Talking to my children about getting old

I’m 66.  I’m fortunate that my health is pretty good and that I’m still working and living an active, and (I think) productive and full life.  But I can feel the aging taking place in me – in my vision and hearing and those aches that have developed in various parts of my body.  And I know that the time has come, perhaps it is well past time, for me to get together with my children and talk about issues relating to my aging. 

Some people refer to this as “the conversation” and dread it. But given my life experience as an elder law attorney, and as former child of aging parents, I recognize that it’s better to prepare the ground for the future.  I know that problems can be avoided and burdens reduced if families plan in advance.  
  

I’m not saying that the time has already come for my children to step in – it’s too early for that. When children try to take over too early it can lead to embarrassment and humiliation for the parent.  But it is time to prepare for the future day when they may need to step in – and to give them the tools and advance support that they will need. It’s time for my children to gain at least some awareness of my financial, estate planning, and health care arrangements. 

So the time has come to start “the conversation” – which I don’t see as a single event but as an ongoing dialogue that will continue over the coming years. Our lives and circumstances and attitudes change over time.  If I get there, I expect that my perspective on life will be very different at age 90. Certainly my health and financial situations will have changed.  I need to keep my children updated. 

But, of course, care dependency due to accident or illness can arise suddenly at any time. Whenever it might occur, I know that my long term illness would affect my whole family.  My children would have to step into new caregiver and care advocate roles.  It would be a big transition for them that I know will go much more smoothly if our family has prepared in advance.

Emotionally, these are difficult issues for parents to discuss with children.  No one likes to think that a day may come when they won’t be able to manage their finances or make other decisions. And many parents do not want to disclose information about their finances and other personal matters to their children. Moreover, discussion of such topics usually makes both the parent and the children uneasy. As a result, many families don’t talk about these issues until a crisis occurs; then, unfortunately, it may be too late.

But there are many potential advantages to having the conversation and planning in advance.  We can:

·       Give our children the opportunity to know what we want and don’t want.

·       Limit the possibility that our children will step in too soon;

·       Reduce future emotional pain for our family;

·       Increase our potential to remain independent and in control of our lives for as long as possible;

·       Give our children the legal powers they will need if they ever do have to step in;

·       Reduce the stress and anxiety involved if our children have to make difficult decisions during a time of crisis;

·       Reduce financial problems and losses and protect our financial security;

·       Help ensure that the right person will be making the right decisions for us if we ever lose the capacity to make decisions ourselves;

·       Increase the potential that we will always be treated with dignity and respect;

·       Reduce the potential for family disagreements;

·       Protect our assets from the cost of any care we may need;

·       Help ensure that our personal preferences and choices are known and will be followed;

·       Limit the potential involvement of courts and state protective service agencies in our lives. 

Children do not have to know everything about their parent’s lives.  They don’t need exact facts and figures.  But there are some key pieces of information that should be shared:

·       Financial Power of Attorney - Who is to serve as financial decision maker in the event of the parent’s incapacity?  Has a power of attorney been prepared to provide authorization? Where is the power of attorney document located? How can the family obtain it when needed?

·       Health Care Agent - Who should make health care decisions for the parent in the event of an accident or illness?  Where is the legal authorization located? Has the parent given instructions for treatment in the event of terminal illness or permanent coma?

·       Income, Assets and Debts - It is not necessary for the children to have a listing of the parent’s income and assets, but they should know where to get this information if it is ever needed.  If it is not provided to the children, it could be held by the parent’s lawyer, accountant, or a trusted friend. 

·       Health Insurance - children should be aware of their parent’s health insurance coverage including retirement benefits, Medicare, Medicaid, Veterans, and long term care insurance.

·       Wills, Trusts, and Life Insurance Policies.  The children should know where these documents are located. 

The best time to discuss future legal, financial and health care decisions is when the parent is healthy and competent.  When and where the initial conversation should take place and who should be present are issues you should consider in advance.  Some parents want to include as many family members as possible.  If so, a family get-together on a holiday may present a relaxed opportunity. 

Should all of the children be included?  Should children’s spouses be present as well? Your answers will vary depending on your family situation.  As a general rule, it is helpful if you can include all of the children in the meeting.  Excluding a child may only cause problems later.  If the family situation is tense, you may want to include the parent’s lawyer or financial advisor in the meeting. The presence of this professional “outsider” can help keep things objective and more businesslike.  

Often it is the children who are most hesitant to begin the conversation with their parents.  It is only natural to want to postpone thinking about difficult issues - life without the parent or a parent who needs care.  Children who were once so dependent on the parent may have difficulty accepting the reality that someday the roles may be reversed. 

Families can benefit greatly if they can overcome their natural reluctance to discuss and plan for the future.  Talking and planning in advance is a great kindness that parents and children can do for one another.  Someday it may be of immeasurable help to the entire family.  And there is one immediate benefit - after the discussion, everyone usually feels like an enormous burden has been lifted off their shoulders.    

{The picture included above is one of me and my children in 1981}

Aging Waiver Program can help Care Dependent Seniors remain at home

Some of us need help in carrying out the basic tasks that we require each day to care for ourselves. As we age, the risk of our needing such “long-term care” is likely to grow. But when we do need long-term care, we normally don’t want to move to a nursing home to get the help we need.  We want to remain in our own homes. We want to stay with our families and maintain our independence and dignity.

Unfortunately our long-term care system has long been structured to provide public financial support to us much more readily if we go to a nursing home. Now, the public financing system has begun to change, and both Pennsylvania and the federal government are trying to give people more of what they want—long-term care that is based at home or at least in the community, rather than in a nursing facility.

This article will describe one program that can help give frail seniors the support they need to stay in their homes and avoid the nursing home.  This program is commonly called the "Aging Waiver."   

What is the Aging Waiver Program

 

Pennsylvania receives federal Medicaid funding under programs that involve federal approval of “waivers” from standard Medicaid rules that allow states to provide long term care services to people in their homes. Pennsylvania has established many such Medicaid waiver programs.  A listing of them is available on the Department of Public Welfare’s website at: http://www.dpw.state.pa.us/ServicesPrograms/MedicalAssistance/003670306.htm. See also, "Pennsylvania's Home and Community Based Services Initiatives."

The waiver program that is of most significance for seniors is the Home and Community-Based Waiver for Individuals Aged 60 and Over (“Aging Waiver).” Seniors who would otherwise need nursing home care, but who can have their needs met at home, can obtain government financed services and support if they meet the program’s qualification requirements. 

The primary purpose of the Aging Waiver is to offer individuals the choice of receiving services in the community as an alternative to institutional care, and to achieve cost savings by delaying or avoiding institutionalization.

Aging Waiver services are provided at no cost, and no co-payments are required. However, the cost of services provided under the program are subject to Medicaid estate recovery. Fears of Medicaid estate recovery (which are often unwarranted) may deter individuals from applying for the Aging Waiver program, and consumers should discuss the potential for estate recovery with an elder law attorney to help alleviate these concerns.

To qualify for services provided under the Aging Waiver the applicant must meet Medicaid’s stringent financial and functional need requirements. The financial eligibility requirements for the Aging Waiver are similar to (but in some ways more restrictive than) Medicaid funded nursing facility care. Unlike qualification for nursing home care, the Aging Waiver recipient must normally have income below 300% of the federal poverty standard ($2,022 per month in 2011). 

The Aging Waiver program imposes the same functional (level of care) requirements as for Medicaid nursing facility services. This means that an applicant must be determined to require the level of care normally provided by a nursing facility.

Overall administration of the Aging Waiver resides with the Office of Long Term Living(OLTL).  Waiver enrollment and Level of Care determinations take place at the local Area Agency on Aging (AAA) with oversight by OLTL. 

Services are provided through qualified providers that are enrolled as Medical Assistance providers. The contracting AAA monitors its enrolled waiver providers. Federal law gives individuals who are denied Aging Waiver services (or their provider of choice) the right to request a Fair Hearing under 42 CFR §431 Subpart E. The same hearing rights apply if a Waiver recipient’s services are suspended or reduced or terminated.

AAA care managers are responsible for Aging Waiver service plan development with input from the participant. Care managers are required to ensure that participants are receiving care and services to prevent institutionalization in accordance with 42 CFR Section 441.301.

Pennsylvania’s Aging Waiver is a Medicaid Home and Community-Based Services (HCBS) waiver program authorized under §1915(c) of the Social Security Act. Federal approvals of waiver programs, including Pennsylvania’s Aging Waiver, are limited in time. Each five years Pennsylvania must seek federal approval to renew its Aging Waiver. A copy of the Pennsylvania Aging Waiver that was approved in December 2008 is available online at http://www.paelderlaw.com/pdf/Aging_Waiver_Renewal.pdf.

Eligibility

To be eligible for the Aging Waiver, the applicant must be a Pennsylvania resident age 60 or older, who is determined to be nursing facility clinically eligible, and who can be cared for safely at home. An applicant must meet all of the following requirements:

• be age 60 and older,

• reside in the county in which the application is filed,

• require a nursing facility level of care,

• meet the financial requirements, including spousal resource attribution rules; in general, the applicant must have income not exceeding 300 percent of the current Federal Benefit Rate ($2022 in 2011)  and $8,000.00 or less in countable assets,

• choose home care over facility placement.

Unlike Medicaid eligibility for care in a skilled nursing facility, the income of the applicant can often present an insurmountable barrier to qualification for Medicaid financed home care under the Aging Waiver. This is because the medical “spend-down” to eligibility rules that are  applicable in the nursing facility context are not applicable for applicants seeking home care under the Aging Waiver.  Note that the income of the spouse of an applicant is not considered in determining income eligibility for the Aging Waiver. 

Medicaid transfer penalty rules apply to the Aging Waiver. Planning options to accelerate financial qualification for the Aging Waiver program are similar to those that apply to residents of nursing homes. Medicaid Estate Recovery rules also apply.

 

In order to qualify for the Aging Waiver Program the applicant must be assessed and determined to be clinically eligible for nursing facility care, but able to be cared for safely at home. The level of care determination is made through an assessment conducted by the Area Agency on Aging or its representative.

Services Provided Under the Aging Waiver Program

Following a complete assessment to determine eligibility, an area agency on aging care manager designs a care plan with the consumer and his or her representatives. The care manager will thereafter monitor the home services.

Upon enrollment in the waiver program, the care manager provides the consumer with listings of the providers who are included in the plan and certified by DPW to provide the home services. Consumers are able to choose which of the listed agencies they want to provide services. The following are some of the services that may be available to help individuals remain at home:

• home-delivered meals

• personal care

• cleaning/laundry/home support services

• home modifications

• home medical supplies

• caregiver respite services

• emergency response systems

• transportation

• physical, occupational, and speech therapy

• adult day care

• home-health aides/companion services

• registered nurses

An applicant receiving hospice benefits can also qualify for the Aging Waiver program.

The Aging Waiver program can help you reside in your home, where you want to be, rather than in a nursing home. If you are a senior who lives in Pennsylvania, the experienced elder law attorneys at Marshall, Parker and Associates, can answer your questions and help you find the best way to qualify for the Aging Waiver, LIFE, and other programs that can help you stay in your home.  

CMS proposes new regulations for Medicare Advantage Plans and Medicare Prescription Drug Plans

The Federal Government’s Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to revise the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations. The rule applies provisions of the Health Reform law to Medicare Advantage Plans and the Medicare prescription drug program.   

The new regulation will give CMS authority to terminate Part C and Part D sponsors which perform poorly. CMS says that the rule will also strengthen beneficiary protections; improve program efficiencies; and clarify program requirements. CMS is also considering changes to the long term care facility conditions of participation pertaining to pharmacy services.

CMS is the federal regulatory agency that administers the Medicare program and works in partnership with state governments to administer Medicaid and the State Children's Health Insurance Program (SCHIP) program. Regulatory agencies like CMS must create regulations according to processes specified in the Administration Procedure Act (APA). The APA requires agencies to publish all proposed new regulations in the Federal Register for at least 30 days before they take effect, and to allow interested parties to comment. CMS is allowing a 60 days comment period for this new Part C and Part D proposed rule. 

Joe Baker, President of the Medicare Rights Center issued a press release offering initial support for the new rule, which he says “supports continued improvements to consumer protections and quality of care in Medicare Advantage and under the Medicare prescription drug benefit, as outlined in new proposed rules from the Centers for Medicare & Medicaid Services (CMS). The rules strengthen CMS’s oversight ability and raise the quality bar by, for example, allowing the agency to terminate plans with consistently poor performance. Inspired by the experiences of the Medicare beneficiaries we counsel, who often find the private Medicare market overwhelming and difficult to navigate, the Medicare Rights Center has been a long-time advocate for policies that create meaningful, understandable choices for people with Medicare. We believe this policy improves the beneficiary experience by emphasizing the importance of the quality—rather than the quantity—of plans available.   

Also of note, the rules aim to eliminate conflicts of interest that create waste and harmful incentives to inappropriately prescribe prescription drugs in long-term care facilities. This will help protect patients whose safety is at risk as a result of improperly prescribed powerful drugs, such as anti-psychotics.”  

The proposed rule is available at http://www.ofr.gov/OFRUpload/OFRData/2011-25844_PI.pdf.  

Related post: Changes Coming to Medicare Advantage Plans

Family Caregiver Support Bill amended in Pennsylvania House

On October 4, 2011 a bill to update Pennsylvania's Family Caregiver Support Program was amended in the Pennsylvania House.The following day, October 5th, the amended bill HB 210 was passed unanimously by the House.

Prior to the amendment, HB 210 would have increased the maximum funding assistance from $200 to $600 monthly for basic costs and from $2,000 to $6,000 total for home modifications such as grab bars and wheelchair ramps.

The amendment effectively makes 4 changes:

1)   It returns the normal maximum reimbursement to $200 monthly for basic costs;

2)     It adds a provision that the basic monthly reimbursement amount may be increased above the $200 norm in cases where there is a demonstrated need;

3)     However, it provides that monthly reimbursement is limited to $200 for any AAA whose average monthly reimbursement exceeds $300 across its entire caregiver support caseload;

4)     It reduces the home modification total funding maximum from $6,000 back to $2,000.

For other posts on Family Caregiver Support in Pennsylvania, see:

Pennsylvania needs to update Caregiver Support Law 

Pennsylvania Scores Poorly in Support of Caregivers and Affordability of Long-Term Care

Social Security payments to increase in 2012

The Social Security Administration has announced that monthly Social Security and Supplemental Security Income (SSI) benefits for more than 60 million Americans will increase 3.6 percent in 2012.

The 3.6 percent cost-of-living adjustment (COLA) will begin with benefits that nearly 55 million Social Security beneficiaries receive in January 2012. Increased payments to more than 8 million SSI beneficiaries will begin on December 30, 2011.

The COLA is usually determined by comparing the third-quarter consumer price index with the previous year’s third quarter. However, this year the comparison will be with the third quarter of 2008.  Monthly Social Security and Supplemental Security Income (SSI) benefits did not automatically increase in 2010 or 2011 since there was no increase in the Consumer Price Index from the third quarter of 2008, the last year a COLA was determined. See the social Security Information Fact Sheet at http://www.ssa.gov/pressoffice/factsheets/colafacts2011.pdf. 

Unfortunately, the benefits of the COLA increase in 2012 may be offset by an increase in Medicare premiums. 

More Information:

AARP Bulletin: Social Security COLA Increase Likely
Washington Post: Federal retirees to get COLA increase
Washington Post:  Not so fast — higher Medicare premiums could erase part of Social Security increase

LIFE program can keep frail seniors at home

The LIFE program provides health-care and supportive services for older persons who are certified to need a nursing home level of care but are able to live safely at home. If you have limited financial resources and your income is within 300 percent of the Federal Benefit Rate (currently $2,022 per month) your participation in the LIFE program may be fully covered by a combination of Medicaid and Medicare.

On a national level, this wonderful but little known program is referred to as PACE (Program of All-inclusive Care for the Elderly). The name was changed in Pennsylvania to avoid confusion with our state pharmaceutical assistance program. The Pennsylvania program is generally referred to as LIFE (Living Independently For Elders).

The LIFE program brings together all the medical and social services needed to provide community-based care for seniors who are frail enough to meet the Medicaid standards for nursing-home care. The program is designed to meet all of its participants health related needs. You are generally provided with transportation to and from your home to an adult day health center where you can participate in activities and medical appointments. However, services may also be given in your home, a hospital, or a long term care facility where necessary.

Because the LIFE interdisciplinary health care team authorizes and coordinates all your health care services, the program becomes a one-stop alternative that simplifies your access to health care. And increased coordination of your care can result in improved quality of that care.

The Balanced Budget Act of 1997 established the PACE model as a permanent provider type under both the Medicare and Medicaid programs. Most LIFE participants are eligible to receive services under both Medicare and Medicaid. The joint funding sources may be sufficient to provide total care for dually eligible beneficiaries.

Like another home care alternative - the Aging Waiver Program, LIFE serves individuals who are 60 years of age or older, who would otherwise qualify clinically to be in a nursing facility, but who choose instead to remain in their homes with the support of LIFE program services. (The age threshold for LIFE can be reduced to age 55 depending on the program). Clinical eligibility for participation in LIFE programs is determined through an assessment done by the local Area Agency on Aging, in cooperation with the individual’s personal physician.

To qualify for Medicaid payment for LIFE services, the individual’s available income and available resources must be at or below 300% of the federal benefit rate. The available resource ceiling is $8,000. Limited “spend down” is available since the LIFE program rules do allow individuals with income in excess of the ceiling to qualify for partial Medicaid funding by paying a monthly share of the cost of LIFE services, with Medicaid paying the monthly remainder. If an individual wishes to pay privately for participation in the LIFE program, his/her monthly premium is equal to that amount that would otherwise be paid by Medicaid.

Enrollment is voluntary. Once enrolled, PACE becomes the sole source of all Medicare and Medicaid covered services, as well as other medical, social, or rehabilitation services required by the enrollee. If an enrollee requires placement in a nursing home, the LIFE provider is responsible for the cost of care. An enrollee’s needs are determined by PACE’s team of care providers, which includes primary care physicians, nurses, therapists, social workers, personal care attendants, dieticans, and drivers.

With capitation plans like PACE, providers receive a flat monthly fee in return for covering the entire spectrum of care for enrollees from acute to long-term. The payment does not vary no matter how many services are provided. This provides a strong incentive for the LIFE program to keep its participants healthy.
Pennsylvania has the most vigorous PACE program of any state. People can thrive under the program. But many seniors are unaware of or don't understand the value of the LIFE alternative. And, depending on where you live, it may not be an option for you. As of September 2011, LIFE is available in many but not all geographic areas of Pennsylvania. A list of areas and providers is available on the Department of Aging website, http://www.portal.state.pa.us/portal/server.pt?open=514&objID=733117&mode=2.

For Further Information:
 
National information about PACE is available on the National Pace Association website at www.npaonline.org.
 
A USA Today article featured the PACE program: No need for nursing home if PACE handles senior care