Medicare spending for durable medical equipment, like hospital beds and motorized wheelchairs. The bill passed the House in July but died in the Senate.
Medical equipment industry leaders credit Price with helping reverse or delay some cuts through the recently signed 21st Century Cures Act, according to the blog of the Iowa-based VGM Group, which describes itself as “the nation’s premier purchasing organization” and a “silent partner” to thousands of independent providers of home medical equipment. The company and its executives have contributed more than $17,000 to Price. One leader aired his gratitude to the congressman in another blog post calling the delay of the cuts a “red letter day” for durable medical equipment suppliers.
Price has also helped protect companies that provide home health aides and nursing care to homebound seniors — a lucrative industry that prosecutors have identified as prone to fraud. Alarmed by a Medicare plan to review such claims prior to payment, industry leaders turned to Price and another congressman for help, according to the Partnership for Quality Home Healthcare, which lauded both men for listening to their concerns.
Home health companies also contributed more than $24,000 to Price from 2013 to earlier this year.
Criticizing the cost-saving plan as overly broad and impeding patients’ access to care, in September, Price introduced a bill that would delay the claim-review project a year. The bill, cosponsored by Rep. Jim McGovern (D-Mass.), stalled in a subcommittee in October.
Support for Traveling Doctors
In Congress, Price has been a vocal critic of America’s medical malpractice system — a bugaboo for many surgeons but also for a company based in his district that has provided reliable campaign donations. That firm, Jackson Healthcare, staffs hospitals and practices with temporary doctors, called locum tenens.
One of Price’s largest PAC contributors is Richard L. Jackson, the company’s chairman and CEO. The two spoke together in 2009 at a forum aimed at limiting malpractice lawsuits. Both men have asserted doctors’ attempts to avoid such lawsuits have led to costly and excessive medical care. In a 2010 interview, Jackson mentioned that he had discussed “defensive medicine” with Price, and other Congress members. Price, for his part, has referenced Jackson Healthcare’s study on the high cost of such health care.
The malpractice issue has had particular relevance to the locum tenens industry and to Jackson’s company in particular. It has faced multiple lawsuits over the alleged misdeeds of temporary doctors, including care of patients in Veterans Affairs and Indian Health Service hospitals.
Price has repeatedly introduced legislation to curtail malpractice cases and, on another front, to protect the tax status of traveling doctor companies. In September he introduced the House version of a bill that would help change the IRS code to classify travelling doctors as contractors, not employees, so that the company providing them wouldn’t be legally vulnerable for taxes in distant states. A Senate version was introduced earlier by Georgia Republican Sen. Johnny Isakson. The bills died in committee last year.
Jackson and his son, Shane, the company’s president, have supported Price with donations to his campaign and joint fundraising committee, which contributes to Republican campaigns. Since 2011, Jackson and his son, have contributed at least $43,000 to Price’s campaign or a joint fundraising committee with $35,000 arriving last January.
A spokeswoman for Jackson said Price’s bill would not have affected his company since, in practice, it already regarded its doctors as contractors, as did the government.
But Sean Ebner, president of another major traveling doctor company, said the measure would have eliminated the possibility of a surprise tax bill.
“The designation of who’s an independent contractor can change state by state,” Ebner, who heads Staff Care, said in an interview. “[The bill] removes ambiguity, which would be positive.”
Influence with the FDA
If confirmed as HHS secretary, Price would oversee many of the rules and regulations and bottlenecks that regularly draw howls from the medical industry. He would also have authority over the FDA, which regulates pharmaceuticals. The agency may soon have purview over a company that Price has personally invested in.
The Australian firm Innate Immunotherapeutics reported in an annual report that it plans to bring its key Multiple Sclerosis drug to the FDA for approval. Several months ago, Price purchased between $50,000 and $100,000 worth of stock in the company, according to a routine financial disclosure required of Congress members.
The FDA is also currently mulling another regulatory issue that could make or break the company of a top contributor. Parker H. “Pete” Petit, along with his family has contributed $35,900 to Price’s campaign and leadership PAC since 2010. Petit also was finance chair for Trump in Georgia and, with his family, contributed $125,000 to the president-elect’s PAC.
Petit is the CEO of MiMedx, a Georgia biotech firm in Price’s district, which has contested a decision from the FDA on some products to aid wound healing.
In August 2013, the FDA concluded in a letter that the products, which consist of discarded placentas and amniotic fluid, should be regulated since their manufacturing constituted manipulating human tissue. The FDA letter sent MiMedx stock tumbling and spurred a securities lawsuit filed in federal court in Georgia. The case accused MiMedx of misleading investors by downplaying the gravity of the FDA’s scrutiny. A nearly $3 million settlement was reached in April.
Petit has acknowledged seeking congressional help on the issue, without being specific. The FDA said it couldn’t comment on the matter. MiMedx did not return calls.
Elizabeth Lucas contributed to this report.
CAGUAS, Puerto Rico — Before the virus overwhelmed Puerto Rico, Zika already lurked in Keishla Mojica’s home.
First her partner, John Rodríguez, 23, became infected. His face swelled and a red, itchy rash covered his body. Doctors at the time diagnosed it as an allergy.
Two months later, Mojica, 23, had the same symptoms. Medics administered shots of Benadryl to soothe the rash and inflammation. She didn’t give it much more thought.
A month later she also found out she was pregnant, and that eventually led to a surprising revelation. The rashes hadn’t been caused by allergies, but instead by Zika, a virus known to cause serious birth defects.This KHN story also ran on NPR. It can be republished for free (details).
Since 2015, the virus, which is spread by mosquitoes and sexual contact, has risen from relative obscurity to a worldwide menace. Puerto Rico marks the epicenter of the outbreak in the United States. As of Dec. 16, the commonwealth’s health department reported 35,648 confirmed cases, including 2,864 pregnant women. Federal health officials have declared a public health emergency here and anticipate 25 percent of the population will have contracted the virus by the end of 2016.
The epidemic raises difficult personal questions for women like Mojica, who live on an island with strong religious undercurrents and a health care infrastructure bowing under the weight of fiscal debt. Is abortion acceptable or can faith overcome the fear? If a baby is born with disabilities like microcephaly, characterized by an abnormally small head, or cognitive impairments, how will families provide the care a child will need?
In response to the association between congenital defects and the virus, virtually all pregnant women on the island undergo testing for Zika as part of their prenatal care. Dr. Alfonso Serrano, 57, chairman of the obstetrics and gynecology department at HIMA San Pablo Hospital in Caguas and Mojica’s doctor, said the testing has shown that 5 to 8 percent of his patients contracted Zika.
Even though the threat of Zika frightens women, he said, most of his patients don’t consider abortion.
“It’s not something that is talked about every day,” he added.
Serrano attributes the aversion to terminating a pregnancy as more of a cultural idiosyncrasy than particularly devout faith. Abortion is easy to obtain here and relatively inexpensive, but surveys show that an overwhelming majority of residents said they oppose the practice.
For Mojica, abortion was the first thought that crossed her mind when she heard she had been infected. She told no one but her mother and Rodríguez about the diagnosis. She cried and prayed often. Public service announcements on television about the outbreak angered her. But Mojica never actually discussed the possibility of an abortion with anyone, and she realized quickly that she couldn’t choose that option.
“I waited until they gave me the results and that they verified everything,” she said. But Mojica added that she quickly put aside any thoughts about abortion. “I said, ‘No, forget it. Everything’s fine. Forget about it.’ That was in the moment.”
Religious Objections To Abortion
The echoes of Roman Catholicism introduced by Spanish colonial rule still reverberate through contemporary Puerto Rican society. Ninety-nine percent of its residents believe in God. Children greet their elders by asking for a benediction, to which they reply, “Dios te bendiga” — “May God bless you.”
But the church’s influence is declining. Just over half of the population self-identifies as Catholic, according to a 2014 Pew Research Center survey. In contrast, the number of Protestants has surged, now comprising a third of residents.
Puerto Ricans and religious leaders generally don’t support abortion. More than 70 percent of Catholics and eight out of 10 Protestants on the island morally oppose the procedure, according to Pew.
In February, the Catholic Archbishop of San Juan released a statement responding to the health department’s advisory to use condoms as part of preventing Zika transmission. The church’s stance against birth control are “well-known,” he said, encouraging couples to practice “personal discipline,” or abstinence from sex.
The Pentecostal Fraternity of Puerto Rico (FRAPE) — a network of Pentecostal churches across the island — also view their opposition to abortion as a non-negotiable tenet.
“God is the giver of life,” said FRAPE president Alberto Rodríguez. “And he has absolute control to take it or give it.”
Although rates have declined in recent years, thousands of women in Puerto Rico continue accessing abortion services. Seven of the island’s eight clinics performed 5,363 abortions in the fiscal year starting July 2013, based on the most recent data available from the commonwealth’s health department. More than 2,000 had undergone one other abortion. And roughly 1,350 women had sought two or more procedures.
Mojica was a faithful member of a Seventh-day Adventist congregation — which does allow for abortion in cases of certain congenital abnormalities — but says she now converses with God on her own.
Resources Available For Kids with Disabilities
Recent research suggests that Zika causes a wider range of congenital problems that previously suspected. And with a quarter of Puerto Rico’s residents thought to be infected, it is unclear how many babies will have special needs. But finding adequate care for children born with disabilities is difficult in Puerto Rico, where services are fragmented, poorly funded and already oversubscribed. Nearly half the population lives in poverty.
The Division of Children with Special Medical Needs, part of the commonwealth’s health department, runs some programs to assist families with children with disabilities, such as Advancing Together, a service that trains caregivers and helps families set up a development plan for the child. But the program expires when the child turns three, and responsibility for services is transferred to the Puerto Rican Department of Education, which has consolidated or closed dozens of schools in recent years due to declining enrollment rates and strapped budgets. Thirty percent of students attending public schools on the island in 2013 were enrolled in individualized education programs.
Nonprofit groups also play a role in helping children with special needs, such as Support for Parents of Children with Impediments and the Muscular Dystrophy Association. Yet, therapy services available are extremely limited, said Miguel Valencia, director of the Division of Children with Special Medical Needs. Although half the island’s residents rely on Medicaid for health insurance, Valencia said, many specialized clinicians no longer accept the plan due to low reimbursement rates.
Puerto Rican residents do not qualify for Social Security Administration’s Supplemental Security Income program, which provides assistance if a medical condition results in severe disability, chronic illness or death. The service is limited to individuals living in the 50 states, the District of Columbia and the Mariana Islands.
Waiting For Jayden
Among the pixels of black and shades of orange, the ultrasound image shows the outline of a human face with his eyes closed directly facing the camera. It appears modulated, akin to a half finished piece of pottery. The five stubby fingers of his right hand are pressed against his forehead as if he is lost in contemplation.
It is a sonogram, one of the first portraits of Mojica’s son, who she plans to name Jayden Aramick.
The nursery overflows with outfits in anticipation of his arrival early this year. Black Converse booties and Batman onesies hang in the armoire. Wooden letters spell his name on the wall above the crib.
Although the baby continues to grow without complications or signs of microcephaly, Mojica’s son still faces possible developmental delays from the virus that could develop after he arrives. But at this point, the risk no longer weighs on her conscience. She has given her worries to God.
“What He says is what will come to be,” she said.