Medical Care at the End-of-Life

Medical Care Immediately Prior to Death

In the first half of the 20th century, most people who died had an accident or contracted a disease or they had physical disorders that inevitably lead to death. Life-saving medical interventions such as sophisticated resuscitation, complicated surgeries, life-saving treatments, ventilators, feeding tubes and other life-support were rarely used or even available. Nowadays there is great emphasis on curing medical problems sometimes to the exclusion of recognizing that death might be a more welcome outcome.

Surveys indicate that older people are often more afraid of death than younger people. But for all Americans — young and old — there is a great fear of death.  Oftentimes, the families of those near death will go to great lengths to try interventions that may be ineffective in prolonging life. Estimates are that about 30% of Medicare reimbursements are spent on people in the last year of their life. It is a fact that much of this medical care did little to prevent death and prolong life.

According to the Dartmouth Atlas study on death:

“The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine’s focus is disproportionately on curing, or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers.”

The Dartmouth Atlas project uncovered some startling differences in what happens to Americans during their last six months of life. The level of hospitalization during those months varies greatly from one region to the next.

The Atlas researchers asked why this was so.  Why is someone living in Miami so much more likely to receive a great deal of high-tech, expensive medical services, while someone with the same condition who lives in Minneapolis receives so much less? The answer appears to have very little to do with religious or spiritual beliefs or personal preferences.  Rather, the answer appears to be that the capacity of the local health care system – the per-capita supply of hospital beds, doctors, and other forms of medical resources – is the dominating influence. Those who live in areas like Miami, where there are very high per capita supplies of hospital beds, specialists, and other resources, have one kind of end of life experience. Those who live in areas like Minneapolis or San Francisco, where acute care hospital resources are much scarcer, have very different kinds of deaths.

The question, then, is which is better? From the dying person’s perspective, more is not necessarily a good thing.  That is, more visits to doctors for someone who is very sick can be stressful and exhausting. For many people a hospitalized death is something to be avoided if at all possible. From the perspective of the health care system, much of the care being given is futile, and accomplishes little. People who live in areas with very high utilization of hospital resources do not live longer than people who die in areas where utilization is lower – and if extension of life is not the goal of intervention, what is?

Deciding How and When to Stop Curing and Start Caring

Some people are content to leave decisions regarding their death in the hands of others. By doing so, they may expose themselves to unnecessary and futile treatments as outlined above. They may experience numerous visits to the emergency room in the last stages of their life. And their dependency on others often results in great stress to family members when loved ones at the end-of-life lose their capacity and didn’t make their last wishes known. Families are often forced to make decisions about life-support and treatment without knowing whether their loved one would have wanted these interventions.

Advance Directives

These, are the minimum documents you need to make sure your wishes for health and medical care and end of life decisions are honored.

• Durable Power of Attorney for Health Care
• Living Will
• POST (Physician Orders for Scope of Treatment)
• HIPAA Release

A patient or his or her spouse or a family member will typically call 911 in the event of a life-threatening emergency. Very seldom will the advanced directives end up with anyone in the emergency room. Therefore, medical decisions are generally made by family members who show up at the hospital. The actual health treatment wishes of the patient may be at home in the desk drawer. It is therefore extremely important to remember to take these documents to the emergency room whenever a crisis arises. It is also critical that family members be made aware of your wishes and the existence of your advance medical directives as well as where they can be found.

When it comes to these very difficult questions timing is everything. In order to maintain control as long as possible and have an effect on your own end of life decisions you must choose to act now. Your decisions need to be made known and documented correctly. Good planning is no accident!

Call us today and let us help.

Idaho Estate Planning

Promote Your Page Too

Medicaid Planning Part III

Introduction

In Medicaid Planning Part II we covered:

• Intent to Return Home
• Medicaid Treatment of a Home
• Special Home Exemption Rule
• Joint Tenancy

Transfer Title of the Property to the Community Spouse

Transfers to a spouse of any assets are exempt from Medicaid eligibility rules. An institutional spouse, anticipating Medicaid, can transfer title in the home to the community spouse and it has no effect on Medicaid eligibility. This can be done either with a quit claim deed or through a trust. With the asset no longer in the name of the care recipient, Medicaid recovery cannot use the house as a basis for recovering its costs. And the community spouse can transfer the house to a member of the family and as long as this is done beyond the five-year look back period, then Medicaid can’t assess a penalty period for a transfer of assets for less than value. It’s important to use a legal adviser to make sure you do this properly.

Trust to Avoid Probate

Common trusts to avoid probate are called “living” or “inter vivos” trusts. A trust never dies, thus it is not subject to probate. Most arrangements make the trust the owner of the property with the original owner(s) as trustee(s) (caretaker as it were) and beneficiaries(s). Thus, the property reverts to the estate at death. Most people initiate these trusts to avoid probate. Assets in these trusts, other than a primary residence, are transparent to Medicaid. These trust assets are subject to Medicaid spend down rules.

The trust can be used in states where Medicaid recovery only uses primary residences passing through probate as being subject to recovery. However, a growing number of states do not recognize these arrangements to avoid probate estate recovery and go after primary residences in revocable trusts regardless of ownership.  Idaho does not ignore the trust, however, Health and Welfare will require that the trustees of the revocable or living trust transfer the primary residence back out of the trust to the beneficiaries.  This, then, allows Health and Welfare to recover the value of benefits paid from the house now destined to go through probate.

To do it right for these states requires an irrevocable trust with no life interest, set up 5 years or more before a Medicaid claim. Very few people are willing to do these kinds of trusts.

Some people also include a so-called “life interest” in property in arrangements where property is gifted or in irrevocable trusts. The life interest gives them use of the property until their death even though they don’t own it. Medicaid in many states does not recognize life interest and the property is considered to be in the ownership of the person who gifted it and subject to look back rules and recovery.

Move Loved One Needing Care to Another State

A person needing Medicaid covered care in one state may not qualify under that state’s rules but might qualify under the rules of a neighboring state. Of particular concern are candidates suffering from dementia or Alzheimer’s. It’s difficult to quantify their need for care and in some states, those people who are cognitively impaired might not get help with Medicaid even though their needs might be greater than the needs of those who are physically disabled.

Families should consider moving loved ones who have been declined in one state, to live with a member of the family in another state and possibly qualifying in that state. In addition the new state may be more lenient with Medicaid recovery procedures.

A second reason may be that the current state of residence has a very tight supply of Medicaid beds and there is a waiting list. Moving the loved one to a state where there are more available Medicaid beds may avoid the family having to temporarily cover the cost of a non-Medicaid nursing home bed while waiting for one to become available.

Give Away Assets

We have already discussed the moral implications of using Medicaid planning strategies for unfairly qualifying for Medicaid and shifting the burden of cost to the taxpayers. New look back rules under the Deficit Reduction Act have effectively done away with gifting strategies used in the past to accelerate eligibility for Medicaid. This does not mean that gifts cannot be used, but planning must be done many years in advance. Under these new circumstances the whole concept of gifting in order to qualify for Medicaid is much more complicated and consulting with a professional familiar with the Medicaid requirements is essential..

Good planning is no accident. All of the issues discussed above are best handled in advance. To secure your future care, get started now.

Idaho Estate Planning

Promote Your Page Too

Medicaid Planning Part II

Introduction

In Medicaid Planning Part I we covered:

• Income Annuity in the Name of the Community Spouse
• Prepaid Funeral Instead of or in Addition to Burial Funds
• Use of Spend Down Resources

Intent to Return Home

If a single person receiving Medicaid care in a facility has a house, that property could be subject to sale to pay for Medicaid expenses. The house is only protected if a qualifying child or dependent lives there or if the recipient intends on returning home. Some states require a medical doctor to certify a return home, but in many states it only requires the signature of the recipient whether that recipient has justification or not. In the states that allow it, always have your loved one sign an intent to return home. At least you have use of the property while your loved one is still alive.

Most families sell the home and end up with a large amount of cash that must be spent down before the loved one qualifies for Medicaid. Keeping the home avoids losing the entire value of it to spend down. By retaining the home, Medicaid recovery may not seek the full value of the home when the loved one dies.

Potential rental income from the house would also go towards paying the facility cost and reduce the amount that Medicaid would have to pick up. This could mean that Medicaid recovery using this strategy might go after a smaller share of its cost in the recovery process.

Medicaid Treatment of a Home

If the community spouse lives in the home then the home is exempt from determining Medicaid eligibility. It does not count as an asset and prevent the institutional spouse from receiving Medicaid help. On the other hand, any other real estate property, not the primary residence, will have to be converted to cash and spent down before Medicaid will start paying the bill.

If the community spouse living in the home does not in turn need Medicaid help in the future then one of two things can happen to the house after the death of the institutional spouse. Legally Medicaid has a claim against the property for recovery services. And in some states a lien against the property, called a TEFRA lien, can be filed in anticipation of Medicaid’s cost. The lien can be filed before the death of the care recipient but only a few states actually do that. States that have authority to file these liens often don’t do it until after the death. At the death of the community spouse, the property cannot be sold until the lien is satisfied, or the lien is satisfied from the proceeds of the sale.

Even though few states are efficient at Medicaid recovery, especially when it comes to a primary residence, you will be miles ahead of the game every time to contact and work with a competent adviser when dealing with recovery issues. You can never assume what your state recovery program will actually do.

Special Home Exemption Rule

It is often the case that a daughter will move in to take care of Mom or Dad or both. In this case Medicaid has a special leniency rule to allow transfer of the home to the daughter and not result in a penalty for a transfer for less than value. If the child provides care for a parent in a parent’s home for at least two years, and that care kept the recipient out of a nursing home, the property can be transferred to the child without penalty and the property will not be a subject asset for Medicaid recovery. Medicaid will require some proof of this. Typically an affidavit from a third-party care provider such as a doctor or an agency stipulating that the care was given for at least two years and resulted in keeping the care recipient out of a long-term care facility, will be sufficient evidence. It’s important to use a legal adviser to make sure you do this properly.

Joint Tenancy

Many people anticipating Medicaid services are tempted to put a child’s or sibling’s name on property titles to avoid probate and Medicaid recovery. This may not be a good idea.

There are at least four problems.

• If the other person on the title becomes subject to a judgment, even one arising from an accident, then at least 50% of the property can be lost to the judgment.  This would also the case in a bankruptcy and there could a similar issue in a divorce proceeding.
• The other person on the title must consent to any disposition of the property. He or she might not agree with what the original owner wants to do.
• Re-doing the title must occur at least 5 years prior to claim in order to avoid look back rules and a sanction on a gift to a non spouse owner.
• The person assuming joint ownership has received a gift and loses the step-up in basis at death. Capital gains taxes may have to be paid. And if the property is not the principal residence of the new tenant, the capital gains exclusion cannot be used either.

Good planning is no accident. All of the issues discussed above are best handled in advance. To secure your future care, get started now.

Idaho Estate Planning

Promote Your Page Too

The Problem with Government Long Term Care

Public Misconception Provides a False Sense of Security

Surveys by organizations that support long term care planning, such as the AARP, consistently reveal that a majority of the American public thinks the government will provide long term care services when the time comes for needing those services.

A recent national survey by the AARP, of people 45 years and older, discloses that 59% of respondents think Medicare will pay for extended nursing home costs and 52% believe Medicare will cover assisted living costs. In reality, Medicare coverage for nursing homes is very short-term (the average is 27 days) and Medicare does not cover the cost of assisted living at all.

Another recent survey by America’s Health Insurance Plans –AHIP — also supports these findings. If we add on another 25% or 30% of respondents who simply don’t know how their long term care costs will be covered or who erroneously believe they have insurance for long term care, about 80% of the American public is laboring under a false sense of security. These people think they are covered for long term care when they are not.

Cost-of-care reports released by the government also appear to support the myth that the government provides the bulk of care. Quoting a recent Government Accounting Office study for Congress:

“Presently, the majority of long term care services — about 80 percent — is paid for by governmental programs with private pay and long term care insurance making up the difference. In June 2007, according to the Centers for Medicare & Medicaid Services(CMS), which overseas nursing facility care, 65 percent of all nursing home residents relied on Medicaid and an additional 14 percent depended on Medicare for their care and services.”

It is no wonder that the public is confused. How can some sources claim that government provides little long term care if the government itself claims payment for 80% of long term care costs? The answer lies in the fact that the majority of long term care services in this country are provided free of charge by family members, friends or volunteers.

In order to put things into perspective, the National Care Planning Council did a study that estimates the number of yearly hours provided for long term care by various private and government care providers (the study focuses on hours not dollars). Based on this study, the National Care Planning Council estimates that only 16% of all long term care services are provided by the government. The other 84% is provided free of charge or paid for out-of-pocket by private funds. In addition, the vast majority of these care hours are provided in the home or in assisted living and not in nursing care facilities.

Because many family caregivers are in the workplace and have difficulty providing help for loved ones, Americans should realize that planning for long term care is an important issue when planning for retirement. The government does not provide the amount of care the public thinks it does.

Government Programs Can Stifle Innovation and Limit Freedom of Choice

Medicare and Medicaid contract directly with private providers who are certified to provide care on behalf of these agencies. These eldercare companies are reimbursed directly for the services they provide. Payments to providers from Medicare are based on performance of certain predetermined activities defined by Medicare. Each type of activity has a different reimbursement rate depending on the level of care required and the cost of care in the geographic area. Unlike Medicare, Medicaid typically provides an average per capita payment for each Medicaid recipient receiving long term care in a facility or in a community setting.

Both Medicare and Medicaid require evidence of certain services provided by doctors, nurses and aides and detailed logs of these completed services must be kept. Any services rendered by a Medicare or Medicaid approved provider that are not preauthorized by regulation are generally not be covered.

There are a number of new models for nursing care and for community-based care that have proven successful in improving the health, functionality and mobility of long term care recipients. Unfortunately, these innovative efforts are typically not reimbursed by Medicare or Medicaid because they are not predetermined services. Because close to 80% of all nursing home residents rely on Medicare or Medicaid reimbursement for their care, certified providers are forced to offer the prescribed government services for all their residents. This high dependency on government funding means facilities must conform to government mandates or go out of business. In turn, the reliance on government-mandated reimbursement essentially stifles any efforts to provide better and potentially more effective alternative care in nursing homes or in other community settings.

The rigid reimbursement model from Medicare and Medicaid also limits freedom of choice for care recipients. Government long term care beneficiaries must choose a government-certified provider for their care. Government programs also favor nursing home care over other settings such as assisted living or home care. There are reasons for this bias and we will discuss these limitations in a future article. However, the result of a nursing home bias is that care recipients generally have little choice but to receive their care in a nursing home.

Government program directors are aware of the shortcomings in the system and an effort is being made to improve delivery and offer more choice, but it appears to be moving glacially slow. The fault really lies with the reimbursement model for care services and that needs to be changed in order to encourage innovation and provide more choice in care settings.

Needless to say, good Care Planning takes into account the weaknesses mentioned in this article. The professionals at Idaho Estate Planning have the tools and expertise necessary to help you avoid these pitfalls. Call us today to set up a consultation. The appointment is free of charge. Let us help you plan for your future needs.

Idaho Estate Planning

Promote Your Page Too

4 Steps of Long Term Care Planning Part II

Step 1-Knowledge & Preparation are the Keys to Success

This step requires an understanding of the variety living arrangements and different settings under which care is provided. In addition, understanding the provisions and limitations of government programs is essential because the public generally has a misconception that the government will step in and provide care when the time is needed.

Take time to investigate the options for short and long term care in your area. Knowledge of the choices available to you and the annual costs involved will make the steps that follow easier.

Government programs are limited and according to research by the National Care Planning Council, only 16% of all long term care services are provided by government programs. The other 84% is provided free of charge by family members, friends, charity, church groups or volunteers or paid for by private funds.

Step 2-Funding the Cost of Long Term Care

Much emphasis is being placed on purchasing long term care insurance or arranging for reverse mortgages in order to fund the cost of care. These can be useful tools for providing funding but in reality, this approach for planning is not working that well.

After 30 years of being touted as the ultimate solution, less than 2% of the American public and only 9% of seniors own long-term care insurance policies and using reverse mortgages may be a good strategy but in practice, few seniors are using them to pay for care.

Financial planning is an important part of being prepared for long term care if and when it becomes necessary. The scope of investment tools available to Americans has dramatically increased over the last few decades. Consult with an experienced professional to determine the best course of action.

Step 3-Using Long Term Care Professionals

Long term care services are complicated and provider contacts are fragmented throughout the community. For the majority of Americans, eldercare becomes a frustrating do-it-yourself process. This approach is unnecessary. Using care professionals is the most cost effective and efficient way to provide help for a loved one.

Those people who need help with long term care and use the services of professionals often find they save money over doing it themselves. They also reduce their stress and they free up a considerable amount of their personal time. Another benefit with using professional help, such as a care manager, elder law attorney or mediator, is to help you alleviate or avoid family conflicts that often arise as a result of caregiving.

Hiring professional advisers or providers to help with long term care is no different than using professionals to help with other complex issues such as investing, car repairs, dealing with taxes or legal problems. With their education and training, long term care professionals also bring experience that only comes from dealing with countless hands-on, caregiving challenges.

Step 4-A Written Plan that is Accepted by All Involved

The first three steps in the planning process are designed to give you a wealth of information about long term care. It is important for you to have an understanding of care systems and the resources you can turn to when the need arises. However, knowledge of long term care systems is not enough. You must take some tangible action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself.

The final fourth step in the planning process is making a care plan. You need to prepare a written plan for you or a loved one. The challenge of dealing with long term care will unfold for you in a more manageable manner if you make a plan and put it in writing. You will experience less stress, have fewer costs, require less time committed and have fewer family conflicts.

At Idaho Estate Planning we have all the resources you need to put a plan together. We have the experience and expertise to help you maintain your options and protect yourself as well as your loved ones now and into the future. The best time to plan is always now!

4 Steps of Long Term Care Planning Part I

The Importance of Planning for Eldercare

According to some sources, 60% of us will need long term care sometime during our lives. It is important for all of us to prepare for that day when we will need to help loved ones with care or we will need long term care for ourselves.

We may prepare financially for unexpected disasters by covering our homes, automobiles and health with insurance policies. But no other life event can be as devastating to an elderly person’s lifestyle, finances and security as needing long term care. It drastically alters or completely eliminates the three principal retirement dreams of elderly Americans:

1. Remaining independent in the home without intervention from others
2. Maintaining good health and receiving adequate health care
3. Having enough money for everyday needs and not outliving assets and income

Sadly, the majority of the American public does not plan for the devastating crisis of needing eldercare. This lack of planning also has an adverse effect on the family, with sacrifices made in time, money, family lifestyles and even affecting the family’s or caregiver’s medical and emotional health.

Because of changing demographics and potential changes in government funding, the current generation, more than any before them, needs to plan for long term care before the elder years are upon them.

What Is Long Term Care?

The need for long term care arises when an individual requires, from someone else, assistance with medical care, daily living activities, comfort, supervision or advice. This need for care may be caused by an accident, disease process, or frailty. Such conditions may require help with the ability to move about, dress, bathe, eat, use a toilet, medicate, and avoid incontinence.

Also care may be needed to help the disabled person with household cleaning, preparing meals, transportation, shopping, paying bills, visiting the doctor and answering the phone. Oftentimes, long term care in the form of supervision or confinement is needed due to cognitive impairment from stroke, mental retardation, depression, dementia, Alzheimer’s, Parkinson’s Disease and so on. Most long term care is provided at home by family members.

What Is Long Term Care or Eldercare Planning?

For seniors, the terms “long term care” and “eldercare” are synonymous. For younger people, “long term care” is the more appropriate phrase.

For the uninformed family member, eldercare or long term care might appear to be a very straightforward and easy-to-understand process. Unfortunately, the reality is that long term care is very complicated and finding care systems and providers is a frustrating and time-consuming process. There is no one single source to help caregivers find services or solve problems with a simple phone call or a single community contact. For this reason, planning for care requires a great deal of prior knowledge in order to avoid operating in a crisis mode trying to find help when the need for care suddenly arises.

However, knowledge of long term care systems is not enough. Because it can happen suddenly, at any time, you must take action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself. This action involves

• Determining the care settings and services you or a loved one most likely would want.
• Providing funding for paying the cost of care, especially when government support programs are lacking or require sacrifice of assets.
• Completing a survey to determine necessary financial and legal arrangements to be made.
• Completing a written long term care planning document to provide instructions to caregivers and to your care coordinator in advance of needing eldercare.
• Assigning a care coordinator and determining the role of other family members, friends or advisers involved in caregiving.
• Holding a planning meeting and drawing up a written agreement for involvement between all those who are willing to participate in future caregiving for you or a loved one.

There are four crucial steps necessary in this process for long term care planning. The four steps are based on the following concepts:

1. Knowledge and preparation are the keys to success.
2. Having funds to pay for care greatly expands the choices for care settings and providers.
3. Using professional help relieves stress, reduces conflict, and saves time and money.
4. Success is assured through a written plan accepted by all parties involved.

In Part II we will discuss these steps in greater depth.

The Importance of Planning for Eldercare

According to some sources, 60% of us will need long term care sometime during our lives. It is important for all of us to prepare for that day when we will need to help loved ones with care or we will need long term care for ourselves.

We may prepare financially for unexpected disasters by covering our homes, automobiles and health with insurance policies. But no other life event can be as devastating to an elderly person’s lifestyle, finances and security as needing long term care. It drastically alters or completely eliminates the three principal retirement dreams of elderly Americans:

1. Remaining independent in the home without intervention from others
2. Maintaining good health and receiving adequate health care
3. Having enough money for everyday needs and not outliving assets and income

Sadly, the majority of the American public does not plan for the devastating crisis of needing eldercare. This lack of planning also has an adverse effect on the family, with sacrifices made in time, money, family lifestyles and even affecting the family’s or caregiver’s medical and emotional health.

Because of changing demographics and potential changes in government funding, the current generation, more than any before them, needs to plan for long term care before the elder years are upon them.

What Is Long Term Care?

The need for long term care arises when an individual requires, from someone else, assistance with medical care, daily living activities, comfort, supervision or advice. This need for care may be caused by an accident, disease process, or frailty. Such conditions may require help with the ability to move about, dress, bathe, eat, use a toilet, medicate, and avoid incontinence.

Also care may be needed to help the disabled person with household cleaning, preparing meals, transportation, shopping, paying bills, visiting the doctor and answering the phone. Oftentimes, long term care in the form of supervision or confinement is needed due to cognitive impairment from stroke, mental retardation, depression, dementia, Alzheimer’s, Parkinson’s Disease and so on. Most long term care is provided at home by family members.

What Is Long Term Care or Eldercare Planning?

For seniors, the terms “long term care” and “eldercare” are synonymous. For younger people, “long term care” is the more appropriate phrase.

For the uninformed family member, eldercare or long term care might appear to be a very straightforward and easy-to-understand process. Unfortunately, the reality is that long term care is very complicated and finding care systems and providers is a frustrating and time-consuming process. There is no one single source to help caregivers find services or solve problems with a simple phone call or a single community contact. For this reason, planning for care requires a great deal of prior knowledge in order to avoid operating in a crisis mode trying to find help when the need for care suddenly arises.

However, knowledge of long term care systems is not enough. Because it can happen suddenly, at any time, you must take action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself. This action involves

• Determining the care settings and services you or a loved one most likely would want.
• Providing funding for paying the cost of care, especially when government support programs are lacking or require sacrifice of assets.
• Completing a survey to determine necessary financial and legal arrangements to be made.
• Completing a written long term care planning document to provide instructions to caregivers and to your care coordinator in advance of needing eldercare.
• Assigning a care coordinator and determining the role of other family members, friends or advisers involved in caregiving.
• Holding a planning meeting and drawing up a written agreement for involvement between all those who are willing to participate in future caregiving for you or a loved one.

There are four crucial steps necessary in this process for long term care planning. The four steps are based on the following concepts:

1. Knowledge and preparation are the keys to success.
2. Having funds to pay for care greatly expands the choices for care settings and providers.
3. Using professional help relieves stress, reduces conflict, and saves time and money.
4. Success is assured through a written plan accepted by all parties involved.

In Part II we will discuss these steps in greater depth.

Veterans Long Term Care Benefits

Veteran’s Benefits Connected to Service Disabilities

These medically necessary services include home care, hospice, respite care, assisted living, domiciliary care, geriatric assessments and nursing home care. In order to receive the services, a veteran must be enrolled in VA’s health care system. Veterans with service-connected disabilities have priority for health care enrollment acceptance.

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 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.

State Veteran’s Homes

The Veterans Administration in conjunction with the states helps build and support state veteran’s homes. Money is provided by the Federal Government to help with construction, and a daily subsidy is provided for each veteran using these nursing homes. These homes are generally available for any veteran and sometimes the nonveteran spouse and are run by the states, often with the help of contract management. There may be waiting lists in some states.

Most state homes offer nursing home care but some may offer assisted living, domiciliary (a form of supported independent living), and adult day care

State veterans homes are not free but are subsidized and the cost could be significantly less than a comparable facility in the private sector. Some of these homes can accept Medicaid payments.

Disability Payments

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 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 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.

Pension is available to all active-duty veterans who served at least 90 days in the military and at least 1 day 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.

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. However, income can be adjusted for unreimbursed medical expenses and this allows veterans with household income larger than the pension amount to qualify for a monthly benefit.

All active-duty veterans who served at least 90 days during a period of war are eligible for pension and additional disability allowances — aid and attendance or housebound allowances. Surviving single spouses of these veterans are also eligible for lesser benefits and for the allowances.

Veterans’ service would include World War II, the Korean Conflict, the Vietnam Conflict Period and the Gulf War conflict.

Pension can pay up to $1949.00 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.

The secret for receiving a successful award for aid and attendance or housebound ratings is not in filling out the form but in knowing what documents and evidence must be submitted with the application. Knowing the secrets for a successful award – with the special case of long term care recipients – is 95% of the battle. A knowledgeable consultant can provide information to shorten the VA’s decision window of 6 to 12 months to possibly 3 or 4 months.

At Idaho Estate Planning we understand how to maximize the benefit or avoid a denial. We can also provide guidance for meeting the asset test. We provide the best strategies for reallocating assets through trusts or income conversions to allow for the best possible accommodation of assets for beneficiaries thus avoiding or reducing taxes, family disputes and Medicaid penalties.

We are VA Accredited and we know how to help you get the benefits you earned through your greatly appreciated service to our country.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning

Recognizing Symptoms of Dementia

The Brown family reunion has always been an event everyone looks forward to. Family visits, games, stories and everyone’s favorite foods are always on the agenda. On the top of the menu is Grandmas Lemon Coconut Cake. Grandma always makes the traditional cake from her old family recipe. This year, however, the cake tasted a little on the salty side, perhaps a half cup full of salty.
Though the family was disappointed over the cake, of more concern was Grandma’s confusion with the recipe and her similar confusion about the loved ones around her. Could something be wrong with grandma’s mental state?
One might say that for an elder person a little forgetfulness or confusion is normal, but when do you know if there is a serious problem, such as dementia?
An online article from FamilyDoctor.org outlines some common symptoms in recognizing dementia.
“Dementia causes many problems for the person who has it and for the person’s family. Many of the problems are caused by memory loss. Some common symptoms of dementia are listed below. Not everyone who has dementia will experience all of these symptoms.

• Recent memory loss. All of us forget things for a while and then remember them later. People who have dementia often forget things, but they never remember them. They might ask you the same question over and over, each time forgetting that you’ve already given them the answer. They won’t even remember that they already asked the question.
• Difficulty performing familiar tasks. People who have dementia might cook a meal but forget to serve it. They might even forget that they cooked it.
• Problems with language. People who have dementia may forget simple words or use the wrong words. This makes it hard to understand what they want.
• Time and place disorientation. People who have dementia may get lost on their own street. They may forget how they got to a certain place and how to get back home.
• Poor judgment. Even a person who doesn’t have dementia might get distracted. But people who have dementia can forget simple things, like forgetting to put on a coat before going out in cold weather.
• Problems with abstract thinking. Anybody might have trouble balancing a checkbook, but people who have dementia may forget what the numbers are and what has to be done with them.
• Misplacing things. People who have dementia may put things in the wrong places. They might put an iron in the freezer or a wristwatch in the sugar bowl. Then they can’t find these things later.
• Changes in mood. Everyone is moody at times, but people who have dementia may have fast mood swings, going from calm to tears to anger in a few minutes.
• Personality changes. People who have dementia may have drastic changes in personality. They might become irritable, suspicious or fearful.
• Loss of initiative. People who have dementia may become passive. They might not want to go places or see other people.”

Dementia is caused by change or destruction of brain cells. Often this change is a result of small strokes or blockage of blood cells, severe hypothyroidism or Alzheimer’s disease. There is a continuous decline in ability to perform normal daily activities. Personal care including dressing, bathing, preparing meals and even eating a meal eventually becomes impossible.
The Alzheimer’s Organization reports that 5.3 million Americans suffer from Alzheimer’s disease, the most common cause of dementia. They also report that there are 10.9 million unpaid caregivers helping those afflicted by the disease. In 2000, there were an estimated 411,000 new (incident) cases of Alzheimer’s disease. For 2010, that number is projected to be 454,000 new cases; by 2030, 615,000; and by 2050, 959,000. To read the full report, visit www.alz.org.
In the beginning, family members find part time caregivers for their loved one. At first, loved ones need only a little help with remembering to do daily activities or prepare meals. As dementia progresses, caregiving demands often progress to 24 hour care. Night and day become confused and normal routines of sleeping, eating and functioning become more difficult for the patient. The demented person feels frustrated and may lash out in anger or fear. It is not uncommon for a child or spouse giving the care to quickly become overwhelmed and discouraged.
Now is the time to address concerns you may have for yourself or a loved one. At Idaho Estate Planning we have the experience and the resources you need.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning

Maintaining Control of Your Health Care Options

Being In Control
Perhaps the most important goal of any estate plan is to allow the client to maintain control. Most of our clients here at Idaho Estate Planning are very intent on “being in control” as long as possible. They want to make their own decisions about whether to go into a “facility” or stay in their house. (Usually the choice is to stay at home as long as possible.) However, the ability to be in control and stay at home is challenged constantly.

Some of the challenges to being in control consist of those disabilities we all fear:  Alzheimer’s disease, dementia, other mental challenges and numerous physical disabilities. The biggest question becomes, “How do I maintain control if I suffer one of these disabilities?” While these situations are varied (and extremely difficult), there are some basics that will allow you to exercise control, that is, allow you to voice your opinion is such a situation.

Durable Power of Attorney for Health Care
First and foremost, you need to execute a Durable Power of Attorney for Health Care. This is a legal document that allows you to personally choose who will make decisions or give instructions if you are not able to, whether from mental or physical disability. This is an extremely important document to have in your estate plan. It is, therefore, extremely important to carefully consider who you want giving instructions to health care providers on your behalf. Typically, this is a spouse.

But, if the spouse is unable to fulfill this responsibility, who will take over? This requires great thought and consideration. Who has the skill set to take on this responsibility? Who understands what you want to have happen? These are not easy decisions and should not be undertaken lightly.

Living Will
A Living Will is a form created by statute that allows you to express a preference if it is determined by two doctors that you are in a terminal state and being kept alive by artificial life support measures. The Living Will also applies if you are determined to be in a persistent vegetative state (some call this being “brain dead”). The Living Will allows you three basic choices: 1) to forego all life preserving efforts being applied whether artificial or natural; 2) to forego any life preserving efforts applied; or 3) only natural efforts applied including food or water or both. In reality, while these situations do occur, they are rare.

The POST
The Physician Orders for Scope of Treatment or “POST” is a more detailed legal document that allows you be very specific in how treatment, whether artificial or natural is applied to you. You can choose to forego intravenous feeding or the use of a feeding tube. You can choose to forego intubation to keep you breathing. You can choose to forego “aggressive methods” to preserve your life. Each of these is an option that you choose.

HIPAA
If your Living Will or POST is needed, it is your Health Care Agent as established in your Power of Attorney for Health Care who gives the instructions to the health care professionals. These documents, then, work together to help you maintain control of your own situation. One more document that makes all the others work better is the HIPAA release. This is an informational release in which you give the health care professionals permission to provide your health information to your Health Care Agent or other family members. In essence, the Power of Attorney allows your Health Care Agent to talk to the doctor. The HIPAA release allows your doctor to talk to your Health Care Agent.

These, then, are the minimum documents you need to make sure your wishes for health and medical care and end of life decisions are honored. Now is the time to address these concerns and plan for the most difficult of times. Once it starts raining (or hailing as it did yesterday), it’s a little late to start fixing the roof. Once you are incapacitated, it’s too late to do this planning.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning

Interesting Animal, The Living Trust

The misinformation and misunderstanding of trusts as an estate planning tool runs rampant these days.  While on one hand, you hear popular personalities that give financial advice, who extol the virtues of the living trust (Suze Orman is one of these), on the other hand, a number of financial personalities are conflicted on the need for such an advanced tool.  One such personality has provided conflicting advice concerning the revocable living trust.

Recently in his newspaper column, Dave Ramsey a fairly popular financial advice radio host gave his opinion of what he called “an animal running around called a living trust.”  He stated, “This is a document that will cost you anywhere from $1,500 to $4,000 to have drawn up, and it’s really overdone in the estate planning world. It’s not needed nearly as much as some people would have you think. To tell the truth, it’s more of a gimmick than anything else. The idea is that you put everything you own in trust now, and when you die you save on probate taxes.  It’s a good theory, but the downside is that once you do it you have to operate your life in a trust. And that’s a real pain in the b***!”

Therefore, while conceding that “it’s a good theory,” Ramsey tells us not to use one because it’s a “gimmick” and such a “pain”.  Yet in a radio broadcast not long before the column was written, Ramsey states, “the living trust has some advantages …. It helps you get privacy while you are alive and helps you avoid probate tax on the state level.”   He then states, “A living trust does not make sense economically unless you have assets over $400,000, and it requires a lot of work.  I would suggest you consult an advisor specifically about your situation.”

If you are confused about what Ramsey is telling us, you’re not alone.  I would wager that Ramsey does not have a living trust and, therefore, cannot speak to what a “pain” it might be.  Yet, we have over two thousand clients who agree that a “living trust has some advantages” and have designed and implemented an estate plan with a living trust as the foundation.  They have protected themselves and their children and often their grandchildren from the reach of the government, creditors, ex-spouses, etc., and ensured the privacy of themselves and their families.  To this end, none of them feels the living trust is a “pain in the b***” or a “lot of work”.  Rather, if it is a labor, it is a labor of love.

If you find yourself confused with “advice” circulating about the use of living trusts and whether one is the appropriate tool for you, do as Dave instructed the radio caller “consult a [qualified] advisor specifically about your situation.”  If you have questions, please call us for a free consultation and we’ll help you sort out what tools work best to meet your needs.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning