Feds Release New Quality Data Online

McKnight's Long Term Care News reports that the federal government has released new data on the quality of care delivered in skilled nursing facilities.  Centers for Medicare & Medicaid (CMS)  added five brand new quality-related measures to Nursing Home Compare. 

Transparency of outcomes “continues to intensify,” with this posting of the inaugural SNF Quality Reporting Program (QRP) measures, said Amy Stewart, RN, curriculum development specialist with the American Association of Directors of Nursing Services.  She encouraged nursing homes to check their scores on the five newly published SNF measures as soon as possible to know what the potential clients are seeing, and be ready to discuss the results. Scores will be of more interest than ever before to hospitals and other healthcare entities looking to partner with SNFs.

The five quality measures included in this latest release include:

• Percent of residents that developed new or worsening pressure ulcers during their stay in an SNF (1.7% is the nationwide rate in SNFs according to CMS);
• Percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in treatment plan (95.8% nationally according to CMS);
• Percentage of patients that experienced a fall resulting in a major injury during their stay in a SNF (0.9% nationally according to CMS);
• Medicare spending per beneficiary for patients in SNFs (showing whether Medicare spends more, less or about the same, per episode of care for a patient treated in a SNF compared to how much Medicare spends on an episode of care across all SNFs nationally);
• Rate of successful return to home or community from a SNF (48.57% nationally according to CMS).

CMS decided not to include a sixth quality measure it had previously planned to employ: Potentially preventable 30-day post-discharge readmission. Instead, the agency will allow for additional time to test and determine if there are modifications needed to better display this measure.

CMS has posted a FAQ (Frequently Asked Questions) on its website to answer some of the most common questions related to this release.

While some measures may seem duplicative of those used in the Five-Star Rating System, which includes all residents, these SNF QRP measures are specific to Medicare Part A residents only.

2019 Medicare Advantage Plans Incorporate Long Term Care, Aging in Place Benefits

Some Medicare Advantage Plan (hereafter simply "Plan") issuers are quietly and carefully adding home-based and community-based long-term care (LTC) benefits for 2019, according to Allison Bell, ThinkAdvisor's insurance editor. According to an excellent ThinkAdvisor article, officials at the Centers for Medicare and Medicaid Services (CMS). estimate that about 1.5 million of the 2019 enrollees, or 7.5% of Medicare Advantage plan enrollees, may have access either to support services in the home or community, or to extra benefits designed to help enrollees cope with the burden of diabetes or other chronic conditions. CMS officials have not, however, estimated how many enrollees might have access solely to the new home- or community-based services.  

A previous blog article discussed these changes; see the article entitled, "Trump Administration Embraces Aging In Place- 2019 Advantage Plans Permitted to Incorporate Long Term Care," available by clicking here. 

In Arizona and California, for example, units of Anthem Inc. are openly stating that they will use the new flexibility to beef up the benefits offered by some plans.  Enrollees in certain Anthem plans will have access to what amount to LTC benefits provided for a short period of time:

• Three meals delivered per day for up to 42 days.
• Four four-hour shifts of in-home assistance with daily living activities, such as laundry.
• 40 hours of respite care for caregivers per year.
• One visit per week for adult day care center services, for older adults who need supervision.
• Health care appointment transportation services.

Traditionally, commercial insurers have referred to benefits for small amounts of LTC-type services with terms such as “convalescent care benefits,” or “short-term care benefits.”  SCAN Health Plans of Long Beach, California, says it will offer new in-home benefits through most plans in Southern California, but it’s not easy to tell which new benefits will be related to the new rules.

UnitedHealth Group Inc.’s UnitedHealthcare unit says it will make telemedicine services available to 1.7 million enrollees through phones and computers, and health-related transportation services available to 1.7 million enrollees. The company is also offering a care management and care planning service for caregivers to most of its Medicare Advantage plans. It’s not clear from the company’s 2019 plan announcement whether those beneits are related to the new CMS rules.

Lack of clarity is a real problem. Unfortunately, for someone looking at the CMS 2019 Plan Information or even the plan issuers’ own benefits summary sheets, it is not easy to tell which plans will take advantage of the new CMS benefits flexibility.  Moreover, the value of these additional services, and possible resulting costs are difficult for a lay person to evaluate.  For these reasons, we strongly urge clients to establish a relationship with a trusted advisor.  Locally, many of our clients use the advisors at Harding, Harding & Associates. 

Traditionally, Medicaid has been the government health program that pays for nursing home care.  Federal rules have blocked Medicare from paying for long-term care.  Medicare has paid for skilled nursing care for people recovering from serious acute health care problems, and promised to pay for limited home health care services.

But Medicare has not paid for nursing home care for people who are in a nursing home simply because they are frail or have trouble with the activities of daily living, such as bathing or eating.  Medicare has also avoided paying for other types of in-home services, such as help with cleaning or laundry, that might help keep older people in their homes.

In May, CMS said it would change Medicare Advantage benefits rules, to give issuers ways to offer new benefits for the “social determinants of care” that might help reduce overall medical spending.  Officials suggested, for example, that, in some cases, spending a little money on transportation services or meal delivery for someone with serious health problems might be a good way to avoid spending a lot of money on hospital care. 

CMS Announces 2019 Medicare Premiums and Deductibles

On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Medicare Part B Premiums/Deductibles

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, an increase of $1.50 from $134 in 2018. An estimated 2 million Medicare beneficiaries (about 3.5%) will pay less than the full Part B standard monthly premium amount in 2019 due to the statutory hold harmless provision, which limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits. The annual deductible for all Medicare Part B beneficiaries is $185 in 2019, an increase of $2 from the annual deductible $183 in 2018. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts (IRMAA) affect roughly 5 percent of people with Medicare Part B.  The total premiums for high income beneficiaries for 2019 are shown in the following table:

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Medicare Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,364 in 2019, an increase of $24 from $1,340 in 2018. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2019, beneficiaries must pay a coinsurance amount of $341 per day for the 61st through 90th day of a hospitalization ($335 in 2018) in a benefit period and $682 per day for lifetime reserve days ($670 in 2018). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $170.50 in 2019 ($167.50 in 2018).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $240 in 2019, an $8 increase from 2018. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $437 a month, a $15 increase from 2018.

For more information on the 2019 Medicare Parts A and B premiums and deductibles (CMS-8068-N, CMS-8069-N, CMS-8070-N), please visit https://www.federalregister.gov/public-inspection.

Social Security Announces 2019 Changes

The Social Security Administration (SSA) has released the 2019 benefit changes.   Based on the increase in the Consumer Price Index (CPI-W) from the third quarter of 2017 through the third quarter of 2018, Social Security and Supplemental Security Income (SSI) beneficiaries will receive a 2.8 percent increase or COLA for the year 2019. 

SSA also announced an increase in the SSA taxable maximum amount to $132,900. The indivdiual's amount for SSI for 2019 will increase to $771 per month. 

The tax rate for most people is 7.65%, the combined rate for Social Security and Medicare. The Social Security portion (OASDI) is 6.20% on earnings up to the applicable taxable maximum amount. The Medicare portion (HI) is 1.45% on all earnings. Also, as of January 2013, individuals with earned income of more than $200,000 ($250,000 for married couples filing jointly) pay an additional 0.9 percent in Medicare taxes (not reflected in the 7.65% combined rate reported above). 

The detailed fact sheet is available here.

Declining SNF Utilization

There is increasing evidence that either (1) utilization of nursing homes is rapidly diminishing, or (2) utilization of nursing homes has reached saturation, and competition is closing less competitive operations.  One would like to think that seniors and their families are implementing "Aging in Place" planning in order to avoid institutionalization. The issue is complicated, however, and although what is occurring is demonstrable, the underlying causes are unclear. 

The New York Times recently published an article discussing the phenomenon entitled "In the Nursing Home, Empty Beds and Quiet Halls,"explaining that a once vibrant facility now stands closed due to a drop in demand.  According to the article, "[t]he most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused. ... Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent."  

The occupancy rate for skilled care nursing homes has been trending downward, and as a result facilities close.  According to the article, somewhere between 200-300  close annually.  The article  offers some possible explanations for the phenomenon given the number of baby boomers that one might think would cause an increase in demand.  The article suggests the decreasing utilization is caused by:  

• Increased regulations and more financial belt-tightening;
• Hospitals' use of observation status,which affects Medicare coverage for subsequent SNF care;
• More surgeries on an out-patient basis;
• Increasing number of Medicare Advantage plans;
• Increased competition through other housing options;
• The shift to Medicaid covering care in the community, with "Money Follows the Person [having] moved more than 75,000 residents out of nursing homes and back into community settings."

The article speculates whether this trend will reverse itself once the boomers start reaching age 80 and beyond. The article also discusses whether the lower demand provides more options for those in need of nursing home care.

Conservator Owes Duty to Nursing Home to Timely Apply for Medicaid

A Connecticut appeals court has held that a nursing home resident's conservator owes a duty of care to the nursing home to timely apply for Medicaid on behalf of the resident. Bloomfield Health Care Center of Connecticut, LLC v. Doyon (Conn. App. Ct., No. AC 40281, Oct. 9, 2018).

A nursing home petitioned the court to appoint a conservator for one of its residents, Samuel Johnson, to assist him with his Medicaid application. The court appointed Jason Doyon as conservator in April 2014. Mr. Doyon waited nine months to file a Medicaid application on Mr. Johnson's behalf. The state denied Mr. Johnson's first Medicaid application due to lack of information. Mr. Doyon filed a second application, which the state approved, but Mr. Johnson did not receive any Medicaid benefits before May 2015.

The nursing home sued Mr. Doyon for negligence in failing to apply for and obtain Medicaid benefits on behalf of Mr. Johnson in a timely manner. Mr. Doyon asked for summary judgment, arguing that he did not owe a duty of care to the nursing home. The trial court granted Mr. Doyon summary, holding that the conservator owed no duty to the nursing home.  The nursing home appealed the lower court's judgment.

The Connecticut Court of Appeals reversed.  The court held that Mr. Doyon owed the nursing home a duty of care. The court rules that it was "readily foreseeable that, if [Mr. Doyon] failed to timely obtain Medicaid benefits for [Mr.] Johnson, the [nursing home] would suffer harm as a result because it would not be reimbursed for the cost of [Mr.] Johnson’s care." The court also concludes that "the benefits of encouraging conservators to carry out their duties with care and preventing financial harm outweigh any corresponding minimal increase in litigation."

The decision continues a trend of decisions favoring nursing homes when eligibility applications for Medicaid are not timely or properly prosecuted.  The decision should also concern family caregivers; the trend might foreshadow greater success on the part of nursing homes in disputes with family members who act as fiduciaries without court appointment.  Family often acts in court-appointed roles, or more informal roles without careful consideration of the liabilities of service. The bottom line is that Medicaid applications should be taken seriously, and the applications completed and submitted as quickly as possible.   

Wealthy Nursing Home Residents Would Prefer to Age in Place- Would Pay Family For Care

A new survey of wealthy seniors suggests that many of nursing homes’ potential residents would prefer to receive long-term care at home, and would be willing to pay their own family members for it.

That’s according to responses of more than 1,000 U.S. adults, age 50 or older, with an annual household income of $150,000 or more. The Harris Poll, conducted on behalf of the Nationwide Retirement Institute, found that about 71% of seniors would prefer to rely on a family member for long-term care. And 70% of those surveyed would not expect that help, unless they were able to pay relatives.

About 56% of respondents said that they “would rather die” than live in a nursing home, and 47% said they’re worried about becoming a burden to their families.

“Affluent adults fear nursing homes but are concerned their care needs will challenge their family if they require caregivers,” Nationwide VP Holly Snyder said in a press release.

About 77% of respondents said, if needed, they’d most prefer to receive long-term care at home. That’s compared to 1% preferring to receive skilled care in a nursing home. Reasons for those worries included loss of control of their lives (68%), detachment from the community (32%) and seeing family less often (30%).

More details from the seventh annual survey can be found on Nationwide’s website here.

A Military App for Military Moms and Dads - Babies on the Homefront App is Military Parent Approved

[The following article is penned by Jennifer Novak, Senior Writer and Training Specialist for Military Family Projects and reprinted with permission of USAA] 

Babies on the Homefront is so much more than messaging—it’s designed to strengthen the bond separated service members have with their families. And it works! 

As the wife of a service member, I can tell you that separations are hard. But they were even harder for my children. Every separation and transition caused an enormous amount of pain for our little ones. With a background in early childhood, I know that these moments of stress, worry, and feelings of loss can have a profound impact on children’s development and well-being--including how fast their brain grows! As a mother, I knew it was important to provide my children with a sense of security and to help maintain the connection they felt with their father while he was away.  

My husband’s time as an active duty service member was full days, weeks, and months of separation due to deployment, training, work-ups, changes in work schedules--not to mention all the moving from one duty station to another! Babies on the Homefront is designed to keep up with the many transitions military families go through and to maximize the relationship that can be maintained long distance. Through secure messaging, creative baby games, sharing updates, and finding answers to all your parenting questions, this app has been a great tool for keeping my husband in the know.   

Never Miss a Beat 

“When do you think we will get to talk to Daddy again?” is a question that came up all too frequently in my military family. Depending on the type of separation, the ability to talk to their father could change dramatically. A week-long training out of town might still mean daily video calls, but a work-up at sea? They may not see him or hear his voice the entire time he was gone. It’s important for babies and toddlers to stay connected with the active duty parent as much as possible during deployment. A young child needs to know that his parent remains an important part of the family and that he is held in his parent’s heart and mind. 

Through the app, you can make the parent away part of a daily or weekly routine. Gather around the app to look at shared photos and videos. Even if the parent is unable to call home as planned, record a video message that can be watched later instead. The parent at home can share memories of the deployed parent, including times that the parent spent with the young child. These stories can paint a vivid and loving picture of the deployed parent and the special role that parent played, and continues to play, in the child’s life. 

Capturing Milestone Moments 

The shared media gallery is more than a space to upload photos – it’s an opportunity to build a shared visual story of both photo and video content that can help keep the parent in the mind of the child and the child in the mind of the parent. While sharing moments is easier than ever with email and social media, there are still drawbacks – the military email system is often unreliable and isn’t a baby-friendly way of communicating. Staying connected through social media means forgoing privacy for the sake of staying in touch. This app has a safe and secure way to capture, upload, and share photos with service members away from home. Each photo and video is saved and collected in a timeline so that they can be replayed again and again. 

The Right Answers at the Right Time 

No matter how well I thought we had prepared our children – by being honest about what to expect, by talking to them about what was happening, by telling them about what daddy was doing when he was away – every separation and transition came with challenging behaviors and parenting challenges. I’ve looked for answers in parenting books, websites, apps, forums, and newsletters. Babies on the Homefront gives you access to parenting resources right in the app. The extensive in-app library provides quick resources and age-based tips for parents to learn more about child development, milestones, self-care, and resources for how to prepare for separations and reunifications.   

Play Together, Stay Together 

As your one-stop parenting app, Babies on the Homefront is filled with interactive game ideas and playful activities for babies and toddlers. Play simple touch screen games together designed to help young children learn or watch video clips demonstrating new activities and play ideas. Playing together is one of the best ways to encourage learning, to stimulate growth and development, and to help your child feel safe, loved, and special. There is no shortage of ideas to keep you and your young ones moving and learning at any age.   

This app is the perfect solution for military families to stay connected. The needs of the military will always require family separations, but with Babies on the Homefront, you have the power to make this a little easier on our little ones and to strengthen the relationships parents have with their children and each other. This isn’t just good for children – it also empowers our fighting force through the security of knowing they can maintain their relationships with their children, even when they are away.  

You can learn more about the app, and/or download the app here. 

Veterans to Receive "Combat-Injured Veterans Tax Fairness Act" Letters

In 2016, Congress passed a law known as the Combat-Injured Veterans Tax Fairness Act. The law entitles more than 133,000 injured veterans to tax refunds as far back as 1991. The objective of the law is to ensure that veterans who suffer service-ending combat-related injuries aren’t taxed on the severance payment they receive from Department of Defense (DOD).

The DOD is just beginning to send letters to the eligible veterans with information explaining how to claim the tax refunds. The letters will provide an explanation of a simplified method for claiming the refund, and explain the time limits for making the claims.

The amount of time for claiming the tax refunds is limited.  Veterans who have claims for refunds can amend their tax returns claiming the refund in the normal limitations period for filing amended tax returns, or three years.  Obviously, some of these amended returns are already time barred.  The law gives veterans an alternative time frame, or one year from the date of the letter from DOD. In other words, veterans can make a claim for the refund for one year from the date of their letter from the DOD, or within three years of the original filing deadline for the return, whichever expires later.

There are a couple of ways a veteran can claim the refund.  A veteran can either send in a claim based on the actual amount of the disability severance payment received by filling out Form 1040X, but a veteran must carefully follow the instructions for making the claim.  Alternately, a veteran can opt for a simplified method. The veteran can simply choose to claim a standard refund amount based on the calendar year in which the veteran received the severance payment. The veteran then writes “Disability Severance Payment” on line 15 of Form 1040X and enters on lines 15 and 22 the standard refund amount listed below that applies:

• $1,750 for tax years 1991 – 2005
• $2,400 for tax years 2006 – 2010
• $3,200 for tax years 2011 – 2016

For more information talk with your tax attorney or go here. 

Ohio Guardian's Sale of Medicaid Recipient's House Approved as being In Her Best Interest

A guardian can sell a Medicaid recipient's house even though the mortgage loan was in default, because the mortgage company had not foreclosed on the property and it was in the recipient's best interest to sell the property and retain her Medicaid benefits.  That is the decision of an Ohio Court of Appeals in the case of  Gasper v. Adkins (Ohio Ct. App., 10thDist., No. 17AP-294, Sept. 27, 2018).

Christopher Gasper was appointed guardian of Diantha Adkins, who was in a nursing home and receiving Medicaid benefits. Mr. Gasper petitioned the court to sell Ms. Adkins' house. The company that held the mortgage objected to the sale, claiming the mortgage loan was in default.  The company holding the mortgage argued that the guardian could not sell the property, but the guardian could only sell the ward's right to redeem the property from foreclosure.  The company that held the mortgage had not filed for foreclosure, though, so the company's argument would mean that the ward would have to continue to hold ownership of the property, which the guardian argued threatened the ward's Medicaid benefits. 

The court rejected the mortgage company's argument, found that the sale of the property was in the best interest of Ms. Adkins and authorized Mr. Gasper to execute a deed in lieu of foreclosure. The mortgage company appealed, arguing that the court couldn't authorize the sale of the property free and clear of the mortgage lien without the mortgage company's consent.

The Ohio Court of Appeals, 10th District, affirmed, ruling that the guardian was entitled to sell the property. According to the court, because the mortgage company had not foreclosed on the property, Ms. Adkins was not "divested of legal ownership" at the time Mr. Gasper sought the authority to sell her real estate. The court also held that it was in Ms. Gasper's best interest to sell the property in order to not jeopardize her Medicaid benefits.

Most Affluent Seniors Want to Age In Place Including Relying on and Compensating Family For Long Term Care

McKnight's Long Term Care News, reports the results of a new survey of wealthy seniors which suggests that many of nursing homes’ potential residents would prefer to receive long-term care at home, and would be willing to pay their own family members for it.

The Harris Poll, conducted on behalf of the Nationwide Retirement Institute, conducted a survey that gathered responses of more than 1,000 U.S. adults, age 50 or older, with an annual household income of $150,000 or more.  The survey found that about seventy-one percent (71%) of seniors would prefer to rely on a family member for long-term care. More, seventy percent (70%) of those surveyed would not expect that help, unless they were able to pay relatives.

Only one percent (1%) stated that they preferred to receive skilled care in a nursing home. The majority of respondents (56%) said that they “would rather die” than live in a nursing home, and just less than half of the respondents (47%) said they worry about becoming a burden to their families.  Reasons for those worries included loss of control of their lives (68%), detachment from the community (32%) and seeing family less often (30%).

The overwhelming majority of respondents (77%) said, if needed, they’d most prefer to receive long-term care at home.  

More details from the seventh annual survey can be found on Nationwide’s website here.

Alzheimer's Association Launches Program to Connect Dementia Care Experts with Assisted Living Communities

According to an Alzheimer's Association press release, the Association is launching an innovative pilot program aimed at enhancing the care people living with Alzheimer’s and other forms of dementia receive in assisted living facilities. Modeled after Project ECHO® (Extension for Community Healthcare Outcomes) – a “telementoring” program that uses videoconferencing technology to share information – the new pilot will connect dementia care experts with leaders from assisted living communities across the country. The six-month program will combine bi-weekly presentations with interactive case studies to help enhance person-centered, high quality dementia care in community-based settings.  Go here to see a video describing how Project Echo® works. 

“The Alzheimer’s Association is excited about leveraging the ECHO model™,” said Morgan Daven, senior director, health systems, Alzheimer’s Association. “It allows us to create an ongoing dialogue between dementia care experts and those on the front lines providing care to individuals living with Alzheimer’s and other dementias. Project ECHO provides not only an opportunity for dementia experts to share their insights, but also a forum to explore real case studies from the field to better address the common challenges facing communities providing dementia care.”

Project ECHO, developed by the University of New Mexico in 2003, was first used to train primary care clinicians in rural communities to treat patients with hepatitis C. Subsequent studies found that hepatitis C care provided by Project ECHO trained community providers resulted in outcomes equal to those provided by specialists at a university. Since then, the model has been used to educate providers and improve care for other complex conditions, including: HIV, tuberculosis, chronic pain, endocrinology and behavioral health disorders. This will be one of the first models used to improve quality dementia care in long-term and community-based settings.

“The ECHO model has a proven track record of success,” Daven said.  “It will enable us to disseminate the latest and greatest research and recommendations for dementia care to communities in a timely and efficient manner. Communities will be able to use this information to improve care for people living with dementia. Ultimately, we would like to expand this pilot program across the country.

The six-month pilot program will consist of 12 sixty-minute sessions. Designed specifically for leaders and staff from assisted living communities, the sessions will examine content areas put forth in the Alzheimer’s Association Dementia Care Practice Recommendations released earlier this year. The recommendations, developed by dementia care experts, emphasize person-centered care and are based on a comprehensive review of current evidence, best practice, and expert opinion. Key topics addressed in the sessions, include: 

• Fundamentals of person-centered dementia care
• Detection and diagnosis for nonphysicians
• Person-centered assessment and care planning
• Co-morbidities and medical management for nonphysicians
• Information, education and support needs of individuals living with dementia and caregivers
• Evidence-based nonpharmacological practices
• Progressive support for activities of daily living
• Building and supporting the workforce
• Supportive and therapeutic environments
• Interventions for transitions in care
• Evaluating person-centered practices

The Alzheimer’s Association is partnering with the New York Academy of Medicine (NYAM) to evaluate the initial pilot. NYAM created the first-ever evaluation toolkit and resource guide for users of the ECHO model in 2016. The evaluation will assess key areas including process, impact and sustainability. The Alzheimer’s Association will use the evaluation to inform and enhance future offerings of the program.

In addition to having ongoing engagement with dementia care leaders, pilot participants will have open access to resources provided during the program and will receive a certificate upon completion. Sixteen assisted-living facilities are participating in the initial pilot, they include: Affinity Living Group (Ahoskie House), Brandywine Living (Pennington), Brightview Senior Living (Canton), Brookdale Senior Living (Westlake, Ohio Clare Bridge Alzheimer’s and Dementia Care Program), The Chelsea at Tinton Falls, Forest Hills of DC/Forest Side Memory Care, Genesis Healthcare (Granite Ledges of Concord), Juniper Communities (Brookline’s Wellspring Memory Care Community), The Kendal Corporation (The Admiral at the Lake), HCR Manor Care (Arden Courts of Winter Springs), Senior Lifestyle (Liberty Heights), Senior Resource Group (Maravilla Santa Barbara), Senior Star (Dublin Assisted Living and Memory Support), Silverado (Kingwood Memory Care Community), St. Paul Elder Services Inc., and Sunrise Senior Living (Brighton Gardens of St. Charles).

The pilot program is offered free of charge to participants. Individual donors Bill and Susan Thomas and Robert and Jill Thomas are funding the assisted living pilot program.  

A companion pilot aimed at health care providers is also being launched. It will focus on resources and information relevant to clinical practice and is aimed at helping primary care clinicians not specialized in dementia care, better diagnose, care and support individuals living with Alzheimer’s and other forms of dementia.

VA Rule Changes to Aid & Attendance Effective 10/18/2018

The Veteran's Administration has published new rules regarding Aid and Attendance eligibility.  These rule changes were long anticipated, but now become effective October 18, 2018, thirty days after publication which occurred on September 18th, 2018.  Applications and transfers prior to that date are governed by the old rules.

THE NEW RULES

Three-Year Look-Back For Asset Transfers: Beginning October 18, 2018, there will be a 3-year look back on asset transfers for less than fair market value. Previously you could transfer assets in one month, and apply for benefits the next month with no look back at all. The 3-year look back has eliminated the option of last-minute planning with immediate benefits. Note however, that any transfer prior to October 18, 2018 will be protected and not subject to the new laws; however, the transfers need to be made strategically in the right way.


Penalty for Asset Transfers: Transfers made during the look-back period will be subject to a penalty period (a period of ineligibility) that can last up to 5 years. The penalty is calculated by using a set amount as a divisor (the monthly MAPR for a veteran with one dependent, which is currently $2,169.00 per month for Improved Pension with Aid & Attendance), regardless of whether the application is for a surviving spouse or a qualifying veteran. Once determined, the penalty period begins on the first day of the month that follows the last asset transferred.


Net Worth Test: The prior “asset test” was “sufficient means” which was generally around the $80,000 mark. Under the new regulations, the asset limit is now set at $123,600 for 2018 and increased each year with inflation. The asset test takes into account all assets (minus the primary residence and personal belongings like cars) plus annual gross income, minus permissible medical expenses. Be sure to check with an experienced attorney who is also accredited agent by the VA to determine whether your assets are countable or exempt under the new laws.


Allowable Medical Expenses: The changes now allow qualified veterans and widows to deduct Independent Living Facilities expenses as a deductible medical expense as long as a physician, physician assistant, certified nurse practitioner, or clinical nurse specialist says that the person EITHER needs assistance with 2 ADLs (Activities of Daily Living) OR supervision due to cognitive or physical limitations. Previously only home care, assisted living and nursing home care costs were allowed as deductions.

CALL TO ACTION!

If you are a Veteran or Widow(er) of a Veteran and want or need help paying long term care costs, you should:

• Contact a VA  Elderlaw Attorney as soon as possible to determine if you would benefit from VA Benefits Planning.
• Complete ALL asset protection planning before the October 18th deadline. All transfers that occur prior to October 18th will not be penalized under the new rules, even if an application for benefits is filed after that date. To be protected from the impact of the new rules, all planning should be completed by October 18th.

If you provide services for Veterans, you and your team need to know about these new rules. Contact our office to find out about upcoming educational workshops and training opportunities on the VA’s updated rules or to refer your clients directly to us as time is of the essence.

Read the new rules and a discussion of the changes here: Net Worth, Asset Transfers, and Income Exclusions for Needs-Based Benefits.

Read the following prior articles published on this blog regarding the changes:

• Proposed VA Regs Would Create Transfer Penalties for Pension Applicants
• NAELA Says the VA Could Be Sued If Proposed Transfer Regs Are Enacted

Must-Know Statistics About Long-Term Care

Christine Benz, Morningstar's director of personal finance, has penned an excellent article regarding long term care.  In it, she collects the most fascinating array of statistics regarding long-term care, caregiving, and the financial consequences of both.  

Ms. Benz describes the issue of what to do about long term casts later in life as the "single unsolved problem in the retirement plans for many middle- and upper-middle-income adults."  

She warns against the wealthy being too cavalier about their ability to pay the cost of long-term care: 

"[v]ery high-income, high-net-worth people can plan to self-fund long-term care costs, though I'd advise them to do the math on long-term care cost inflation before getting too comfy with the idea that they'll have enough to do so. 

Meanwhile, she warns that most people without significant financial assets will need to rely on Medicaid-provided long-term care; Medicaid and other government programs cover the majority of the long-term care costs in the U.S.

For those in the middle, she describes the choices as "stark and rather unappealing:" 

Sandwiched in the middle are people with some, even significant, financial assets--just not necessarily enough to comfortably fund a $300,000 (or more) long-term care outlay at the end of their lives. For them, the choices are stark and rather unappealing. They could purchase traditional long-term care insurance and risk premium hikes. Alternatively, they could purchase one of the increasingly popular hybrid life/long-term care products and face an opportunity cost, as discussed here. Or they could forego insurance altogether, planning to self-fund care or use nonportfolio assets, such as a home sale, to cover any long-term care costs.

Add to these unappealing choices the surprises that often await long-term care recipients, including, but not limited to state resource recovery laws and filial responsibility- and the choices are worse than "stark;" they are potentially devastating.  

Every year, Ms. Benz compiles facts and figures regarding long-term care in an effort to aid in decision making and planning.  These statistics follow organized by subject matter.  

Usage of Long-Term Care

• 52%: Percentage of people turning age 65 who will need some type of long-term care services in their lifetimes. 
• 47%: Estimated percentage of men 65 and older who will need long-term care during their lifetimes.
• 58%: Estimated percentage of women 65 and older who will need long-term care during their lifetimes.
• 2.5 years: Average number of years women will need long-term care.
• 1.5 years: Average number of years men will need long-term care.
• 14%: Percentage of people who will need long-term care for longer than five years.
• 10%: Percentage of Americans over age 65 who have Alzheimer's dementia. 
• 33%: Percentage of Americans over age 85 who have Alzheimer's dementia. 
• 64%: Percentage of Americans with Alzheimer's dementia who are women.
• 123%: Percentage increase in the number of people who died from Alzheimer's dementia, 2000-2015.
• -11%: Percentage decrease in the number of people who died from heart disease, 2000-2015.
• 22%: Percentage of individuals over 65 in the highest income quintile who will have a long-term care need of two years or longer.
• 31%: Percentage of individuals over 65 in the lowest income quintile who will have a long-term care need of two years or longer.
• 45%: Percentage of people requiring significant long-term care help (assistance with two or more activities of daily living) who are under age 65.
• 8%: Percentage of people between the ages of 40 and 50 who will have a disability that will require long-term care services.

Paying for Care

• $30 billion: Long-term care expenditures in the U.S., 2000.
• $225 billion: Long-term care expenditures in the U.S., 2015.
• 57.5%: Percentage of individuals turning 65 between 2015 and 2019 who will spend less than $25,000 on long-term care during their lifetimes.
• 15.2%: Percentage of individuals turning 65 between 2015 and 2019 who will spend more than $250,000 on long-term care during their lifetimes.
• $341,840: Estimated lifetime cost of care for someone with dementia. 
• $18,200: Median annual cost for adult day care (five days/week), 2017.
• $45,000: Median annual cost for assisted-living facility, 2017.
• $85,775: Median annual nursing-home cost, semiprivate room, 2017.
• $97,455: Median annual nursing-home cost, private room, 2017.
• $215,770: Average annual nursing-home cost, private room, Manhattan, 2017.
• $51,100: Average annual nursing-home cost, private room, Monroe, Louisiana, 2017.
• $23,394: Median annual income from all sources for individuals who are 65 or older.
• $39,823: Median annual income for households headed by people 65 or older.
• 3.8%: Five-year annual inflation rate in nursing-home costs, private room, 2017.
• 5.5%: One-year annual inflation rate in nursing home costs, private room, 2017.
• 19%: Percentage of long-term care costs that were paid out of pocket, 2013.
• 8%: Percentage of long-term care costs that were paid by private insurance, 2013. 
• $263,200: Median household wealth for adults age 65 or older with no disabilities. 
• $94,200: Median household wealth for adults age 65 or older with limitations on two or more activities of daily living. 

Caregiving 

• 34.2 million: The number of Americans who have provided unpaid care to an adult 50 or over in the past 12 months.
• 16.1 million: The number of caregivers for someone with Alzheimer's or other dementia. 
• $470 billion: The estimated dollar value of long-term care provided by unpaid caregivers, 2013. 
• 65%: The percentage of caregivers who are female.
• 33%: Approximate percentage of caregivers to people with Alzheimer's/other dementias who are daughters.
• 25%: Approximate percentage of caregivers who are "sandwich generation" caregivers, providing care to children as well as older adults. 
• 34%: The percentage of caregivers who are age 65 or older.
• 33%: The percentage of people providing care to people age 65 or older who describe their own health as fair or poor. 
• 83%: Percentage of care provided to older adults that is delivered by friends or family members. 
• 65%: The percentage of older adults with long-term care needs who rely exclusively on friends and family members to provide that assistance.
• 34.7: Average number of hours worked by unpaid caregivers who have jobs in addition to caregiving. 
• 70%: The percentage of caregivers who suffered work-related difficulties due to their caregiving duties.
• 36%: The average percentage of caregivers for people age 50 or older who said they were experiencing high levels of financial strain.
• 10%: The estimated percentage of older adults who have suffered from some form of elder abuse. 
• 7%: The estimated percentage of elder-abuse cases that are reported to authorities.

State and Federal Funding 

• 51%: Percentage of long-term care services and supports that were provided through Medicaid, 2013.
• 20%:  Percentage of long-term care services and supports that were provided through other public sources, 2013.
• 62%: Percentage of nursing home residents whose care is provided by Medicaid. 
• 20%: Percentage of Medicaid funding that went to pay long-term care costs in 2016. 
• 50%: Expected increase in Medicaid spending for long-term care between 2016 and 2026.
• $123,600: Maximum amount of assets that a healthy spouse can retain for the other spouse to be eligible for long-term care benefits provided by Medicaid, 2018. (Actual amounts vary by state.) 
• $3,090: Maximum amount of monthly income that a healthy spouse can receive for the other spouse to be eligible for long-term care benefits provided by Medicaid, 2018. (Actual amounts vary by state.) 
• 100: Days of care in a skilled nursing facility ("rehab") covered in full or in part by Medicare following a qualifying hospital stay.

Long-Term Care Insurance 

• 125: Number of insurers offering standalone long-term care policies, 2000. 
• Fewer than 15: Number of insurers offering standalone long-term care policies, 2014. 
• 380,000: Number of individual long-term care insurance policies sold, 1990.
• 129,000: Number of individual long-term care insurance policies sold, 2014. 
• 72,736: Number of hybrid life/long-term care policies sold to individuals, 2009.
• 305,068: Number of hybrid life/long-term care policies sold to individuals, 2013.
• 4.5 million: Number of individuals with long-term care insurance coverage, 2000. 
• 7.25 million: Number of individuals with long-term care insurance coverage, 2014. 
• $1.98 trillion: Maximum potential benefit of all long-term care policies in force today.
• $1.87 billion: Annual claims on long-term care insurance policies, 2000.
• $9.2 billion: Annual claims on long-term care insurance policies, 2017.
• $1,677: Average annual premium, long-term care policies being sold, 2000.
• $2,772: Average annual premium, long-term care policies being sold, 2015.
• 99%: Percentage of new long-term care policies that cover both nursing home and in-home care.
• 0.5%: Percentage of all businesses offering long-term care insurance to their employees.
• 20%: Percentage of businesses with 10 or more employees offering long-term care insurance to their employees. 
• 13.9%: Percentage of applicants ages 50-59 denied long-term care coverage due to health issues. 
• 44.8%: Percentage of applicants ages 70-79 denied long-term care insurance due to health issues.