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    Eldercare

    Government Programs-Part One

    Veterans Benefits to Help Your Parents

    The Department of Veterans Affairs provides three types of long term care benefits for veterans.

    VA Health Care

    The first type is benefits provided to veterans enrolled in VA health care who have substantial service-connected disability. These medically necessary services include home care, hospice, respite care, assisted living, domiciliary care, geriatric assessments and nursing home care.

    Some of these services may be offered to veterans in the health care system who do not have service-connected disabilities but who may qualify because of low income or because they are receiving Pension income from VA. These recipients may have to provide out-of-pocket co-pays or the services may only be available to these non-service-connected disabled veterans if the regional hospital has funds to cover them.

    Currently, veterans desiring to join the health care system may be refused application because their income is too high or they do not qualify under other enrollment criteria. Increased demand in recent years for services and lack of congressional funding have forced VA to allow only certain classes of veterans to join the health care system.

    Veterans’ Homes

    The second type of benefit is state veterans homes. The US Department of Veterans Affairs in conjunction with the states helps build and support state veterans homes. Money is provided by VA to help share the cost of construction with the state, and a subsidy of $71.42 a day is provided for each veteran using nursing home care in a state home. These facilities are generally available for any veteran and sometimes the non-veteran spouse and are run by the states, often with the help of contract management. Most state veterans homes offer nursing home care but they may also offer assisted living, domiciliary care and adult day care.  There may be waiting lists for acceptance into veterans homes in some states.

    State veterans homes are not free but are subsidized; however, the cost could be significantly less than a comparable facility in the private sector. Some of these homes can accept Medicaid payments. A complete list of state veterans homes can be found athttp://www.longtermcarelink.net/ref_state_veterans_va_nursing_homes.htm

    Disability Payments

    The third type of benefits for veterans is disability payments. These include Compensation, Pension and survivors death benefits associated with Compensation and Death Pension.

    Compensation is designed to award the veteran a certain amount of monthly income to compensate for potential loss of income in the private sector due to a disability or injury or illness incurred in the service. In order to receive compensation a veteran has to have evidence of a service-connected disability. Most veterans who are receiving this benefit were awarded an amount based on a percentage of disability when they left the service.

    However, some veterans may have a military record of being exposed to extreme cold, having an in-service non-disabling injury, having tropical diseases, tuberculosis or other incidents or exposures that at the time may not have caused any disability but years later have resulted in medical problems. In addition, some veterans may be receiving compensation but their condition has worsened and they may qualify for a higher disability rating. Veterans mentioned above may qualify for a first-time benefit or receive an increase in compensation amount. Applications should be made to see if they can receive an award. There is no income or asset test for compensation and the benefit is nontaxable.

    Aid and Attendance Benefit

    Pension is available to all active duty veterans who served on active duty at least 90 days during a period of war. There is no need to have a service-connected disability to receive pension. To be eligible the applicant must be totally disabled if he or she is younger than 65. Proof of disability is not required for applicants age 65 or over. Apparently, being old is evidence in itself of disability.  Pension is sometimes known as the “aid and attendance benefit.”

    Veterans’ service to qualify for Pension would include World War II, the Korean Conflict, the Vietnam Conflict Period and the Gulf War conflict. The veteran did not have to serve in combat but only had to be in the service during that period of time and only one day of the 90 days of service had to occur during the period of war.

    The purpose of this benefit is to provide supplemental income to disabled or older veterans who have a low income. If the veteran’s income exceeds the pension amount then there is no award.

    Submission of Claims

    Compensation and Pension claims are submitted on the same form and VA will consider paying either benefit. Generally, for applications associated with the cost of home care, assisted living or nursing home care, the Pension benefit is a better option.

    Pension can pay up to $1,843 a month to help offset the costs associated with home care, assisted living, nursing homes and other unreimbursed medical expenses. The amount of payment varies with the type of care, recipient income and the marital status of the recipient. There are income and asset tests to qualify.

    VA claims this benefit is only for low income veterans but a special provision in the way the benefit is calculated for recurring medical expenses (long term care costs associated with home care, assisted living or nursing homes) could allow veteran households earning between $2,500 and $5,000 or more a month to qualify.

    There are also death benefit payments associated with Compensation and Pension that are available to surviving spouses of veterans or surviving dependents.

    The National Care Planning Council estimates that up to 33% of all Americans over the age of 65 might be eligible for a Pension benefit under the right circumstances.  That’s how many war veterans or their surviving spouses there are in this country. If your mother or father served in the armed forces it is definitely worthwhile to check into the benefits that may be available to them.

    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.

    Do Your Parents Have a Durable Power of Attorney?

    Estate planning is such an ominous term. Most of us try to avoid it as long as possible because it deals with our death and ultimate demise. I would rather we rename it “Transition Planning”. It is the planning we must do for our parents and ourselves to avoid legal delays and complications when the ownership and/or control of our assets shifts to another person or entity.

    I have observed a number of situations where estate planning was not done properly. One that is still vivid in my mind involves one of my clients who was a retired physician. He was failing both physically and mentally when his wife decided to place him in a nursing home. She began making decisions regarding his finances, continuing to use their joint check book to pay the bills and make purchases, etc. Then without warning, she was contacted by the attorney of the Doctor’s first wife’s family stating that she had no authority to act in his behalf even though she was his second and current wife.

    The family alleged that she was acting irresponsibly and making financial decisions that would result in the depletion of the Doctor’s assets so that nothing would be left for his  children. Unfortunately,she had no document that stated she had the right to act in his behalf. She was forced to go to Probate Court to prove that he was incompetent and become his conservator. (A conservator has the legal right to act on behalf of a mentally incompetent individual.)

    She had to testify before a judge in probate court that her husband was incompetent—an event that proved very embarrassing for the whole family. The judge ruled that the Doctor could not handle his own affairs and his wife was named as his conservator. But the legal process took more than a month.

    The whole mess could have been avoided if the Doctor had signed a very short three page document called a “Durable Power of Attorney” while he was still healthy. This document gives an individual the right to make financial decisions for you when you are no longer able to make decisions for yourself. A regular power of attorney only allows you to act in the person’s behalf if they are mentally competent. The “Durable” power works regardless of the individual’s mental state.

    Elder Mediation Resolves Family Conflicts

    “My daughter is insisting I move in with her,” complains Martha. “She just wants to control my life and take away my freedom,” she continues.

    Jenny, Martha’s daughter worries that her mother keeps falling, and fears one day she will break her hip or hit her head.

    “I’ll take my sister to court before I will let her get control of mom and my inheritance,” exclaims Jim about Jenny’s desire to move her mother in with her.

    It is amazing how quickly formerly cordial relationships between family members will sour when the family has to deal with care of elderly parents or inheritance at their death. Sometimes the consequence of dealing with the final years of elderly parents can break families apart and create long-lasting animosity.

    The National Care Planning Council has seen an increase in requests from caregiving children for help in solving disputes with siblings. In one case, the caregiver was being sued by her sister for abusing their parent and stealing the Social Security checks. In another, the caregiving child would not allow siblings to see their mother, claiming they would take advantage of her.

    A lot of times it is a “she said,” “he said” situation with neither party really understanding what the elder person needs or wants.

    Some families find it hard to communicate with each other when their parent is in need of care. Perhaps when they grew up together they were not accustomed to come together as parents and children to work out problems. And now those children are older and taking care of parents and they don’t have this family council strategy to rely on. It may seem unnatural to them. But that is often exactly what is needed, especially in situations where perhaps one child is caring for the parents and the others are left out of the loop.

    Children all have a common bond to their parents and as a result a common obligation or responsibility to each other. When disagreements arise, suspicions begin to grow. Suspicions or distrust often lead to anger and the anger often leads to severing the channels of communication between family members. This can occur between parent and child or between siblings or between all of them.

    It is often at this point that a neutral third party can come in and repair the damage that has been done and help correct the problems that have come about because of the disagreement.

    A practitioner experienced in elder mediation is a perfect choice for solving disagreements due to issues with the elderly. You can learn more about Elder Mediation at mediate.com

    Moving Mom to Assisted Living

    Four weeks ago my mom contracted a stomach virus and was sent to the hospital to recover. While she was there the Doctors discovered that she also had a urinary tract infection. After a week in the hospital she was sent to a nursing home for rehab. When I visited her there I noticed that her memory had deteriorated dramatically. She thought I was my Dad (who died 10 years ago) After three weeks in rehab. she had gained enough strength to return to her independent Living Retirement home. But we were told that she would need round the clock aides for a few weeks.

    A week has gone by now and it looks clearer that she will need extensive care for some time. Using aides from a service firm is costing her $400 a day. Her memory has improved somewhat but she is still confused and gets up several times during the night to see if the door is locked and to go to the bathroom. We cannot continue to pay for private aides because it will end up costing $12,000 a month.

    Unfortunately we live 3 hours away from Mom’s home. We have decided we have to find a facility closer to us, possibly an assisted living facility that helps those who are memory impaired. The most difficult step now is to convince her to make that move. She has a number of friends in her community. But the real question is will she miss those people? Will another move cause her fragile memory to deteriorate even more? Do we need to tell her what to do or get her approval.?

    We are meeting with her doctor on Friday. Out of that meeting we may convince her that the doctor recommends that she move close to us. I am very anxious about telling her she’s got to move. I don’t know how she will respond and what the result will be. I know one thing. The current situation cannot go on for very long or her assets will disappear and she will have no choices.