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    Bob Mauterstock

    Government Programs-Part Two

    Medicaid

    How can Medicaid pay for your parents’ extensive health care costs? Medicaid is a program jointly funded by the federal and state governments. Each state manages its own program. Medicaid is designed to provide assistance to the indigent. A third of the payments from Medicaid provide payments for the elderly who are in nursing homes. Other funds are provided for those who are disabled or without financial resources. Medicaid does not currently provide any benefits for assisted living or home care. It is strictly for those individuals who are in a nursing home.

    In the past, a number of families transferred assets from their parents to other family members to qualify them for Medicaid assistance. Parents transferred their homes, investments, and savings accounts to their children and then applied to Medicaid. Unfortunately, the number of the elderly applying for Medicaid has increased so much in recent years that it has become a very substantial part of most states’ budgets.

    Restrictions on Qualification

    As a result, the federal government has put severe restrictions on qualification for Medicaid. Monthly income limits differ depending on whether the applicant is single or married. For a married couple, the spouse remaining in the community (community spouse) can retain all of his or her income. The community spouse’s income would not be counted in determining the applicant’s eligibility for Medicaid. However, all of the applicant’s income must be counted for his or her long-term care except for certain deductions. These deductions may include a personal need allowance not to exceed $60 per month (less in some states), an allowance for a dependant child living at home and, depending on the community spouse’s income, a portion of the spouse’s income for living expenses known as the Minimum Monthly Maintenance Needs Allowance (MMMNA). In 2008, this amount ranges from $1,711 to a high of $2,610 per month.

    If the community spouse’s income is less than the MMMNA, a portion of the applicant’s income may be used to meet that minimum. The balance will go to the nursing home providing care. If the applicant is single, he or she cannot exceed Medicaid income limits and qualify. The limit for 2008 is approximately $1,911 per month but varies from state to state.

    Countable Assets

    To qualify for medicaid coverage, the recipient’s countable assets cannot exceed $2000. The  community spouse of the Medicaid recipient may keep half of the couple’s joint assets up to $104,400 (in 2008). In any case the community spouse may keep the first $20,880 (in 2008), even if it exceeds half of the couple’s assets. These figures vary from state to state.

    Countable assets consist of all investments such as stocks, bonds, mutual funds, checking and savings accounts and CDs. Countable assets also include any personal or real property as well as any art and collectibles.
    Non-countable assets consist of personal possessions such as clothing, jewelry and furniture and the applicant’s primary residence. Further, non-countable assets include one vehicle not to exceed $4500 for unmarried applicants (there is no value limit for a vehicle for married applicants). Non-countable assets also include prepaid funeral plans, certain amounts of life insurance and retirement funds which cannot be cashed in because they are in payment status (however the latter will be considered under the income limits).

    Based on these restrictions, it is very difficult for most people to qualify for Medicaid unless they have already used up their assets to pay for care. But the income restrictions usually exclude most people from being accepted into the program.

    Be Careful With Gifts

    The federal government has made it extremely difficult for a family to attempt to transfer assets away from their parents to qualify for Medicaid. The sick parent must apply for Medicaid at the time they wish to enter the nursing home. The government first calculates the family’s assets and income. If these meet the qualifications, Medicaid then checks to see if the parents have made any gifts to their children or others within the last five years. If the parents have made any gifts that delay their qualification for Medicaid, the government uses a very simple formula.  They are very thorough in checking all your parents’ financial records bank accounts and investment reports. Let’s assume your parents transferred $100,000 from their bank accounts to you four years ago and your father has just entered a nursing home. The nursing home then applies for Medicaid to cover his costs.

    The Feds then look over his records and determine that four years prior to entering the home, he gave you $100,000. They then divide this gift by the average monthly cost of a stay in the nursing home in your father’s state to determine the number of months your dad is disqualified from getting Medicaid. In Massachusetts, in 2008, that number was $7380. $100,000 divided by 7380 is 13.5. That means Medicaid will not pay for his care for 13.5 months even though he qualifies based on current income and assets.

    Gifts of all different kinds can disqualify you. Some families have tried some very subtle techniques to transfer assets from their parents to others. Setting up a joint account with a son or daughter and then removing the parent’s account is one technique that is no longer allowed. Putting a home in the name of a son or daughter or other family member or friend fits into the same category. Purchasing a “life estate” in an adult child’s home by paying off their mortgage is also disallowed.

    Use of Annuities

    A technique that often worked in the past was for your parents to transfer their assets to an insurance company for an immediate annuity to pay a monthly income. They planned that this would no longer count the lump sum as a countable asset. The state has countered that by comparing the amount of the annuity with the life expectancy of the recipient. If the projected payout exceeds their life expectancy, this difference will trigger a period of ineligibility. Even if the annuity is taken on the life of the healthy spouse, the state will require that the government be listed as the beneficiary of the annuity.

    In the Tax Relief and Health Care Act of 2006, the government made it clear that they are eliminating all the loopholes that families can use to qualify their parents for Medicaid unless they are truly destitute. Medicaid has become a very large part of each state’s budget and they know that they must control its growth in the future.

    What we want in a doctor

    Many of us are frustrated by our interactions with our doctors. They often seem rushed and only focused on tests and medication. Rarely do we see a doctor who just sits back and asks “How are you doing?”  Dr. Thomas Graboys was such a doctor. In his book “Life in the Balance” he describes what he seeks in a doctor now that he is sick himself with Parkinson’s disease. I thought it would be very beneficial to share his words with you.

    Illness interrupts (book excerpt: Life in the Balance)

    Thomas Graboys, MD

    A few days before a regular six-month appointment with my neurologist, John Growdon, in late 2006, I was asked what, if anything, I would like him to do for me that he wasn’t doing already. My answer was quick and sarcastic: “I’d like him to call me every month to ask how I’m feeling,” I snapped, as if a busy doctor with hundreds of patients in his care would have time for that.

    But the more I thought about it, the more I realized that my glib remark cut close to the truth. I want to be on his radar screen. I want him to be thinking about my case, not just when I am in his office, but when he reads about new treatments and new insights into Parkinson’s and Lewy body dementia. I want him to be turning my case over in his head once in a while, and I want to know that while there is nothing that exists today to reverse my dementia, he is thinking from time to time about how to make my life better.

    When I saw Growdon a few days later, I asked if we could increase the frequency of our regular consultations from every six months to every three months, to which he readily agreed. Why? For the simple reason that the Parkinson’s path is taking me through very unfamiliar and forbidding territory. I want a guide — someone I trust who knows the medical terrain, someone who has been down the path with others — to be there in spirit and in mind.

    I want someone mindful of the pitfalls, the traps, and the forks in the road. It may well be that little will change in my clinical condition over three-month intervals, but I don’t want to see Growdon every three months merely to size up incremental changes in my symptoms or to tweak my medications; I also want the comfort of his presence and to know that every once in a while we can, in [former New York Times literary critic Anatole] Broyard’s words [written while dying of prostate cancer], brood over my situation together.

    In my own practice, I developed a keen sense of just how deeply appreciated and how profoundly comforting small acts of kindness and mindfulness can be for the patient and his or her family. Dropping in on a hospitalized patient at the end of a busy day, not to check the chart or to do a quick exam, but just to say “Hello, I just came by to see how you are. Is there anything you need?” Calling a patient at home a few weeks after their annual visit to see how their new diet and exercise program is progressing.

    Writing a letter of condolence to the family of a patient who has died (a sorely neglected necessity, in my view). These small acts say to the patient and the family, “I know you ache, I know you suffer, I know you are in pain,” and allow doctor and patient to meet on the common ground of their mutual humanity.

    I am not a surgeon, but when a patient of mine was scheduled for surgery, cardiac or otherwise, I always tried to pay a social visit in the hospital the night before, or tried calling them at home if they weren’t yet hospitalized. I can’t prove it, of course, but I believe such a visit or call decreases operative mortality. Such social calls were invariably welcomed and comforting. There is no way to measure the curative and healing power of such a bond between doctor and patient, but I am utterly convinced of its salutary effect.

    It is also hard to overstate the importance of the doctor’s literal laying-on of hands. Years ago I had a patient, Mrs. H, who had been hospitalized with terminal gastric cancer. It was her cancer, not her heart disease, that was threatening her life; but every day, as I rounded with my medical students and stopped to examine Mrs. H, I routinely listened to her heart. One day, under pressure of time, I forgot; and as I turned to leave, she said, “Dr. Graboys, aren’t you going to listen to my heart?” I was embarrassed and flustered in front of my charges and immediately struck by the fact that although she knew her heart was not her major problem, she needed and wanted the reassurance of my touch.

    As I reflected on the experience later, I also realized that Mrs. H. had interpreted my actions as a commentary on her condition. My failing to listen to her heart that day signaled a loss of hope in her situation. If I could no longer be bothered to examine her heart, it meant the cancer was so serious that it had rendered her heart problem irrelevant. Conversely, by examining her heart, I had been signaling hope that she was not succumbing to her cancer.

    Similarly, a doctor’s words — as my mentor, Bernard Lown, [MD, renowned cardiologist and Nobel Peace Prize winner] has written — can maim or they can heal. The physician who offers nothing more than impeccable clinical judgment can, nevertheless, draw the cloak of illness tight around a patient with carelessly chosen words.

    Too many times, patients have come to me and said that another cardiologist described their heart as a “widowmaker” or a “time bomb.” The stress and anxiety thus induced by the doctor can turn him into a prophet. Words that allay stress, words that allow room for hope — not false hope, but hope — can allow the patient to shift the burden of worry onto the physician.

    So I know what I look for in a doctor.

    Protect your parents from fraud

    Young@Heart

    Last night I had the privilege of watching a movie entitled Young@Heart. It is a documentary showing a group of older people (average age 80) who get together with a chorus director (Bob Cilman) and form a chorus which sings such contemporary hits such as “Every Breath You Take”, “Yes I can,can” ‘I got you” and many others. The  movie is absolutely heart warming as it shows these elderly folks rehearsing two to three times a week to prepare for a concert, some leaving their hospital beds  to get to rehearsal.

    While crying, laughing and dancing as I watched the DVD, I realized something very important was being shown to us. When old people have a purpose, a passion, they live longer, more satisfying lives. Steve Martin, one of the chorus members (not the comedian) said it well. “If you stop moving you will become a target”. During preparation for the concert two members of the group died, but the chorus continued on, dedicating their efforts to their fallen friends. And even those who passed on, up to their dying day, were trying to make it back to rehearsals and sing.

    This is a strong lesson for us and our parents. What are your parents’ passions? Encourage them to stay involved in the activities they love and even find new ones to explore. Hopefully they will happen upon an angel like Bob Cilman, the chorus director of Young@Heart who nurtered the members along the way to enjoy and expand themselves. It’s not such bad advice for each of us, no matter what our age. Follow your passion. Stay involved and grow a little every day.

    I encourage you to watch Young@Heart. Better yet, watch it with your parents. You will all be inspired.

    Caregiver = Angel

    Approximately one year ago I learned what it was really like to be a caregiver and the receiver of care. In December of 2007 I had ankle surgery and was told by the Doctor that I couldn’t put weight on the ankle for six weeks. As a result I was confined to a wheelchair and a walker ( I had a terrible time using crutches) I needed help taking a shower, getting into the bathroom, couldn’t negotiate stairs and generally had a difficult time taking care of myself.

    I was home and away from work for over a month. During that period of time my wife had the primary responsibility of taking care of me.  I learned how frustrating it was to be relatively helpless. But more important than that I realized the pressure I put on my wife to take care of me. Every time I needed something I expected her to be immediately available to get it for me. I often found myself calling out her name ( sometimes yelling it) and waiting for her to arrive to fulfill my request. One time when she was in the basement washing clothes I yelled her name for a good twenty minutes. I thought she had left the house and gone somewhere,  I panicked.  I found that I often became irritable and grumpy when it took her more than a few minutes to respond.

    Our caregiving experience only lasted about 30 days. I  imagined what it would be like if Mary had needed to take care of me for months and even years. Then I thought of some of my client families with one spouse debilitated by a stroke, Parkinson’s Disease or dementia.  And of course you know who the caregiver is 90% of the time. It is a wife, daughter or daughter in law. How many of us men would have the stamina and patience to take care of a spouse or our parents?

    These women are angels. They take better care of their parents and husbands than themselves. But unfortunately this takes a toll. They often have to leave the workplace to take care of a family member. As a result they often lose income, retirement benefits and seniority inside their company. But worse than that they often suffer physically from being a caregiver. Stress and physical exhaustion takes it’s toll, often making them sicker than those they take care of.

    We must take care of these angels, our wives, daughters and daughters in law. Because we know that they would take care of us.