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.

Healthcare

Coronavirus Pandemic Dilemma for the Senior Living Workforce

It’s a cautionary tale that provisions in a coronavirus-related relief action by the US government could have severely curtailed the workforce in senior assisted living, independent living, memory care, and continuing care retirement communities. The bill, HR 6201, is a multi-billion dollar aid package known as Families First Coronavirus Response Act. The bill has recently been signed into law by the US President. Influential leaders, CEOs, and corporate Presidents in the senior care and housing industry addressed facility workforce concerns directly to the House Speaker Pelosi (D-CA) and Senate Majority Leader McConnell (R-KY) before the passing of H.R.6201.

Families First Coronavirus Response Law

The Families First Coronavirus Response Law expands unemployment and Medicaid benefits, provides for free coronavirus testing, and mandates paid sick leave and childcare. Now that schools have closed throughout the country for an indefinite time, the fear is that many senior care workers will, unsurprisingly, put their family before their healthcare worker employment. A reprieve of sorts was added before the law being enacted, which states that only certain employees can qualify for paid sick leave.  Because of these loopholes, healthcare workers like first responders, and hospital and nursing home staff are ineligible for paid sick leave per the Families First Coronavirus Response Law (FFCRL) amid fears of staffing shortages among medical providers.

Healthcare worker exemption from some FFCRL benefits is a relief to the senior housing industry but by no means mitigates other workforce challenges during the coronavirus pandemic. The pervasiveness of this contagion means that healthcare workers will be exposed to, and some will fall ill with full-blown coronavirus symptoms and illness. Obviously, in these cases, the healthcare worker will be removed from the senior living facility for quarantine and recovery and to protect the facility’s residents and staff. One coronavirus confirmed healthcare worker begins a domino effect within a facility. Regular operations become short-staffed, and operators face the Centers for Disease Control and Prevention (CDC) protocols that co-workers must also face quarantine.

How Healthcare Workers are Responding to COVID-19 Pandemic

Beyond coronavirus exposure, symptoms, and the diagnosed virus itself, there is the problem of how healthcare workers respond in a pandemic. The non-stop news and social media coverage of the coronavirus has put many Americans on edge, including health care workers. In a crisis, some people respond logically and calmly, while others may become fearful of their own circumstances and respond emotionally. Most healthcare workers would put their own family’s health needs and care before any employment, and in a free society, there is nothing to compel them to stay in a job if they choose to tend first to their own family.

If your loved one is in a senior living facility, what can you do to mitigate the negative consequences of workforce disruption due to the coronavirus? In the short term, if you are able and your senior is well enough, you can put them under your care. Beyond family care, unless you have the resources for private pay at any cost, you, like the rest of us, are in the system and have to wait out the virus and its effects. There is no guarantee moving forward how the coronavirus will play out in senior living communities, America, and around the world.

One of the few things you do have control over is to assure your loved one has proper legal documents for end of life decisions. Take the time to review them to ensure they are in order. A do not resuscitate order (DNR), durable medical power of attorney, and end of life wishes should be on file with your loved ones living facility and the local hospital. Additional legal copies of these documents should remain in your car or on your person in the event a facility is unable to locate the paperwork. Preparing for the worst-case scenario is a harsh reality; however, it could make the difference between chaotic suffering and a peaceful passing.

We can help draft appropriate documents for you and your loved ones. Learn more about your options and contact our Reno office by calling us at (775) 853-5700.

Healthcare

Understanding HealthCare Power of Attorney: Specific VS. General

You have the right to decide what kind of medical treatment you want to receive from doctors and health-care providers. If you can speak up at the time, you can express your wishes yourself. But if you become incapable because you’re ill or injured, you need to plan in advance. Designate a person whom you trust to speak for you. You do this by creating what’s known as an “advance directive” or health care power of attorney.

You also have a choice about the kind of document you prefer. You can ask for a short document that simply conveys general authority on your agent to make health-care decisions for you – or you can opt for a longer document that details the specific powers you give to your agent.

For both versions, we offer a checklist to assist you in discussing your wishes with your agent beforehand.

The General Version

This version is short, clear, and easy to understand. It states, generally, that you have given your agent the authority to speak for you. Your agent knows your wishes, because you have discussed those wishes with him or her beforehand.

The Specific Version

This version goes into detail about what you would like your agent to do for you. For example, it includes the request that providers and your agent consult with you if possible. If not possible, it includes a list of procedures that you authorize your agent to decide on your behalf. Included are decisions about what kind of residential facility you want to be placed in, that an agent can visit you and bar others from visiting if appropriate, can advocate for pain relief, can consent to psychiatric treatment, can decide about anatomical gifts and organ donation, and the document provides procedural details about enforcement.

You will be covered with either version. The choice is yours.

Living Will

You may also want a separate Living Will for end-of-life decisions. This document becomes effective when you can no longer care for yourself, walk, talk, recognize loved ones, or are in the final stage of an incurable illness. At that point, you can decline expensive, high-intensity care that likely would not improve quality of life.

Choosing Your Agent

The person you choose to be your health-care agent must be someone you can depend on to have good communication skills, remain calm in difficult situations, and deal flexibly with complexity that might arise in reconciling your wishes with available medical options. Choose that person carefully.

Health Care Preferences Checklist

We can offer you a checklist, to help you discuss your wishes with your agent. This is not an easy conversation. It’s hard to contemplate a time when our health has declined or we suffer injury or accident. It is also challenging to try to imagine various scenarios involving situations that can be complicated by numerous medical contingencies.

Still, your agent needs to know what you would want in a variety of situations. These include whether to decline or accept life support and mechanical interventions, when you would opt for or decline surgery, and your preferences about blood transfusions, medication, and religious observance.

For certain states, the checklist also contains a signature line that proves you have discussed your wishes as to feeding and hydration tubes. Otherwise, if your agent doesn’t know what you would decide, the law in some states would take away from your agent the right to decide about those kinds of measures.

Don’t hide your documents!

When it comes time to use your documents but they can’t be found, or if your agent or family don’t understand them or ignore them, you will have spent your time, effort, and money in vain. Make sure your documents are readily available. Give a copy of them to your agent and ask your doctors to include them in your medical records.

You will have done your best to see that your values and health-care choices will be honored. We are here to help, please contact our Reno office by calling us at (775) 853-5700.

Healthcare

How Veterans Can Qualify for a VA Pension Without Being Disabled

Many veterans may miss out on US Military benefits as they are always changing; it is important to understand how to navigate this life-changing aid option. Many wartime veterans receive a disability pension due to injury. But did you know that wartime veterans age 65 or more may qualify for a VA Pension without being disabled? The Veteran’s Administration qualifications for this type of VA Pension include:

  • Your military service discharge is deemed anything other than dishonorable conditions,
  • Your service was 90 or more active duty days with at minimum one day of service during a period of wartime.
  • You are age 65 years or older,
  • Your countable family income is below a threshold set every year by law.

2020 Family Income Limits (Effective December 1, 2019)

If you are a…Your yearly income must be less than…*
Veteran with no dependents$13,752*
Veteran with a spouse or a child$18,008**
Housebound veteran with no dependents$16,805
Housebound veteran with one dependent$21,063
Veteran who needs aid and attendance and has no dependents$22,939
Veteran who needs aid and attendance (A/A) and has one dependent$27,195
Two veterans married to each other$18,008
Add for each additional child to any category above$2,351
*Some income is not counted toward the yearly limit (for example, welfare benefits, some wages earned by dependent children, and Supplemental Security Income. It is also important to note that your medical-related expenses are considered when determining your yearly family income. *To be deducted, medical expenses must exceed $687 ** To be deducted, medical expenses must exceed $900

The financial information chart above, published by military.com, is commensurate with the numbers posted on the Veteran’s Administration website.  Be aware; there is a look-back period that will determine if you have transferred assets in the three years previous to filing your claim. There would be a penalty period rate of $2,266 if you did move assets for less than fair market value during this period.

The VA will pay a qualified veteran the difference between personal countable family income and the yearly income limit category into which they fall. Payments are made in 12 equal installments per month and rounded down to the nearest dollar. As an example, a single veteran with a $5,000 annual income qualifies for an annual limit of $13,752. Subtracting that veteran’s income from the income limit yields an annual pension rate of $8,752, which translates into a VA monthly pension check of $729.33 or $729.00 rounded down to the nearest dollar value.

The VA website recognizes the following wartime periods that determine if your service was during an eligible wartime period:

  • World War II (December 7, 1941, to December 31, 1946)
  • Korean conflict (June 27, 1950, to January 31, 1955)
  • Vietnam War era (February 28, 1961, to May 7, 1975, for Veterans who served in the Republic of Vietnam during that period. August 5, 1964, to May 7, 1975, for Veterans who served outside the Republic of Vietnam.)
  • Gulf War (August 2, 1990, through a future date to be set by law or presidential proclamation)

In addition to VA pension, wartime Veterans may also qualify for an additional allowance called Aid and Attendance. To qualify medically for VA Aid and Attendance, one of the following must be true:

  • Another person is required for you to perform daily activities such as bathing, dressing, and feeding, or
  • You spend a large portion, or all of your day in bed due to illness, or
  • Due to a loss of mental or physical abilities related to a disability you are a patient in a nursing home, or
  • Your eyesight is severely limited (wearing glasses or contacts your eyesight is 5/200 or less in both eyes or your concentric contraction visual field is 5 degrees or less)

There are similar benefits available to surviving spouses of wartime Veterans. If you are a wartime veteran or the surviving spouse of a wartime Veteran, we can help you determine whether you could qualify for pension benefits.

While eligible veterans or surviving spouses can apply for benefits on their own through the www.va.gov  website, it is advisable to seek the advice of counsel before applying. There may be planning options available to avoid a penalty period and speed up the qualification process. If you would like to explore whether you might qualify for VA pension benefits, please contact our Reno office by calling us at (775) 853-5700.

Healthcare

How Telehealth Services are Growing Coverage on Medicare

The Centers for Medicare & Medicaid Services (CMS) recently announced, in response to the COVID-19 outbreak, an increase of access to Medicare telehealth services. This means that Medicare beneficiaries can receive more benefits from their doctors without having to travel to a healthcare facility.

The terms “telehealth” and “telemedicine” refer to the ability to exchange medical information from one site to another through electronic communication to improve a patient’s health.  With the rapid rise of COVID-19 cases, there is the urgency to expand the use of technology to help people who need routine care. Telehealth will keep vulnerable beneficiaries and those with mild symptoms in their home, but with access to the care they need by phone and video rather than requiring an office visit.

Prior to this change, Medicare would only pay for telehealth on a limited basis, and only for persons in a designated rural area. Now Medicare beneficiaries will be able to receive the following services through telehealth: common office visits, mental health counseling, and preventive health screenings. This will help keep more of the at-risk population (Medicare beneficiaries) able to visit with a doctor from home, rather than traveling to a doctor’s office or hospital which puts the beneficiary and others at risk. Telehealth visits will be treated the same as regular, in-person visits and will be paid by Medicare at the same rates.

These changes go into effect for services starting March 6, 2020, and will continue for the duration of the COVID-19 Public Health Emergency. For more information, view the fact sheet prepared by CMS.

Better access to telehealth is a big step in getting Medicare beneficiaries appropriate care in the least restrictive way If you have questions, please do not hesitate to contact our Reno office by calling us at (775) 853-5700.

Healthcare

Medicare, Medicaid, and Out Of Pocket Cost for Alzheimer’s Disease

According to the 2020 Alzheimer’s Association report entitled Alzheimer’s Disease Facts and Figures (alz.org),  many Americans who will be living with crippling dementia are contemplating the next steps for their health options. Health care and long-term care costs for individuals with Alzheimer’s Disease and Related Dementias (ADRD) are staggering as dementia is one of society’s costliest conditions.

The year 2020 sees total payments for all individuals with dementia diseases to reach an estimated 305 billion dollars. This substantial sum does not include the value of informal caregivers who are uncompensated for their efforts. Of this 305 billion dollars Medicare and Medicaid are projected to cover 67 percent of the total health care and long-term care costs of people living with dementia, which accounts for about 206 billion dollars of the total cost of care. Out of pocket expenditure projections are 22 percent of total payments or 66 billion dollars. Other payment sources such as private insurance, other managed care organizations, as well as uncompensated care account for 11 percent of total costs or 33 billion dollars.

The Centers for Medicare and Medicaid (CMS) cite that 27 percent of older Americans with Alzheimer’s or other dementias who have Medicare also have Medicaid coverage. As a comparison, the percentage of those Americans without dementia is 11 percent. The addition of Medicaid becomes a necessity for some as it covers nursing home and other long-term care services for those individuals with meager income and assets. The extensive use of CMS services, particularly Medicaid, by people with dementia translates into extremely high costs. Despite the high rate of expenditure by federal social and health services, Americans living with Alzheimer’s and other forms of dementia still incur high out-of-pocket expenses compared to beneficiaries without dementia. Much of these costs pay for Medicare, additional health insurance premiums, and associated deductibles.

Older Americans living with Alzheimer’s or other forms of dementia have twice the number of hospital stays per year than those without cognitive issues. Dementia patients with comorbidities such as coronary artery disease, COPD, stroke, or cancer, to name a few, have higher health care costs than those without coexisting serious medical conditions. In addition to more hospital stays, older Alzheimer’s sufferers require more home health care visits and skilled nursing facility stays per year than other older people without dementia.

Cost projections for Medicare, Medicaid, and out of pocket costs for Americans living with Alzheimer’s disease or other forms of dementia continue to increase. The average life span of an American with Alzheimer’s is 6 -8 years, and as the disease progresses, so do the requirements of care and support. This care and support include medical treatment, prescription medications, medical equipment, safety services, home safety modifications, personal care, adult daycare, and ultimately residence in a skilled nursing facility. Disease-modifying therapies and treatments remain elusive, and there is no cure for Alzheimer’s and other dementia diseases. ADRD imposes a tremendous financial burden on patients and their families, payers, health care delivery systems, and society.

In the absence of a cure, the Alzheimer’s Association predicts the total direct medical cost expenditures in the US for ADRD will exceed 1 trillion dollars in 2050 because of increases in elderly population projections. Health policy planners and decision-makers must gain a comprehensive understanding of the economic gravity that Alzheimer’s and other dementia diseases present to the US population. The direct and indirect total medical and social costs and accompanying solution-driven mandates must be identified to CMS, private insurance groups, facilities with dementia units, and family systems that function as non-compensated caregivers.

We help families plan for the possibility of needing long term care, and how to pay for it. If you have questions or need guidance in your planning or planning for a loved one, please do not hesitate to contact our Reno office by calling us at (775) 853-5700.

Elder Law, Elder Living, Healthcare

Lawmakers Discuss the Future of Healthcare

In June, Washington, D.C. political publication, The Hill hosted a Future of Healthcare Summit to address critical issues in healthcare, from the Medicare for All proposals made by Democratic presidential hopefuls to the opioid crisis. Speakers included policymakers, health officials, and industry leaders, on both sides of the aisle.

Sen. Joe Manchin (D-W.Va.), for example, took a critical stance on the idea of Medicare for All at the summit. His statements are summarized here. His concerns are practical; “We can’t even pay for Medicare for some,” he said, referring to an earlier report that Medicare will exceed its hospital insurance fund by 2026. Manchin, accordingly, prefers to fix the Affordable Care Act rather than create an entirely new system.

Another issue discussed at the summit was that of data security. As health care becomes increasingly digitized, the risk to people’s privacy rises, as evidenced by recent data breaches. Lawmakers are responding to these breaches, Sen. Mark Warner (D-Va.) by reaching out to health care groups for input on strategies to improve cybersecurity, and Sens. Amy Klobuchar (D-Minn.) and Lisa Murkowski (R-Alaska) by introducing the Protecting Personal Health Data Act. Read more about this here.

High-cost drugs are another upcoming issue in the health care world, discussed in this The Hill article. Innovative cures may merit a high price, but some companies are asking such massive sums for potentially life-saving solutions that they are inaccessible to the people who need them. Accordingly, lawmakers are trying to come up with solutions to make these drugs more affordable, such as Sen. Chuck Grassley (R-Iowa), who has considered allowing Medicaid to pay for drugs over time.

In the same vein, Rep. Tom Reed (R-NY.) called for the cost of insulin to be lowered in an op-ed in The Hill, available here; he notes that insulin prices have doubled in the last seven years, and tripled in the decade prior, that out-of-pocket insulin costs can exceed $300 a vial, and that patients are often racking up debt or skipping doses with serious health consequences. Reed is pushing for transparency from insulin manufacturers and has introduced the SPIKE Act, which would require justification for price hikes. Likewise, Rep. Buddy Carter (R-Ga.) has expressed his concern in a recent op-ed about the prices for drugs which treat cancer and is also pushing for transparency to lower costs.

Meanwhile, Reps. David Trone (D-Md.) and Donald Norcross (D-N.J.) wrote into The Hill, responding to issues of addiction raised at the conference. Trone drew attention back to the opioid crisis and its ongoing effects and described the steps being taken to combat it. Norcross called for enforcement of the 2008 requirement that insurance cover mental health and substance-use disorders to the same extent physical ailments are covered, and for continued funding and new strategies to deal with substance abuse.

Finally, Sen. Tammy Baldwin (D-Wis.) criticized the Trump administration as “sabotaging our health system” by destabilizing the health care market and creating difficulties in accessing it. She cites specific efforts the administration has made to reduce access, including supporting attempts to overturn the Affordable Care Act. Baldwin has responded by supporting the ENROLL Act to restore funding for the Navigator, which had previously been reduced by the Trump administration and by introducing the No Junk Plans Act to reel back the administration’s expansion of junk insurance plans.

From data security to drug prices, The Hill’s Future of Healthcare Summit covered a lot of ground. These issues in health care and the responses proposed to solve them continue to develop.

The Schulze Law Group can help you or a loved one create a thorough medical plan for the later years in your life. If you live in the Reno, Nevada area, and you have any questions, please give us a call at (775) 853-5700, or click here to message us through our website.