Long-Term Care: Scan the Options


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Long-Term Care: Scan the Options is a project Davis & Neal produced for the South Central Alabama Development Commission, Area Agency on Aging (SCADC) which serves Bullock, Butler, Crenshaw, Lowndes, Macon and Pike Counties, Alabama. This project included a booklet, posters and postcards to help seniors and caregivers become knowledgeable of the options, cost and availability of long-term care and how to make arrangements for care. The content and art were produced by Neal.

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Long-Term Care: Scan the Options

  1. 1. July 2011Preparation of this publication was financed, in part, throughgrants received from Auburn University at Montgomery andthe Alabama Department of Senior Services as developed byDavis & Neal, Attorneys-at-Law, and administered by theSouth Central Alabama Development Commission AreaAgency on Aging. Text and Graphics by Jan Neal, Davis & Neal 1
  2. 2. South Central Alabama Development Commission Area Agency on Aging 5900 Carmichael Place Montgomery, Alabama 36117 334-244-6903 1-(800)-243-5463 Fax (334) 271-2715 http://scadc.net/ Serving Bullock, Butler, Crenshaw, Lowndes, Macon and Pike Counties OUR MISSION: To foster the development of a comprehensive andcoordinated service delivery system that will address the optimum needs of older adults and their families and will allow older individuals tomaintain independence with dignity in their own homes and communities for as long as possible. 2
  3. 3. Table of Contents I. Overview of Long-term care 4 II. Long-term care at home 5 A. Services through AAA 5 B. Services through Medicare 6 C. Benefits through the VA 9 D. Long-term care insurance 10III. Practical Considerations for Early Planning 11 A. Income and Health Insurance Screening 11 B. Family Paid Caregivers 13 C. Authority Issues 15IV. Long-term care in independent senior living facilities and Continuing Care Retirement Centers (CCRCs) 16 V. Long-term care in assisted living 17 A. Qualifying for Regular Assisted Living Facility Care 17 B. Special Care Assisted Living Facilities (SCALF) 17VI. Long-term care in nursing home facilities 18 A. General population care 18 B. Dementia care 18 3
  4. 4. Overview of Long-Term CareLong-term care is a necessary condition of life cess of arranging for long-term care. Herefor many senior and disabled persons, yet we will examine the different levels of long-comprehensive and accurate information term care and provide information onconcerning long-term care can be very difficult qualifying to receive and pay for theseto find. This information shortage is different levels of care.compounded by the timing at which caretakersand senior/disabled persons frequently search The Alabama Department of Senior Servicesfor information. Often a family finds itself (ADSS) is the service and planning stateobtaining a crash course on long-term care agency that administers programs for seniorplanning at the very time a member of the citizens and people with disabilities. At thefamily is desperately ill and in need of local level, The South Central Alabamaimmediate long-term care arrangements. Development Commission (SCADC) is theNeedless to say, making arrangements in an designated Area Agency on Aging establishedemergency is less than optimal. Becoming to foster the development of a comprehensiveinformed about long-term care resources and coordinated service delivery system forbefore dealing with an emergency will make older adults living in Bullock, Butler,you an informed consumer when the time Crenshaw, Lowndes, Macon and Pikecomes for you to make decisions about long- Counties. The Area Agency on Aging isterm care for yourself or someone for whom responsible for advocacy, planning andyou care. provision of supportive services, nutrition services, and where appropriate, theAccording to the National Clearinghouse, in establishment, maintenance, or construction2009 the following average prices existed in the of multipurpose senior centers. AdditionallyUnited States: SCADC administers a variety of home and community-based services to help older$198 per day for a semi-private room in a adults maintain independence with dignity innursing home; $219 per day for a private room a home environment for as long as possible.in a nursing home; $3131 per month for care in Further, SCADC is a designated Alabamaan assisted living facility (one-bedroom unit); Senior Resource Center (ADRC) which$21 per hour for a home health aide; $19 per educates seniors and their families regardinghour for homemaker services; $67 per day for services and benefits available to them bycare in an adult day health care center. providing person-centered access to information through a single entry point and helps those seeking information about long-The goal of this resource guide is to provide term services to plan for their care. Further,information to seniors and disabled persons SCADC’s ADRC provides access to optionsand caregivers about the various options for both public and private, thus helping seniors,long-term care, how to qualify for benefits and persons with disabilities and caregivers makeprograms that meet long-term care needs and more informed choices regarding long-termwhere to find help while going through the pro- care. 4
  5. 5. Long-Term Care Begins at HomeLong-term care begins at home for those who are able to make a plan of care to meet their needswhile continuing to live in their own homes. The first step to accomplish this goal is to have acomplete medical and social assessment to determine the services a person needs, and the secondstep is locating those services available through governmental programs at no additional expenseas well as finding the money to pay for services that are not readily available through governmentalprograms. Persons who are able to remain at home usually piece together services from a numberof sources, and this is why well informed caregivers – family and professional – can make such aprofound difference in the quality of life for a senior or disabled person. Since medical care is soexpensive, no stone can go unturned to locate appropriate free services and financial support forwhich a care recipient may qualify in order to pay for those services not otherwise provided throughgovernmental programs. Area Agency on Aging Services Helping Care Recipients Stay at HomeBesides the long-term care assessment services provided by The Senior Resource Center(ADRC), SCADC Area Agency on Aging provides a number of services that can assist a person tostay in his or her own home: The Alabama Cares ProgramThe Alabama Cares Program, also known as the National Family Caregivers Program, providessupport to family caregivers in the form of resources, education and services including CaseManagement, Counseling, Respite, and Supplemental Services. SenioRx: Partnership for Medication AccessSenioRx helps eligible individuals 55 and older in applying for free and low-cost medications andnutrition supplements made available through pharmaceutical company programs. Eligible personsmust have no prescription coverage, have chronic medical condition and meet certain incomerequirements. Wellness education is also provided. This program also provides drug coverage forpersons eligible for Social Security Disability who have not yet met the 24 month waiting periodbefore becoming eligible for Medicare. The State Health Insurance Program (SHIP)SHIP provides individual insurance counseling, advice and assistance to Medicare beneficiariesregarding Medicare, Medicaid, long-term care insurance, supplemental health insurance, QMB,SLMB, Q-I- and Medicare Part D prescription drug plans and low income subsidies.Medicaid Waivered Services provides home and community-based services to older adults andpersons with disabilities in their communities who are at risk of institutional care. Attention is givento client care, protecting the health and welfare of the client, and client free choices in providers andworkers. Services available through this program include Case Management, Respite, Homemaker,Personal Care, Companion, Frozen Meals and Adult Day Health. 5
  6. 6. Supportive Services are designed to provide a system of transportation; identification ofpotential clients; legal advice, counseling, education, and representation; and appropriate in- home assistance to clients. Programs available includeTransportation, Outreach, Information and Referral, Homemaker, and Legal Assistance.Nutrition Services are provided to individuals 60 years of age or older who are eligible sothat they receive Congregate, Home-Delivered and in few instances Frozen Meals five daysa week in the planning and service area. In addition center participants enjoy a variety ofactivities including exercise, educational programs, games, music, arts and crafts, volunteeropportunities, recreation, special events, and computer instructions in some locations.To access the services described here, you may contact the Area Agency on Aging throughagency contact information provided at the front of this guide. Medicare Helping Care Recipients Stay at HomeMedicare provides a number of services that can help a person remain at home. Theseservices include Home Health Care, Hospice and durable medical equipment.In order to qualify for Medicare Home Health Care Services a Medicare recipient mustmeet certain requirements. All of the following conditions must be met for Medicare to payfor Home Health Care Services:1. A doctor must determine that the person needs medical care at home and must provide a plan of care;2. The patient must need intermittent (part-time) skilled nursing care, physical therapy, speech-language therapy, or to continue occupational therapy;3. The home health agency caring for you must be certified by Medicare as approved by the Medicare program to provide care; and4. The patient must be homebound, or normally unable to leave home without help.It is important to recognize that the “homebound” requirement does not mean that a patientmust be unable to ever leave home in order to qualify for Medicare Home Health Services.It does mean that leaving home is not easy and takes considerable effort. A homeboundperson can go out for medical treatment or can leave home for short and infrequent non-medical reasons such as going to the hairdresser or church services. Further, a“homebound” person can leave home for adult day care and remain qualified for MedicareHome Health Care Services. 6
  7. 7. When the Medicare recipient meets the four threshold requirements listed above Medicare willpay for the following Home Health Care Services:Skilled Nursing Care, which includes nursing services that can only be performed safely by alicensed practical nurse or a registered nurse. These services can be provided on a part-timeor intermittent basis.Home Health Aide Services, which are services performed by an aide to support nursingservices and includes personal care services such as bathing, toileting and dressing. Whilethese services are performed by an aide who is not a licensed nurse, these services cannot beprovided unless the patient is also getting skilled nursing services or other therapy.Physical Therapy, Speech-language Therapy, and Occupational Therapy for unlimited time solong as a doctor indicates that these services are needed. Physical Therapy Services includeexercise to strengthen the body or to restore movement that has been lost or teach a patienthow to perform needed activities such as moving from a bed into a wheelchair. Speech-language Therapy are services to help a person regain or strengthen the ability to speak.Occupational Therapy is exercises to help the patient perform usual activities by himself orherself, such as helping a patient learn how to dress or perform personal care such asshaving. Occupational Therapy can continue when ordered by the doctor even after skilledcare is no longer needed.Hospice Services are a separate health care system provided to care recipients who arecertified by their doctors to be terminally ill with a life expectancy of six months or less. Theservice is usually provided at the patient’s home, and the patient or his legal representativemust opt to receive hospice services rather than the regular Medicare services. Medicareservices are normally provided to cure a patient of illness; hospice services are non-curativemedical and support services designed to help the patient and his or her family move throughthe dying process. After the patient elects Hospice Services he or she selects a Medicarecertified hospice provider from a list of all providers in the area, and a care plan is developed.Hospice services may include home care and inpatient care as needed, and a variety ofservices not otherwise covered by Medicare. For instance, respite care is provided to allowfamily caregivers time to get away and recuperate. Hospice uses a team approach with thepatient and family working with social workers, nurses, doctors, clergy and volunteers tocollectively carry out the care plan to meet the needs of the care recipient. Of particularbenefit for patients and families support, the hospice team can be contacted 24 hours per day,seven days per week. It is important that the patient and caregivers recognize that onceHospice Services are selected, the hospice provider directs the location of medical care, andthe patient calls the hospice provider (e.g. the nurse in charge of direct care) in evenemergencies for assistance in dealing with the medical issue. 7
  8. 8. The election to accept hospice services is an election for up to two 90-day periods followed byan unlimited number of 60-day periods, and the benefit periods may be used consecutively orat intervals. Regardless to how the benefit periods are used, the patient must be certified asterminally ill at the beginning of any benefit period.Durable medical equipment (DME) is provided by Medicare Part B and includes reusablemedical equipment such as hospital beds, walkers, wheelchairs, seat lifts, home oxygenequipment, etc. In order for Medicare to pay, the particular equipment needed must beprescribed as medically necessary by the care recipient’s doctor. The equipment must beprovided by a Medicare certified supplier.Often some home modifications in conjunction with durable medical equipment provided byMedicare is the assistance someone needs to be able to remain living independently at home.For instance some home modifications such as tub rails, stair glides and wheelchair ramps arenot considered durable medical equipment, but if resources can be found to pay for theseupgrades, it may make the difference in maintaining one’s life at home as opposed to movingto a higher institutional level of care.In-patient psychiatric care is covered by Medicare, and there is a geriatric psychiatric unit at L.V. Stabler Memorial Hospital in Greenville (Butler County), AL. , Greenville, L. V. StablerMemorial Hospital.It can be very difficult to find help for patients with dementia, andoften they end up in locked nursing home units because the familycannot care for them at home and do not know of any otheroptions. The illusive nature of dementia is another part of theproblem, and the lack of geriatric specialists in large numberspresents a population with very special needs often treated bygeneral practitioners. Many general practitioners are very good attreating the demented patient, but nothing can compare tospecialized training with specific care plans created bypsychiatrists, nurses and social workers who specialize in geriatriccare for patients with cognitive deficits. Not all dementia isAlzheimers; other physical illnesses and medication interaction cancause dementia. The L. V. Stabler geriatric psychiatric program’sgoal is to help patients return to as much independent living aspossible. This is accomplished by in-patient structured plans ofindividual counseling, medication evaluation, group therapy,coordinated activities and family support. The 13 bed facility is foradults 55 years of age and older, and admission is voluntary.Patients must meet clinical admission criteria. For moreinformation call 334-383-2247. 8
  9. 9. VA Helping Care Recipients Stay at Home The Veterans Administration offers benefits specifically for veterans and their dependents to help them cover the cost of attendant care. The two benefits compared below are specifically tied to the veteran’s or his dependent’s limitations in handling activities of daily life and need for help accomplishing those activities. While these benefits are available for veterans and their dependents at home, in assisted living facilities and in nursing homes, it is included here where we are examining resources to help a care recipient obtain the care he or she needs at home.Improved Pension Improved PensionHousebound Benefits Aid & Attendance BenefitsVeteran Service Requirement: to qualify the Veteran Service Requirement: to qualify thecare recipient must be a war-time veteran with care recipient must be a war-time veteran with90 days of active duty, 1 day beginning or 90 days of active duty, 1 day beginning orending during a period of War. Veteran mustnot have been dishonorably discharged. ending during a period of War. Veteran must not have been dishonorably discharged.Medical Requirement: to qualify medically the Medical Requirement: to qualify medically theveteran or surviving spouse must need regular veteran or surviving spouse must need theassistance, but is not as limited as those who assistance of another person to perform dailywould qualify for Aid and Attendance. tasks, such as eating, dressing, undressing, taking care of the needs of nature, etc.Income/Resource Requirement: A veteranalone must have countable income LESS than Income/Resource Requirement: A veteran alone$14,457 per year and a veteran with a spouse must have countable income LESS thanmust have countable income LESS than $19,736 per year and a veteran with a spouse$18,120 per year. A widow or widower of aveteran must have income below $9696 per must have countable income LESS thanyear, and more income is allowed with more $23,396 per year. A widow or widower of adependents. Program eligibility requires limited veteran must have income LESS than $12,681net worth. per year, and more income is allowed with more dependents. Program eligibility requires limited net worth.To Apply: Contact the county VA Officer. To Apply: Contact the county VA Officer.Note: This is a "Pension Benefit" and IS NOTdependent upon service-related injuries for Note: This is a "Pension Benefit" and IS NOTcompensation. dependent upon service-related injuries for compensation. 9
  10. 10. Long-Term Care Insurance Helping Care Recipients Stay at HomeLong-term care insurance was originally designed to protect purchasers from the catastrophicexpense associated with long-term care in a nursing home. However, over time the public hasclearly voiced a preference for home care over care in an institution. In response to that preference,long-term care insurance companies now offer a variety of in-home services to help individuals payfor services to assist a person with activities of daily living. In fact most policies sold today arecomprehensive policies which cover services in different long-term care settings including at home.The majority of policies sold today are comprehensive policies. They typically cover care andservices in a variety of long-term care settings to include at home skilled nursing care, occupational,speech, physical and rehabilitation therapy, and personal care. Some policies also cover homemakerservices, such as meal preparation or housekeeping as well; adult day health care centers; hospiceand respite; assisted living; and other residential care facilities and nursing homes.Consumers should be aware of limitations on coverage, such as prior hospitalization requirements,and pre-existing condition exclusions. It is important to thoroughly understand what is beingpurchased, so a good deal of homework is involved in examining long-term care policies. Be surethat the services purchases are not services that are already covered by Medicare.There are incentives in the form of resource protection offered by Medicaid for a person to purchaselong-term care insurance.For policies issued prior to March 1, 2009, Medicaid will not consider resources of a person equal tothe amount of long-term care insurance benefit payments in determining Medicaid eligibility when thelong-term care insurance policy has paid at least the first three years of nursing home care and/orhome health care services.
For policies issued on or after March 1, 2009, Medicaid will not consider resources equal to theamount of benefits paid (dollar-for-dollar) by an Alabama Long-Term Care Insurance PartnershipPolicy (Partnership Policy) for long-term care services received in determining Medicaid eligibility andin estate recovery. The amount to be excluded will be above and beyond the standard resourceexclusion provided under the Medicaid State Plan. To qualify for this exclusion, the individual must becovered by a Partnership Policy that has been certified by the Alabama Department of Insurance as apolicy that covers a person who was a resident of Alabama when coverage first became effectiveunder the policy. Medicaid will provide reciprocity with respect to long-term care insurance policiescovered under other state. 10
  11. 11. Practical Considerations for Care at Home: Income and Health Insurance ScreeningThe cost of staying at home can be very expensive, and it is not unusual for a caregiver to be calledupon to supplement the income of a care recipient. While many resources do exist to help an individualreceive long-term care at home, there are often critical services that must be purchased. An example issitter services for the care recipient suffering from dementia. Home health care agencies can providethis service, but the cost is high, averaging around $19 per hour. Another shortage some care recipientsface is insufficient funds to pay for prescription drugs, even with full drug coverage through MedicarePart D. The potential income shortfall is a compelling reason why locating any benefits for which thecare recipient might qualify is an important part of developing a long-term care plan.While there are many programs designed to supplement the income or reduce the cost of essentialneeds for seniors, finding, understanding and applying for benefits can be complicated. Often caregiversfeel like they do not have time to provide personal care because they are drowning in paperworkassociated with efforts to obtain benefits for their care recipients.Apart from the services offered at the Area Agency on Aging (see page 5 of this resource guide) thereare multiple public benefit programs available for seniors and disabled persons with lower incomes orparticular health conditions. Programs to supplement income and health care costs exist through SocialSecurity/Medicare, The Veterans Administration, The Alabama Medicaid Agency and The Department ofHuman Resources, and more.There are several places a senior or caregiver can go to obtain more information on benefits. TheSCADC Area Agency on Aging ADRC can screen an individual to determine programs for which thatperson might qualify and make the appropriate referral. Legal Assistance is a program provided throughthe Area Agency on Aging with priority given to income maintenance and access to health care, so thatprogram can also screen for public benefits.Another source of income to consider is a reverse mortgage which is a way for the person who needscare to convert the equity in his or her home to cash. A reverse mortgage is similar to a traditional equityline of credit, but with some big differences. Namely, the homeowner takes money against the home butdoes not have to repay the loan so long as he or she lives in the home, pays the property tax andinsurance and keeps the property from deteriorating. The lender pays the homeowner in a lump-sum,monthly payment of a line of credit, and there are no restrictions on how the funds can be used. Thereare multiple types of reverse mortgages, but the type discussed here is a Home Equity ConversionMortgage (HECM) insured by the federal government.Persons age 62 and older can qualify for a HECM, and if the home is jointly owned, all ownersmust be 62 before the property is eligible to use for a HECM. Unlike a traditional mortgage,when a homeowner applies for a HECM, he or she will not be required to provide an income orcredit history to get the loan, and no monthly payments are due from the homeowner to thelender. Instead the lender makes payments at a given interest rate. Over time the loan amountincreases, and when the last homeowner/borrower dies, sells the home or permanently movesout, the loan becomes due an payable. In that event the heirs of the homeowner can pay off thedebt or the lender will sell the property to get back the money that was loaned. 11
  12. 12. The income from a HECM is non-taxable, but care needs to be taken that income not interferewith need based income such as SSI. A person who qualifies for SSI can have a HECM, butonly if the payment is spent during the month it is received. If money remains in the name ofthe SSI recipient the following month, it becomes a resource. If it exceeds $2000 for anindividual or $3000 for a couple, SSI eligibility will be lost.It is very important that a person fully understand how a reverse mortgage works before gettingone. The HECM is offered by private lenders, but are government insured. This means that ifa person outlives his life expectancy or the value of property drops, the person will continue toreceive the payments promised, and the proceeds recoverable by the lender is limited to thehome alone. To be insured by the Federal Housing Administration (FHA), the borrower mustpay, as part of the loan financed, an insurance premium along with an origination fee, servicingfees, closing costs, etc. In order to fully comprehend what expenses will be charged againstthe property and eventually taken by the lender, the federal government requires the HECMborrower to meet with a reverse mortgage counselor. The cost of that consult is rolled into theloan along with the other upfront fees.Due to the lower value of housing since the housing market decline, the FHA has had to modifythe HECM requirements by allowing less to be borrowed against home equity and by charginghigher ongoing insurance premiums on reverse mortgages. Another type of reverse mortgageknown as the HECM Saver Program became available in October 2010 to offer drasticallylower upfront fees in exchange for consumers borrowing a lower amount against their equity.The insurance premium is eliminated and replaced with a .01 percent fee on the value of thehome. The drawback is that 10 to 18 percent less of the equity value in the home can beloaned.The reverse mortgage market is constantly evolving at this time due to the shifting homevalues, so it is very important that consumers interested in these types of loans to obtaincurrent information before entering the market to apply for a HECM. Additional informationabout reverse mortgages is available online to the web site of The American Association ofRetired Persons ( AARP) at http://tinyurl.com/28frfbr or The National Clearinghouse for Long-Term Care at http://tinyurl.com/3rhummo.Apart from increasing income, coordinating insurance coverage is essential in planning forlong-term care. Health insurance can be extremely hard to understand. Seniors, disabledpersons and caregivers can obtain a health insurance check up through the State HealthInsurance program and Legal Assistance, both services offered by the Area Agency on Aging.Do not wait until an emergency is looming. Get information now. 12
  13. 13. Practical Considerations for Care at Home Family Paid CaregiversWhen a care recipient makes arrangements to receive the care he or she needs at home, thatcare should come with a realistic consideration of future potential declining health and theneed for institutional care. With that in mind, it is important to keep in mind that shouldnursing home care be needed, the long-term care patient will most likely need to qualify forMedicaid to pay for institutional care. Since Medicaid will look back five years to examine theapplicant’s financial transactions, there are issues of which the care recipient and caregiversneed to know BEFORE nursing home Medicaid is needed. For each $5000 worth ofuncompensated value given away (as of 2011) within five years of Medicaid application, atransfer penalty of one month of ineligibility may be imposed. This can result in terriblecircumstances of a senior needing nursing home care, having less than enough resources topay for care and ineligible for Medicaid.Often families work together to keep a spouse and/or parent at home, and, in so doing, familymembers may provide a large amount of the caregiving services or hire someone to provideintermittent services. A frequent example is bathing, dressing, toileting, cooking, help witheating and sitters to protect a dementia patient from wandering. Caregivers need tounderstand that Medicaid has highly specific rules about payments made for personal careservices, requiring a legally enforceable written agreement for personal care services to beprovided in exchange for anything of value. If a legally enforceable written agreement is notexecuted, money paid for personal care services is presumed to be a transfer of assetssubject to a transfer penalty. To avoid a transfer penalty the following requirements must bemet: At the time of the receipt of the services, the services were recommended in writing and signed by the applicant’s physician, as necessary to prevent the admission of the applicant to a nursing facility and the services may not include the providing of companionship and related services; At the time of the receipt of the services, the applicant was not residing in a nursing facility; 13
  14. 14. At the time of the receipt of the services there already existed a written and signed agreement executed between the applicant and provider for the specific service(s) rendered; andAt the time of receipt of the services, the transfer of the consideration (money and/orproperty) to the provider relative occurred.The agreement required by Medicaid must fully describe the type, frequency and duration ofthe services being provided to the applicant in such a way that they can be documentedwhen provided; and the amount of consideration (money and/or property) being received bythe provider/relative. Further, the payment for services must be comparable to the usualand customary rates in the local area. Services provided must be documented with timesheets and attendance logs, and payment to reimburse a care provider for purchases mustbe proven by receipt.While Medicaid can enforce this rule for any paid caregiver, the agency is more likely toenforce the rule if the care provider is a paid family member. In some situations Medicaidwill accept a certified statement by a paid non-family caregiver. It is the best practice toalways take this rule seriously and contact Legal Assistance services if payment will bemade to any caregiver since without such an agreement there is a possibility that theeventual Medicaid application within five years will result in transfer penaltiesIt is not at all unusual for caregivers in their 60’s to be providing care for parents who are intheir 80’s or 90’s. Caregivers who have not reached full retirement age (for those bornbetween 1943 and 1955, age 66) who have taken early retirement benefits at age 62 shouldbe aware of the fact that their early retirement benefits can be reduced for earned income.The earned income limit is $14,160 (in 2011). For caregivers who have not reached fullretirement age in 2011, their Social Security Retirement benefits will be reduced one dollarfor every two dollars earned over $14,160 ($1180 per month). For caregivers who do reachfull retirement age during 2011, Social Security will deduct $1 for every $3 earned above$37,680 until the month the caregiver reaches full retirement age. This is an importantconsideration for the paid caregiver in long-term care planning. After reaching fullretirement, there is no reduction of benefits for earned income. When planning for long-termcare for parents, the Social Security reduction can be a major consideration.If a senior or disabled person resides in the home of another, and money is paid to thecaregiving family, it is important to document any money paid as either caregiving chargeswith a written caregiver agreement in place and/or to charge an amount for room and boardin the form of a pro-rata share of mortgage, utilities, groceries, etc. Do not just pay anarbitrary amount for care.Often grown children will pay expenses for parents such as moving expenses. Logically itseems that the children could reimburse themselves for those expenses. Medicaid will 14
  15. 15. consider repayment of those expenses a gift subject to a transfer penalty unless a promissory note evidences the debt. Do not pay expenses for a care recipient without documenting the debt if you want to be reimbursed. Another financial problem caregivers frequently run into is providing explanations to Medicaid for checks written for cash. Seldom do individuals keep receipts for cash spent. Keep records for cash purchases when possible, and keep checks written for cash to a minimum. Practical Planning Considerations: Authority IssuesAuthority issues can sneak up on a caregiver. He or she can move right along performing the jobs thatneed to be done, and, suddenly, out of no where, an insurmountable problem appears. Property has tobe sold or a lien given to Medicaid or an income trust created to qualify a care recipient for Medicaid. Ifno one has legal authority to perform these acts, that legal authority has to be acquired. If the carerecipient has dementia or is too sick to execute a power of attorney to name a legal representative, thefamily has no choice but to file for a guardianship or conservatorship in the probate county where thecare recipient lives. The process of having a court appoint a guardian (to make decisions over the body)and a conservator (to make decisions about the finances) can be costly because the petitioner must paya filing fee, attorneys fees, publication fees and purchase a bond. While these expenses can bereimbursed from the estate of the care recipient, often there are not enough resources in the estate ofthe care recipient. Further compounding this problem is the fact that once aguardianship/conservatorship is established, the probate court retains jurisdiction over the care of theperson who needs protection, and the guardian and conservator must account to the court every threeyears to show all money received and spent on behalf of the person who needs protection, and the bondrequired by the court has to be paid every year until the guardianship/conservatorship is terminated bythe court – usually at the death of the individual being protected.All of the complications of the guardianship/conservatorship system can be avoided by execution of anadvance directive. This is the reason why one of the most important things a care recipient can do is tomake appropriate advance directives so that the person of his or her choice will have necessary authorityto handle the business and health care decisions for the care recipient without depleting the resources ofthat person’s estate when the resources are needed to pay for long-term care. A durable power ofattorney is a document that can name a person to handle financial decisions, routine medical decisionsand end of life decisions. The person making a durable power of attorney can name the same person tohandle all functions, or he or she can name different people to handle the different functions. In thatmanner, the durable power of attorney is an extremely flexible document that can be crafted to eachindividual person’s wishes.Many people have living wills. A living will is a document that addresses end of life decisions when aperson’s condition is terminal or he or she is permanently unconscious. The living will has beenamended by law to be called an Advance Directive for Health Care, and it is longer and permits themaker to name a surrogate decision maker or not. It also allows the maker to designate specific care heor she might want if his or her condition should be terminal or if he or she should be permanentlyunconscious. The living wills created prior to the emergence of the Advance Directive for Health Careremains valid even though all these old documents do is inform the physician to allow the patient to diewith dignity and not be kept alive by artificial means. 15
  16. 16. Independent Living in the long-term care continuumOften seniors will opt to downsize, sell their home and live independently in independent seniorliving facilities where recreation and community are focused values. Usually such facilities offeroutstanding activities, and neighbors close in age, but no direct assistance other than theservices previously described herein through the Area Agency on Aging and Medicare orprivately purchased. There are multiple types of independent living communities, but thesefacilities share the common feature of limiting resident admissions to age 55 and older. Thevarious types of independent living communities include subsidized senior housing, seniorapartment complexes, retirement communities and continuing care retirement communities.Recognize that persons living in these types of communities still have ultimate control over theirown lives and maintain independent home environments. Home based services can beprovided in these communities just like in any home environment.Subsidized senior housing is subsidized by the U.S. Department of Housing and UrbanDevelopment (HUD) and are available for low income seniors. A person may move tosubsidized senior housing to pay rent based on his or her income and to eliminate the high costof living in a home they have had for many years that now is too hard to keep up. The seniorwould enjoy lower utilities, elimination of yard maintenance, homeowner insurance and propertytax. The savings would free up funds needed to be able to pay for long-term care assistancewith activities of daily life. Senior apartment complexes can include community services as part of the rent charged. These services might be recreational programs, transportation and meals served in a communal dining room. While these services are not medical assistance, sometimes the community services are just the small amount of help a senior needs to continue to be able to live independently. Retirement communities are usually considered single family housing units of some description. The units might be condominiums, townhouses or single-family houses. While there is no defined requirement, retirement communities are generally places where individuals purchase a unit and pay additional monthly fees to additional services such as recreation, clubhouses, pools, etc. Continuing Care Retirement Communities (CCRC’s) are facilities that provide access to independent living, assisted living and skilled nursing facilities in one community. As a person ages and needs more care he or she can move to the next level. This can be a good arrangement for a married couple so that each can receive the care he or she needs while still living close together. 16
  17. 17. Care in Assisted LivingAssisted Living facilities are medically based care communities. From the outset it is importantto recognize that Medicare and Medicaid do not pay for assisted living facilities and there aresome restrictions on who can live in these facilities. For many years assisted living facilitieswere not regulated in Alabama, but regulations were passed in 2001 following several wellpublicized cases of injury and death to persons living in Alabama assisted living facilities. TheAlabama Department of Public Health is the agency responsible for regulating these facilities inAlabama.Alabama regulations recognize two levels of care. They are the traditional Assisted LivingFacilities (ALF) and Specialty Care Assisted Living Facilities (SCALF). Both levels offerassistance with activities of daily living, medications, community meals and help with bathing ordressing if needed, but the SCALF level of care has staff trained to work with residents whosuffer from dementia, and they have architectural features to assure the safety and health of theresidents who have diminished capacity. There are 340 facilities licensed in Alabama with 85licensed for SCALF, and approximately 27 percent of Alabama’s 9960 assisted living beds arelicensed to provide SCALF services.Assisted Living Facilities (ALF’s) must evaluate whether or not the facility can meet the needs ofthose applying for admission, and, generally, the ALF resident should not be “cognitivelyimpaired” to where he or she cannot care for his or her own needs or direct others to do sowhen inability to care for his or her own needs arise from physical disability. Further, the ALFresident should not be a person with a level of dementia at risk for wandering since ALF’s arenot required to be locked facilities. Residents must be able to understand the unit dosemedication system in use by the facility in order to live in an ALF.Many people who would like to receive care in an ALF or SCALF cannot due to the high cost notcovered by Medicare or Medicaid. The cost of ALF and SCALF varies from facility to facility, andSCALF is more expensive than ALF, but as a general rule of thumb, ALF/SCALF care is half to60 percent of the cost of nursing home care.There are a number of assisted living facilities in the SCADC region. For more informationabout what is available, contact the SCADC Area Agency on Aging. 17
  18. 18. Care in a Nursing HomeIt is never too early to begin exploring the options to pay for nursing home care because nursinghome care frequently catches families by surprise. According to Medicaid, the the average costof nursing home care in Alabama in 2010 was around $5000 per month, the cost far exceededthat amount in urban areas of the state. It is not unusual to see care over $6000 per month. Atthat rate a person will privately pay $72,000 per year for nursing home care.Medicare covers only a limited amount of nursing home care and only if a person meets specificrequirements. Medicare will pay for the first 20 days of care provided the patient has a threeday prior hospitalization and is admitted to a nursing home and requires skilled care. While theMedicare literature will indicate that Medicare pays for up to 100 days of nursing home care, thetruth is that if the patient continues to have skilled care ordered by the doctor, on day 21 a co-payment of $141.50 per day begins. That means that in a month even with Medicare paying,the patient will pay over $4000 per month in copayments. Under the best of circumstancesMedicare will pay for only 20 full days of care and another 80 days if, and only if, skilled carecontinues to be ordered, and will pay for only about 1/3 of the cost of care while the patient pays$141.50 per day. After 100 days Medicare pays nothing.As you can see, qualifying for Medicaid to pay for nursing home care quickly becomes animportant concern for those who will need nursing home care on a long-term basis.Another option for nursing home care is the Veterans Administration which has a federal andstate program addressing health care needs of veterans. There are four VA nursing facilities inAlabama: Bill Nichols State Veterans Home in Alexander City; William F. Green State VeteransHome in Bay Minette; Floyd E. Tut Fann State Veterans Home in Huntsville; and a newer facilityin Pell City expected to be completed in 2012 . The care provided at State VA homes cost $147per day, but after the federal and state government subsidies are paid, the veteran is left owing$11.64 per day. This is a highly affordable nursing home care option.Information about nursing homes and their performance levels can be found at thewww.medicare.gov web site with a tool called Nursing Home Compare. It can be located athttp://tinyurl.com/2d7alxc.It is a violation of federal law to require the family of patients to sign up to be a guarantor on thebill. To protect him or herself from personal liability, the individual should sign all documents,particularly the nursing home contract, as follows: Mary Smith by John James, power ofattorney. The caregiver should never sign just his or her own name. 18
  19. 19. For help with Medicaid issues you may contact the Area Agency on Aging and ask for help fromthe Legal Assistance services provided by the Area Agency on Aging.Patients with dementia are an isolated population in nursing facilities out of necessity. If apatient wanders, for he or she to be protected, placement is appropriate only in a nursing homethat has a locked unit to prevent the patient from wandering out of the facility and risking injury.A very important service for the patient and family members is the Long-Term CareOmbudsman, an individual who investigates complaints from patients and their legalrepresentatives concerning care in nursing home facilities. The Ombudsman for the SouthCentral Alabama Development Commission, Area Agency on Aging can be contacted forassistance at the agency contact number provided at the beginning of this resource guide. ConclusionAccording to the Administration on Aging (AOA):“The older population--persons 65 years or older--numbered 39.6 million in 2009 (the latestyear for which data is available). They represented 12.9% of the U.S. population, about one inevery eight Americans. By 2030, there will be about 72.1 million older persons, more than twicetheir number in 2000. People 65+ represented 12.4% of the population in the year 2000 but areexpected to grow to be 19% of the population by 2030.”These are staggering numbers that reveal how important long-term care issues are now andhow the importance of these issues will grow in the next few decades. Imagine a populationconsisting of almost one-fifth needing long-term care. Imagine, at a bare minimum, onechild/grandchild and his or her spouse for each senior needing care. Even with such a modestprojection, over half of the population would be struggling with long-term care issues by 2030.While finding long-term care now is an urgent need for those with aging familymembers, eventually that urgent need will be shared by more and more of the population.Home and community based care will likely become more necessary as greater numbers ofseniors need assistance with activities of daily life while governmental budgets shrink. This isthe time to learn as much as possible, coordinate resources and plan creatively for the futurechallenge.To learn more about Alabama’s senior and disabled persons network of services, visit the website of Alabama Department of Senior Services (ADSS) at the following address:http://www.alabamaageline.gov/To learn more about what your Area Agency on Aging can do to assist you, visit the web sitefor South Central Alabama Development Commission (SCADC) at the following address: http://scadc.net/.For individual help, contact the program you need through the contact information provided atthe beginning of this resource guide entitled “SCADC Contact Information.” 19
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