Elder Law, Elder Living, Estate Planning, Healthcare

How Do the Stimulus Payments Affect Medicaid?

The federal government has issued direct payments, “stimulus checks”, to most Americans to invigorate the economy after the devastating coronavirus pandemic. This money is to ease the pain of the Covid pandemic and to jump-start the economy.

The stimulus money should have arrived in the same way that Social Security payments or tax refunds are made, either direct-deposited into a bank account or mailed as a paper check. If the money has not arrived, or for guidance in general, consult the IRS website:

https://www.irs.gov/coronavirus/economic-impact-payment-information-center#more. Other options are to call 800-919-9835 or 800-829-1040, or you can visit your local Taxpayer Assistance Center.

Those who are receiving means-tied government assistance, like SSI, VA benefits, or Medicaid to pay for long-term care, need not worry that stimulus money will be counted against them for eligibility. As long as recipients spend the money within twelve months, the money will not push them over the maximum amount they are permitted before they are penalized.

Recipients may use the money to buy new clothing, cell phones or televisions, toiletries, snacks, dental treatment, or improved quality of medical supplies. They may buy an irrevocable funeral trust, to avoid future expense to family members. They may give the money away to family or charities. The money might pay for updating estate-planning documents, or for consulting a geriatric care manager. (Some commentators believe that you could give the money away to family or charities. While this may be OK under federal law, it’s probably best not to take chances with how the states may interpret it. Spend the money, don’t donate it.)

Provided that the money is not spent on what could be called an asset or an investment – like, for example, rare coins or stocks or bonds – the money will not be counted against the asset limit for Medicaid eligibility. And, again, the money must be spent within twelve months. It must not be forgotten-about or left unnoticed in a bank account.

It also must not be misappropriated by nursing homes or assisted-living facilities. If this has happened to you or your loved one, inform the facility manager that the money must be refunded to the resident. Cite the law that carves out the payment from being counted toward federally assisted programs like Medicaid: 26 U.S.C. § 6409.  Or, show them a handout downloadable from the Congressional Research Service.

If the facility will not refund the money, contact your state’s attorney general. Then lodge a complaint with the Federal Trade Commission.

Recipients of assistance, like anyone else, are free to spend their stimulus money. The money is theirs. It is tax-free. It is intended to be spent, and it should be spent, in any way the recipient would like (subject to the conditions above).

This is one time when spending is unquestionably a good thing – for buyers and sellers.

If you have questions or would like to discuss your situation in a confidential setting, please don’t hesitate to reach out. Please contact our Reno office by calling us at (775) 853-5700.

Elder Law, Elder Living, Estate Planning, Healthcare

American Nursing Homes Face a Dilemma

Our country’s nursing facilities are home to the most vulnerable to the COVID-19 pandemic. When the novel coronavirus did hit, these nursing homes became its ground zero as many residents and workers did not receive testing, and staff found obtaining personal protective equipment a struggle. Some facilities tended to downplay the severity of the outbreaks. Couple these issues with some state governments mandating the reintroduction of recovering COVID-19 patients back into nursing home facilities, and the perfect storm came into being. The Washington Post reports that according to the best estimates, about half of COVID-19 deaths have been nursing home residents. Currently, that half represents more than 52,500 of our senior population.

The Wall Street Journal is reporting that according to two studies, nursing home residents who are dying from COVID-19 on average could have expected to live for another decade. Even the more senior residents, 90 and older, with multiple ailments, are losing more than one year of life. These studies challenge the perception that the coronavirus tends to kill elderly people who were likely to die soon anyhow.

A New Perspective on Elder Care

The coronavirus pandemic is forcing us to take a hard look at where our loved one should receive care if care at home is not a safe option. As the number of nursing home deaths continues to increase, the news media is finding it harder than ever to gloss over the unpalatable reality of these deaths.

Now more than ever it is important for families to come together when a decision must be made about a loved one’s care. We help families discuss options for care and how to plan to pay for appropriate care. If you’d like to discuss your particular situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700 with any questions.

Estate Planning, Healthcare

You got the COVID-19 Vaccine, Now What?

Eligibility to receive the COVID-19 vaccine is becoming more and more widespread. According to the medical community, vaccinated individuals are significantly less likely to contract COVID-19; however, they may pose a health risk to others. What then is appropriate behavior for vaccinated Americans when considering the health of others? For the moment, not much has changed.

First of all, experts have told us that the COVID-19 vaccines take at least two weeks from receiving the second dose (or the single dose of Johnson and Johnson) to build up your immune response. The Pfizer vaccine offers 95 percent efficacy, while the Moderna vaccine provides 94 percent efficacy, so you are highly resistant to COVID-19 but not completely immune. According to MarketWatch, Dr. Gregory Poland, infectious disease expert and director of the Mayo Clinic’s Vaccine Research Group in Rochester, Minnesota, the .9 percent difference in efficacy rates is “meaningless.” However, according to preliminary data, those who are vaccinated may still contract coronavirus though, they are more likely to be asymptomatic. In the same MarketWatch post, Dr. Thomas Russo, chief of infectious disease, University at Buffalo in New York, says, “… it’s not clear whether those vaccinated people would be able to pass it to others.” We are still in a time of great uncertainty regarding this pandemic.

There is a low risk of infection when socializing with other fully vaccinated individuals; however, most experts believe it will take months to achieve herd immunity as a nation. Herd immunity occurs when a large enough percentage of the population develops long-lasting immunity through naturally occurring infection resistance or vaccinations to a particular virus or disease.

Should you visit your local grandparent or other older relative now that you have the vaccine? Dr. Russo told MarketWatch if both you and your loved one are fully vaccinated, “the benefits of the visit will outweigh these small risks that they could have of developing a severe case of coronavirus.” The unprecedented rates of social isolation of the American elderly have taken a huge toll on their physical, mental, and emotional well-being. If you and your loved one have been fully vaccinated, make arrangements to meet safely.

The medical community speculates that a vaccination rate of 70 to 80 percent can bring about herd immunity in the US, but we are just beginning the nation’s vaccination journey. The advent of open borders and easing air travel restrictions from other countries continues to provide challenges. In the future, you might need to present a negative COVID-19 test to cross international borders. Currently, those Americans returning from Mexico must now meet this requirement before entering the US. The “slow the spread” protocols remain in place even though you are fully vaccinated.

Once you are fully vaccinated your way of life may not change for a while. It is still important to reach out to friends and loved ones who may still be suffering from feelings of isolation and/or depression. You may be able to visit a loved one in a care facility once you are fully vaccinated. And if you haven’t already, now is a great time to think about your future health, and to make sure you have the correct legal documents in place in case you are unable to make decisions due to illness or incapacity in the future. We would be happy to speak to you about what documents you should be thinking about, including a health care directive, living will, or other documents specific to your wishes and desires. If the past year has taught us anything, it is to expect the unexpected and plan accordingly. We can help!

If you have questions or would like to discuss your personal situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700.

Estate Planning, Healthcare

Planning and Preserving Quality of Life

As lawyers prepare powers-of-attorney documents so that when our clients can no longer act for themselves, the documents will convey on other trusted people the authority to act on our clients’ behalf.

But when it comes to actually using those documents at the time of a health-care crisis, clear and powerful documents are just the beginning. The decision-points can (and must) be put down on paper in advance, but when it comes to end-of-life situations, the clarity on which we lawyers thrive can be very hard to find.

Sitting in her lawyer’s office, the client may have been quite certain about health-care decisions. She does not want her life prolonged by a battery of aggressive treatments, where these would not preserve her quality of life. She does not want blood transfusions, dialysis, repeated courses of antibiotics and chemotherapy, cardiopulmonary resuscitation, or breathing and feeding tubes. She does not want to die inert in the ICU, surrounded by machines and strangers. She wants to die at home, surrounded by loved ones, at a time when she retains presence of mind to make her peace.

But that goal doesn’t just happen from wishing it and stating it. It happens with additional careful preparation for the realities. As the end of life approaches, the clarity we lawyers enjoy can be elusive. When a person gets a prognosis of two to five years (maybe), where, along that continuum, would be the time to start declining aggressive treatment? When there’s always one more intervention that may (or may not) produce a good result? When one decision could create an ever-widening array of complications? When, step by step, the patient becomes less and less able to exercise autonomy, and where treatment decisions by caregivers are not in line with the care the patient was clear about when she was sitting in the lawyer’s office?

No matter how clear the powers-of-attorney documents, with all these imponderables, the patient can end up in a situation many miles away from what she wanted. And there’s no possible do-over.

Powerful and clear power-of-attorney documents are an essential first step and we lawyers are glad to take care of that part. Beyond that, though, thorough preparation is essential.

Consider that the best result may be one that cares for comfort right now, in the moment. The question is not necessarily about how long life can be prolonged. The question may be, rather, how comfort can be maintained – in this moment, and then the next moment, and the next. The question is how life can be made better right now. Watch a video by palliative-care physician B.J. Miller, on why this is so important, here.

Make concrete plans. These include specifying what you want to happen if you’re no longer able to live independently; choosing wisely whom you want to act for you, to make sure your plans will be followed; being ready with your health-care documents before you find yourself deposited in the emergency room or ICU; and seeking the reassurance that your loved ones will be cared-for when you’re no longer there. Judy MacDonald Johnson has prepared simple, forthright worksheets to help with this process, here.  She speaks about these worksheets in this moving video.

There is no doubt that the process in safeguarding quality of life at the end of it is possibly the most challenging of all. But if that process can create as much pleasure as possible through an extremely difficult time of life, and if forthrightly engaging in that process would facilitate a passing more in line with what we would envision, the worth of the process will be felt. The transition will be smoother and more meaningful for the dying person, and a kinder legacy will be left behind for those who accompany us on this journey.

If you have questions or would like to discuss your personal situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700.

Elder Law, Healthcare

Creating an effective COVID-19 Vaccine for Seniors is a Challenge

Older Americans, who are the most at risk of COVID-19, are the least likely demographic to respond well to a vaccine. A vaccine shot works by fooling the body into believing it has been infected with a virus, thereby prompting its immune system to fight the intruding pathogen by making antibodies. Unfortunately, as we age, antibody production weakens, part of the process known as immunosenescence. A compromised immune system makes older adults more susceptible to viral and bacterial infections. The Wall Street Journal reports that 90 percent of flu deaths in the US every year are people over the age of 65.

What’s age got to do with the COVID-19 Vaccine?

The thymus, located center of your chest just below the neckline between the lungs, is a major source of pathogen fighting T-cells. Some of these specialized cells help the immune system make additional defenses against infection called antibodies. As we age, the thymus production of adaptable T-cells is depleted as the thymus fills with fatty tissue. The result is an old immune system that is ill-equipped to fight off new viruses. The Center for Disease Control and Prevention (CDC) posted a July 17 analysis of more than 50,000 COVID-19 deaths in the US, identifying that 80 percent were people age 65 or more.

An aging thymus also complicates the development of a COVID-19 vaccine. A vaccine’s design provides instructions to our immune system, which T-cells help to guide appropriately. However, the thymus has exhausted most of its reserve T-cells that adapt to recognize unknown pathogens by the age of 50; thus, the ability to “train” other immune cells to fight is lost. Many vaccines rely on the skill sets of fully functional T-cells.

A Shift from Traditional Methods of Developing Vaccines

Traditionally, the biopharmaceutical vaccine market has concentrated efforts on childhood vaccines. Martin Friede, a coordinator for vaccine and product and delivery research with the World Health Organization (WHO), states, “Up until very recently most of the focus of the vaccine community has been on saving lives of young children. The people who need the vaccine the most may actually be the people in whom the vaccine might not work.” Friede further comments that it isn’t solely about the thymus as individual vitality can translate into different vaccine responses. Some older people may be off to play a round of golf while others may be too frail to walk unaided.

Deputy director of clinical research for the Institute of Vaccine Safety at Johns Hopkins Bloomberg School of Public Health, Dr. Kawsar Talaat, echoes Friede’s sentiments, “We hadn’t been designing vaccines for the elderly for a long time.” Dr. Talaat is helping to facilitate coronavirus vaccine developers to test their shots in older adults. The Food and Drug Administration (FDA) is also working with drug and biotech companies easing restrictions for experimental vaccines to be tested earlier during clinical trials on older adults.

Updates on Testing COVID-19 Vaccine Options

The New York biopharmaceutical giant Pfizer is currently conducting tests for potential COVID-19 vaccines in older people. The company is studying whether increasing the vaccine dosage could better protect the elderly as higher doses in existing flu vaccines make them more effective in older populations. At Moderna Therapeutics, results from a phase-one trial of its novel mRNA vaccine are in; however, a second phase two trial is being conducted specifically for adults age 55 and older. Many biotech and pharmaceutical companies are eager to be the first to introduce a successful FDA approved COVID-19 vaccine.

If the development of a COVID-19 vaccine specifically for the elderly remains elusive, scientists are hopeful that immunizing others around them can make a difference. Vaccinating children, health care workers, and potentially silent coronavirus carriers, could create enough herd immunity and would lower the risk of older people becoming infected. Sometimes it is possible to protect a vulnerable group by targeting other groups around them. Meanwhile, the work continues to find a workable COVID-19 vaccine for the most vulnerable Americans, the elderly.

We help seniors and their families deal with challenges around appropriate care and how to pay for it. If you would like to discuss your situation with us, please don’t hesitate to reach out.

If you’d like to discuss your particular situation, please don’t hesitate to reach out. Please contact our Reno office by calling us at (775) 853-5700 with any questions.

Healthcare

Virtual Care: The Changing Face of Telemedicine

Telemedicine is the digital information distribution of healthcare-related services. Not long-ago telemedicine was an innovative practice, primarily a supplement to hospitals’ information strategy managing patient care and their data more efficiently. During the coronavirus pandemic and its associated urgent healthcare needs, hospitals and medical offices are making telehealth capabilities more available than ever before. Long-distance patient and clinician contact, advice, reminders, care, education, intervention, monitoring, and remote admissions have become the norm.

Increasing Shift to Virtual Medical Care

The push for comprehensive virtual medical care quickly without a standardized platform has left many healthcare facilities struggling to meet demand with technological data integrity and consistent user interface. Just as individual’s panic led to purchasing toilet paper, hand sanitizer, and other essential household items creating shortages, hospitals “pandemic-purchased” telehealth solutions to ride out the crisis led to a hodgepodge of tech solutions. This situation led to medical information security breaches, dropped call and video conferencing, poor audio and video quality, and distorted or incorrect information relayed to patients and health insurance companies alike.

Patients who were sheltering in place and rather fearful at the outset of the pandemic were initially forgiving of technological glitches. Today, however, patients have higher expectations of telemedicine and seek seamless experiences. Patients are also taking advantage of the ability to test-drive options from home, exploring physician expertise, availability, disposition, and price point before committing to a particular doctor, health care practitioner, or hospital facility. Additionally, patients are enjoying the experience and are now more likely to seek virtual care. It turns out that a patient using telehealth is more likely to adhere to prescription and wellness regimes, which is an advantage to public health overall. On average, telemedicine saves a patient more than 90 minutes otherwise wasted in commuting to an appointment and waiting to be seen by a doctor.

Telemedicine Being Embraced by Clinics and Hospitals

Clinics and hospitals are also embracing the benefits of telemedicine. Virtual medicine has played a vital role in quickly flattening the curve by getting to as many patients as possible without compromising social distancing and urgent care only protocols. Patients with chronic conditions and other non-urgent care, including routine follow-ups, can still engage with their physicians, allowing medical care, decreased patient anxiety, and maintaining facility reputation through patient retention. This continuity of care is essential, especially for urgent non-COVID-19 related health issues.

Health care facilities and medical professionals are now able to reach a new demographic of patients through telemedicine, particularly those in rural areas or those who list time, convenience, and proximity as barriers to making an initial consultation. Fully 76 percent of hospitals now employ telemedicine services, and two-thirds of patients report a willingness to use telehealth in the future, even after the pandemic ends.

Telemedicine Saves Time and Money

Telemedicine also yields significant savings of time and money for healthcare organizations and patients. An average in-office visit is 121 minutes, including 101 minutes of commute and waiting time. Therefore, a patient is only experiencing about 20 minutes of interaction with their doctor. A full one-third of patients have left a doctor’s office because the wait was too long. Telemedicine reduces wait times, no-shows, and cancellations saving time and money. There are also flexible insurance benefits to take advantage of when using telehealth.

What Telemedicine Platforms and Service are Right for You?

How can you best assess your hospital or doctor’s office telemedicine platform and service? Medicaleconomics.com cites four questions that you must ask to find the service best suited to your needs. Telemedicine can vary drastically among categories such as compliance, quality, convenience, and features, so keep the following in mind as you search for the right fit.

  1. Look for easy to use technology. As a patient, you should have no trouble downloading and accessing a telehealth app. It should be easy to use and intuitive and be available on multiple digital devices such as a tablet, phone, or laptop.
  2. Is the software provide HIPPA compliant and secure? Privacy issues are a major concern when using non-healthcare specific solutions like Zoom, Skype, FaceTime, and others. Ensure your telehealth provider keeps your sensitive information digitally safe.
  3. Make sure that the platform provides quality audio and video transmission. You will feel more comfortable, and your session will yield the best results knowing that communication is clear. Miscommunication can lead to misdiagnosis and have tragic health consequences.
  4. Shop around before committing. Read online reviews and speak to others about their telehealth experiences. Finding reputable healthcare facilities doesn’t stop with a board-certified physician. Facility reputation can be the difference between ease of interaction, diagnosis, and follow-up regarding insurance.

Embracing telemedicine can open your healthcare to expert physicians, save you time, and maintain the significant benefit of social distancing. Look for a healthcare organization with the right telemedicine framework for you. It will help you stay current with your routine medical care despite the coronavirus pandemic.

If you have questions or would like to discuss your personal situation, please don’t hesitate to contact us. Please contact our Reno office by calling us at (775) 853-5700.

Healthcare

Understanding Gains in Alzheimer’s and ALS Research

Good news on the health front is so welcome these days. Now there is some, for the huge numbers of people suffering from Alzheimer’s dementia and ALS (Amyotrophic Lateral Sclerosis, commonly known as Lou Gehrig’s disease). Researchers have found links between those two dread illnesses, and the new understanding is showing promising results in the laboratory using drugs and genetic alteration.

New Insights on The Alzheimer’s Disease Research

The developments for both conditions center around relatively new insights into brain function. It seems that brain cells require a certain fluidity or agility to move between two rates of neuronal firing. Any further explanation plunges into the deep weeds of physics and neurology, but a recent interview on National Public Radio with researchers likened the healthy process as similar to the fluidity with which water changes from vapor to dewdrop to ice. In the case of the two illnesses, it seems that brain cells that should act with comparable fluency turn “sticky” instead. Dr. J. Paul Taylor, a neurogeneticist at St. Jude Children’s Research Hospital in Memphis and with the Howard Hughes Medical Institute, likened the disease process to what happens when honey is left in the refrigerator. Dr. Taylor won the 2020 Potamkin Prize for Alzheimer’s research.

Also quoted in the NPR interview was biophysical engineer Cliff Brangwynne, of Princeton and also with the Howard Hughes Medical Institute. He likened a healthy brain cell to acting like people coming and going at a party, chatting with each other, but the cells in ill brains have lost that ability to communicate fluidly.

Millions stand to benefit. According to the Alzheimer’s Association, one in three seniors dies with Alzheimer’s or other dementia. More than 16 million Americans provide unpaid care for such people. Between 2000 and 2018, deaths from heart disease have decreased 7.8% while deaths from Alzheimer’s have increased 146%.

New Insights on ALS Research

As for ALS, Johns Hopkins estimates that the illness affects as many as 30,000 in the United States, with 5,000 new cases diagnosed each year. Estimates suggest that ALS is responsible for as many as five of every 100,000 deaths in people aged twenty or older, most commonly in people over age sixty. The disease process causes terrible suffering.

Pharmaceutical company Bayer and Dewpoint Therapeutics are partnering to produce treatments using this new technology for dementia, ALS, and other cancer conditions as well.

Diseases like Alzheimer’s and ALS can cause not only emotional stress for families, but financial stress as well. We help families deal with legal and financial issues related to caring for a loved one with a serious disease. If you’d like to discuss your particular situation, please don’t hesitate to reach out. Please contact our Reno office by calling us at (775) 853-5700 with any questions.

Healthcare

Why You Should Have a Strategy for Your Aging Parents Before a Medical Crisis Hits

Many adult children in the US live far away from their parents. Managing aging parents or in-law medical events can be a serious challenge without proper preparation and understanding of what your parents’ strategy may or may not be, no matter where you live. Do you know what legal documentation your parents have in place regarding their medical care? Do they have advance directives that can help guide your medical decision-making process? Do you and your spouse openly discuss the situations of each other’s parents?

Medical advancements facilitate aging Americans’ longevity even with comorbidities such as high blood pressure, diabetes, kidney disease, atrial fibrillation, and other health issues. Hospitals can typically fix non-life-threatening conditions easily enough, but what happens when a parent is released to return home? Are you prepared? Is there a plan? Many adult children tend to practice avoidance, denial, and wishful thinking when thinking about their aging parents’ behalf in a potential medical crisis. It is advisable to organize and prepare for the changes that inevitably come to your parents’ health.

More than ever, seniors are choosing to live independently and with autonomy about their life decisions. Even if your parents are in a well-run continuing care retirement community, there will come a day when their health will force a change in their lifestyle and living arrangements. Many parents will resist “help,” which they may consider more as interference. Whether they believe they are being a burden to you or decline a geriatric care manager’s services due to “cost” concerns, most older people do not want others interfering in their private affairs. 

The goal is to find a way to help while still affording your parents the dignity and respect they want and deserve. To achieve a comprehensive plan on your parents’ behalf, travel to them for an honest discussion. If this is not possible due to COVID-19 restrictions, then virtual meetings are best, followed by phone calls as hearing loss typically makes communicating useful information difficult. Even on a screen, a face-to-face connection allows a parent to read lips, which is a typical strategy for older people experiencing hearing loss.

Review what legal paperwork your parents have and make sure it is in order. Many documents have a signature from many years ago, and things may have changed. If there is no designation of a medical power of attorney, be sure there is a document naming a “personal representative” to address restrictions outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This document allows the waiving of privacy concerns that permits access to a parent’s medical information while the parent is in the hospital.

Create an up-to-date list of all your parents’ doctors. The list should include medical contact information and all medicines (prescription or otherwise) that the parents take. If their general physician is not a geriatric specialist, it will help to find them one. Post-hospital fog and newly prescribed medications from an adverse health event can create confusion in an older parent. A geriatric doctor will know to look for and resolve these types of issues. Ask about the parameters for health care intervention, such as dialysis, post-hospital during the time of COVID-19?

Explain to your parents that being released from a hospital for a non-life-threatening, yet serious health episode is usually followed by the need for a care manager, at-home nursing care, or at least companion care. This additional care should not fall to a spouse if the parents live together. A spouse has their unique role to fill as well as personal health challenges with which to contend. Heaping an increased responsibility for spousal health care upon them may be damaging to their health.

Before an unforeseen medical crisis can occur, identify several qualified agencies in your parents’ hometown. Review each agency and candidate carefully. It is easier to integrate a suitable candidate at the outset than having the chaos of retaining and releasing multiple workers. Remember that a candidate who works for one parent may not be another parent’s preference in the future. Maintain a strong relationship with the agency provider. They are an essential resource, and you will probably need them in the future.

Take the time to learn the specifics of your parents’ healthcare and living arrangements. Coordinating your plan of response is contingent upon whether your parents live independently, in assisted living, or a retirement community. Wherever it is your parents live, their first desire will be to go home after an unexpected hospitalization. The desire to return home is a universal truth. Knowing the agencies that can quickly provide the type of care your parent needs in their home setting will go a long way to a successful transition. The road to recovery may require a few weeks of nurse visits, physical or occupational therapists, or simply companionship. The faster you can meet the need, the easier it will be on your parent.

If a full recovery is not possible, what will be your plan to address the new status of their normal? How much more medical oversight and assistance will they require? Know that in these instances, a parent can quickly spend through Medicare allotments afforded for temporary care. If they do not have long-term care, and many aging Americans do not, you will have to find ways to help them receive the care that they require.

If there are multiple adult children, is there an expectation that all siblings share information and work on the problems at hand, or is one in charge? Is this designation formally documented? Managing sibling relationships is key to avoiding family conflict. Also, understand your parents’ financial arrangements. Most parents will ask about the cost of any new healthcare service being arranged and decline using it. It is hard for a parent to spend down the money they worked their entire life to amass.

Knowing your parents’ aging strategies will not address every issue you might encounter because they may not have all the necessary decisions and documents in order. You can only work within the authority they choose to provide. As attorneys, we can help identify gaps in their planning and recommend ways to fill those gaps so everyone can have peace of mind.  If you’d like to discuss ways we can help, please don’t hesitate to reach out. Please contact our Reno office by calling us at (775) 853-5700 to learn more about your Medicaid planning needs.

Healthcare

Preserving Quality when Planning for End of Life

When our clients can no longer act for themselves, powers-of-attorney documents are prepared, the documents will convey on other trusted people the authority to act on our clients’ behalf.

But when it comes to actually using those documents at the time of a health-care crisis, clear and powerful documents are just the beginning. The decision-points can (and must) be put down on paper in advance, but when it comes to end-of-life situations, the clarity on which we lawyers thrive can be very hard to find.

Sitting in her lawyer’s office, the client may have been quite certain about health-care decisions. She does not want her life prolonged by a battery of aggressive treatments, where these would not preserve her quality of life. She does not want blood transfusions, dialysis, repeated courses of antibiotics and chemotherapy, cardiopulmonary resuscitation, or breathing and feeding tubes. She does not want to die inert in the ICU, surrounded by machines and strangers. She wants to die at home, surrounded by loved ones, at a time when she retains presence of mind to make her peace.

But that goal doesn’t just happen from wishing it and stating it. It happens with additional careful preparation for the realities. As the end of life approaches, the clarity we lawyers enjoy can be elusive. When a person gets a prognosis of two to five years (maybe), where, along that continuum, would be the time to start declining aggressive treatment? When there’s always one more intervention that may (or may not) produce a good result? When one decision could create an ever-widening array of complications? When, step by step, the patient becomes less and less able to exercise autonomy, and where treatment decisions by caregivers are not in line with the care the patient was clear about when she was sitting in the lawyer’s office?

No matter how clear the powers-of-attorney documents, with all these imponderables, the patient can end up in a situation many miles away from what she wanted. And there’s no possible do-over.

Powerful and clear power-of-attorney documents are an essential first step and we lawyers are glad to take care of that part. Beyond that, though, thorough preparation is essential.

Consider that the best result may be one that cares for comfort right now, in the moment. The question is not necessarily about how long life can be prolonged. The question may be, rather, how comfort can be maintained – in this moment, and then the next moment, and the next. The question is how life can be made better right now. Watch a video by palliative-care physician B.J. Miller, on why this is so important, here.

Make concrete plans. These include specifying what you want to happen if you’re no longer able to live independently; choosing wisely whom you want to act for you, to make sure your plans will be followed; being ready with your health-care documents before you find yourself deposited in the emergency room or ICU; and seeking the reassurance that your loved ones will be cared-for when you’re no longer there. Judy MacDonald Johnson has prepared simple, forthright worksheets to help with this process, here.  She speaks about these worksheets in this moving video.

There is no doubt that the process in safeguarding quality of life at the end of it is possibly the most challenging of all. But if that process can create as much pleasure as possible through an extremely difficult time of life, and if forthrightly engaging in that process would facilitate a passing more in line with what we would envision, the worth of the process will be felt. The transition will be smoother and more meaningful for the dying person, and a kinder legacy will be left behind for those who accompany us on this journey.

Learn more about your health care planning options and contact our Reno office by calling us at (775) 853-5700.

Elder Law, Elder Living, Estate Planning, Healthcare

Will the Cost of Long-Term Care lead to the Loss of My Home?

People work hard all their lives to own a home, and it is often their most valuable and significant possession. Homeownership is the American Dream. So, when health begins to fail and the need for long-term care arises, we often get this fear-filled question from our clients: will they take away my home?

The enormous and on-going costs of nursing-home care are astronomical, on average around $8,500.00 a month depending on location. The joint federal and state Medicaid program foots the bill for one in four of around 75 million recipients in this country. This is an enormous drain on government funds. To recoup some of those costs, then, the Medicaid rules permit states to take the value of a recipient’s home in some cases, to reimburse the program for funds it has expended.

Yet, because a home is such an essential family possession, the rules treat a primary residence as exempt – that is, its value is not counted as available to pay for nursing-home care from the home-owner’s pocket, before Medicaid kicks in. The home is protected, to a certain extent, for the benefit of Medicaid recipients and their close relatives.

That protection can be lost, however. The value of the house can be counted against a Medicaid applicant, and benefits denied or curtailed, when:

*     A home-owner has no living spouse or dependents, and

*     The owner moves into a facility permanently, with no intent to return home, or

*     The owner dies.

In other words, as long as the owner expresses the intent to return home, and the owner’s spouse or disabled or blind child live in the home, the home will not be counted against the owner for Medicaid-eligibility purposes.

Once the owner passes, however the state may place a lien on the home, to secure reimbursement of the value of the Medicaid services the owner received. This lien makes it impossible to sell the home or refinance a mortgage, without first paying the state what it may be owed.

As elder law attorneys we know a number of ways to protect homes from this kind of attachment. If you come to us at least five years before you anticipate needing nursing-home care, we can preserve your home or its value such that Medicaid will not count it, or lien against it, at all.

Or, if a child moves into the home and cares for an ailing parent for two years, permitting the parent to stay home and out of a nursing home, the house can then be given as a gift to that child without any Medicaid penalty or disqualification. Ordinarily, Medicaid heavily penalizes giving away property, but this is one exception.

There are other strategies available. The home can be given to a disabled child without penalty or disqualification. Or, you might keep the right to live in the house for your lifetime and deed the remainder interest to others, who will then own the house after you pass. However, each strategy comes with risks that must be fully explored before determining the correct one.

An overall plan that is tailored to suit each individual, and to meet as many contingencies as possible, requires juggling a number of puzzle-pieces. There is no one cookie-cutter solution. The key is to plan before you or your spouse may need nursing-home care.

As one piece in the overall picture of a balanced estate plan, we can help you save your home. We welcome the opportunity to work with you, please contact our Reno office by calling us at (775) 853-5700.