What is the difference between Continuing Care and Skilled Care?

Question:  My sister and I are caregivers to our mother and have been for quite some time.  However, we still don’t understand what the difference is between Continuing Care and Skilled Care.  Would you please define these two elder care terms for us?

Answer:  Skilled care is ideal for patients who cannot live independently due to fairly pronounced physical or cognitive ailments.  Although the level of care delivered is not the same degree as in an acute care situation that necessitates a hospital visit, a patient receiving skilled care must generally be monitored by a team of skilled nurse providers and other health team members, twenty-four hours a day.  The most common location for a patient to receive skilled care is in a nursing home, which is now commonly referred to as a skilled nursing facility (“SNF”). 

In contrast, the term “continuing care” generally refers to care provided in some sort of a facility that can accommodate a wide variety of capabilities in its residents – ranging from complete independence to a need for quite a bit of care and assistance.  There are now many so-called continuing care retirement communities (“CCRC’s”) that offer this sort of spectrum of care to residents.  In a CCRC, seniors can “age in place,” meaning the resident does not need to relocate when their deteriorating health means an increasing level of care is required.  That can give residents a sense of comfort and can decrease their anxiety about what will happen in a health crisis. 

Sometimes, a health issue is so pronounced there is no other option than for a brief of long-term residency in a SNF, since a CCRC may have an upper limit to the level of care they are equipped to handle.  Sometimes, a CCRC may have a separate portion of the facility that is effectively its own skilled nursing facility.  There, a resident may be able to stay in their original residence from full independence up until assisted living, but then relocate when skilled nursing is required.  A small move to a different area within the same facility would likely be less traumatic than relocation to an entirely different, unfamiliar SNF. 

What are the advantages and disadvantages of a CCRC?  The obvious advantage is the desirability of living somewhere where the resident can likely receive whatever type of care they need for the near foreseeable future.  Because many residents in a CCRC need little or no care, it will be easier to participate in activities to stay active and to find peers with which to socialize.  The main disadvantage of a CCRC is they can be quite expensive and they do not accept residents on Medicaid. 

What are the advantages and disadvantages to a skilled SNF?   The main “advantage” so to speak is a SNF may be the only place in which a resident can be taken care of properly.  For example, many CCRC’s simply cannot care for a resident who developed pronounced dementia, whereas many (but not all) SNF’s may be equipped for that sort of patient.  A disadvantage of SNF’s is that almost all the residents will be quite frail and/or very ill.  For a senior who is only moderately weak or having slight difficulties, it will probably be demoralizing to now be surrounded by the very sick.  

Financially speaking, the private pay cost for SNF’s are extremely expensive, so expensive that patients are unable to bear the costs out-of-pocket for very long.  However, almost all SNF’s can and do accept residents on Medicaid.  For those that have the financial means, and assuming a senior’s heath conditions permit it, residency in a CCRC can be highly desirable. 

The key point to bear in mind is it is undoubtedly advantageous to start planning for long-term care long before there is a health care crisis.  For some seniors, their primary concern is to make sure they are well-cared for, and in the residence setting they find most desirable.  Many seniors would also like to take steps to make sure the assets they have worked a lifetime to accumulate are not squandered unnecessarily.  I highly recommend that a senior and/or the family of a senior consult with a competent elder law attorney as soon as they can, when they are financially sound and they are in good health.  That is the ideal time to devise a good plan that addresses both health needs and financial issues, for the present and for the future, that is also flexible enough to be updated and adapted when family circumstances do change.

Henry C. Weatherby, Attorney at Law
Weatherby & Associates, PC
Bloomfield, Connecticut
Premium Member of the national ElderCare Matters Alliance, Connecticut chapter


Today’s Q&A on ElderCareMatters.com deals with options for Elder who has newly diagnosed Alzheimer’s Disease

Question:  “Help!  My mother has been diagnosed with Alzheimer’s Disease and my family and I have no idea how to proceed in helping her.  At what point do we consider nursing home care, and how will we afford this, etc??  Please provide us with some guidance as to how we should proceed and what our options may be.”

Answer:  The first place to start is with your mother’s doctor.  He will be in the best position to assess your mother’s need for long-term care.  This could be an immediate need or one that will develop over a period of time.  If the doctor feels that she needs immediate long-term care then he will complete the necessary paperwork to have your mother’s condition reviewed by the Medicaid people in your state.

Assuming that Medicaid agrees that your mother needs long-term care at this time, your next step is to sit down with an experienced Medicaid planning attorney.  The Medicaid planning attorney will review your mother’s legal documents –particularly her durable power of attorney- to make sure that they comply with current law.  Of course, if your mother is still married, then the attorney will review your Dad’s documents as well.  If not, then he will prepare a new durable power of attorney for her (again, she must be competent at this stage to avoid a guardianship proceeding) and perhaps your Dad as well.

The Medicaid planning attorney will review your mother’s monthly income and overall wealth to determine what type of Medicaid planning tools are needed to protect her estate.  If she has too much monthly income (over $2130 per month), then he will prepare a Qualified Income Trust to insure that she passes the income test.  If she received less than $2130 per month, then this step will be unnecessary.

Next, the attorney will review her assets.  As a Medicaid applicant she is only allowed to retain $2,000 in assets (cash or cash equivalents, stocks, bonds, etc.).  If excess assets exist, the attorney will look to see what other avenues are available to protect the remaining assets.  This may include a personal services contract, trusts for the benefit of a disabled adult or minor child, purchasing a pre-paid funeral contract, setting aside and designating a burial fund, purchasing a burial plot and arranging for and paying for the headstone.  There may be other purchases for clothing, etc. that may come into play to get her down to the $2,000.00 limit.  If Mom is married this will be somewhat easier as she can transfer property to your father without incurring a penalty.

Either your Mother’s doctor or the attorney that you pick to help you should be able to recommend the proper living environment for your mother.  I would suggest that you personally visit all of the facilities that are discussed to make sure that you get the proper fit for your mother.

The Medicaid application can be completed by any number of people.  Your attorney may do it, a paralegal can do it or someone at the assisted living facility or nursing home can do it for you.  The attorney and the paralegal, of course, will charge you for this work.  It is best to seek their help as they should have the needed experience to do it properly and to avoid the pitfalls that you might see.

As long as you put together a good team of doctor and attorney you should not find the application process to be all that difficult.  The difficulty usually comes up with searching for the back-up documents that support your answers on the Medicaid application.  Just remember that each application is different from the last one so do rely on the help of the individuals mentioned in this answer.

ElderCareMatters.com is a good resource to use to find Medicaid Planning Attorneys across America who can help you with these types of Elder Care Matters.

I. Michael Tucker, Attorney at Law
Law Office of I. Michael Tucker, PLC
Altamonte Springs, Florida  32701
Member of the national ElderCare Matters Alliance, Florida chapter


Attorney/Caregiver Encourages ALL Elder Care Professionals to be listed on ElderCareMatters.com

Question:  “I am not only an attorney, but also a member of a family that is struggling with a host of elder care matters, similar to what millions of other families across America are wrestling with.  With this in mind, I would appreciate it if you would let me know what I can do to help you encourage ALL Elder Care Professionals across America to be listed on this online Elder Care Directory.  In my opinion, ElderCareMatters.com is quite simply a wonderful resource to help all families across America with their elder care matters, including 1) finding elder care professionals near them,  2) finding useful elder care articles and 3) getting answers to a wide range of elder care questions.  Thank you for providing American families with this wonderful online Elder Care Directory.

Answer:  Thank you very much for your kind comments regarding ElderCareMatters.com.  It is our goal here at ElderCareMatters.com to provide ALL families across America with an easy to navigate online resource so that they can find competent, caring Elder Care Professionals near them as well as find useful Elder Care Articles plus get their questions about Elder Care Matters answered by some of America’s top Elder Care Professionals.

Although we now have tens of thousands of Elder Care Professionals listed on ElderCareMatters.com, we too believe that ALL Elder Care Professionals across America should be listed on this national online Elder Care Directory.  With this goal in mind, any assistance you can provide us in “getting the word out” within your state to encourage ALL Elder Care Professionals to get listed on ElderCareMatters.com would be appreciated, not only by us but also by the tens of thousands of American families who rely on ElderCareMatters.com every month to help them plan for and/or deal with their family’s elder care matters.

Phillip G. Sanders, MBA, MSHA, CPA
Founder of ElderCareMatters.com – America’s online Directory of Elder Care Resources


Today’s Q&A on ElderCareMatters.com is about the VA covering nursing home care?

Question:  Does the VA cover nursing home care?

Answer:  The Department of Veterans Affairs (VA) may provide long-term care for service-related disabilities or for certain eligible veterans. There might be a waiting list for VA nursing homes. The VA also provides some at-home care. The V.A. provides nursing home and other long-term care — the V.A. calls it “extended care” — for many veterans. Nursing home care can be provided in VA or private nursing homes for veterans who are in need of care, but are not acutely ill and not in need of hospital care. Priority is given to veterans with service-connected disabilities. If space and resources are available, other veterans may be considered. Veterans who do not have service-connected disabilities for which they’re entitled to compensation must agree to make a co-payment. They furnish a financial statement, and VA establishes a co-payment based on that information.

To be eligible for nursing home care, you must be enrolled in the VA health care system or be eligible for VA health care without the need to enroll.

Those eligible for V.A. nursing home or non-institutional long-term care include:

  • Veterans with a service-connected disability rating (or combined disability ratings) of 70 percent or higher.
  • Veterans with a 60-percent service-connected disability rating who are unemployable, or who have a rating of “permanent and totally disabled.”
  • Veterans with a service-connected disability that’s clinically determined to require nursing home care.
  • Veterans who require nursing home care for any nonservice-connected disability and who meet income and asset criteria.
  • Other veterans on a case-by-case basis, with priority given to veterans with service-connected disabilities and those who need care for post-acute rehabilitation, respite, hospice, geriatric evaluation and management, or spinal cord injury.

In addition, Veterans who do not qualify for extended care may receive Aid and Attendance from the VA, which is a different program with different criteria.  This program is designed to help veterans stay in their homes instead of going to a nursing home.  Unfortunately, the amount a Veteran can receive in Aid and Attendance is insufficient to pay for skilled care. At that point it is frequently necessary for the Veteran to transition to Medicaid for payment of Nursing Home Care.

If you have additional questions about VA benefits, you may want to talk with an attorney near you about this Elder Care Matter, many of whom can be found on ElderCareMatters.com. 

James C. Siebert, Esq.
The Law Office of James C. Siebert & Associates
Arlington Heights, Illinois  60004
Member of the national ElderCare Matters Alliance, Illinois chapter


Today’s Q&A on ElderCareMatters.com is about Appealing Medicaid Denials

Question:  The state has denied my mother’s request to receive long term care Medicaid benefits.  Is there any way we can appeal this decision, and how would we go about doing this?

Answer:  You have the right to appeal the decision denying your mother’s Medicaid.  I cannot answer as to the exact procedures for any state other than Illinois. It is extremely important that you act immediately, because you generally have a very limited time in which to file your appeal. In Illinois, the Decision form which the State sends out has the specific instructions regarding the steps necessary to appeal the denial of benefits.  I do not know if that is also true in your State, but I would think there would be some explanation with the decision. I strongly recommend that you immediately hire an experienced Elder Law Attorney to represent your mother.  First the Attorney can evaluate the decision to see why benefits were denied. Frequently, when someone files an Application themselves or with the assistance of someone other than an Attorney, the application is completed incorrectly or insufficient information is provided to the State. In Illinois, the State will deny an application because it is incorrectly completed, does not contain the required back up documentation or you fail to provide the additional documentation the State requests within the time they give you, usually 10 days. These denials occur even though the applicant is entitled to Medicaid and would receive it if the application was done correctly.  Obviously, denial may also be because your mother does not qualify for Medicaid or because she has made improper transfers of assets which cause her disqualification. An Elder Law Attorney can advise you whether the reason for the denial is appealable or whether there are additional steps necessary to protect your mother’s interests. It is imperative that you act immediately and I cannot emphasize enough the importance of hiring an experienced Elder Law Attorney, many of whom can be found on ElderCareMatters.comAmerica’s #1 online Directory of Elder Care / Senior Care Resources.

James C. Siebert, Esq.
The Law Office of James C. Siebert & Associates
Arlington Heights, Illinois  60004
Member of the national ElderCare Matters Alliance, Illinois chapter


Today’s Q&A on ElderCareMatters.com is about Medicare’s rules regarding payment for ambulance services

Question:  My brother has Medicare as his primary insurer and Plan F as his Secondary Supplement (Mutual of Omaha).  He has congestive heart failure, requires oxygen, kidney failure, problems with vision, diabetes and is unable to walk.  He is confined to his home.  His wife provides his care. He is unable to ride in a car.  He cannot walk or support himself to get in and out of car and he needs supervision and oxygen when making a trip. He also requires a bariatric stretcher due to his weight.  He has dialysis three days a week and Medicare provides ambulance service to and from the facility due to medical necessity.  If he has any type of surgery, Medicare provides an ambulance.  When he goes for a follow up visit after surgery or when he has an appointment with a specialist, the ambulance service states that Medicare will not pay under any circumstances.  I have called Medicare and received conflicting answers to this question.  I need clarification.  I have also received conflicting answers from different ambulance services.  He lives in a small town and there is only one ambulance service available with a bariatric stretcher.  How does a person who cannot ride in a car get ambulance service for follow up appointments after surgery and to specialist’s offices when needed?  He has had two cataracts removed and needs to see an ophthalmologist that is about 43 miles from his home.  What are our options?  He is unable to pay for this service himself and from what I read on the Medicare site, the ambulance trip should be covered if medically necessary.  Any help would be appreciated.

Answer:  The rules regarding Medicare payment for ambulance services can be complex. Medicare will pay for the emergency transportation to a hospital or a skilled nursing facility when other transportation could endanger your health.  Medicare will also cover ambulance services in certain specific circumstances, one of which is if you have End-Stage Renal Disease, need dialysis, and need ambulance transportation to or from a dialysis facility because other transportation could endanger your health.  That is why your brother receives the services when going for dialysis.  

In addition, in some cases, non-emergency ambulance transportation may be provided when you need ambulance transportation to diagnose or treat your health condition and use of any other transportation method could endanger your health.  Medicare may cover limited non-emergency ambulance transportation if you have a statement from your doctor stating that ambulance transportation is necessary due to your medical condition. This would seem to apply to your brother cannot ride in a car and needs an ambulance with a bariatric stretcher.  The ambulance company needs to fully document why your brother needs the ambulance transportation.  If it fails to properly document it, Medicare will deny coverage.  If this happens, contact the doctor who treated you or the discharge social worker at the hospital to get more information about your need for ambulance transportation.  Then have the ambulance company resubmit the bill to Medicare. If you or anyone else needs more information regarding what Medicare covers regarding ambulance services, Medicare has a publication on the subject at www.medicare.gov/Pubs/pdf/11021.pdf. Good luck.

James C. Siebert, Esq.
The Law Office of James C. Siebert & Associates
Arlington Heights, IL  60004
Member of the national ElderCare Matters Alliance, Illinois chapter

 


Update on changes in the VA’s Aid & Attendance Program

Question:  My family and I read with interest last week’s update regarding proposed 2013 changes to the VA’s Aid & Attendance program, and we were wondering whether you could provide us with an update as to where these proposed changes actually stand.  Have any of these changes been implemented (and if yes, when), and if they have recently been changed, will we need to re-do the VA Aid & Attendance application that we submitted just last month for our 87 year old mother?

Answer:  The changes have been proposed by Congress.  I believe they are currently in committee.  There are several organizations that are concerned about the proposed 3 year look back.  What we know at this point is if they happen they will not take effect until next year.  However, this is no guarantee that they will not be effective immediately.  There have also been some recent changes in regard to annual reporting commonly called an EVR.  The VA has eliminated the need to provide the annual report.

The VA has also made the rules pertaining to unreimbursed medical expenses stricter with respect to Independent Living Facilities providing care through 3rd party companies.   The have differentiated between an ADL (activity of daily living) and an IADL (instrumental activity of daily living).  Specifically, the VA is now requiring among other requirements, assistance with 2 ADL’s; walking/transferring; eating; bathing; dressing and toileting and cognitively impaired.    IADL’s no longer count as an ADL such as medication reminders, meal preparation, laundry etc…

As for submitting a new application I do not believe it is necessary at this time.  However, the VA has developed a new form for a Veteran and surviving Spouse of a Veteran called a Fully Developed Claim.

Hope this helps.

Don L. Rosenberg, Attorney and Counselor
The Center for Elder Law
Troy, Michigan
Member of the national ElderCare Matters Alliance, Michigan chapter


Today’s Q&A on ElderCareMatters.com is about the VA requiring a 3 year look-back period

Question:  We are about to begin the process of filling out the VA Application Form for Aid and Attendance for our 83 year old mother. However, we now understand that the Veteran’s Administration recently changed some of the rules; for example, they have changed what they consider to be an “unreimbursed medical expense.”  Can you please share with us any other substantive changes made by the VA that may impact families like ours who desperately need this additional money for our elderly parents?

Answer:  Changes that benefit all current beneficiaries in 2013 include a cost of living upward adjustment in the monthly rate paid on the VA Aid and Attendance Benefit.  However, other changes are in the pipeline for prospective applicants for the VA Aid and Attendance Benefit.  On June 7, 2012, the U.S. Senate Special Committee on Aging held a hearing regarding the VA’s Aid and Attendance program.  The purpose of the hearing was to examine the extent to which the spirit of the program is fulfilled, namely to cover the long-term care costs for veterans of limited means and their spouses.  Senators Richard Burr (R-NC) and Ron Wyden (D-OR) are introducing new legislation to limit the extent to which veterans of more substantial means are receiving the benefit.  The most significant proposed change in the piece of legislation is that the VA would require a look-back period for applicants applying for the Aid and Attendance program as Medicaid currently does now, which will be three years.  The look-back period for Medicaid is five years.  In response to this legislation, the Veterans Administration also stated that they are drafting regulations to impose the 3-year look back period.    Other changes being examined include determining when specific types of assets such as annuities, trusts, and private retirement income should be considered in determining net worth.   One positive change for prospective applicants is the streamlining of the application process, including but not limited to, developing a consumer guide to help prospective applicants better understand the program.

James J. Ruggiero, Jr., Esq., AEP
Ruggiero Law Offices, LLC
Paoli, Pennsylvania  19301
610-889-0288
Member of the national ElderCare Matters Panel of Experts
Premium Member of the ElderCare Matters Alliance, Pennsylvania chapter

 


Today's Question of the Day on ElderCareMatters.com is Answered by Two (2) Elder Care Experts

Question:  “My 80 year-old, widowed mother is selling her large home and plans to move into a smaller, more manageable residence.  She hopes to be able to stay in her new home the rest of her life. She is in reasonably good health at this time and has long term health care insurance to help pay for future needs. She has a comfortable savings, but is not wealthy.  Half of her assets have been placed in a trust and the remainder is available for her use.  With the sale of her current home she will be able to buy her new home without taking out a mortgage, but we do not know if that is the best option.  What advantages/disadvantages are there to her paying-in-full for her new home or getting a mortgage?  Should the new residence be purchased by the trust?  Is there any reason she should rent versus buy? Any suggestions will be appreciated.”

Answer:  Hello and thank you for your question.  It is wonderful that Mom is still going strong and has planned well for her later years. We see the majority of older American’s wanting to age in place and her long term care insurance will be a great help to her when she needs the in home assistance.  There is not a standard answer to the question of mortgage vs. no mortgage or rent vs. buy and is individual for each person and/or family.   Here are some thoughts/questions for comparison purposes to assist you in choosing the best solution for Mom.  What are the closing costs related to having a conventional mortgage vs. a cash transaction, how much cash down payment was used, what is the monthly payment with taking a conventional mortgage, what is the property tax amount, homeowners insurance amount and if applicable, a homeowners association fee, does the use of this cash have an impact on any cash reserve for an unseen emergency, how does the monthly payment of rent compare to a mortgage payment- is it less or more and last but not least, who will assist Mom in the maintenance required in homeownership.  Perhaps a family discussion with Mom will help clarify everyone’s understanding of the differences. The real estate property can be put into the trust with either a mortgage or cash transaction and is subject to lender approval if obtaining a mortgage.

Laurie A. Libby, Reverse Mortgage Advisor
Genworth Home Equity Access, Inc.
Irvine, California  92614
Member of the national ElderCare Matters Alliance, California chapter

 

Answer:  Your Mother is lucky to have so many options. It is difficult to give you an answer to such a broad question without some additional information. I will assume a few things in order to give you a general answer.

The first assumption I am going to make is that the Trust you are referring to is an Irrevocable Trust instead of a Revocable Trust. I am making that assumption since you have indicated that half of her money is in the Trust and the other half is available for her use. If the Trust was a standard Revocable or Living Trust the assets and monies held within the Trust would be available for your Mother’s use. On the other hand if you had some asset protection planning done in the past with an Elder Law Attorney the creation and funding of the Irrevocable Trust would protect that half of her assets from both Probate and from Long Term care costs; however the principal of the Trust would not be available to your Mother.  I am also going to assume that you mean your Mother has long term care insurance, and not simply health insurance. If it is long term care insurance, it will pay for her care up to a set dollar figure per day for a number of years, typically 3 to 5 years.  This is a very important distinction, since if she only has health insurance, such as Medicare Part A and part B, along with a Supplemental insurance policy, that insurance will cover her medical needs and hospitalization, but not long term care costs beyond the 100 days of Medicare rehabilitation.  The availability of Long Term Care Insurance makes Asset Protection planning easier to accomplish even for a person of limited means. It is important that you confirm that your Mother’s Trust is an Irrevocable Trust and that she does in fact have long term care insurance.

Assuming it is an Irrevocable Trust, and that your Mother does have long term care insurance, and then you may want to purchase the house outright and place it along with a certain amount of the proceeds or other assets into the Irrevocable Trust. You need to have an analysis completed by an Elder Law Attorney to confirm that your mother will have sufficient funds for her care to cover the look back period which is currently 5 years, so that if she needs to apply for Medicaid she can do so without a penalty period.

I strongly recommend that you retain an Elder Law Attorney prior to deciding on how to proceed. If done correctly your Mother will be able to protect some assets for you and the rest of the family, while making sure that she is never left unprotected. However, these are complex analyses which require a great deal more information than you have provided.  If done incorrectly you could jeopardize your mother’s potential care. I suggest that you look on ElderCareMatters.com to find the name of an experienced Elder Law Attorney in your area.

James C. Siebert, Esq.
The Law Office of James C. Siebert & Associates
Arlington Heights, Illinois  60004
Member of the national ElderCare Matters Alliance, Illinois chapter


Hawaii Elder Law Attorney Suggests Alternative Approach to Yesterday’s Q&A: Mediation

Question:  “My mother is 91 years old and has Dementia/Alzheimer’s. She does not know how to read or write, but recently she apparently granted Power of Attorney for her finances to my elder sibling. This was done in secrecy and did not take the rest of the family into consideration. Now my sibling has taken over my mother’s house and her bank funds and has placed my mother in a nursing home where she is kept overmedicated.  I’m concerned about how something like this could have happened.  Is there anything I and the rest of my family can do now to have this Legal Directive reversed?

Answer:  This is a heart-wrenching scenario that is played out in countless families every day across America.  There is a legal approach to the problem that could be expensive, could worsen your current family dynamics, and could take longer than your 91-year-old mother has left.  It would involve securing medical opinions concerning your mother’s current capacity to sign legal documents (and, as precisely as they can tell you, when she lost legal capacity), appointment of a legal representative for your mother, and unwinding the asset transfers and other things your sibling has done.  The term used for the legal representative may be guardian or it may be conservator, depending on where you live.  You will need an experienced attorney in your State to guide you through the process and represent you in court.

Before you go down that road, consider bringing all of your siblings and other interested family members together to talk about what has been done and why.  The answers to those questions may surprise you.  More importantly, the family may find a way to move forward in a unified manner that meets your mother’s needs and at the same time preserves (or mends) family harmony.  You may find that a trained mediator can help your family members explain their positions and understand each other’s positions.  The mediator could be a pastor, a counselor, a lawyer, or a trusted family member or friend who may or may not fit into any of those categories.  If no one comes to mind, there may be a Neighborhood Justice Center or similar service in your area that can provide mediation services.  This is an alternative worth exploring, and, if it is unsuccessful, it will not prevent you from pursuing the kind of legal approach outlined above.

Scott A. Makuakane, Esq., CFP
Est8Planning Counsel LLLC
Honolulu, Hawaii  96813
State Coordinator of the national ElderCare Matters Alliance, Hawaii chapter


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