Achieving a Better Life Experience (ABLE) Act Would Create Tax-free Accounts for the Disabled

Sara Wolff (center) is calling on Congress to allow disabled
 Americans to save and still receive benefits like
 Social Security Disability Insurance payments and Medicaid.

Many families struggle with planning for the future of a child with severe disabilities. While they are able to save for the educational needs of their other children through “529” college tuition plans, these plans do not fit well the needs of a child with severe disabilities.  The disabled child may, now, or in adulthood, need the long term services and supports of the Medicaid program and/or the income assistance of the Supplemental Security Income (SSI) program.  Since the child may live for many decades beyond the ability of the parents to supplement the services they receive through Medicaid, most parents recognize the need for saving and securing funds for the child.  Others want to ensure the financial security of a disabled child who has a level of disability required for Medicaid eligibility, but for now, is managing to function without the use of those benefits. Still others want to ensure that their family member can exercise control over the funds in the account without endangering the Medicaid and SSI benefits on which they may rely.

Although Supplemental Needs Trusts and/or Wholly Discretionary Trusts for Special Needs offer a savings solution, many families have found it too expensive to establish a trust which meets the requirements of the Medicaid and SSI programs.  While many attorneys will prepare these for reduced fees for those in need, it is not uncommon to pay five to ten thousand dollars for these solutions.  The ABLE Act (S.313 / H.R.647) would give individuals with disabilities and their families access to accounts that would allow individual choice and control while protecting eligibility for Medicaid, SSI, and other important federal benefits for people with disabilities.

The Senate Finance subcommittee on taxation and IRS oversight may have never heard testimony from someone quite like Sara Wolff.  Ms. Wolff, 31, was born with Down syndrome, but that hasn’t stopped her from becoming involved in politics. She testified before the subcommittee on the Achieving a Better Life Experience (ABLE) Act, which would create tax-free savings accounts for those with disabilities. Earlier this year, she wrote a change.org petition calling on Congress to pass the ABLE Act. The petition garnered more than 250,000 online signatures.

“Just because I have Down syndrome, that shouldn’t hold me back from achieving my full potential in life,” Ms. Wolff of Moscow, Pa., said in a statement. “I can work a full-time job, be a productive member of society, and pay taxes – but because of outdated laws placed on individuals with disabilities, we hold people like me back in life.”

Ms Wolf is also a board member of the National Down Syndrome Society (NDSS), which is championing the bipartisan legislation. The Senate bill is sponsored by Sen. Robert Casey, Pennsylvania Democrat, and Sen. Richard Burr, North Carolina Republican.  Support for the House bill is being led by Rep. Ander Crenshaw, Florida Republican; Rep. Cathy McMorris Rodgers, Washington Republican; Rep. Pete Sessions, Texas Republican; and Rep. Chris Van Hollen, Maryland Democrat.

“The bill aims to ease financial strains faced by individuals with disabilities by making tax-free savings accounts available to cover qualified expenses such as education, housing and transportation,” said an NDSS statement.

Ms. McMorris Rodgers, whose seven-year-old son Cole has Down syndrome, called on Congress to “advance this crucial legislation.”  “As the mom of a son with Down syndrome, I see firsthand how federal policies limit—not expand— opportunities for those with disabilities.  And the ABLE Act will change that,” said Ms. McMorris Rodgers in a statement. “It will make sure that Cole — and the millions like him who have special needs — will be able to save for their futures and reach their full potential.”

The ABLE Act  has 74 Senate co-sponsors, including Senate Majority Leader Harry Reid and GOP Minority Leader Mitch McConnell.  “Passing this landmark legislation will go a long way to help people with Down syndrome and other disabilities realize and achieve their own hopes, dreams and aspirations,” NDSS Vice President of Advocacy and Affiliate Relations Sara Hart Weir said in a statement.

Members of the U.S. Senate said Friday, September 26th, that they have an agreement that will allow the Achieving a Better Life Experience, or ABLE, Act to proceed to the full Congress.  The bill’s chief sponsors and leaders of the Senate’s Committee on Finance said in a joint statement that they expect the legislation to be considered when Congress returns to Washington in November.

Under the measure, people with disabilities would be able to create special accounts at any financial institution where they could deposit up to $14,000 annually. The ABLE accounts could accrue up to $100,000 in savings without risking an individual’s eligibility for government benefits like Social Security. What’s more, Medicaid coverage could be retained no matter how much money is deposited in the proposed accounts.

Modeled after the popular 529 college savings plans, funds deposited in ABLE accounts could be used to pay for education, health care, transportation, housing and other expenses. Interest earned on savings within the accounts would be tax-free.

The ABLE Act has been under consideration in Congress since 2006.  It is time that this proposal was enacted into law.

If you want to follow this legislation, Autism Speaks will do that for you by clicking here.  

The National Disability Institute has useful information here.

You can sign Sara's petition here.

Read more: http://www.washingtontimes.com/news/2014/jul/22/act-would-create-tax-free-savings-accounts-disable/#ixzz38RqDdzBf

and http://www.disabilityscoop.com/2014/09/19/deal-savings-accounts/19689/

Preparing for Medicare Open Enrollment

Oct. 15 marks the start of Medicare's seven-week annual election period, when current beneficiaries can add, drop or switch prescription-drug plans and make other coverage changes.

In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.

In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.

The Affordable Care Act has sparked fears that Medicare Advantage plans, which cover about 30% of Medicare beneficiaries, will raise premiums, reduce benefits and pare their networks of doctors and hospitals. The reason: Under the law, Medicare will reduce payments to Medicare Advantage plans by some $156 billion by 2022, to bring per-person payments in line with those of traditional Medicare.

Citing the ACA, the nation's largest Medicare Advantage insurer, UnitedHealth Group, has cut an estimated 10% to 15% of the doctors and hospitals from its nationwide network. Consumer advocates say the insurer targeted providers with the sickest and most expensive patients, leaving patients in the middle of treatments in the lurch. The company says the changes enable it to better coordinate care and denies that patients in the middle of treatments are adversely affected, extending exceptions to members in active treatment.

Because some of the cuts occurred at times of the year when patients are unable to switch plans, Sen. Sherrod Brown (D., Ohio) and Rep. Rosa DeLauro (D., Conn.) recently introduced legislation that would bar insurers from dropping providers outside of Medicare's annual open-enrollment period.

Because Medicare Advantage can change annually, it's important to examine your options during open enrollment, from Oct. 15 to Dec. 7.  You should call your providers to make sure they still participate in your plan.  You can also use the "Plan Finder" tool at medicare.gov to compare premiums, copayments and deductibles for Part D prescription-drug plans in your area.

During open enrollment, you can switch to either a Medicare Advantage plan or to traditional Medicare, which allows you to see any doctor who takes Medicare. From Jan. 1 to Feb. 14, Medicare Advantage participants may switch to traditional Medicare.

Medicare beneficiaries whose claims are denied should also know that, despite rising backlogs in Medicare's appeals system, two recent lawsuits indicate that those who press their cases have a good chance of success. The procedure differs depending on whether you're in traditional Medicare, a Medicare Advantage plan or a Part D prescription-drug plan. Typically, each appeal can be heard five times, the last time in a federal court.

Since 2010, success rates in the first two rounds of appeals of denied claims for home health-care coverage have plunged to 5% or less, according to a class-action lawsuit the nonprofit Center for Medicare Advocacy in Willimantic, Conn., filed on June 4 in the U.S. District Court in Connecticut against the Department of Health and Human Services, which oversees the agency that administers Medicare.

The center's director of litigation, Gill Deford, told the Wall Street Journal that consumers who want a "meaningful review of their Medicare claims" should continue to the third round of appeal—before an administrative law judge—where odds of success jump to 40% or more.

The average wait for a decision from an administrative law judge is 398 days, up from 95 days in 2009, according to HHS. In a federal lawsuit filed Aug. 26, also in Connecticut, the Center for Medicare Advocacy seeks to force the government to take steps so that appeals can be decided within the 90 days the Medicare statute requires.

When appealing, ask your doctor for a letter explaining why you need the treatment in question. Those who go before an administrative law judge may benefit from retaining a medical or legal advocate. Most State Health Insurance Assistance Programs provide free counseling.

This post is based upon a Wall Street Journal article which can be read here.

What Happens When We All Live to 100?

Gregg Easterbrook, contributing editor of The Atlantic has penned an excellent and thought-provoking article in What Happens When We All Live to 100? (the pictures accompanying the article are equally excellent):  

For millennia, if not for eons—anthropology continuously pushes backward the time of human origin—life expectancy was short. The few people who grew old were assumed, because of their years, to have won the favor of the gods. The typical person was fortunate to reach 40.

Beginning in the 19th century, that slowly changed. Since 1840, life expectancy at birth has risen about three months with each passing year. In 1840, life expectancy at birth in Sweden, a much-studied nation owing to its record-keeping, was 45 years for women; today it’s 83 years. The United States displays roughly the same trend. When the 20th century began, life expectancy at birth in America was 47 years; now newborns are expected to live 79 years. If about three months continue to be added with each passing year, by the middle of this century, American life expectancy at birth will be 88 years. By the end of the century, it will be 100 years. 

Viewed globally, the lengthening of life spans seems independent of any single, specific event. It didn’t accelerate much as antibiotics and vaccines became common. Nor did it retreat much during wars or disease outbreaks. A graph of global life expectancy over time looks like an escalator rising smoothly. The trend holds, in most years, in individual nations rich and poor; the whole world is riding the escalator.

Projections of ever-longer life spans assume no incredible medical discoveries—rather, that the escalator ride simply continues. If anti-aging drugs or genetic therapies are found, the climb could accelerate. Centenarians may become the norm, rather than rarities who generate a headline in the local newspaper.

Pie in the sky? On a verdant hillside in Marin County, California—home to hipsters and towering redwoods, the place to which the Golden Gate Bridge leads—sits the Buck Institute, the first private, independent research facility dedicated to extending the human life span. Since 1999, scientists and postdocs there have studied ways to make organisms live much longer, and with better health, than they naturally would. Already, the institute’s researchers have quintupled the life span of laboratory worms. Most Americans have never heard of the Buck Institute, but someday this place may be very well known.

To read the rest of this fantastic article, go here. 

Salvation Army: Partners in Caring

I just received my annual "thanks" for supporting the Salvation Army.

Your compassionate support is providing struggling families with food, clothing, shelter and much-needed hope. Thank you!

You are having a tremendous impact in our community! Through your concern and generous support of The Salvation Army, you are reaching out to our neighbors in greatest need.

Thanks to you, hungry children are being fed. Families are finding safe shelter. And people in crisis are being helped back on their feet.

This past year you have helped us reach out with:

• Food services for the hungry

• Nights of safe shelter

• Disaster Emergency help for families in need

• Clothing and furniture distributions for the less fortunate

• Counseling and spiritual direction for lost souls.

And so much more, more than we can count. Thank you so much!

Of course, no thanks is necessary.  I have witnessed first hand the difference this fine organization makes, and have  testimony in abundance from clients and friends recounting the beneficial efforts of the Army of volunteers.

It strikes me though, that I never see slickly produced commercials by the Salvation Army tugging at my heart-strings, asking me to adopt a child, a pet, a family, or a community.  I can recall no television or radio advertisement with the haunting voice of a popular singer rising and falling as a voice-over urges me to donate and "donate now."

I cannot recall the Salavation Army paying to sponsor a sports event,  professional sports franchise, concert, or music festival as have so many other charities.  Yet the Army continues to wage war against poverty, hunger, homelessness, substance addiction, and to fill physical, and spiritual needs.

My wife and I have numbered as amazing clients three who owe their very lives to the Salvation Army.  One family recounted to us how, following WWII, their entire family and community in Eastern Europe were dispossessed of home, property, and wealth- for being German.  Despite that these families had no ties or connection to Germany for five generations before the war, Germanic names were despised after the war. The fact that the patriarch of the family had died fighting Nazi Germany alongside the rest of the free world saved these families for a time, but the service was soon forgotten and they were made refugees. But, there were no aid programs, and traditional charities refused to help.  The Salvation Army, however, came to the rescue.  The family recounted an eerie and ironic journey by train during which Jewish refugees and Christian refugees shared the similarities of their plight as they were rescued from Eastern Europe, some to ultimately reside in Akron, Ohio.

The family serves the Army to this day.

A Dutch family described a. similar situation in a more recent time.  Political upheaval in Central America stranded their father.  The company for whom he worked maintained kidnapping insurance, and often retained experts to rescue kidnapped employees, but because their father was not kidnapped, they simply abandoned him.  Working through local churches in the region, the Salvation Army was able to rescue those otherwise trapped and abandoned.

The Salvation Army does amazing work.   

You can help.  Consider a donation here. 

    

New Regs May Increase Pay for Home Care Workers, Which Might Harm Seniors and Others

A federal regulation scheduled to go into effect on January 1, 2015, could force employers to pay previously exempt caregivers the federal minimum wage and time-and-a-half for overtime.  While this may seem like a good deal for the caregivers, it could result in cutbacks to services for seniors and people with disabilities if states limit caregiver hours in response to the new regulations.

Congress initially passed the Fair Labor Standards Act (FLSA) in 1938 to give most workers a guaranteed minimum wage and overtime protection.  The original FLSA did not apply to many domestic workers hired directly by households, so in 1974 Congress amended the FLSA to cover many people who work in private households.  However, the 1974 amendment did not apply to "companionship" workers who assist elderly patients or people with disabilities, and it also stated that live-in domestic workers were not entitled to overtime pay.

In 2013, the Department of Labor issued a final regulation altering these rules for the first time since 1974.  The new regulation, which goes into effect on January 1st, narrows the definition of "companionship" services and requires third-party employers like home health care agencies to meet all minimum wage and overtime laws for all employees. 

Under the new rules, an employee qualifies as a "companionship" worker only if he spends less than 20 percent of his work time assisting a senior or person with disabilities with activities of daily living or instrumental activities of daily living.  In addition, if the worker provides any medically necessary services, then he is not engaged in "companionship" work.  In all cases, if the employee is not considered a companion, then he must be paid the minimum age and must receive overtime pay.  These exceptions from minimum wage and overtime rules apply only to workers employed by the senior, person with disabilities or his or her household.  If the worker is employed by a third party, or in many cases if the worker is employed by both the person with disabilities and a third party (like a state agency), then he will always be subject to minimum wage and overtime rules, even if he is a live-in employee who would typically not be subject to overtime rules, and even if the only service performed is companionship.

Although the new regulations could mean more money for caregivers who may not currently receive minimum wage or overtime protection, there could also be some negative consequences for consumers and caregivers.  Since many state agencies are now going to be considered third-party employers, they may implement their own regulations limiting the number of hours that caregivers can work in order to avoid being out of compliance with these new federal rules.  This could lead to reduced services for people who need them and fewer hours for caregivers.  Of course, limitations upon such services can mean that many seniors are left without an alternative to institutional care.

These new rules also further complicate the decisions of a senior directly employing caregivers.  In addition to increasing the actual cost of care, the regulations will likely reduce the the planning flexibility of caregivers and their employers.  A family that requires a caregiver for ten hours a day, for example, might be forced to retain two caregivers instead of one, in order to avoid the additional cost of overtime, and to comply with limitations of hours.  These complications may make the goal of "aging in place" even harder to achieve.

According to an advocacy fact sheet from the National Senior Citizens Law Center, only California has addressed these concerns in its 2014-2015 budget, which leaves most seniors and people with disabilities in limbo as the January 1st implementation deadline approaches.

For more on this complicated problem, you can view an assortment of materials on the Department of Labor's website here and download the National Resource Center for Participant-Directed Services' toolkit here.

Medicare Increases Coverage of Mental Health Services

Medicare has increased the amount of mental health coverage beneficiaries are entitled to. After years of unequal treatment, Medicare now covers mental health care the same way it covers physical illnesses.

Previously, Medicare covered only 50 percent of the cost of mental health treatment. In 2008, Congress passed a law that required Medicare to gradually begin covering a greater portion of the cost until it was equal to the amount Medicare pays for outpatient medical care.

In 2014, Medicare began covering 80 percent of the approved amount for outpatient care, including visits to psychiatrists and licensed drug and alcohol counselors. Beneficiaries will still have to pay any applicable deductibles and coinsurance amounts. These new coverage rules apply to Original Medicare only. Individuals covered by a Medicare Advantage plan may have different costs and rules. 

Medicare still puts a cap on inpatient mental health coverage, paying for no more than 190 days of inpatient psychiatric hospital services during a beneficiary’s lifetime.

For more information on Medicare's coverage of mental health, click here.

Roth IRAs Dim as Inheritance Vehicles- Beware the Rush to Covert

Roth IRA's may sound like a great idea for passing wealth to family members—the funds essentially can grow tax-free over your lifetime and theirs. But, before you rush to convert all or part of a traditional retirement account to a Roth for your loved ones, take a long hard look.

Roth conversions- account holders converting a traditional IRA to a Roth, ostensibly in order to capture the benefit s of tax-free, rather than tax deferred growth, often rely upon a common supporting "story" that requires estate taxes (quite avoidable with good planning), high income taxes on the IRA at death (also for which good planning can make a difference), and healthy returns on the Roth investment to pay the investor back for taxes paid making the conversion(which are sometimes unrealistic, especially over time). It is not uncommon for consumers to believe that their traditional IRA's will suffer extraordinary taxes upon death, 50-75% in many cases! While unquestionably those with large IRA's and estates exceeding five million dollars may witness such excessive tax consequence (federal estate tax, state estate tax, federal income tax, state income tax), the reality for most taxpayers is, fortunately, less severe.

Roth IRAs are not always a good way to pass wealth. Whether such a conversion makes sense depends heavily on tax rates—of both the account owner and heirs—and whether lawmakers approve proposed rule changes that could eliminate some of the estate-planning perks of Roths.

Many people use Roths for bequests because account holders don't have to start taking distributions at age 70½ as they do with traditional IRAs. The money can sit untouched and grow tax-free throughout the owner's lifetime—a big plus for those who don't need the assets to live on. And while those who inherit any type of IRA must start taking distributions immediately, they are permitted to stretch out those payments over their lifetime, allowing the bulk of a Roth account to continue growing tax-free.

Two proposals in President Obama's 2015 budget, if approved, would change all that.

The first would require Roth owners to start taking distributions at age 70½. If that happens the Roth IRA would typically be rendered bereft of value by the time an account holder could leave the asset to an heir.

Long Term Care Differs Under Medicare and Medicaid

Although their names are confusingly alike, Medicaid and Medicare are quite different programs. Both programs provide health coverage, but Medicare is an “entitlement” program, meaning that everyone who reaches age 65 and is entitled to receive Social Security benefits also receives Medicare (Medicare also covers people of any age who are permanently disabled or who have end-stage renal disease.)

Medicaid, on the other hand, is a public assistance program that that helps pay medical costs for individuals with limited income and assets. To be eligible for Medicaid coverage, you must meet the program’s strict income and asset guidelines. Also, unlike Medicare, which is totally federal, Medicaid is a joint state-federal program. Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive federal money, which pays for about half the state’s Medicaid costs. (The state picks up the rest of the tab.)

The most significant difference between Medicare and Medicaid in the realm of long-term care planning, however, is that Medicaid covers nursing home care, while Medicare, for the most part, does not.  Medicare Part A covers only up to 100 days of care in a “skilled nursing” facility per spell of illness. The care in the skilled nursing facility must follow a stay of at least three days in a hospital. And for days 21 through 100, you must pay a copayment of $152 a day (in 2014). (This is generally covered by Medigap insurance.)

In addition, the definition of “skilled nursing” and the other conditions for obtaining this coverage are quite stringent, meaning that few nursing home residents receive the full 100 days of coverage. As a result, Medicare pays for less than a quarter of long-term care costs in the U.S.

In the absence of any other public program covering long-term care, Medicaid has become the default nursing home insurance of the middle class. Lacking access to alternatives such as paying privately or being covered by a long-term care insurance policy, most people pay out of their own pockets for long-term care until they become eligible for Medicaid.

The fact that Medicaid is a joint state-federal program complicates matters, because the Medicaid eligibility rules are somewhat different from state to state, and they keep changing. (The states also sometimes have their own names for the program, such as “Medi-Cal” in California and “MassHealth” in Massachusetts.) Both the federal government and most state governments seem to be continually tinkering with the eligibility requirements and restrictions. This is why consulting with your attorney is so important.

As for home care, Medicaid has traditionally offered very little -- except in New York, which provides home care to all Medicaid recipients who need it. Recognizing that home care costs far less than nursing home care, more and more states are providing Medicaid-covered services to those who remain in their homes.

It’s possible to qualify for both Medicare and Medicaid.  Such recipients are called “dual eligibles.”  Medicare beneficiaries who have limited income and resources can get help paying their out-of-pocket medical expenses from their state Medicaid program. For details, click here.

Most Terminal Dementia Patients in Nursing Homes Given Pointless and Potentially Dangerous Drugs

Tim Mullaney, staff writer for McKnight's, posted the following article:

Nursing homes administer largely pointless and potentially harmful drugs to a majority of residents with advanced dementia, according to findings in JAMA Internal Medicine. 

Out of more than 5,400 residents under consideration, about 54% received a “medication with questionable benefit,” the investigators determined. Alzheimer's disease drugs such as donepezil (Aricept) and memantine (Namenda) were the most commonly administered. There is little evidence that they improve cognitive functioning for people with advanced stages of dementia, and potentially put residents at risk for falls or urinary tract infections. 

About 20% of the residents were on a lipid-lowering agent. These also are associated with a host of troublesome potential side effects, including confusion and muscle fatigue, and may do little to extend the life of these residents. 

The costs associated with these medications is substantial, the study authors found. The mean 90-day expenditure for these drugs was $816. This represents more than a third of the medication expenditures for residents with advanced dementia. 

“While it can be difficult for family decision-makers to discontinue medications that treat the chronic diseases of their loved ones as they transition toward comfort care, minimizing questionably beneficial interventions is an important therapeutic option consistent with recommendations by the Institute of Medicine about care quality at the end of life,” the authors wrote. 

Hospice patients with a do-not-resuscitate order were less likely to be on a questionable medication, they determined. They did not find any “facility-level association” in terms of having a dementia special care unit, more beds, or a higher percentage of residents with a DNR. The findings should prompt physicians to reconsider their prescribing practices for late-stage dementia patients, the Regenstrief Institute's Greg A. Sachs, M.D., wrote in an accompanying JAMA editorial. 

The findings are based on an analysis of a nationwide long-term care pharmacy database linked to the Minimum Data Set. The numbers came from 2009 and 2010. The authors are affiliated with a variety of institutions, including the University of Massachusetts Medical School in Worcester and the Wistar Institute at the University of Pennsylvania. Findings were posted online Monday ahead of print.

The study supports what is an increasing body of evidence supporting the the use of advanced directives, particularly when coupled with utilization of hospice care.  Apart, or together, there is good evidence that each impacts favorably end-of-life health care, and in this study, particularly for   patients suffering from dementia. 

Feds Move to Protect Some Surviving Spouses of Reverse Mortgage Holders

A new federal rule has taken effect aimed at protecting certain spouses of reverse mortgage holders from being forced out of their homes when the mortgage holder dies.

Borrowers must be 62 years or older to qualify for a reverse mortgage.  Until now, if one spouse was under age 62, the younger spouse had to be left off the loan in order for the couple to qualify.  Some lenders have actually encouraged couples to put only the older spouse on the mortgage because the couple could borrow more money that way.

But couples often did this without realizing the potentially catastrophic implications.  If only one spouse's name was on the mortgage and that spouse died, the surviving spouse would be required to either repay the loan in full or face eviction.  Although this prospect is, perhaps, explained by the disclosures made in specific instances, the truth is that most seniors are unaware, informed generally by advertisements touting the benefits of reverse mortgages,  which assure seniors that they can remain in their homes.

In 2012, AARP sued the Department of Housing and Urban Development (HUD) on behalf of the surviving spouses of individuals who took out Home Equity Conversion Mortgage (HECM), the most widely available reverse mortgage and are administered by HUD.  The spouses in the suit could not sell and repay their loans because, due to the housing downturn, the homes were worth less than the balance due on the reverse mortgage.

In a decision issued September 30, 2013, the U.S. District Court for the District of Columbia agreed with AARP and told HUD to find a way to shield surviving spouses from foreclosure and eviction.

HUD developed a new rule that took effect August 4, 2014, and that better protects at least some surviving spouses.  Under the rule, if a couple with one spouse under age 62 wants to take out a reverse mortgage, they may list the underage spouse as a “non-borrowing spouse.”  If the older spouse dies, the non-borrowing spouse may remain in the home, provided that the surviving spouse establishes within 90 days that she has a legal right to stay in the home (this could, for example, be an ownership document, a lease, or a court order).  The surviving spouse also must continue to meet the other requirements of a reverse mortgage holder, such as paying property taxes and insurance premiums.

However, the non-borrowing surviving spouse cannot access the remaining loan balance, and the new rule protects only spouses who were married to the borrowing spouse at the time the loan was taken out.  Spouses who married the borrowing spouse after the mortgage was taken out are not protected. 

One major downside is that under the new rule, spouses will no longer be able to leave a younger spouse off the mortgage in order to get a larger loan amount.  This means that loan amounts will be less for such couples because loans are based on the younger spouse’s age.  This is a particularly unfortunate event where the younger spouse is unable to support the couple, and is not the heir of the home at any rate, such as where there is a prenuptial agreement.

Finally, the new HUD rule affects only loans written after August 4, so it does not protect non-borrowing spouses on existing reverse mortgage loans, as Hayward, California, elder law attorney Gene Osofsky points out in his excellent blog post on the new rule. However, Osofsky notes that surviving non-borrowing spouses on older loans might still attempt to seek protection under the umbrella of the court’s ruling in the AARP case. 

Prof. Jack M. Guttentag, the self-styled “Mortgage Professor,” has been critical of the change and sees one particularly ominous consequence. Writing in a July 19 article, he said that in anticipation of death a borrower could draw the full amount of any unused credit on the loan, making it accessible to the non-borrowing spouse.  “This is a horror show waiting to happen that will seriously endanger the integrity of the program,” Guttentag warns.  He does not elaborate on what the horror show could be, but presumably it involves more foreclosures. 

Many Skilled Care Providers Still Unaware of New Medicare Rules Permitting Chronic Condition Care

Even though Medicare is now covering skilled care for beneficiaries who are not improving, many are still being denied coverage, according to Judith Stein, director of the Center for Medicare Advocacy.  Stein told Reuters columnist Mark Miller that despite a nationwide educational campaign mandated by the recent settlement of a lawsuit, many providers don't have information about the settlement or understand the new rules.  

Under the settlement agreement in Jimmo v. Sebelius, the federal government agreed to end Medicare’s longstanding practice of requiring that beneficiaries with chronic conditions and disabilities show a likelihood of improvement in order to receive coverage of skilled care and therapy services. The new rules require that Medicare cover skilled care as long as the beneficiary needs skilled care, even if it would simply maintain the beneficiary's current condition or slow further deterioration. 

Coupled with the existing Medicare rules permitting home health care for homebound patients, the ruling means a dramatic improvement in the ability of patients with chronic conditions to receive medical care in their homes under Medicare, rather than more expensive care traditionally performed in skilled nursing facilities requiring private pay (spend-down) and Medicaid.  Of course, if the public and care providers are unaware of these changes, there will be no change to the status quo.   

As part of the implementation of the settlement, the Centers for Medicare and Medicaid Services (CMS) has posted online resources and updated its Medicare manual to reflect the changes. CMS launched an educational campaign in January to explain the settlement and the revised manual provisions to providers, but many providers remain unaware of what is covered or how to bill Medicare for the services. Importantly, consumers are typically unaware of their rights.  The campaign was not aimed at Medicare beneficiaries, so few are aware of the rules, and that they can fight a denial of coverage.

Miller focuses on one beneficiary, Robert Kleiber, 78, who receives weekly visits from a physical therapist to alleviate symptoms of his Parkinson’s disease.  Kleiber’s wife recently learned that the treatments should be covered under Medicare’s new rules but so far she has been unable to convince the home health care provider of this.

Stein said she is getting "a lot of inquiries from people who have had problems getting access to care. There’s still a great deal of education that healthcare providers need to get on this. Many of them just aren’t aware of what they need to do to proceed."

For Miller’s column, click here.

For the Center for Medicare Advocacy’s page of self-help packets for improvement standard denials and appeals, click here.

Six Questions to Ask Before Making Gifts

Many seniors consider transferring assets for estate and long-term care planning purposes, or just to help out children and grandchildren. Gifts and transfers to a planning trust often make a lot of sense. They can save money in taxes and long-term care expenditures, and they can help out family members in need and serve as expressions of love and caring.

But some gifts can cause problems, for both the generous donor and the recipient. 

Following are a few questions to ask yourself before writing the check:

Why are you making the gift? Is it simply an expression of love on a birthday or big event, such as a graduation or wedding? Or is it for tax planning or long-term care planning purposes? If the latter, make sure that there's really a benefit to the transfer. If the value of your assets totals less than the estate tax threshold in your state, your estate will pay no tax in any case. For federal purposes the threshold is $5.34 million (in 2014). Gifts can also cause up to five years of ineligibility for Medicaid, which you may need to help pay long-term care costs.

You should also check with your own elder law attorney or financial planner to make sure that the objective you are seeking can be (or best be) attained through the gift.  For example, some gifts that lay persons believe will help either don't help, or in fact may worsen the situation.  A home is not a countable asset when applying for Medicaid, for example, meaning that the home and its value are protected for a spouse living in the home.

A gift of the home removes the home from protection for the community spouse, and causes what would have been an unnecessary spend-down of other assets.  Gifts with retained life estates, and gifts held for the benefit of, and used for the support of the senior may not accomplish the objective sought.   

Are you keeping enough money? If you're making small gifts, you might not need to worry about this question. But before making any large gifts, it makes sense to do some budgeting to make sure that you will not run short of funds for your basic needs, activities you enjoy -- whether that's traveling, taking courses or going out to eat -- and emergencies such as the need for care for yourself or to assist someone in financial trouble.

Is it really a gift (part one)? Are you expecting the money to be paid back or for the recipient to perform some task for you? In either case, make sure that the beneficiary of your generosity is on the same page as you. The best way to do this is in writing, with a promissory note in the case of a loan or an agreement if you have an expectation that certain tasks will be performed.

Is it really a gift (part two)? Another way a gift may not really be a gift is if you expect the recipient to hold the funds for you (or for someone else, such as a disabled child) or to let you live in or use a house that you have transferred. These are gifts with strings attached, at least in theory. But if you don't use a trust or, in the case of real estate, a life estate, legally there are no strings attached. Your expectations may not pan out if the recipient doesn't do what you want or runs into circumstances -- bankruptcy, a lawsuit, divorce, illness -- that no one anticipated. If the idea is to make the gifts with strings attached, it's best to attach those strings legally through a trust or life estate.

Is the gift good for the recipient? If the recipient has special needs, the funds could make him or her ineligible for various public benefits, such as Medicaid, Supplemental Security Income or subsidized housing. If you make many gifts to the same person, you may help create a dependency that interferes with the recipient learning to stand on his own two feet. If the recipient has issues with drugs or alcohol, he may use the gifted funds to further the habit. You may need to permit the individual to hit bottom in order to learn to live on his own (i.e., don't be an "enabler").

Do you understand the tax consequences of the gift?  Sometimes there are adverse tax consequences in making a gift.  The most commonly misunderstood of these is the loss of the step-in basis of appreciated property to the fair market value on the date of death.  This -step-up in basis means, in essence, that your heirs can sell your assets in which you have capital gains without incurring a capital gains tax.  Donors can sometimes overlook this benefit.   At a minimum, a short conversation with an elder law attorney or tax professional will make clear the consequences and the options available to best accomplish your objectives. 

If after you've answered all of these questions, you still want to make a gift, please go ahead. Unless the gift is for a nominal amount, however, it is advisable to check with your attorney to make sure you are aware of the Medicaid, tax and other possible implications of your generosity.

Five Reasons Why Joint Accounts May Be a Poor Estate Plan

Many people, including seniors, view joint ownership of investment and bank accounts as a cheap and easy way to avoid probate since joint property passes automatically to the joint owner at death. Joint ownership can also be an easy way to plan for incapacity since the joint owner of accounts can pay bills and manage investments if the primary owner falls ill or suffers from dementia. These are all benefits of joint ownership, but three potential drawbacks exist as well:

Risk. Joint owners of accounts have complete access and the ability to use the funds for their own purposes. Many elder law attorneys have seen children who are caring for their parents take money in payment without first making sure the amount is accepted by all the children. In addition, the funds are available to the creditors of all joint owners and could be considered as belonging to all joint owners should they apply for public benefits or financial aid.  Many elder attorneys have seen their clients' accounts embroiled in creditor claims and nasty divorces against their clients' children. 

Inequity. If a senior has one or more children on certain accounts, but not all children, at her death some children may end up inheriting more than the others. While the senior may expect that all of the children will share equally, and sometimes they do in such circumstances, but there's no guarantee. People with several children can maintain accounts with each, but they will have to constantly work to make sure the accounts are all at the same level, and there are no guarantees that this constant attention will work, especially if funds need to be drawn down to pay for care.

The Unexpected. A system based on joint accounts can really fail if a child passes away before the parent. Then it may be necessary to seek guardianship to manage the funds or they may ultimately pass to the surviving siblings with nothing or only a small portion going to the deceased child's family. For example, a mother put her house in joint ownership with her son to avoid probate and Medicaid’s estate recovery claim. When the son died unexpectedly, the daughter-in-law was left high and dry despite having devoted the prior six years to caring for her husband's mother.

Disputes. Planning based upon individual accounts really does nothing to inform your family regarding your ultimate wishes.  Do you ultimately want to prefer one family member over another?  If the effect of planning using individual accounts results in an inequality to family members, was it intended or anticipated?  Of course, the resulting ambiguity is the cause of lawsuits, claims, disagreements, and hard feelings.  

Fraud.  Asset transfers late in life are particularly troubling, if they work to defraud your heirs and/or are not a reflection of your wishes.  A plan based upon individual assets and accounts does little to protect your family.  On the other hand, a comprehensive plan involving a trust or well-drafted will can better protect your family from late-in-life transfers by informing your family and authorities of your estate planning objectives.  

Joint accounts do work well in two situations. First, when a senior has just one child and wants everything to go to him or her, joint accounts can be a simple way to provide for succession and asset management. It has some of the risks described above, but for many clients the risks are outweighed by the convenience of joint accounts.

Second, it can be useful to put one or more children on one's checking account to pay customary bills and to have access to funds in the event of incapacity or death. Since these working accounts usually do not consist of the bulk of a client's estate, the risks listed above are relatively minor.

For the rest of a senior's assets, wills, trusts and durable powers of attorney are much better planning tools. They do not put the senior's assets at risk. They provide that the estate will be distributed as the senior wishes without constantly rejiggering account values or in the event of a child's incapacity or death. And they provide for asset management in the event of the senior's incapacity.

For more information review the previous post regarding direct transfer designations, such as Transfers on Death (TOD) and Payable on Death (POD) designations.  Joint ownership, TODs and PODs share many of the same disadvantages.   

Albert Pujols is a Champion for Kids with Special Needs

Los Angeles Angels of Anaheim designated hitter Albert Pujols is one of the greatest sluggers in baseball. In April, he hit home run number 500, putting him in some elite company. And as the 2014 season has progressed, Pujols has kept hitting home runs — climbing the all-time list (he’s currently at number 21 with 515 dingers) and helping his team reach the top of the American League West.

But Pujols’ accomplishments on the field are nothing compared to what he has done off it. His daughter Isabella has Down syndrome, and since his days as a St. Louis Cardinal Pujols has been an active advocate for kids and adults with special needs. He has partnered with the Down Syndrome Association since 2001, and in 2005 he founded his own non-profit organization, the Pujols Family Foundation, with his wife, Deidre. The foundation promotes awareness of special needs issues and helps kids and families living with Down syndrome both in the US and his native Dominican Republic. 

Pujols’ is also helping raise awareness by being the cover model for Toys “R” Us’ 20th annual Toy Guide for Differently-Abled Kids. The guide launched today, and it’s a resource for anyone looking for a great toy for the special needs kid in their life.

To read the full article posted on SIKids.com, go here. 

Hospitals Referring to Fewer SNF's

According to Jeff Terkowitz, senior manager with Avalere, between 2009 and 2012 – the most recent year for which CMS has released comprehensive Medicare data – there was an increase in the average number of SNFs that received a volume of patient referrals from hospitals. However, that trend may be slowing; the .3% increase in average number of SNFs to which hospitals discharged patients in 2012 came after increases of .7% and .9% per year from 2009-2011.

In 2009, short-term acute care hospitals discharged patients who were admitted on average to just over 37 different SNFs following the hospital stay.  In 2010 and 2011, that number grew, with hospital patients going to just under 38 and just under 39 SNFs, respectively.  By 2012, that number reached 39.14, a slight increase from 2011.

Hospitals, therefore, are still sending patients to many different SNFs, indicating, according to Terkowitz, that referral networks may not be well established.  But, he suspects that even though the total number of SNFs is still going up, there is a higher concentration of patient volume at a smaller number of facilities. He notes, for example, that between 2009 and 2012, there was a slight increase in concentration during which time the average hospital went from having just over nine SNF partners who received 10 or more patients to having 9.54 partners receiving that higher volume. 

He warns that the environment is rapidly changing, though; "there are many examples of hospitals moving towards tighter, more coordinated post-acute care networks."