Vaccines can become less effective over time. Even individuals fully vaccinated as children may need to update their immunizations. Medicare Parts B and D offer vaccination coverage.
Medicare Part B covers shots for the flu, hepatitis B, pneumococcal (pneumonia), and COVID-19. Medicare covers 100 percent of the cost of these vaccines if you go to an approved provider, and you do not have to pay a deductible or coinsurance. Medicare Advantage plans are also required to provide these vaccines at no additional costs.
Medicare covers one flu shot per flu season, which runs from November to April, and not the calendar year. For example, if an individual gets a flu shot in January and again in November of the same year, Medicare would pay for both.
Medicare covers two different pneumonia shots. Medicare recipients can get the first shot at any time and it will cover the second shot if it's administered at least one year after the first shot.
Hepatitis B shots are free for anyone considered medium or high risk for contracting the virus. End-stage renal disease and diabetes are two conditions that place individuals into a higher risk category. A medical professional can help determine an individual’s risk level.
Medicare Part D plans (as well as Medicare Advantage plans with built-in Part D) should cover all other commercially available vaccines, including shingles and Tdap (tetanus, diphtheria, and pertussis), when they are reasonable and necessary to prevent illness. Contact your Part D plan to make sure it covers the shot you need. To limit your copay, you should go through an in-network provider that will either handle billing your Part D plan electronically or coordinate this with a pharmacy.
Ask your vaccine provider if it can bill your Part D plan directly. If your doctor or pharmacy can’t do this, the provider will have to bill you for the entire cost of the vaccination and you’ll have to request reimbursement from your plan. And note that the plan will reimburse for only the approved amount, which may be less than what the provider charged you.
Keeping current on your vaccinations is one of the best ways to prevent serious illness and disease. Talk with your doctor to determine what vaccines you need to minimize risks to your health.
For more from the Medicare Rights Center on Medicare’s vaccination coverage, click here.
Overwhelmed by the stress of long hours, low pay and exposure to the COVID-19 virus, nursing home workers are quitting in record numbers. The labor hemorrhage has turned what was already a chronic staffing problem into a full-blown crisis in many facilities and entire states as understaffed nursing homes struggle to care for patients, accommodate family visitation, and admit new patients waiting in hospitals to be discharged.
The crunch has even forced some states – including New York, New Jersey, Minnesota, Maine, New Hampshire and Indiana — to deploy the National Guard to empty bedpans, give baths and distribute meals.
“It’s beyond a crisis,” Katie Smith Sloan, the president of LeadingAge, an association of nonprofit long-term care facilities, told The New York Times. “For many providers across the country, it’s a collapse.”
‘No One Would Come’
According to the U.S. Bureau of Labor Statistics, 425,000 employees, many of them of them nursing assistants, have left the nursing home workforce since February 2020. Certified Nursing Assistants (CNA), provide 80 to 90 percent of direct care for long-term care patients and make up 40 percent of nursing home employees.
In a June 2021 survey by the American Health Care Association and the National Center for Assisted Living, 94 percent of nursing home providers reported a shortage of staff, and 58 percent were limiting admissions because of the shortages.
With fewer nursing assistants working in short-staffed facilities, residents don’t get as much one-on-one interaction with their caregivers as they need, don’t get as many showers, and don’t get turned as often in bed to prevent bedsores from developing.
One North Carolina woman witnessed it first-hand with her 74-year-old mother, according to an Associated Press report. When visitors weren’t allowed inside the nursing home, she saw through her mother’s window that sometimes she sat for hours in a soiled diaper, with matted hair and a bedsore the size of a fist. Unable to use a phone by herself, the mother would cry for assistance.
“She would call out for help and no one would come,” her daughter said. “There was no one around.”
Meanwhile, although nursing homes contain less than one-half of 1 percent of the U.S, population, they account for 2 percent of the COVID-19 cases and 25 percent of the deaths, according to a report by the advocacy group U.S. PIRG.
Admissions Backlog Hurting Hospitals
Faced with the loss of employees during the pandemic and the difficulty in recruiting replacements in a competitive market economy, nursing home administrators have been forced to limit new admissions and close off whole floors in their facilities.
This has caused hospitals to keep patients longer who are waiting to be discharged to long-term care after surgery or illnesses and has resulted in fewer beds being available for COVID-19 cases flooding hospital emergency rooms.
While the pandemic has made the staffing crisis in nursing homes more acute, the problem isn’t a new one. It’s a systemic failure in the nursing home industry that’s been neglected for years, according to long-term care experts.
Nursing home workers are among the lowest paid employees in the U.S. economy, earning near-poverty wages, the Paraprofessional Healthcare Institute reported in 2016. With a median salary of $19,000 a year, more than a third of nursing home workers relied on public benefits like food stamps, housing subsidies and cash assistance. Given the low wages, long hours and stressful work, keeping and recruiting nursing home workers when other jobs are available and less demanding is a challenge. Before the pandemic, CNAs in nursing homes had an average annual turnover rate of 129 percent, according to the journal Health Affairs, with some facilities reaching a 300 percent replacement rate. (Consumers can now find out a nursing home's turnover rate.)
Nursing home owners are aware of the problem but claim that they can’t raise wages for workers due to the funding that’s available to them. While some long-term care patients pay their own way, most nursing home funding comes from Medicare and Medicaid. Medicare reimburses facilities for short-stay patients coming from hospitals for rehabilitative services, while Medicaid’s reimbursements are determined by the states, and the program pays for the majority of long-stay patients in nursing home populations.
On average, Medicaid pays half as much per day for long-term care as does Medicare ($206 v. $503), according to a 2018 analysis by the non-profit National Investment Center for Seniors Housing & Care.
“Everyone knows that Medicaid underpays,” David Gifford, chief medical officer for the American Health Care Association (AHCA), which represents assisted living and long-term care facilities, told CNN. “Salaries are about 70 percent of our revenue overall and so we just can't offer competitive salaries compared to hospitals and other settings.”
Some nursing home providers as well as federal, state and local governments are taking steps to address the staffing crisis. An October 2020 U.S. Department of Health and Human Services report found that increased wages and augmented benefits like child care, transportation, housing and food support, were being offered to retain staff in some facilities and localities. Hard-hit Minnesota recently announced a plan to train 1,000 new CNAs.
Meanwhile, the Biden Administration’s Build Back Better plan would provide funding for higher wages, tuition assistance and other incentives for nursing homes to attract qualified staff, and would help reduce waiting lists for Medicaid-funded alternatives to nursing home care by giving state home and community-based service (HCBS) programs an additional $150 billion over 10 years. The proposal would also make permanent a program called Money Follows the Person to help nursing homes return younger residents and some older adults to their homes.
For more on the rights of nursing home residents, click here.
Medicare premiums are rising sharply next year, cutting into the large Social Security cost-of-living increase. The basic monthly premium will jump 15.5 percent, or $21.60, from $148.50 to $170.10 a month.
The Centers for Medicare and Medicaid Services (CMS) announced the premium and other Medicare cost increases on November 12, 2021. The steep hike is attributed to increasing health care costs and uncertainty over Medicare’s outlay for an expensive new drug that was recently approved to treat Alzheimer’s disease. Because most recipients have their Medicare premium deducted from their Social Security check, the upswing in Medicare premiums means that the Social Security cost-of-living increase of 5.9 percent, which was the largest in 39 years, will be smaller for most people.
While the majority of beneficiaries will pay the added amount, a “hold harmless” rule prevents Medicare recipients' premiums from increasing more than Social Security benefits. This “hold harmless” provision does not apply to Medicare beneficiaries who are enrolled in Medicare but not yet receiving Social Security, new Medicare beneficiaries, seniors earning more than $91,000 a year, and “dual eligibles” who get both Medicare and Medicaid benefits.
Meanwhile, the Part B deductible will rise $30, from $203 to $233 in 2022, while the Part A deductible will go up by $72, to $1,556. For beneficiaries receiving skilled care in a nursing home, Medicare's coinsurance for days 21-100 will increase from $185.50 to $194.50. Medicare coverage ends after day 100. (For more information about Medicare's nursing home coverage, click here.)
Here are all the new Medicare payment figures:
Part B premium: $170.10 (was $148.50)
Part B deductible: $233 (was $203)
Part A deductible: $1,556 (was $1,484)
Co-payment for hospital stay days 61-90: $389/day (was $371)
Co-payment for hospital stay days 91 and beyond: $778/day (was $742)
Skilled nursing facility co-payment, days 21-100: $194.50/day (was $185.50)
So-called “Medigap” policies can cover some of these costs. For more information about Medigap, click here.
Premiums for higher-income beneficiaries ($91,000 and above) are as follows:
Individuals with annual incomes between $91,000 and $114,000 and married couples with annual incomes between $182,000 and $228,000 will pay a monthly premium of $238.10.
Individuals with annual incomes between $114,000 and $142,000 and married couples with annual incomes between $228,000 and $2846,000 will pay a monthly premium of $340.20.
Individuals with annual incomes between $142,000 and $170,000 and married couples with annual incomes between $284,000 and $340,000 will pay a monthly premium of $442.30.
Individuals with annual incomes above $170,000 and less than $500,000 and married couples with annual incomes above $340,000 and less than $750,000 will pay a monthly premium of $544.30.
Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $578.30.
Rates differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $91,000 and less than $409,000 will pay a monthly premium of $544.30. Those with incomes greater than $409,000 will pay a monthly premium of $578.30.
The Social Security Administration uses the income reported two years ago to determine a Part B beneficiary's premium. This means that the income reported on a beneficiary's 2020 tax return is used to determine whether the beneficiary must pay a higher monthly Part B premium in 2022. Income is calculated by taking a beneficiary's adjusted gross income and adding back in some normally excluded income, such as tax-exempt interest, U.S. savings bond interest used to pay tuition, and certain income from foreign sources. This is called modified adjusted gross income (MAGI). If a beneficiary's MAGI decreased significantly in the past two years, she may request that information from more recent years be used to calculate the premium. You can also request to reverse a surcharge if your income changes.
Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. CMS estimates that the Medicare Advantage average monthly premium will be lower in 2022, from an average of $21 in 2021 to $19 in 2022.
For Medicare’s press release announcing the new premium, co-payment and deductible amounts for 2022, click here.
When applying for Medicaid’s long-term care coverage, in addition to the strict income and asset limits, you must demonstrate that you need a level care typically provided in a nursing home.
Whether you are applying for nursing home coverage or through a Medicaid waiver program for coverage at home, you must meet the level-of-care requirement set by the state. Each state has its own criteria for determining if you meet the mandated level of care, and the criteria is not always clear.
The state looks at an applicant’s functional, medical, and cognitive abilities to determine if care in a nursing home is called for. In general, you must be unable to care for yourself or pose a danger to yourself without outside help. The following are the factors usually considered when making a level-of-care determination:
You need help with two or more “activities of daily living” (such as bathing, dressing, eating, moving, and going to the bathroom).
You need frequent medical care, such as assistance with medication, injections, IVs, or other medical treatment.
Your cognitive ability is impaired by Alzheimer’s disease or another form of dementia, you have trouble making decisions on your own, or you are unable to process information.
You have behavior problems, such as wandering away from home or aggressiveness.
When assessing a Medicaid applicant, the state will conduct the evaluation. The state may require a doctor’s diagnosis, but it will also likely require the applicant to answer a series of questions about his or her ability to perform activities of daily living as well the applicant’s mental abilities and behavior problems and the applicant’s family’s ability to provide support.
To apply for Medicaid, contact your local Medicaid office. An elder law attorney can help you navigate the Medicaid application process, which is not easy. To find an attorney near you, click here.
Medicaid long-term care benefits traditionally pay mainly for nursing home care, but the federal government can grant “waivers” to states allowing them to expand Medicaid to include home and community-based services. The downside is that receiving care in a nursing home is an entitlement, while getting care at home is not.
Medicaid is a joint federal-state program that provides health insurance coverage to low-income children, seniors, and people with disabilities. In addition, it covers care in a nursing home for those who qualify. Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive federal money, which pays for about half the state's Medicaid costs. (The state picks up the rest of the tab.) A Medicaid waiver allows states to waive some of the federal rules with the intention of providing services to individuals who wouldn’t normally be covered by Medicaid. The waiver must be approved by the federal government.
The most common type of Medicaid waiver expands Medicaid to cover home care to individuals who need a high level of care, but who would like to remain at home rather than enter a nursing home. Care that may be provided by a waiver includes personal attendants, home health aides, medical supplies and equipment, respite care, counseling services, transportation, homemaking services, hot meal delivery, and more.
Each state sets up its own waiver program, so the rules and requirements vary widely. Usually, to qualify an applicant must need a level of care similar to what is needed to qualify for Medicaid coverage in a nursing home. The point of the waiver is to allow an individual who would normally need nursing home care to remain at home, which is typically a far less costly form of care. States may also target different health conditions, such as HIV, Alzheimer’s disease, diabetes, cystic fibrosis, among others. Each state also sets its own income and asset levels for its waiver programs, which may vary from state to state, and may be different from the income and asset levels used for Medicaid coverage of nursing home care.
The downside of state waiver programs is that waivers are not an entitlement, meaning that states are allowed to limit the number of people who qualify for services under a waiver. Just because an applicant meets the criteria for eligibility does not mean the applicant will be approved for the services. As a result, waitlists for filled programs can run for months or years.
To find out your Medicaid home care options, you should check with your elder law attorney.
To find and apply for a waiver program in your state, contact your state Medicaid office.
The year was 1983: The U.S. invaded Granada. A gallon of gas cost 96 cents. Michael Jackson’s ‘Thriller’ video premiered. That year was also the last time that Social Security recipients saw a cost-of-living increase steeper than the one just announced for 2022. This year, Social Security benefits will rise 5.9 percent, the sharpest upsurge since 1983’s 7.4 percent jump.
Cost-of-living increases are tied to the consumer price index, and rising inflation rates and gas prices caused by the ongoing coronavirus pandemic mean Social Security recipients will get a large boost in 2022. The 5.9 percent increase dwarfs last year’s 1.3 percent rise, and over the past decade hikes have averaged just 1.65 percent. The average monthly benefit of $1,565 in 2021 will go up by $92 a month to $1,657 a month for an individual beneficiary, or $19,884 yearly.
The cost-of-living change also affects the maximum amount of earnings subject to the Social Security tax, which will grow from $142,800 to $147,000.
For 2022, the monthly federal Supplemental Security Income (SSI) payment standard will be $841 for an individual and $1,261 for a couple.
Part of the increase will be eaten up by higher Medicare Part B premiums, however. The standard monthly premium for Medicare Part B enrollees has not been announced yet, but it is projected to rise $10 a month to $158.30.
Most beneficiaries will be able to find out their specific cost-of-living adjustment online by logging on to my Social Security in December 2021. While you can still receive your increase notice by mail, you have the option to get the notice online instead.
For more on the 2022 Social Security benefit levels, click here.
The federal government has expanded access to protections for spouses of reverse mortgage holders who are not named in the loan document, allowing more such spouses the ability to stay in their home if the borrowing spouse dies or moves to a care facility.
A reverse mortgage allows homeowners to use the equity in their home to take out a loan, but borrowers must be 62 years or older to qualify for this type of mortgage. Up until 2014, if one spouse was under age 62, the younger spouse had to be left off the loan in order for the couple to qualify for a reverse mortgage. But couples often did this without realizing the potentially catastrophic implications. If only one spouse's name was on the mortgage and that spouse died, the surviving spouse would be required to either repay the loan in full or face eviction.
In 2014, the Department of Housing and Urban Development developed a rule that better protected at least some surviving spouses. Under the rule, if a couple with one spouse under age 62 wants to take out a reverse mortgage, they may list the underage spouse as a “non-borrowing spouse.” If the older spouse dies, the non-borrowing spouse may remain in the home, provided that the surviving spouse establishes within 90 days that he or she has a legal right to stay in the home (this could, for example, be an ownership document, a lease, or a court order). The surviving spouse also must continue to meet the other requirements of a reverse mortgage holder, such as paying property taxes and insurance premiums.
While this rule was beneficial to many non-borrowing spouses, it left some out: It applied only to loans taken out after the law became effective in 2014 and did not cover spouses of borrowers who had to leave the home due to medical reasons. In May 2021, the Federal Housing Authority issued a new rule that addresses these issues and expands the protection to the following spouses:
All non-borrowing spouses, not just ones whose loans began after 2014
Non-borrowing spouses of borrowers who had to move to a health care facility for more than 12 consecutive months
Spouses who were in a committed relationship with the borrower at the time of the loan, but were prevented from marrying the borrower due to their genders, provided they eventually married before the borrower’s death
The new rule also eliminates the requirement that non-borrowing spouses demonstrate that he or she has a marketable title or the legal right to remain in the home.
This rule still does not cover spouses who were not married to the borrower at the time of the loan (except in the case of same-sex marriages that were prohibited at the time). Additionally, the non-borrowing surviving spouse still cannot access the remaining loan balance.
Medicare prescription drug (Part D) plans can have a coverage gap—called the “donut hole”–which limits how much Medicare will pay for your drugs until you pay a certain amount out of pocket. Although the gap has gotten much smaller since Medicare Part D was introduced in 2006, there still may be a difference in what you pay during your initial coverage compared to what you might pay while caught in the coverage gap.
When you first sign up for a Medicare prescription drug plan, you will have to pay a deductible, which can’t be more than $445 (in 2021). Once you’ve paid the deductible, you still need to cover your co-insurance (also called co-payment) amount (depending on your drug plan), but Medicare will pay the rest. Co-insurance is usually a percentage (for example, 20 percent) of the cost of the drug. If you pay co-insurance, these amounts may vary throughout the year due to changes in the drug’s total cost.
Once you and your plan pay a total of $4,130 (in 2021) in a year, you enter the coverage gap, aka the notorious donut hole. Previously coverage stopped completely at this point until total out-of-pocket spending reached a certain amount. However, the Affordable Care Act has mostly eliminated the donut hole. In 2021, until your total out-of-pocket spending reaches $6,550, you’ll pay 25 percent for brand-name and generic drugs. Once total spending for your covered drugs exceeds $6,550 (the “catastrophic coverage” threshold for 2021), you are out of the coverage gap and you will pay only a small co-insurance amount.
Once you are in the coverage gap, your yearly deductible and co-insurance payments count toward the amount you need to pay to reach catastrophic coverage. The amount of out-of-pocket costs that you have to pay to reach catastrophic coverage will vary, depending on the type of drugs you take. In the case of brand name drugs, you will pay only a certain percentage of the price, but the entire price will count toward the amount you need to qualify for catastrophic coverage. With generic drugs, only the amount you pay will count toward getting you out of the donut hole.
Bear in mind that only payments for drugs that are covered by your plan count towards the out-of-pocket threshold. Your premium and the portion of the drug cost that Medicare pays do not count toward reaching catastrophic coverage, either. Also, any help with paying for Medicare Part D costs that you receive from an employer health plan or other insurance does not count toward this limit.
To qualify for Medicaid coverage of long-term care, you must satisfy very complicated financial eligibility rules—rules that often can be traps for the unwary. One of the most significant traps is Medicaid's right to recover its expenses from your estate after you die – a practice known as “estate recovery.”
Under current Medicaid law, states are required to attempt to recoup Medicaid spending for long-term care services. Since about the only asset you're allowed to own and still get Medicaid coverage is your home, this right of estate recovery is the state's claim against your home. In other words, if you own a home, Medicaid is really a loan. It will pay for your care, but your house will have to be sold when you die to repay the state for the services it provided.
Now, five elder advocacy groups are calling on Congress to eliminate Medicaid estate recovery after a congressional advisory commission concluded that the practice recoups only a tiny percentage of Medicaid spending while contributing to generational poverty and wealth inequity.
“The burden of estate claims falls disproportionately on economically oppressed families and communities of color, preventing families from building wealth through home ownership, which has been historically denied to communities of color through discriminatory public policy,” the five groups – Justice in Aging, the National Academy of Elder Law Attorneys, the National Health Law Program, California Advocates for Nursing Home Reform, and the Western Center on Law & Poverty – wrote in a jointly authored Issue Brief, Medicaid Estate Claims: Perpetuating Poverty & Inequality for a Minimal Return. “Congress should amend Federal law to eliminate Medicaid estate claims. Alternatively, the law should be amended so that states have the choice of whether to use Medicaid estate claims, as recommended in a recent report to Congress by the Medicaid and CHIP Payment and Access Commission (MACPAC).”
In its March 2021 report to Congress, MACPAC recommended that Congress amend Medicaid law to make estate recovery optional for states, rather than required as it is now. The group, a non-partisan legislative branch agency that provides analysis and recommendations to Congress, the U.S. Department of Health and Human Services (HHS) and the states, also recommends that HHS set minimum standards for hardship waivers under the Medicaid estate recovery program. Currently, it’s up to the states to decide what qualifies as “hardship.”
Pointing out that estate recovery recoups only about 0.55 percent of total fee-for-service long-term care spending, MACPAC recommends that states not be allowed to pursue recovery against any asset that is “the sole income-producing asset of survivors,” homes of “modest value,” or any estate valued under a certain dollar figure.
In their Issue Brief, the five advocacy groups go a step further. Noting that “no other public benefit program requires that correctly paid benefits be recouped from deceased recipients’ family members,” they call for the elimination of estate recovery “so that low-income families are better able to retain wealth and pass it on to future generations. Or, at a minimum, federal law should be amended to make estate claims voluntary.”
The Issue Brief details how Medicaid estate recovery keeps families in poverty, exacerbates racial wealth gaps, and runs counter to efforts to create more affordable housing.
Long-term care involves not only a loss of personal autonomy; it also comes at a tremendous financial price. Proper planning can help your family prepare for the financial toll and protect assets for future generations.
Long-term care can be very expensive, especially around-the-clock nursing home care. Most people end up paying for nursing home care out of their savings until they run out, at which point they can qualify for Medicaid to pick up the cost.
Medicaid rules require that recipients have no more than $2,000 in “countable” assets (the figure may be somewhat higher in some states) and limited income. Any excess assets need to be spent down before you can qualify for Medicaid. In addition, in order to be eligible for Medicaid, you cannot have recently transferred assets. If you transfer assets within five years of applying for Medicaid, you may be subject to a penalty period during which you cannot receive benefits. After you die, Medicaid also has the right to recover from your estate, which in the case of a Medicaid recipient usually means only the house.
Careful planning in advance can help protect your estate for your spouse or children. If you make a plan before you need long-term care, you may have the luxury of distributing or protecting your assets in advance. This way, when you do need long-term care, you will quickly qualify for Medicaid benefits. The following are some tools that can be d in an estate plan to prepare for Medicaid:
Trusts. One of most important estate planning tools you can use is an “irrevocable” trust — a trust that cannot be changed after it has been created. In most cases, this type of trust is drafted so that the income is payable to you (the person establishing the trust, called the “grantor”) for life, and the principal cannot be applied to benefit you or your spouse. At your death the principal is paid to your heirs. This way, the funds in the trust are protected and you can use the income for your living expenses. For Medicaid purposes, the principal in such trusts is not counted as a resource, provided the trustee cannot pay it to you or your spouse for either of your benefits. However, if you do move to a nursing home, the trust income will have to go to the nursing home. And to avoid Medicaid’s “look-back period,” the trust must be funded at least five years before applying for benefits.
Annuities. Annuities are another tool married couples can use to prepare for Medicaid. An immediate annuity, in its simplest form, is a contract with an insurance company under which the policyholder pays a certain lump sum of money to the insurer and the insurer sends the policyholder a monthly check for the rest of his or her life. In most states the purchase of an annuity is not considered to be a transfer for purposes of eligibility for Medicaid, but is instead the purchase of an investment. It transforms otherwise countable assets into a non-countable income stream. As long as the income is in the name of the spouse who is not in the nursing home, it's considered non-countable. For single individuals, annuities are less useful, but if you transfer assets, you may be able to use an annuity to pay for long-term care during the Medicaid penalty period that results from the transfer.
Protecting your home. After a Medicaid recipient dies, the state must attempt to recoup from his or her estate whatever benefits it paid for the recipient's care. This is called “estate recovery.” For most Medicaid recipients, their house is the only asset available, but there are steps you can take to protect your home. Putting your house in a trust can be a good option, but once a house is placed in an irrevocable trust, you cannot remove it. Another option is a life estate, which is a form of joint ownership of property between two or more people. They each have an ownership interest in the property, but for different periods of time. The person holding the life estate possesses the property currently and for the rest of his or her life. The other owner has a current ownership interest but cannot take possession until the end of the life estate, which occurs at the death of the life estate holder.
Talk to your attorney about whether your estate plan should include preparation for possible Medicaid eligibility.