SNF - Stimulus Checks

In May 2009, nearly every nursing home resident in the country will receive a one-time cash benefit of $250. The cash benefits are provided as a result of §2201 of the American Recovery and Reinvestment Act of 2009 (ARRA, also known as the Stimulus Act). Unfortunately, the Center for Medicare Advocacy has heard that some nursing facilities are telling families that facilities, rather than residents, will receive and spend the stimulus money. This is incorrect. Another issue arises if residents' payments are automatically deposited in facility accounts. In these instances, facilities will need to take action to assure that stimulus payments are properly credited to residents.

Advocates should ensure that residents receive and are freely able to use the full amount of their stimulus payments. The Centers for Medicare & Medicaid Services (CMS) is expected to issue guidance soon to state survey agencies about residents' stimulus payments.

What the ARRA Provides

Under the ARRA, residents who receive Social Security, Supplemental Security Income (SSI), Railroad Retirement Benefits, and/or Veterans, Disability Compensation or Pension benefits, will automatically receive a one-time payment of $250. This money will not be considered income and will not be counted as a resource for ten months (including the month the money was received) for purposes of determining eligibility for, or the amount of, benefits under any federal program or any state program with some federal financing. Residents will receive the payment either by direct payment or check, depending on how they ordinarily receive their qualifying benefit. The money is theirs to use for whatever personal purpose they choose.

What the Nursing Home Reform Law Provides

Comprehensive federal rules protecting nursing facility residents' money are applicable to the ARRA stimulus payments.[1]

Under the Nursing Home Reform Law, nursing facilities cannot require residents to deposit their personal funds with the facility.[2] However, if a resident gives written authorization to the facility, the facility "must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph."[3] Facilities may neither refuse to handle residents' funds, on request, nor charge residents for managing their funds.[4]

Facilities that manage residents' funds must deposit amounts in excess of $100 for Medicare residents and in excess of $50 for other residents in interest-bearing accounts that are separate from facility accounts. They must credit all interest to the residents' accounts. Facilities may keep residents' funds below $100 for Medicare residents and below $50 for other residents in a non-interest bearing account or in a petty cash fund.[5]

Facilities "must assure a full and complete separate [at least quarterly] accounting of each such resident's personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record."[6]

When a resident's balance is $200 less than the SSI resource limit for one person, the facility must notify the resident.[7]

When a resident dies, the facility must "convey promptly" the resident's personal funds and an accounting to whoever is administering the resident's estate.[8]

Facilities must purchase a surety bond or provide assurances "satisfactory to the Secretary" about the security of residents' money.[9]

Facilities may not charge residents "for any item or service for which payment is made" under Medicare or Medicaid, except for applicable deductibles or coinsurance amounts.[10] Services covered by Medicare and Medicaid include nursing services, dietary services, activities program, room/bed maintenance services, routine personal hygiene items and services, and medically-related social services.[11]

Facilities may charge residents for other items and services – telephone, personal television, personal comfort items ("smoking materials, notions and novelties, and confections"), cosmetic and grooming items, personal clothing, personal reading matter, gifts purchased on behalf of a resident, flowers and plants, social events and entertainment outside the activities program, private room ("except when therapeutically required"), and "specially prepared or alternative food requested instead of the food generally prepared by the facility,"[12] – but a facility:

Residents who have not received the payment by June 4, 2009 should call the local Social Security office or 1-800-772-1213.

Residents and their advocates should ask the facility about the stimulus payments. If a facility says it is keeping the money or otherwise indicates that the money is unavailable to the resident, the resident may file a complaint with the state survey agency, contact the State nursing home ombudsman program, contact the State Attorney General, and/or contact a private attorney.

On April 21, the Center for Medicare Advocacy and NCCNHR (The National Consumer Voice for Quality Long-Term Care) sent a letter to Thomas Hamilton, Director, Survey and Certification Group, CMS, asking that CMS (1) issue a Survey and Certification Letter to State Survey Agency Directors (directing surveyors to determine compliance with the ARRA in all surveys conducted on or after May 4, 2009) and (2) send a Dear Administrator letter to all nursing home administrators (advising them of the requirements of the ARRA and the Nursing Home Reform Law).[i] The Center and NCCNHR also sent a letter to the Presidents/CEOs of the three national nursing home trade associations, asking for their help and leadership in informing their members about the ARRA.[ii]

Getting the word out about the stimulus payments is critical to ensuring that residents receive and know how they can spend their money. Let us know what is happening.

National Center for Benefits Outreach and Enrollment, National Council on Aging, "$250 Payment is on Its Way to You! For People Living in Residential Facilities" (one-page flyers for residents), http://www.ncoa.org/userfiles/file/250_payment_rf.pdf

Social Security Administration, "Social Security's Economic Recovery One-Time Payments Information Page," http://ssa.gov/payment/

[1] The Nursing Home Reform Law’s protections for residents’ money apply to all residents in facilities that are certified for Medicare or Medicaid or both. More than 99% of facilities participate in one or both programs; generally, only a handful of facilities in each state do not participate.

[2] 42 U.S.C. §§1395i-3(c)(6)(A)(i), 1396r(c)(6)(A)(i), Medicare and Medicaid, respectively.

[3] Id. §§1395i-3(c)(6)(A)(ii), 1396r(c)(6)(A)(ii).

[4] Centers for Medicare & Medicaid Services, State Operations Manual, Appendix PP, Interpretive Guidelines for 42 C.F.R. §483.10(c)(1)-(3), http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.

[5] 42 U.S.C. §§1395i-3(c)(6)(B)(i), 1396r(c)(6)(B)(i); Centers for Medicare & Medicaid Services, State Operations Manual, Appendix PP, Interpretive Guidelines for 42 C.F.R. §483.10(c)(1)-(3), http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf (requires quarterly accounting).

[6] 42 U.S.C. §§1395i-3(c)(6)(B)(ii), 1396r(c)(6)(B)(ii); Centers for Medicare & Medicaid Services, State Operations Manual, Appendix PP, Interpretive Guidelines for 42 C.F.R. §483.10(c)(1)-(3), http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.

[7] 42 U.S.C. §§1395i-3(c)(6)(B)(iii), 1396r(c)(6)(B)(iii).

[8] Id. §§1395i-3(c)(6)(B)(iv), 1396r(c)(6)(B)(iv).

[9] Id. §§1395i-3(c)(6)(C), 1396r(c)(6)(C).

[10] Id. §§1395i-3(c)(6)(D), 1396r(c)(6)(D).

[11] 42 C.F.R. §483.10(c)(8)(i)(A)-(F).

[12] 42 C.F.R. §483.10(c)(8)(ii)(A)-(L)

[13] 42 C.F.R. §483.10(c)(8)(iii) (A)-(C).