TreatiseTreatise

New York Elder Law

 by Samuel Sadin Brookdale Aging
 
 Copyright: 1995-2014
 Last Updated: September 2014

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Product Details

  • ISBN Number: 087224086X
  • Page Count: 1111
  • Number of Volumes: 1
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Thousands of advocates for older, blind, and disabled New York State residents rely on PLI’s New York Elder Law for useful, authoritative guidance on the legal issues confronting their clients and on the ways these practitioners can work more effectively with various federal and state agencies to help their clients.

New York Elder Law taps experts in their respective fields to cover the latest legal issues and pertinent figures with regard to Social Security; Supplemental Security Income; Social Security and SSI Disability; Medicare; Supplemental Medical Insurance; Medicaid for the elderly, blind and disabled; home care; protective services; housing; nursing homes; health care decision-making; veteran’s benefits; and retirement plans.

New York Elder Law contains numerous checklists to save you time and help you stay up to speed with rapidly changing laws and numbers, including up-to-date eligibility and benefit levels, benefit checklists for older adults, and flow charts for step-by-step guidance through complex appeals processes.

Updated at least once a year, New York Elder Law is an essential handbook for attorneys, health care professionals, social workers, financial planners, and other advocates for older clients.

Endorsements:

”Written by the premier authority on elder law in New York, this is an important source book with a winning combination of practical and technical legal information … It puts a powerful tool in the hands of the practitioner.”
—Daniel G. Fish, President, National Academy of Elder Law Attorneys

”[New York Elder Law is] an excellent resource for those who help serve older persons in New York.”
—Nancy M. Coleman, Director, American Bar Association, Commission on Legal Problems of the Elderly

  About the Sadin Institute on Law
  Table of Contents
  Introduction
Chapter 1: Social Security, Old Age, Survivor & Dependency Benefits Barbara Samuels ~
  • § 1:1 : Overview1-3
  • § 1:2 : Sources of Law and Authority1-4
    • § 1:2.1 : Social Security Rulings1-5
    • § 1:2.2 : Acquiescence Rulings1-7
    • § 1:2.3 : Program Operations Manual System (POMS)1-8
    • § 1:2.4 : Hearings, Appeals, Litigation, and Law Manual (HALLEX)1-9
    • § 1:2.5 : Other Sources1-10
  • § 1:3 : Eligibility for Old Age Benefits1-10
    • § 1:3.1 : Age Generally1-10
    • § 1:3.2 : Insured Status1-11
    • § 1:3.3 : Noncitizen Beneficiaries1-12
    • § 1:3.4 : Earnings Records and How Wage-Earner’s Benefits Are Calculated1-15
    • § 1:3.5 : Issuance of Social Security Checks1-15
    • § 1:3.6 : Regular Retirement1-16
    • § 1:3.7 : Early Retirement1-16
    • § 1:3.8 : Delayed Retirement1-17
    • § 1:3.9 : Medicare1-17
    • § 1:3.10 : Earnings After Retirement1-18
    • § 1:3.11 : Nonwage Income1-21
  • § 1:4 : Auxiliary Benefits1-21
    • § 1:4.1 : Spouses1-22
      • [A] : Spouse of a Living Wage-Earner: Husband or Wife1-23
      • [B] : Deemed Spouse1-24
      • [C] : Spouse of Deceased Wage-Earner: Widow or Widower1-25
      • [D] : Divorced Spouse of Living Wage-Earner1-26
      • [E] : Surviving Divorced Spouse1-26
      • [F] : Mothers and Fathers1-27
    • § 1:4.2 : Children1-28
      • [A] : Generally1-28
      • [B] : Children of Same-Sex Marriages1-29
      • [C] : Legitimate Children1-29
      • [D] : Illegitimate Children1-29
      • [E] : Adopted Children1-30
      • [F] : Disabled Adult Children1-31
      • [G] : Grandchildren1-31
      • [H] : Stepchildren1-32
      • [I] : Posthumously Born Children1-33
    • § 1:4.3 : Parents1-33
  • § 1:5 : Processing a Social Security Claim1-34
    • § 1:5.1 : The Process in General1-34
    • § 1:5.2 : The Appeal Process1-35
      • [A] : Generally1-35
      • [B] : Initial Application1-35
      • [C] : Reconsideration1-36
      • [D] : Administrative Law Judge (ALJ) Hearing1-37
        • [D][1] : Generally1-37
        • [D][2] : Assignment of Case to an ALJ1-38
        • [D][3] : After Assignment of Case to an ALJ1-38
        • [D][4] : Prehearing Conference1-39
        • [D][5] : Requesting On-the-Record Decisions1-39
      • [E] : Hearing Procedure1-39
      • [F] : Telephonic Hearing Testimony1-40
      • [G] : Posthearing Period1-41
      • [H] : Hearing Decision1-41
    • § 1:5.3 : Appeals Council Review1-42
    • § 1:5.4 : Good Cause for Late Filing1-45
    • § 1:5.5 : Res Judicata and Collateral Estoppel1-47
    • § 1:5.6 : Overpayments1-48
    • § 1:5.7 : Fleeing Felons Prohibition1-50
      • [A] : Generally1-50
  • § 1:6 : Practical Problems1-52
    • § 1:6.1 : Misplaced Files and Documents1-53
    • § 1:6.2 : Delays1-54
      • [A] : Generally1-54
      • [B] : Administrative Advocacy1-56
      • [C] : Congressional Inquiries1-56
      • [D] : Judicial Intervention: Mandamus and Interim Benefits1-57
    • § 1:6.3 : Dealing with the Administrative Hierarchy1-60
  • § 1:7 : Conclusion1-61
  • Appendix 1A : Eligibility for Old Age BenefitsApp. 1A-1
  • Appendix B : Benefit Reduction Factors for Early RetirementApp. 1B-1
  • Appendix C : Maximum Percentage Benefit of Family MembersApp. 1C-1
Chapter 2: Supplemental Security Income Jill Ann Boskey ~
Barbara Samuels ~
  • § 2:1 : Introduction2-6
  • § 2:2 : Overview2-8
  • § 2:3 : Sources of Law2-9
    • § 2:3.1 : The Statute2-9
    • § 2:3.2 : The Regulations2-10
    • § 2:3.3 : The POMS2-10
    • § 2:3.4 : HALLEX2-11
    • § 2:3.5 : SSA Rulings2-11
    • § 2:3.6 : Program Circulars, Teletypes, and Other Instructions2-11
    • § 2:3.7 : Case Law2-12
    • § 2:3.8 : Acquiescence Rulings2-12
  • § 2:4 : Summary2-14
  • § 2:5 : Categorical Eligibility2-14
    • § 2:5.1 : Blindness2-14
    • § 2:5.2 : Disability2-14
    • § 2:5.3 : Age2-15
  • § 2:6 : Technical Eligibility2-17
    • § 2:6.1 : Residency2-17
    • § 2:6.2 : Application for Other Benefits2-19
    • § 2:6.3 : Permission to Contact Financial Institutions2-19
    • § 2:6.4 : Citizenship2-19
    • § 2:6.5 : SSI Eligibility for Noncitizens2-20
      • [A] : Persons Exempted from the General SSI Ban2-20
        • [A][1] : Refugees, Asylees, and Persons with Deportation Withheld2-20
        • [A][2] : Legal Permanent Resident Who Can Be Credited with Forty Quarters of Work2-22
        • [A][3] : Veteran or Active Duty Member of the Armed Forces, and His or Her Spouse or Dependent Child2-23
        • [A][4] : Certain American Indians2-24
      • [B] : Grandfatherees2-24
      • [C] : Aliens Legally Residing in the United States on August 22, 1996, but Not Receiving SSI on That Date2-24
      • [D] : Aliens Entering the United States After August 22, 19962-25
      • [E] : Proving Legal Permanent Residence or PRUCOL Status2-25
        • [E][1] : Legal Permanent Residents2-25
        • [E][2] : PRUCOL (Permanently Residing Under Color of Law)2-26
      • [F] : Assisting Aliens Seeking to Obtain or Retain SSI2-26
      • [G] : Reporting to INS/ICE Aliens Who Are Not Legally Present in the United States2-27
    • § 2:6.6 : Fleeing Felon Prohibitions2-28
      • [A] : Generally2-28
  • § 2:7 : Financial Eligibility and Living Arrangements2-30
    • § 2:7.1 : Generally2-30
    • § 2:7.2 : Resources2-31
      • [A] : Generally2-31
      • [B] : Defining Resources2-31
      • [C] : Maximum Resource Levels2-32
      • [D] : Countable Resources2-32
      • [E] : Liquid Resources2-35
        • [E][1] : Cash2-35
        • [E][2] : Bank Accounts and Joint Bank Accounts2-35
        • [E][3] : Trusts2-36
        • [E][4] : Stocks, Bonds, Promissory Notes, Mutual Fund Shares, Pension and Retirement Funds2-38
      • [F] : Nonliquid Resources2-38
      • [G] : Deemed Resources2-39
        • [G][1] : Spouses2-39
        • [G][2] : Children2-41
        • [G][3] : Aliens2-43
      • [H] : Excluded Resources2-43
        • [H][1] : Generally2-43
        • [H][2] : The Home2-44
        • [H][3] : Foreclosure Guidance for SSI Property-Owning Recipients2-44
        • [H][4] : Household Goods and Personal Effects2-45
        • [H][5] : Automobile2-46
        • [H][6] : Life Insurance Policies2-46
        • [H][7] : Burial Spaces or Agreements and Burial Funds2-47
        • [H][8] : Property Essential to Self-Support2-48
        • [H][9] : Disaster Relief and Relocation Assistance2-48
        • [H][10] : Funds Excluded Under Other Statutes2-49
        • [H][11] : Personal Injury Awards for Children and Other Trusts2-50
        • [H][12] : Native American Trust Funds and Per Capita Distributions2-50
        • [H][13] : Other Excluded Resources2-50
      • [I] : Resources Excluded for Limited Periods of Time2-51
        • [I][1] : Generally2-51
        • [I][2] : Retroactive Payments, or Underpayments, of SSI or Social Security Benefits2-51
        • [I][3] : Receipts for Replacement of Lost, Damaged, or Stolen Excluded Resources, Including Crime Victim Compensation Payments2-52
        • [I][4] : Promissory Notes or Installment Contracts2-53
        • [I][5] : Earned Income Tax Credits2-53
        • [I][6] : Certain Assistance for Medical Care or Social Services2-53
        • [I][7] : Plan to Achieve Self-Support (PASS Plan)2-53
      • [J] : Disposition of Resources: Transfer of Assets Rules2-53
    • § 2:7.3 : Income2-57
      • [A] : Generally2-57
      • [B] : Defining Income2-57
        • [B][1] : Generally2-57
        • [B][2] : Income Versus Resources2-57
        • [B][3] : Kinds of Income2-58
      • [C] : Earned Versus Unearned Income2-60
        • [C][1] : Generally2-60
        • [C][2] : In-Kind Income2-62
        • [C][3] : Deeming and In-Kind Support and Maintenance2-63
        • [C][4] : Spouses2-63
        • [C][5] : Children2-64
        • [C][6] : Aliens2-64
        • [C][7] : Rent Paid Under a Business Arrangement2-64
        • [C][8] : Valuation of In-Kind Income2-65
        • [C][9] : One-Third Reduction Rule2-66
        • [C][10] : Presumed Maximum Value Rule2-67
        • [C][11] : “Noncountable” In-Kind Support and Maintenance2-68
      • [D] : Deemed Income2-69
        • [D][1] : Generally2-69
        • [D][2] : Spouses2-70
        • [D][3] : Children2-70
        • [D][4] : Aliens2-71
        • [D][5] : Non-Income, Excluded Income, Non-Countable Income2-72
        • [D][6] : Certain Medical Care and Services2-73
        • [D][7] : Certain Social Services2-73
        • [D][8] : Proceeds of a Loan and Repayment of a Debt2-74
        • [D][9] : Sale, Exchange, or Replacement of a Resource and Interest Income on Certain Excluded Resources2-75
        • [D][10] : Income Excluded by Federal Statutes2-76
        • [D][11] : Assistance Based on Need2-76
        • [D][12] : Relocation Assistance, Crime Victim Funds, Replacement of Lost Income, and Weatherization Assistance2-77
        • [D][13] : Certain Scholarships, Grants, and Fellowships2-77
        • [D][14] : Home-Grown Food Eaten by Claimant and Family2-78
        • [D][15] : One-Third of Child Support Payments and Full Value of Certain Foster Care Payments2-78
        • [D][16] : Certain Noncash Items Not Converted to Cash2-78
        • [D][17] : Income Tax Refunds Other Than Earned Income Tax Credits2-79
        • [D][18] : Hostile Fire Pay2-79
        • [D][19] : Up to $60 of Infrequent Unearned Income2-79
        • [D][20] : Earned Income of a Child Who Is Regularly Attending School2-79
        • [D][21] : Up to $30 of Infrequent or Irregular Earned Income Per Quarter2-80
        • [D][22] : Earned Income of a Disabled Claimant Used to Meet Impairment-Related Work Expenses (IRWEs)2-80
        • [D][23] : Earned Income of a Blind Claimant Used to Meet Work-Related Expenses2-80
        • [D][24] : $65 Per Month of Earned Income2-81
        • [D][25] : One-Half of Remaining Earned Income2-81
        • [D][26] : Earned or Unearned Income Used to Fulfill an Approved Plan for Self-Support (PASS Plan)2-81
        • [D][27] : $20 Per Month General Income Exclusion2-81
        • [D][28] : Value of Transportation Ticket2-82
        • [D][29] : Dependent’s Portion of VA Benefits2-82
        • [D][30] : Native American Trust Fund Payments2-82
        • [D][31] : Gifts to Terminally Ill Children2-82
        • [D][32] : Reparation Payments to Victims of Nazi Persecution2-83
        • [D][33] : Interest on Dedicated Savings Accounts2-83
        • [D][34] : Interest Earned on Burial Account2-83
    • § 2:7.4 : Eligibility for and Payment of Benefits: Retrospective Monthly Accounting2-83
    • § 2:7.5 : Living Arrangements and Payment Rates2-85
      • [A] : Generally2-85
      • [B] : Federal Living Arrangements2-86
      • [C] : New York State Living Arrangements2-86
        • [C][1] : Generally2-86
        • [C][2] : Living Arrangements That Cause Total or Partial Ineligibility for SSI Benefits2-88
        • [C][3] : Calculating Benefit Rates: Review and Summary2-88
  • § 2:8 : Practice Tips for Maximizing Benefits2-89
  • § 2:9 : Other Factors Causing Ineligibility for Benefits2-91
    • § 2:9.1 : Failure to Apply for Other Benefits2-91
    • § 2:9.2 : Failure to Accept Vocational Rehabilitation2-92
    • § 2:9.3 : Ineligibility Based on Certain Crimes2-92
    • § 2:9.4 : Failure to Comply with a Request for Information or Whereabouts Unknown2-94
  • § 2:10 : The Application and Appeal Process2-94
    • § 2:10.1 : Generally2-94
    • § 2:10.2 : Filing an Application2-95
    • § 2:10.3 : The Administrative Appeals Process2-96
      • [A] : Generally2-96
      • [B] : Reconsideration2-97
      • [C] : Administrative Law Judge Hearings and Appeals Council Review2-97
    • § 2:10.4 : Federal Court Review2-98
  • § 2:11 : Payment of Benefits2-98
    • § 2:11.1 : Generally2-98
    • § 2:11.2 : Representative Payees2-98
    • § 2:11.3 : Presumptive Disability Payments2-99
    • § 2:11.4 : Emergency Advance Payments2-99
  • § 2:12 : Redeterminations, Overpayments, and Underpayments2-99
    • § 2:12.1 : Generally2-99
    • § 2:12.2 : Redeterminations2-100
    • § 2:12.3 : Underpayments2-101
      • [A] : Generally2-101
      • [B] : Interim Assistance2-101
      • [C] : Other Underpayments2-102
    • § 2:12.4 : Overpayments2-102
      • [A] : Generally2-102
      • [B] : Notice of an Overpayment2-102
      • [C] : Recovery of Overpayments2-103
      • [D] : Reconsideration of Overpayment2-105
      • [E] : Waiver of Overpayment2-106
        • [E][1] : Generally2-106
        • [E][2] : Without Fault2-107
        • [E][3] : Defeat the Purpose2-107
        • [E][4] : Against Equity and Good Conscience2-108
        • [E][5] : Impede Administration2-108
      • [F] : Appeals of Overpayment/Ineligibility Determinations2-108
  • § 2:13 : Conclusion2-109
  • Appendix 2A : New York State SSI Payment Rates for Individuals and Couples in Various Living Arrangements for 1986–2014App. 2A-1
  • Appendix 2B : Chart of Monthly Deeming Break-Even Points for a Federal SSI PaymentApp. 2B-1
  • Appendix 2C : SSI Benefit Levels Chart Effective January 1, 2014App. 2C-1
Chapter 3: Social Security and SSI Disability Barbara Samuels ~
  • § 3:1 : Overview3-4
  • § 3:2 : Impact of Welfare Reform Legislation on Social Security and SSI Disability3-5
    • § 3:2.1 : Substance Abusers3-6
    • § 3:2.2 : SSI Eligibility for Noncitizens3-8
    • § 3:2.3 : Disabled SSI Children3-9
  • § 3:3 : What Does “Disability” Mean? (Adult Standard)3-9
    • § 3:3.1 : Compassionate Allowance3-11
  • § 3:4 : How Is Disability Determined?3-12
    • § 3:4.1 : The Sequential Evaluation3-12
      • [A] : Generally3-12
      • [B] : Step 1: What Is Substantial Gainful Activity (SGA)?3-14
      • [C] : Step 2: What Is a “Severe” Impairment?3-16
      • [D] : Step 3: What Is a Listing and How Does One Meet or Equal It?3-17
      • [E] : Step 4: What Is Past Relevant Work?3-21
        • [E][1] : Generally3-21
        • [E][2] : How PRW Is to Be Evaluated3-22
        • [E][3] : Step 4 Consideration of Employer Accommodations3-23
        • [E][4] : Residual Functional Capacity (RFC)3-24
        • [E][5] : Evaluating the Ability to Perform Past Relevant Work (PRW) on the Basis of Residual Functional Capacity3-26
        • [E][6] : By-Passing Step 4 in Absence of Complete Work History3-27
      • [F] : Step 5: Elements Which Must Be Considered in Determining Whether an Individual Can Perform Other Work in the National Economy3-27
        • [F][1] : Generally3-27
        • [F][2] : Age3-28
          • [F][2][a] : Generally3-28
          • [F][2][b] : Aged Aliens (SSI only)3-29
        • [F][3] : Education3-31
        • [F][4] : Skills3-32
        • [F][5] : Transferability of Skills3-33
        • [F][6] : Levels of Physical Exertion3-34
          • [F][6][a] : Generally3-34
          • [F][6][b] : Exertional Activity3-36
        • [F][7] : Nonexertional Activity3-36
        • [F][8] : Evaluating Disability Under Step 5: The Medical-Vocational Regulations of Appendix 23-39
          • [F][8][a] : Generally3-39
          • [F][8][b] : Avoiding Application of the Medical-Vocational Guidelines3-41
    • § 3:4.2 : Other Considerations3-42
      • [A] : Failure to Follow Prescribed Treatment3-42
      • [B] : Remediability of an Impairment3-43
      • [C] : Pain and Other Subjective Symptoms3-45
      • [D] : Onset and Duration of Disability3-48
      • [E] : Date Last Insured (Title II Only)3-51
      • [F] : Burden of Proof3-54
  • § 3:5 : Other Disability Categories3-54
    • § 3:5.1 : Widow’s and Widower’s Benefits (Title II Only)3-54
    • § 3:5.2 : Adult Child’s Disability Benefits (Title II Only)3-55
    • § 3:5.3 : Children’s Disability Benefits (SSI Only)3-55
  • § 3:6 : Blindness3-58
  • § 3:7 : Proving Disability3-61
    • § 3:7.1 : Generally3-61
    • § 3:7.2 : Sources of Medical Evidence3-61
      • [A] : Generally3-61
      • [B] : Objective Versus Subjective Evidence3-63
      • [C] : Treating, Consulting, and Nonexamining Doctors’ Statements3-64
      • [D] : The Treating Physician Rule in New York State3-67
    • § 3:7.3 : Other Evidentiary Considerations3-69
      • [A] : Incomplete or Inaccurate Earnings Record (Title II Only)3-69
      • [B] : Formal Education Greater Than Claimant’s Actual Attainment3-70
      • [C] : Overstatement of Claimant’s Skills3-71
      • [D] : Other Evidence (Marriage, Divorce, Death, Age)3-72
  • § 3:8 : Insured Status (Title II Only)3-72
    • § 3:8.1 : Disability Insurance Coverage3-72
      • [A] : Generally3-72
      • [B] : Quarters of Coverage, in General3-73
      • [C] : Insured Status for Disability Coverage3-73
      • [D] : How to Find a “Date Last Insured”3-75
      • [E] : Younger Workers and Date Last Insured3-77
    • § 3:8.2 : What Can Be Found in an Earnings Record (ER)3-78
      • [A] : General Information3-78
      • [B] : Deciphering Abbreviations3-79
    • § 3:8.3 : Concepts Related to Disability Entitlement3-81
      • [A] : Period of Disability3-81
      • [B] : Disability Freeze3-81
      • [C] : Primary Insurance Amount (PIA)3-82
      • [D] : Average Indexed Monthly Earnings (AIME)3-82
  • § 3:9 : Representative Payees3-82
  • § 3:10 : Administrative Appeal Process3-83
    • § 3:10.1 : The Appeal Process in General3-83
    • § 3:10.2 : Appeal Process As Applied to Disability Evaluations3-84
      • [A] : Initial Disability Application3-84
      • [B] : Administrative Law Judge Hearings3-85
        • [B][1] : Generally3-85
        • [B][2] : ALJ In-Person and Video Teleconferenced Hearings3-86
        • [B][3] : Expert Testimony via Telephone3-87
        • [B][4] : Medical Experts3-88
        • [B][5] : Vocational Experts3-89
        • [B][6] : Closing Argument3-93
        • [B][7] : After the ALJ Hearing3-93
        • [B][8] : ALJ Decisions3-93
      • [C] : Appeals Council Review3-94
      • [D] : Judicial Review3-96
  • § 3:11 : Postentitlement Disability Issues Including Termination of Disability3-96
    • § 3:11.1 : Generally3-96
    • § 3:11.2 : Work Attempts3-96
    • § 3:11.3 : Work Incentives3-98
    • § 3:11.4 : Reentitlement Period (Title II Only)3-100
    • § 3:11.5 : Termination Proceedings (CDRs)3-101
    • § 3:11.6 : CDR Sequential Evaluation3-103
    • § 3:11.7 : Overpayments3-107
  • § 3:12 : Practical Problems3-109
    • § 3:12.1 : Generally3-109
    • § 3:12.2 : Undeveloped Claims Files3-109
    • § 3:12.3 : Incorrect Factual Information3-110
    • § 3:12.4 : Onset Date3-110
  • Appendix 3A : Residual Functional Capacity: Maximum Sustained Work Capability Limited to Sedentary Work As a Result of Severe Medically Determinable Impairment(s)App. 3A-1
  • Appendix 3B : Residual Functional Capacity: Maximum Sustained Work Capability Limited to Light Work As a Result of Severe Medically Determinable Impairment(s)App. 3B-1
  • Appendix 3C : Residual Functional Capacity: Maximum Sustained Work Capability Limited to Medium Work As a Result of Severe Medically Determinable Impairment(s)App. 3C-1
Chapter 4: Medicare; and Appendices 4A-4F Andrew Koski ~
  • § 4:1 : History and Overview4-6
  • § 4:2 : Program Administration and Sources of Law4-8
  • § 4:3 : Eligibility and Enrollment4-10
    • § 4:3.1 : Eligibility4-10
    • § 4:3.2 : Application4-11
    • § 4:3.3 : Enrollment4-11
      • [A] : Initial Enrollment Period4-11
      • [B] : General Enrollment Period4-12
      • [C] : Working Elderly and the Special Enrollment Period4-13
      • [D] : Failure to Enroll4-14
      • [E] : Appeals4-15
  • § 4:4 : Medicare Appeals Process4-15
    • § 4:4.1 : Redeterminations4-16
    • § 4:4.2 : Reconsideration4-16
    • § 4:4.3 : Administrative Hearings4-17
    • § 4:4.4 : Summary of Part A Appeals Process4-17
    • § 4:4.5 : Summary of Part B Appeals Process4-19
  • § 4:5 : Part A: Hospital Services4-20
    • § 4:5.1 : Coverage and Qualifying Criteria4-20
      • [A] : Benefit Periods4-20
      • [B] : Covered Benefits4-21
      • [C] : Standard for Coverage4-22
    • § 4:5.2 : Rehabilitation Hospitals4-22
    • § 4:5.3 : Reimbursement Structure and Coverage Issues4-23
      • [A] : Admission Denials4-24
      • [B] : Premature Discharges4-25
    • § 4:5.4 : Beneficiary’s Right to Discharge Planning4-25
    • § 4:5.5 : Coverage Denials and Appeals4-27
  • Chart 4-1 : Medicare Hospital Coverage Determination and Appeals Process4-28
    • § 4:5.6 : Which Medicare Denials for Inpatient Hospital Care Should Be Appealed: A Quick Screen to Aid in Identifying Coverable Cases4-29
      • [A] : Additional Advocacy Tips4-29
    • § 4:5.7 : Which Medicare Denials for Inpatient Hospital Rehabilitation Should Be Appealed: A Quick Screen to Aid in Identifying Coverable Cases4-30
      • [A] : Additional Advocacy Tips4-30
  • § 4:6 : Part A: Skilled Nursing Facility Coverage4-31
    • § 4:6.1 : Coverage and Qualifying Criteria4-31
      • [A] : Benefit Periods4-31
      • [B] : Beneficiary Copayment Obligation4-32
      • [C] : Covered Services4-33
    • § 4:6.2 : Reimbursement Structure and Coverage Issues4-33
      • [A] : Provider Decisions4-34
      • [B] : Intermediary Decisions4-35
        • [B][1] : Initial Admissions4-35
        • [B][2] : Approved Admissions4-36
        • [B][3] : Redeterminations4-36
    • § 4:6.3 : Terminations4-37
    • § 4:6.4 : Appeals Overview4-38
  • Chart 4-2 : Medicare Skilled Nursing Facility Claims Submission and Appeals Process4-39
    • § 4:6.5 : Which Medicare Denials for Skilled Nursing Facility Care Should Be Appealed: A Quick Screen to Aid in Identifying Coverable Cases4-40
      • [A] : Other Important Points4-40
  • § 4:7 : Home Health Coverage4-41
    • § 4:7.1 : Coverage and Qualifying Criteria4-42
      • [A] : Homebound Rule4-43
      • [B] : Skilled Nursing Care on an Intermittent Basis4-45
      • [C] : Skilled Therapy Services4-48
      • [D] : Part-Time or Intermittent Services4-49
      • [E] : Chronic, Stable, and Maintenance-Level Patients4-49
    • § 4:7.2 : Claims Submission and Reimbursement Structure4-52
    • § 4:7.3 : Notice Requirements4-52
      • [A] : ABN at Initiation4-53
      • [B] : ABN for Reductions4-53
      • [C] : ABN for Terminations4-53
      • [D] : Other Insurance4-54
      • [E] : Completion of ABN4-54
      • [F] : Exceptions4-55
      • [G] : HHCCN4-55
    • § 4:7.4 : Terminations4-57
    • § 4:7.5 : Appeals Overview4-58
  • Chart 4-3 : Medicare Home Health Claims Submission and Appeals Process4-59
    • § 4:7.6 : Which Medical Denials for Home Health Services Should Be Appealed: A Quick Screen to Aid in Identifying Coverable Cases4-60
      • [A] : Additional Advocacy Tips4-60
  • § 4:8 : Part A: Hospice Coverage4-61
    • § 4:8.1 : Coverage and Qualifying Criteria4-61
    • § 4:8.2 : Deductibles and Coinsurance for Nonhospice Care4-63
    • § 4:8.3 : Election of the Hospice Benefit4-64
      • [A] : Who May Make an Election for Hospice Care4-64
      • [B] : How the Election Is Made and How It Is Revoked4-64
      • [C] : Changing the Hospice That Is Providing Care4-65
    • § 4:8.4 : The Appeals Process4-66
    • § 4:8.5 : Which Medicare Denials for Hospice Care Should Be Appealed: A Quick Screen to Aid in Identifying Coverable Cases4-66
      • [A] : Additional Advocacy Tips4-67
  • § 4:9 : Part B4-67
    • § 4:9.1 : Covered Services4-67
    • § 4:9.2 : Approved Charges and Balance Billing4-70
    • § 4:9.3 : Advance Beneficiary Notice4-72
    • § 4:9.4 : Ambulance Services4-73
      • [A] : Coverage Rules4-73
      • [B] : Nonemergency Services4-74
      • [C] : Physician Certification Rules4-74
      • [D] : Levels of Service4-75
      • [E] : Destination Requirements4-76
      • [F] : Fee Schedule and Mandatory Assignment4-76
    • § 4:9.5 : Part B: Appeals4-77
  • § 4:10 : Medicare and Medicaid4-77
  • § 4:11 : Medicare As Secondary Payer4-78
    • § 4:11.1 : When Medicare Is a Secondary Payer4-78
      • [A] : Automobile and Liability Insurance4-79
      • [B] : Employer Group Health Plan: End-Stage Renal Disease4-79
      • [C] : Employer Group Health Plan: Older Employees and Spouses4-80
      • [D] : Employer Group Health Plan: Disabled Individuals and Family Members4-80
      • [E] : Administration of Medicare As a Secondary Payer Issue4-80
    • § 4:11.2 : Filing Secondary Payer Claims4-81
  • § 4:12 : Private Contracts4-82
    • § 4:12.1 : Private Contract Requirements4-83
    • § 4:12.2 : Private Contract Affidavit4-84
    • § 4:12.3 : Private Contract Not Required4-85
    • § 4:12.4 : Appeals for Private Contracts4-85
  • § 4:13 : Medicare Managed Care4-86
    • § 4:13.1 : Medicare Advantage Plan Options4-86
      • [A] : Benefits4-86
      • [B] : Continuation Area4-87
    • § 4:13.2 : Medicare Advantage Plans4-87
      • [A] : Health Maintenance Organizations4-87
      • [B] : Provider Sponsored Organizations4-88
      • [C] : Preferred Provider Organizations4-88
      • [D] : Private Fee-for-Service Plans4-89
      • [E] : Religious Fraternal Benefit Society Plans4-90
      • [F] : Point of Service Options4-91
      • [G] : Education Campaign4-91
    • § 4:13.3 : Election Periods4-92
      • [A] : Initial Coverage Election Periods4-92
      • [B] : Annual Election Periods4-92
      • [C] : Medicare Advantage Disenrollment Period4-92
      • [D] : Special Election Periods for Persons Age Sixty-Five4-92
      • [E] : Special Election Periods4-93
    • § 4:13.4 : Disenrollment by the Medicare Advantage Plan4-93
    • § 4:13.5 : Disclosure Requirements4-94
    • § 4:13.6 : Access to Services4-95
      • [A] : Emergency and Urgent Care Services4-96
      • [B] : Urgently Needed Services4-96
      • [C] : Post-Stabilization Care4-97
      • [D] : Gag Orders4-98
    • § 4:13.7 : Termination of Medicare Advantage Coverage4-98
    • § 4:13.8 : Appeals4-98
      • [A] : Organization Determinations4-98
    • § 4:13.9 : Non-Expedited Organization Determinations4-100
      • [A] : Requests for Services4-100
      • [B] : Requests for Payment4-100
      • [C] : Written Notification by Practitioners4-100
    • § 4:13.10 : Expedited Organization Determinations4-101
      • [A] : Written Notification4-102
    • § 4:13.11 : Non-Expedited Reconsiderations4-102
      • [A] : Requests for Services4-102
      • [B] : Requests for Payment4-103
    • § 4:13.12 : Expedited Reconsiderations4-103
    • § 4:13.13 : Further Appeal Rights4-105
    • § 4:13.14 : Appeals of Hospital Coverage4-105
    • § 4:13.15 : Grijalva Court Case4-106
      • [A] : Advance Notice of Service Terminations4-106
      • [B] : Fast-Track Appeal4-107
      • [C] : Reconsideration4-108
    • § 4:13.16 : Grievances4-108
  • § 4:14 : Medicare Prescription Drug, Improvement and Modernization Act of 20034-109
    • § 4:14.1 : Background4-109
    • § 4:14.2 : Eligibility4-110
    • § 4:14.3 : Enrollment and Disenrollment Periods4-110
    • § 4:14.4 : Penalty for Late Enrollment4-110
    • § 4:14.5 : Structure of Medicare Part D Drug Benefit4-111
    • § 4:14.6 : Formularies4-111
    • § 4:14.7 : Excluded Drugs4-112
    • § 4:14.8 : Low-Income Subsidy Assistance4-112
    • § 4:14.9 : EPIC4-114
    • § 4:14.10 : Appeals4-114
      • [A] : Coverage Determinations4-114
      • [B] : Redetermination4-115
      • [C] : Reconsideration4-115
      • [D] : Further Appeals4-116
  • § 4:15 : Advocacy Issues4-116
  • Appendix 4A : Medicare Beneficiary Costs 2014App. 4A-1
  • Appendix 4B : Medicare Preventive ServicesApp. 4B-1
  • Appendix 4C : Enrollment and Disenrollment Periods for Medicare Advantage PlansApp. 4C-1
  • Appendix 4D : Medicare Advantage Plan AppealsApp. 4D-1
  • Appendix 4E : Medicare Drug Benefit, 2014App. 4E-1
  • Appendix 4F : Medicare Drug Benefit for Dual Eligible and Other Low-Income BeneficiariesApp. 4F-1
Chapter 5: Supplemental Medical Insurance; and Appendices 5A-5H Andrew Koski ~
  • § 5:1 : Introduction5-3
  • § 5:2 : Medicare Supplement Insurance5-3
    • § 5:2.1 : Gaps in Part A (Hospital) Coverage5-4
    • § 5:2.2 : Gaps in Part B (Outpatient and Physician) Coverage5-4
    • § 5:2.3 : Standardization of Medigap Policies5-5
      • [A] : Limit on Number of Kinds of Policies Sold5-6
      • [B] : Protection Against Sale of Duplicate Coverage5-6
      • [C] : Medigap Coverage for Medicaid Recipients5-7
      • [D] : Open Enrollment5-8
      • [E] : Community Rating5-8
      • [F] : Uniformity5-8
      • [G] : Preexisting Conditions5-8
      • [H] : Medicaid Coverage5-9
      • [I] : Renewability5-9
      • [J] : Minimum Loss Ratio5-9
    • § 5:2.4 : Available Medigap Plans5-9
      • [A] : Core Plan (A)5-10
      • [B] : Plans B Through G5-10
      • [C] : Plans K and L5-10
      • [D] : Plans M and N5-11
    • § 5:2.5 : Choosing a New Medigap Plan: Step by Step5-11
    • § 5:2.6 : Medicare Select5-12
  • § 5:3 : Long-Term Care Insurance5-13
    • § 5:3.1 : State Standards for Long-Term Care Coverage: Minimum-Benefit Options in Plans Offering at Least Twenty-Four Months’ Care5-14
    • § 5:3.2 : State Standards for Less Comprehensive Policies5-14
      • [A] : Nursing Home and Home Care5-15
      • [B] : Nursing Home or Home Care5-15
    • § 5:3.3 : Additional Requirements: What May Not Be Excluded5-15
    • § 5:3.4 : Additional Requirements: What Must Be Included5-16
    • § 5:3.5 : Issues to Consider Before Purchasing Long-Term Care Insurance5-17
      • [A] : Fine Print About Preexisting Conditions5-17
      • [B] : Waiting Period5-18
      • [C] : Actual Costs5-18
      • [D] : Eligibility Criteria for an Insurable Event5-18
      • [E] : Additional Benefits5-19
      • [F] : Inflation Option5-19
      • [G] : Appeals Procedures5-19
  • § 5:4 : Public-Private Program to Finance the Costs of Long-Term Care5-19
    • § 5:4.1 : Minimum Standards for 3/6/50 Plans5-20
      • [A] : Standards for Nursing Home Care5-20
      • [B] : Standards for Home Care5-20
      • [C] : Standards for Respite Care5-21
      • [D] : Standards for Alternate Care5-21
      • [E] : Care Management Benefits5-21
      • [F] : Standards for Elimination Period5-21
      • [G] : Standards of Inflation Protection5-21
      • [H] : Standards of Portability5-22
    • § 5:4.2 : Minimum Standards for Other Plans5-22
      • [A] : 1.5/3/50 Plans5-22
      • [B] : 2/2/100 Plans5-22
      • [C] : 4/4/100 Plans5-23
      • [D] : 2/4/50 Plans5-23
      • [E] : New Benefits for All Plans5-24
      • [F] : New Benefits for Some Plans5-24
      • [G] : Reciprocity5-25
    • § 5:4.3 : Issues to Examine in Selecting Public-Private Partnership Coverage5-26
  • § 5:5 : Favorable Tax Treatment for Long-Term Care Insurance5-27
    • § 5:5.1 : Federal Legislation5-27
    • § 5:5.2 : Benefit Payments Not Counted As Income5-27
      • [A] : Employer Contributions5-28
    • § 5:5.3 : Allowable Deductions5-29
      • [A] : Unreimbursed Expenses5-29
      • [B] : Premiums5-29
    • § 5:5.4 : Effective Dates5-29
    • § 5:5.5 : New York State Legislation5-30
  • Appendix 5A : Deduction for Premiums for Long-Term Care Insurance, 2014 Tax YearApp. 5A-1
  • Appendix 5B : Medicare Coverage 2014App. 5B-1
  • Appendix 5C : Medicare Supplement Insurance Benefit Plans A—J Prior to June 1, 2010App. 5C-1
  • Appendix 5D : Medicare Supplement Insurance Benefit Plans K and LApp. 5D-1
  • Appendix 5E : Medicare Supplement Insurance Plans As of June 1, 2010App. 5E-1
  • Appendix 5F : Checklist for Purchasing Medicare Supplement Health InsuranceApp. 5F-1
  • Appendix 5G : New York State Partnership for Long-Term Care Policies (2014)App. 5G-1
  • Appendix 5H : Checklist for Purchasing Long-Term Care Insurance PoliciesApp. 5H-1
Chapter 6: Medicaid for the Elderly, Blind, or Disabled; and Appendices 6A-6M Douglas J. Chu ~
  • § 6:1 : Introduction6-7
  • § 6:2 : Background and Description of the Medicaid Program6-7
    • § 6:2.1 : Internet Resources6-11
  • § 6:3 : Eligibility Categories6-12
    • § 6:3.1 : Supplemental Security Income (SSI) Recipients6-12
    • § 6:3.2 : Disability Claimants6-12
    • § 6:3.3 : Medically Needy Claimants6-13
    • § 6:3.4 : Medicaid Buy-In Program for the Working Disabled6-13
  • § 6:4 : Elderly, Blind, or Disabled6-15
    • § 6:4.1 : Elderly6-15
    • § 6:4.2 : Blind6-15
    • § 6:4.3 : Disabled6-15
  • § 6:5 : What Medicaid Covers6-15
    • § 6:5.1 : Provider Services6-15
    • § 6:5.2 : Medical Assistance Utilization Threshold Program (MUTS)6-17
      • [A] : Annual Limits6-17
      • [B] : Programs and Services Exempt from MUTS6-18
      • [C] : Need for Emergency Services6-19
      • [D] : Requesting Additional Service Units or Exemption6-19
      • [E] : Override Application Process and Due Process6-21
    • § 6:5.3 : Copayment System6-22
      • [A] : Inability to Pay Copayment6-22
      • [B] : Copayment Annual Cap6-23
      • [C] : Copayment Exemptions6-23
      • [D] : Grievance Procedures6-23
    • § 6:5.4 : Health Insurance Premiums6-24
      • [A] : Employee Health Insurance6-24
      • [B] : Coverage for Medicare Premiums, Copayments, and Deductibles6-24
        • [B][1] : Qualified Medicare Beneficiary (QMB) Program6-25
        • [B][2] : Specified Low Income Medicare Beneficiary (SLIMBs) Program6-26
        • [B][3] : Qualified Individuals 1 (QI-1’s)6-26
  • § 6:6 : Medicaid Application6-26
    • § 6:6.1 : Completing and Submitting an Application6-27
    • § 6:6.2 : Presumptive Eligibility6-27
    • § 6:6.3 : Face-to-Face Interview Eliminated6-29
    • § 6:6.4 : Required Documentation6-29
      • [A] : Missing Documentation6-30
      • [B] : Resource Attestation (Verification of Countable Resources)6-30
    • § 6:6.5 : Time for Determining Eligibility6-32
    • § 6:6.6 : Date of Coverage and Retroactive Reimbursement6-32
      • [A] : Medicaid Reimbursement6-33
        • [A][1] : Three-Month Retroactive Coverage6-33
        • [A][2] : Pending Application Approval6-33
        • [A][3] : Pending Activation6-34
        • [A][4] : Agency Error or Delay6-34
      • [B] : Applying for Reimbursement6-35
      • [C] : Vendor’s Request for Medicaid Payment6-35
    • § 6:6.7 : Annual Renewal6-35
    • § 6:6.8 : Assignment of Third-Party Recovery6-36
    • § 6:6.9 : U.S. Citizenship Requirements6-36
      • [A] : Aliens Permanently Residing in the United States Under Color of Law (PRUCOL)6-38
      • [B] : Qualified Aliens6-38
      • [C] : Non-Eligible Aliens in Nursing Facilities6-38
    • § 6:6.10 : New York State Residency Requirements6-39
      • [A] : Lack of Mental Capacity6-39
      • [B] : Temporary Visits to or Absences from New York6-40
      • [C] : Moving from One Medicaid District to Another6-40
  • § 6:7 : Financial Requirements6-41
    • § 6:7.1 : Rules Regarding Income6-41
      • [A] : Definition of Income6-42
      • [B] : Countable Income6-42
        • [B][1] : Previously Exempt Income That Is Now Counted6-42
        • [B][2] : Employment Income and Income-Producing Property6-43
        • [B][3] : Duty to Apply for Available Funds and Income6-43
        • [B][4] : Personal Injury Recoveries6-44
      • [C] : Non-Countable Income (Exemptions)6-44
        • [C][1] : Health Insurance Premiums (Including Medicare Part B)6-44
        • [C][2] : Interest on a Separate Exempt Burial Account6-45
        • [C][3] : German Restitution Payments6-45
        • [C][4] : $20 Household Income Disregarded6-45
        • [C][5] : “In-Kind” Income or Support6-46
        • [C][6] : Other Restitution Payments6-46
        • [C][7] : Agent Orange Payments6-46
        • [C][8] : Reverse Mortgage Income6-46
        • [C][9] : Income to Supplemental Needs Trust (SNT)6-47
        • [C][10] : Pooled Trusts for Income6-48
        • [C][11] : American Recovery and Reinvestment Act of 20096-49
    • § 6:7.2 : Surplus Income Program (Spenddown)6-49
      • [A] : Surplus Income for Community Care (Non-Home Care Services)6-50
      • [B] : “Pay-In” Program6-51
      • [C] : Requirement to Pay Surplus Income for Home Care Services6-52
      • [D] : Surplus Income and Hospital Services6-53
      • [E] : Surplus Income and Nursing Homes6-53
    • § 6:7.3 : Rules Regarding Resources6-53
      • [A] : Definition of Resources6-53
        • [A][1] : Date to Evaluate Resources6-54
      • [B] : Jointly Owned Bank Accounts and Real Estate6-55
      • [C] : Spousal Resources6-56
      • [D] : Non-Liquid Resources6-56
      • [E] : Resource Exemptions6-57
        • [E][1] : Homestead6-57
          • [E][1][a] : Vacant Homesteads6-58
          • [E][1][b] : Vacant Non-Liquid Homesteads6-58
          • [E][1][c] : Subjective Intent to Return Home6-59
          • [E][1][d] : Homesteads Subject to a Life Estate Deed6-59
          • [E][1][e] : Non-Liquid Resource Due to Legal Impediment6-60
        • [E][2] : Personal Property6-60
        • [E][3] : Life Insurance6-60
        • [E][4] : Burial Funds and Burial Expenses6-61
        • [E][5] : Resources and Incurred Medical Bills6-61
        • [E][6] : Life Insurance and Burial Expenses6-62
        • [E][7] : Irrevocable Burial Trusts6-62
        • [E][8] : German and Austrian Reparation Savings Accounts6-63
        • [E][9] : Robert Wood Johnson Insurance Policies6-63
        • [E][10] : Non-Applicant Spouse Retirement Accounts6-64
        • [E][11] : Supplemental Needs Trusts for the Disabled6-64
        • [E][12] : Availability of Resources (Windfalls and Inheritance)6-65
        • [E][13] : Retirement Funds6-65
        • [E][14] : Annuity Reporting and Beneficiary Requirement6-66
      • [F] : Disposing of Excess Resources6-67
  • § 6:8 : Medicaid Transfer Rules and Penalties After the Deficit Reduction Act of 20056-68
    • § 6:8.1 : Transfer Penalties Only for Institutional Services, No Penalty for Home Care6-69
    • § 6:8.2 : Transfer Rule (Stage 1)—Look-Back Period of Five Years6-69
      • [A] : Five-Year Look-Back for Existing Trusts6-70
      • [B] : Shorter Look-Back for Home Care Applications6-70
    • § 6:8.3 : Transfer Rule (Stage 2)—Calculating the Penalty Period6-71
      • [A] : The Formula6-71
    • § 6:8.4 : Transfer Rule (Stage 3)—Penalty Period Begin Date6-72
      • [A] : Transfers on or After February 8, 20066-72
    • § 6:8.5 : Transfers Exempt from Penalty6-73
      • [A] : Transfers for Fair Market Value6-73
      • [B] : Transfers for Purpose Other Than Qualifying for Medicaid6-73
      • [C] : Transfers to a Blind or Disabled Child6-73
      • [D] : Transfers Between Spouses6-74
      • [E] : Undue Hardship6-74
      • [F] : Returning Transferred Assets6-75
      • [G] : Transfers into a Supplemental Needs Trust (SNT)6-75
    • § 6:8.6 : Transfers of Homesteads on or After October 1, 19896-76
    • § 6:8.7 : Transfers Made by the Non-Applicant Spouse6-77
      • [A] : Transfers by Healthy (Non-Applicant) Spouse6-77
        • [A][1] : Spousal Transfer Example6-77
    • § 6:8.8 : Multiple Consecutive Transfers6-78
    • § 6:8.9 : Life Estates and Transfer Rules6-79
    • § 6:8.10 : Documentation of Transfers6-79
    • § 6:8.11 : Spouse’s Right of Election6-80
    • § 6:8.12 : Transfer Rule Definitions6-80
      • [A] : Assets6-80
      • [B] : Long-Term Care or Institutional Services6-81
  • § 6:9 : Spousal Budgeting Rules6-82
    • § 6:9.1 : Budgeting for When Both Spouses Require the Same Services6-82
    • § 6:9.2 : Budgeting When Both Spouses Require Different Services6-82
    • § 6:9.3 : Budgeting When One Spouse Needs Non-Institutional Services6-82
      • [A] : Spousal Refusal6-83
      • [B] : Marriage Equality Act—Same Sex Marriage6-85
    • § 6:9.4 : Budgeting When One Spouse Is Institutionalized6-85
      • [A] : Snapshot of the Budget6-86
    • § 6:9.5 : Spousal Income Budgeting Rules6-87
      • [A] : Income Allowance of an Institutionalized Spouse6-87
      • [B] : Spousal Impoverishment Income Allowance6-87
        • [B][1] : Community Spouse Excess Income (Twenty-Five Percent Rule)6-88
      • [C] : Family Allowance6-89
    • § 6:9.6 : Spousal Resource Budgeting Rules6-89
      • [A] : Resource Limit of Institutionalized Spouse6-90
      • [B] : Spousal Impoverishment Resource Allowance6-90
      • [C] : Separating Spousal Resources (Ninety-Day Rule)6-91
      • [D] : Exceeding the Community Spouse Resource Allowance6-91
        • [D][1] : Exceptions to the Maximum Allowance6-92
      • [E] : Disclosure of Financial Information6-93
  • § 6:10 : Liens and Rights of Recovery6-93
    • § 6:10.1 : Imposition of a Lien6-93
    • § 6:10.2 : Liens on the Homestead6-94
    • § 6:10.3 : Recovery Against Personal Injury Award6-95
    • § 6:10.4 : Estate Recovery Rules6-95
      • [A] : Recovery Against Estate of Medicaid Beneficiary6-95
      • [B] : Recovery Against Estate of Surviving Spouse6-96
      • [C] : N.Y. Partnership Long-Term Care Policy6-96
      • [D] : Statute of Limitation6-97
    • § 6:10.5 : Debtor and Creditor Law6-97
  • § 6:11 : Appeals6-97
    • § 6:11.1 : Due Process Rights6-97
      • [A] : Right to Written Notice6-98
      • [B] : Right to “Aid Continuing”6-98
      • [C] : Right of Access to Files6-98
      • [D] : Right to Representation6-98
      • [E] : Rights Related to Fair Hearing6-99
      • [F] : Right to Impartial Judgment6-99
      • [G] : Right to Written Decision6-99
      • [H] : Disclosure Rules Under HIPAA6-99
    • § 6:11.2 : Time Factors6-100
    • § 6:11.3 : Fair Hearing Procedures6-100
    • § 6:11.4 : Conference Meeting6-101
    • § 6:11.5 : Judicial Review6-101
  • Appendix 6A : Medicaid Income and Resource Levels for the Medically Needy6A-1
  • Appendix 6B : Medicaid Copayments and Exempt ServicesApp. 6B-1
  • Appendix 6C : Medicaid Copayment ExemptionsApp. 6C-1
  • Appendix 6D : Request for Documentation of Citizenship/Alien StatusApp. 6D-1
  • Appendix 6E : Alien Status Desk Guide Notice of Eligibility for Coverage for the Treatment of an Emergency Medical ConditionApp. 6E-5
  • Appendix 6F : Regional Rates for Nursing HomesApp. 6F-1
  • Appendix 6G : Budgeting Guide for 2013App. 6G-1
  • Appendix 6H : Community Spouse’s Income AllowanceApp. 6H-1
  • Appendix 6I : Community Spouse Resource AllowanceApp. 6I-1
  • Appendix 6J : Guide to Documentation for the Medicaid ApplicationApp. 6J-1
  • Appendix 6K : Not-for-Profit Organizations That Have Pooled Trusts in New York StateApp. 6K-1
  • Appendix 6L : Medical Request for Home Care(Form M-11q)App. 6L-1
  • Appendix 6M : “Q-Tips”—Tips on Preparing the M-11qApp. 6M-1
Chapter 7: Home Care; and Appendices 7A-7F Ellen P. Rosenzweig ~
  • § 7:1 : Introduction7-3
  • § 7:2 : Authorities7-8
  • § 7:3 : Kinds of Home Care Services7-8
    • § 7:3.1 : Medical Home Health Services7-8
    • § 7:3.2 : Personal Care Services7-9
    • § 7:3.3 : Nonmedical Services at Home7-11
  • § 7:4 : Funding Sources7-12
  • § 7:5 : Providers of Home Care Services7-14
    • § 7:5.1 : Certified Home Health Agencies (CHHAs)7-15
    • § 7:5.2 : Long-Term Home Health Care Providers(LTHHCPs)7-15
    • § 7:5.3 : AIDS Home Care Programs (AHCPs)7-17
    • § 7:5.4 : Private Duty Nurses7-17
    • § 7:5.5 : Licensed Home Care Services Agencies (LHCSAs)7-17
    • § 7:5.6 : Assisted Living Programs (ALPs)7-18
    • § 7:5.7 : Limited Licensed Home Care Services Agencies (LLHCSAs)7-18
    • § 7:5.8 : Personal Care Providers7-18
    • § 7:5.9 : Consumer Directed Personal Assistance Programs (CDPAPs)7-19
    • § 7:5.10 : Hospice Programs7-20
    • § 7:5.11 : Managed Long-Term Care Demonstration Projects7-21
      • [A] : Social Health Maintenance Organizations (SHMOs)7-21
      • [B] : Programs for All-Inclusive Care for the Elderly (PACE)7-21
      • [C] : Continuing Care Networks (CCNs)7-22
      • [D] : Evaluated Medicaid Long-Term Care Capitation Program (Commonwealth Projects)7-23
      • [E] : Independence Care Systems (ICS)7-23
      • [F] : Long-Term Care Finance Act of 1997 (LTCFA) Legislatively Designated Sites7-24
      • [G] : Additional LTCFA Plans7-24
    • § 7:5.12 : Expanded In-Home Services for the Elderly Program7-25
  • § 7:6 : Health and Safety Issues7-26
  • § 7:7 : Expanded In-Home Services for the Elderly Program7-27
    • § 7:7.1 : Services7-28
    • § 7:7.2 : Medical Eligibility7-28
    • § 7:7.3 : Financial Eligibility7-29
    • § 7:7.4 : Cost Share Calculation7-30
    • § 7:7.5 : EISEP Appeals7-31
  • Appendix 7A : Reference Guide to Home Care ServicesApp. 7A-1
  • Appendix 7B : 2006 EISEP Client Cost-SharingThresholds and SchedulesApp. 7B-1
  • Appendix 7C : 2006 EISEP Cost Sharing Rate ScheduleApp. 7C-1
  • Appendix 7D : Adult Care Facilities with Assisted Living ProgramsApp. 7D-1
  • Appendix 7E : New York State Long-Term Home Health Care ProgramsApp. 7E-1
  • Appendix 7F : Managed Long-Term Care Demonstration ProjectsApp. 7F-1
Chapter 8: Protective Services Debra Studer Sacks ~
  • § 8:1 : Introduction8-2
  • § 8:2 : Voluntary and Involuntary Services8-5
    • § 8:2.1 : Power of Attorney8-5
      • [A] : Creating a Power of Attorney8-7
      • [B] : The Agent8-9
      • [C] : Acceptance of the Statutory Short Form Powerof Attorney by Third Parties8-10
      • [D] : Appointment of a Monitor8-11
      • [E] : Special Proceeding8-11
      • [F] : Termination and Revocation of the Power of Attorney8-13
    • § 8:2.2 : Representative Payee8-14
    • § 8:2.3 : Civil Commitment8-19
    • § 8:2.4 : Orders of Protection8-26
  • § 8:3 : Protective Services for Persons with Intellectual or Developmental Disabilities8-29
    • § 8:3.1 : Admission to State-Approved Schools8-30
    • § 8:3.2 : Guardianship8-31
  • § 8:4 : Article 81 Guardianship8-36
  • § 8:5 : Protective Services for Adults Program8-48
    • § 8:5.1 : Three Eligibility Criteria8-48
    • § 8:5.2 : Adult Abuse8-49
      • [A] : Definitions of Abuse8-49
      • [B] : Mandatory Reporting8-50
      • [C] : Confidentiality8-50
    • § 8:5.3 : Plan of Care8-53
      • [A] : Family and Friends8-54
      • [B] : Hospitals8-54
      • [C] : Community Support Services and Intensive Case Management for the Mentally III8-55
      • [D] : Long-Term Residential Care Facilities8-55
      • [E] : Other Services8-55
      • [F] : Referrals to Protective Services Program8-58
  • Appendix 8A : Request to Be Selected As Payee (Form SSA-11-BK)8A-1
  • Appendix 8B : “Power of Attorney” New York Statutory Short Form8B-1
  • Appendix 8C : “Power of Attorney” New York Statutory Gifts Rider Authorization8C-1
Chapter 9: Housing Law; and Appendices 9A-9C Andrew Scherer ~
David Robinson ~
  • § 9:1 : Introduction9-3
  • § 9:2 : Overview and Sources of Housing Law in New York9-4
    • § 9:2.1 : Landlord-Tenant Law9-5
      • [A] : Article 7 of the New York State Real Property Law9-5
      • [B] : Rent Laws9-6
    • § 9:2.2 : Housing Programs9-8
    • § 9:2.3 : Eviction Procedures9-9
    • § 9:2.4 : Requirement of Notice9-10
    • § 9:2.5 : Eviction Proceedings9-10
    • § 9:2.6 : Warrant of Eviction9-12
    • § 9:2.7 : Harassment9-12
  • § 9:3 : Housing Discrimination and Tenant Screening9-13
    • § 9:3.1 : Protections Based on Age9-14
    • § 9:3.2 : Protections Based on Disability9-16
    • § 9:3.3 : Protections Based on Source of Income9-17
    • § 9:3.4 : Construction Standards9-18
    • § 9:3.5 : Reasonable Accommodation9-19
    • § 9:3.6 : Exemptions for Housing for Elderly9-21
    • § 9:3.7 : Remedies for Discriminatory Housing Practices9-22
    • § 9:3.8 : Tenant-Screening Reports9-23
  • § 9:4 : Rights of Elderly Tenants9-24
    • § 9:4.1 : SCRIE: Senior Citizen Rent Increase Exemption9-24
    • § 9:4.2 : DRIE: Disability Rent Increase Exemption Program9-29
      • [A] : Income Limit9-29
      • [B] : Criteria9-30
    • § 9:4.3 : Eviction Protections9-30
      • [A] : Cooperative and Condominium Conversions9-30
      • [B] : Personal Use Evictions9-32
      • [C] : Succession Rights9-34
      • [D] : Right to Share Apartment with Roommates9-39
      • [E] : Right to Terminate Leases9-41
      • [F] : Guardian Ad Litem in a Summary Proceeding9-42
      • [G] : Preexisting Tenancy in a Foreclosed Property9-45
  • § 9:5 : Section 202 Housing Program9-47
    • § 9:5.1 : Protections from Termination in a Section 202 Tenancy9-47
    • § 9:5.2 : 80/20 Rental Housing Tax-Exempt Finance Program9-48
  • § 9:6 : Adult Care Facilities9-50
  • § 9:7 : Elderly Homeowners9-51
    • § 9:7.1 : Real Property Tax Exemption9-51
    • § 9:7.2 : Real Property Tax Credit Program9-54
    • § 9:7.3 : Reverse Mortgages9-55
    • § 9:7.4 : Fraudulent Mortgage Practices9-58
    • § 9:7.5 : Home Repair Assistance9-61
      • [A] : RESTORE (Residential Emergency Services to Offer Repairs to the Elderly)9-62
    • § 9:7.6 : Utility Assistance9-63
      • [A] : Home Energy Assistance Program9-63
      • [B] : Home Energy Fair Practices Act9-65
  • Appendix 9A : Annual Income Levels for Real Property Tax Exemption Effective As of July 1, 2009App. 9A-1
  • Appendix 9B : Telephone Numbers for Information on Applying for HEAP Benefits in New York StateApp. 9B-1
  • Appendix 9C : HEAP Income Eligibility Guidelines 2010–11 Effective October 1, 2010–September 30, 2011App. 9C-1
Chapter 10: Nursing Homes Margaret M. Flint ~
  • § 10:1 : Introduction10-2
  • § 10:2 : Sources of Law10-4
  • § 10:3 : Access to Nursing Homes10-6
  • § 10:4 : Residents’ Rights10-9
  • § 10:5 : Financial Policies10-10
  • § 10:6 : Medical Care10-14
  • § 10:7 : Restraints10-17
  • § 10:8 : Transfer and Discharge10-19
    • § 10:8.1 : Bed Reservation10-22
    • § 10:8.2 : Room Assignments and Changes10-23
  • § 10:9 : Remedies10-24
Chapter 11: Health Care Decision Making; and Appendices 11A-11D Raquel Malina Romanick ~
Annette Levinson Kasle ~
  • § 11:1 : Introduction11-2
  • § 11:2 : Right to Refuse Treatment11-4
  • § 11:3 : Patient Autonomy and Self-Determination11-5
  • § 11:4 : Patient Self Determination Act11-6
  • § 11:5 : Health Care Agents and Proxies11-7
    • § 11:5.1 : Confidentiality11-9
    • § 11:5.2 : Notification to the Principal11-9
    • § 11:5.3 : Standard for Decision Making by the Agent11-9
    • § 11:5.4 : Creation and Revocation of the Health Care Proxy11-10
  • § 11:6 : Living Wills11-12
  • § 11:7 : Orders Not to Resuscitate11-13
    • § 11:7.1 : Consenting to a DNR Order11-14
    • § 11:7.2 : Nonhospital DNR Orders11-14
    • § 11:7.3 : Role of the Physician11-15
    • § 11:7.4 : Portability of DNR Orders11-16
  • § 11:8 : Family Health Care Decision Making Act11-17
    • § 11:8.1 : How a Surrogate Is Selected11-17
    • § 11:8.2 : Determining Incapacity11-18
    • § 11:8.3 : Rights of a Surrogate11-18
    • § 11:8.4 : Decision Making for Incapacitated Patients Without a Surrogate11-19
    • § 11:8.5 : Dispute Mediation Protocols11-20
  • § 11:9 : Medical Orders for Life Sustaining Treatment11-21
    • § 11:9.1 : MOLST Forms and DNR Orders11-22
    • § 11:9.2 : Incapacitated Patients11-22
  • § 11:10 : End of Life Counseling Bill11-22
  • Appendix 11A : New York State Health Care ProxyApp. 11A-1
  • Appendix 11B : New York State Living WillApp. 11B-1
  • Appendix 11C : Nonhospital Order Not To Resuscitate (DNR Order)App. 11C-1
  • Appendix 11D : Medical Orders For Life-Sustaining Treatment (MOLST)App. 11D-1
Chapter 12: Veterans’ Benefits; and Appendices 12A-12J Andrew Koski ~
  • § 12:1 : Introduction12-3
  • § 12:2 : Sources of Law12-4
  • § 12:3 : Administration of Benefits12-5
  • § 12:4 : General Eligibility for Benefits12-6
    • § 12:4.1 : Character of Discharge12-6
    • § 12:4.2 : Length of Service12-7
  • § 12:5 : Compensation for Service-Connected Disability12-7
    • § 12:5.1 : Eligibility Requirements12-7
    • § 12:5.2 : “Rating” a Disability12-9
    • § 12:5.3 : Protection of Disability Rating12-10
    • § 12:5.4 : Monthly Benefit Payments12-10
    • § 12:5.5 : Special Monthly Compensation12-10
    • § 12:5.6 : Additional Compensation for Dependents12-10
  • § 12:6 : Pensions for Veterans with Non-Service-Connected Disability12-11
    • § 12:6.1 : Eligibility Requirements12-11
    • § 12:6.2 : Reporting Requirements12-12
    • § 12:6.3 : Veterans Improved Pension Program (VAIP)12-12
      • [A] : Income Restrictions12-13
      • [B] : Net Worth Restrictions12-13
      • [C] : Transfer of Assets12-14
      • [D] : Special Monthly Pension Benefits12-14
    • § 12:6.4 : Effect of Hospitalization and Nursing Home Stays on Pension Benefits12-15
  • § 12:7 : Pension Benefits for Survivors of Veterans12-16
  • § 12:8 : Compensation Payments for Survivors of Veterans12-17
    • § 12:8.1 : Eligibility12-17
    • § 12:8.2 : Payment Rates12-18
      • [A] : Surviving Spouses12-18
      • [B] : Surviving Dependent Parents12-18
      • [C] : Surviving Children12-18
  • § 12:9 : Burial Benefits12-18
    • § 12:9.1 : Burial in a VA National Cemetery12-19
    • § 12:9.2 : Burial Expenses12-19
    • § 12:9.3 : Headstones and Markers12-20
    • § 12:9.4 : Plot Allowance12-20
  • § 12:10 : Health Care Benefits12-20
    • § 12:10.1 : Eligibility Rules12-20
    • § 12:10.2 : Annual Patient Enrollment12-21
    • § 12:10.3 : Eligibility Assessment Procedures12-23
    • § 12:10.4 : Extended Care Services12-24
    • § 12:10.5 : Nursing Home Coverage12-25
    • § 12:10.6 : Domiciliary Care12-26
    • § 12:10.7 : Home Health Services12-27
    • § 12:10.8 : Prescriptions12-27
    • § 12:10.9 : Adult Day Health Care12-27
    • § 12:10.10 : Copayments for Extended Care Services12-28
    • § 12:10.11 : Other Medical Benefits12-30
    • § 12:10.12 : Medical Programs in New York State12-30
    • § 12:10.13 : Medical Care for Dependents and Survivors12-30
  • § 12:11 : Administrative Appeals12-31
    • § 12:11.1 : Due Process Rights and Appeal Steps12-32
    • § 12:11.2 : Notice of Disagreement12-32
    • § 12:11.3 : Board of Veterans’ Appeals12-33
    • § 12:11.4 : Reconsideration12-33
    • § 12:11.5 : Reopening a Claim12-34
    • § 12:11.6 : United States Court of Appeals for Veteran Claims12-34
  • § 12:12 : Overpayments12-34
  • § 12:13 : Other Assistance for Veterans and Their Families12-36
  • Appendix 12A : Service-Connected Disability Compensation, 2005App. 12A-1
  • Appendix 12B : Additional Compensation for Dependents of Veterans Rated 100% or More Disabled, 2005App. 12B-1
  • Appendix 12C : Non-Service-Connected Improved Pension Rates, 2005App. 12C-1
  • Appendix 12D : Non-Service-Connected Improved Pension for Surviving Spouses and Family Members, 2005App. 12D-1
  • Appendix 12E : 2005 DIC Payments to Surviving Spouse of Veteran Deceased on or after January 1, 1993App. 12E-1
  • Appendix 12F : 2005 DIC Payments to Surviving Spouse of Veteran Deceased Prior to January 1, 1993App. 12F-1
  • Appendix 12G : DIC Payments for Surviving Dependent Parents, 2005App. 12G-1
  • Appendix 12H : DIC Payments for Surviving Children, 2005App. 12H-1
  • Appendix 12I : Means Test Threshold, 2005App. 12I-1
  • Appendix 12J : VA Medical Centers in New York StateApp. 12J-1
Chapter 13: Retirement Plans David Pratt ~
  • § 13:1 : Introduction13-3
  • § 13:2 : Legal Background13-4
    • § 13:2.1 : In General13-4
    • § 13:2.2 : ERISA Exemptions13-6
    • § 13:2.3 : ERISA and Other Laws13-7
    • § 13:2.4 : Classifying the Plan13-8
    • § 13:2.5 : Multiemployer Plans13-9
    • § 13:2.6 : Agencies with Pension Jurisdiction13-10
  • § 13:3 : Tax Qualified Retirement Plans13-12
    • § 13:3.1 : Introduction13-12
    • § 13:3.2 : What Is a Qualified Plan?13-13
      • [A] : Defined Contribution Plans13-13
      • [B] : Defined Benefit Plans13-14
      • [C] : Hybrid Plans13-15
        • [C][1] : Cash Balance Plan13-16
        • [C][2] : Pension Equity Plan13-16
        • [C][3] : Eligible Combined Plan13-17
        • [C][4] : Floor Offset Arrangement13-17
        • [C][5] : Target Benefit Plan13-17
        • [C][6] : Age Weighted Plan13-18
        • [C][7] : Cross-Tested Plan13-18
    • § 13:3.3 : Types of Defined Contribution Plans13-19
      • [A] : Profit Sharing Plan13-19
      • [B] : 401(k) Plan13-19
      • [C] : Stock Bonus Plan13-21
      • [D] : Employee Stock Ownership Plan13-21
      • [E] : Money Purchase Pension Plan13-21
      • [F] : Key Differences Between Different Types of Plans13-21
      • [G] : Simplified Employee Pension (SEP) Plan13-23
      • [H] : SIMPLE Plans13-23
    • § 13:3.4 : Reporting and Disclosure Requirements13-24
      • [A] : DOL13-24
      • [B] : PBGC13-24
      • [C] : Information to Participants13-26
      • [D] : Information Reports13-29
  • § 13:4 : Eligible Deferred Compensation Plans13-30
  • § 13:5 : Tax-Sheltered Annuity Plans13-31
  • § 13:6 : Simplified Employee Pension Plans, Individual Retirement Arrangements and SIMPLE Plans13-33
  • § 13:7 : Governmental Plans and Church Plans13-36
    • § 13:7.1 : Governmental Plans13-36
    • § 13:7.2 : Church Plans13-36
    • § 13:7.3 : Nonqualified Plans13-37
  • § 13:8 : Important Provisions of Retirement Plans13-37
    • § 13:8.1 : Eligibility13-37
    • § 13:8.2 : Normal Retirement Age13-38
    • § 13:8.3 : The Benefit Formula; Actuarial Adjustment Factors13-39
    • § 13:8.4 : When Benefits Are Payable13-40
    • § 13:8.5 : Death and Disability Benefits13-42
      • [A] : Death Benefits13-42
      • [B] : Designation of Beneficiary13-43
      • [C] : Disability Benefits13-43
    • § 13:8.6 : Accrued Benefit13-45
    • § 13:8.7 : Vesting13-46
    • § 13:8.8 : Definition of Year of Service13-48
    • § 13:8.9 : How Benefits Are Paid13-49
    • § 13:8.10 : Other Rights Available to Plan Participants and Beneficiaries13-51
      • [A] : Directed Investments13-51
      • [B] : Plan Loans13-51
      • [C] : Hardship Withdrawals13-51
  • § 13:9 : Additional Rights and Protections Under ERISA and the Code13-52
    • § 13:9.1 : Anti-Alienation Rule13-52
    • § 13:9.2 : Exclusive Benefit Rule13-52
    • § 13:9.3 : Fiduciary Duties13-52
    • § 13:9.4 : Interference with Protected Rights13-53
  • § 13:10 : Claiming Benefits Under a Retirement Plan13-53
    • § 13:10.1 : In General13-53
    • § 13:10.2 : Helpful Information and Documents13-56
  • § 13:11 : Litigation Under ERISA13-60
    • § 13:11.1 : Causes of Action13-60
    • § 13:11.2 : Remedies Under ERISA13-61
  • § 13:12 : Taxation of Retirement Plan Benefits13-64
    • § 13:12.1 : In General13-64
    • § 13:12.2 : Rollovers13-65
    • § 13:12.3 : Direct Rollovers13-67
  • § 13:13 : Pension Rights in Divorce13-68
    • § 13:13.1 : General Rules13-68
    • § 13:13.2 : New York Law13-69
  • § 13:14 : The Sarbanes-Oxley Act13-70
  • Table 13-1 : Governmental Plan Exemptions13-71
  • Table 13-2 : Substantive Requirements for Governmental Plans13-72
  Index
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