Long-Term Care

Tuesday, July 8, 2014

How to Pay for Long-Term Care Using Medicaid

By:  Susan M. Graham, Certified Elder Law Attorney, Senior Edge Legal, Boise, Idaho

The latest government report on Medicaid applicants highlighted the four most common methods used to reduce countable assets to qualify for Medicaid in a nursing home. 

The Government Accountability Office issued a report on June 23, 2014, in which about 300 applications for Medicaid in three states, New York, Florida and South Carolina were reviewed. [1]  The report stated the average cost for nursing home care is $7,000 per month, or $85,000 per year.  Medicaid, a joint state and federal program, provides services to certain individuals whose assets are insufficient to meet the costs of necessary long-term medical care. One of the tests that must be met is a measurement of the assets available to a Medicaid applicant.  If the applicant has too many assets, they will not qualify for the Medicaid benefit. 

The report identified the top four methods used to reduce the assets considered to qualify for Medicaid:

  1. The countable assets were used to purchase “exempt” assets, which are assets ignored by Medicaid.One common practice was to prepay a burial.
  2. An annuity that meets the strict Medicaid rules was purchased
  3. Assets were gifted to family members.
  4. Assets were shifted to the healthy spouse, who then purchased an "exempt" annuity, meeting the Medicaid standards.
The Medicaid applicants in these three states surely needed professional help to navigate the complexities of the Medicaid rules and qualify for the benefit of having their nursing home care paid for by the government.   Gifting is a dangerous and aggressive technique.   Often a gift will disqualify an applicant from receiving benefits if the gift was made within five years of applying for Medicaid.  Using annuities to reduce assets requires that the annuity falls within the narrow limits allowed.  This is next to impossible without assistance from a knowledgeable professional.

The GAO report states the obvious:
 “Medicaid spending for nursing home care is projected to increase, placing an additional burden on already strained federal and state resources.”[2]    

What does this mean for you?  Everyone should plan for the need for long-term care and how to pay for it.


[1] “Medicaid:  Financial Characteristics of Approved Applicants and Methods Used to Reduce Assets to Qualify for Nursing Home Coverage,” Government Accountability Office, June 23, 2014.

[2]  Page 1, GAO-14-473 Medicaid Nursing Home Financial Eligiblity

Thursday, November 1, 2012

The downside of Veterans Annuities the salesperson won't tell you about


Florida Certified Elder Law Specialist
Nationally Certified Elder Law Attorney
Florida and New Yokr Bar
The pitches are everywhere in Florida: So-called Veterans Benefits experts offer free seminars to condo associations. They advertise on radio and in newspapers. The companies they represent have patriotic-sounding names. They distribute glossy brochures stuffed with red, white and blue.
So what are these folks selling? Veterans Annuities. The pitch is this: If you are an otherwise eligible veteran who cannot get Aid and Attendance benefits because of excess assets, all you need to do is buy one of these annuities with the excess assets, and voila: instant access to benefits to help you pay the costs of long-term care nursing home, assisted living or home care. It is true enough that the V.A. does not "look back" at asset transfers, but there's a lot more to this issue that you need to consider before taking the leap. 
First, tying up money in an annuity is almost never a good idea for an elderly person. If you ever need the money, you'll incur substantial penalties when you withdraw it.
Second, people need more intensive help as they age, not less. So if you're a veteran or surviving spouse in need of Aid and Attendance benefits, somewhere down the line you may want to apply for Florida Medicaid benefits for long-term care to help you with your more extensive needs. In Florida, if the veteran purchases an annuity and then has to apply for Medicaid for long-term care, the state of Florida MUST be designated as a beneficiary of that annuity for Medicaid expenses. That's the part that the annuity salesperson doesn't tell you, and may not know himself. One thing is for sure: the commission to the salesperson on these products is quite handsome.

Iif you are a veteran or a veteran's surviving spouse and need help, DO NOT purchase an annuity without consulting with a Florida Bar Certified Elder Law Attorney who is also accredited by the V.A. to give benefits advice. Your attorney will help you fully understand the pros and the cons  and explain alternatives  to buying an annuity. All the attorneys of The Karp Law Firm are V.A. accredited.


Sunday, October 7, 2012

6 Ways to Pay for Long Term Care?

By Susan M. Graham, CELA, Senior Edge Legal, Boise, Idaho


The U.S. Government has no money!   Can seniors expect help from the government to pay their long term care expenses? 

Who needs long term care?

People over age 65 have a 50-70% chance of needing care before they die.

What does it cost?

         At home:  $20 per hour to $15,000/month for 24-hour care

         Assisted Living:  $3,500 to $5,000 per month

         Skilled Nursing Care (Nursing Home) $6,000 to $10,000 per month

         Crabby/Difficult Senior:    $16,000 to $18,000 per month

What are the six ways to pay for care?

         Family and friends provide the care for free.

         Take money out of your pocket

          Long Term Care Insurance


          Veteran - Non Service Connected Disability (Aid and Attendance)


How do each of the six ways work?

  1. Family and friends provide the care for free. 

When a spouse becomes a caregiver, it increases the likelihood that they will die before the spouse who is being cared for.   If children are the caregivers, it ruins their lives.  They stop working early, lose out on wages and benefits, and have less time to spend with their own family and friends.  If they are paid without a written contract, this can create problems later if the person needing care wants to qualify for government benefits.

         2.       Pay “Out of Pocket,”  

Pay the expenses for you or your spouse from your funds until you run out of money.


         3.       Long-Term Care (LTC) Insurance.

You purchase LTC insurance.  You decide how much coverage you want in terms of a daily rate to pay for your care and for how long.  To qualify for and purchase LTC insurance, you need to be healthy and have the funds to pay the premiums.  Why buy LTC insurance?  You get the most flexibility to choose the location for your care and how the funds will be spent.  The worry about our government’s ability to pay for your care and everyone else’s care is lessened.

         4.       Medicare.

Medicare is a Federal HEALTH insurance program for people 65 and over.  

There is a short-term residential care component for Medicare if you qualify.   

                  You must be admitted to a hospital for 3 or more days. 

                  When you are discharged to a rehabilitative facility, you must participate in the rehabilitative activities and be improving.

                  If these two events occur, then Medicare will pay 100% for the first 20 days of rehabilitative care.  The bills I have seen for the first 20-day stay range from $6,000 to $30,000.

                  If you continue to be in rehab, Medicare will pay part and you or your supplemental health insurance will pay part of the bills for the next 80 days.

                  This benefit is being taken away with the hospital stating that a person is not “admitted” but rather is in the hospital for “observation.”  That means the patient is ineligible for Medicare coverage for subsequent skilled nursing care in a facility.

                  Also, this benefit is not available if the patient is not “improving” or participating in the rehabilitative activities.

         The result:  Seniors must pay for their post-acute care out of pocket or forego the treatment.


          5.  Veteran’s Non-Service Connected Disability (Aid and Attendance).

The Veterans program will help pay between $1,094 to $2,631 per month for long-term care in your home or a facility. 

How can this benefit be accessed?

         You or your spouse must be

                  Age 65 or older

                  Served 90 days on active duty

                  One day during wartime [1]

                  Received a discharge that is not dishonorable

                  Meet the income test

                  Meet the asset test


            6.  Medicaid (a loan program).

Medicaid is a State  and Federal program that provides for long-term residential care to people who are aged, blind or disabled.  Each state is responsible for administering the Medicaid prorgram in its state.  I will address the program for the “aged.”  Aged means someone is age 65 or older.

What is this benefit?  If a person qualifies, the benefit will pay for the cost of care in assisted living or a skilled nursing home facility that participates in the Medicaid program.  There are some funds to help pay for care at home, but frequently the payment is not enough to provide full care for an individual in their own home.

What does it take to qualify for Medicaid?

The applicant must be blind, disabled (using a social security definition) or age 65 or older.

                 The applicant must have a medical need.

 The applicant must pass an income test.  If they fail this test, it is often possible to take some steps to meet this requirement.

 The applicant has to meet an asset test. This test is complex and cannot be covered in this short article.

Once the Medicaid recipient (and their spouse) dies, the State is entitled to be reimbursed for the funds they paid out on behalf of the Medicaid recipient.

Summary:  What is the best way to plan for long-term care, when it is more likely than not to happen?

  1. Consider LTC insurance, even if you think you can self-insure.
  1. If it is too expensive or too late to get LTC insurance, contact an attorney who is familiar with Medicare, Medicaid and VA benefits to explore other alternatives.   Asset protection is only possible with the right tools.  The sooner planning is done, the more flexibility the individual and their family have for lifestyle choices and the greater the ability to protect a lifetime of earnings. 
  1. A Family Legacy Trust may fit to preserve assets, and help pay for care.
  1. Act now.  Don’t wait for a crisis, because then it may be too late to make choices that are best for the family.   Under the current law, to have the most flexibility in planning, it needs to start five years before a need arises.


This information is intended to be helpful and general and not intended as legal advice.   These rules for Medicare, VA and Medicaid benefits are complex and change frequently.

[1] WWII  12-07-41 to 12-31-1946, Korean 6-27-50 to 1-31-1955, Vietnam 2-28-61 to 5-7-75 for Veterans who served in Vietnam during that period, or 8-5-64 to 5-7-75 inclusive for all others, Persian Gulf 8-2-90 through present.


Friday, July 6, 2012

Do You Know a Child May Have To Pay for Their Elderly Parent’s Care? Ouch!

By Susan M. Graham, Certified Elder Law Attorney, Senior Edge Legal, Boise, Idaho

Paying for long-term care in a nursing home or assisted living facility is expensive.  It can range from $3,000 to $10,000 monthly.  What if the senior cannot pay the bills?

In 2011 a Pennsylvania nursing home received a $90,000 judgment against an adult child of a parent who had an unpaid nursing home bill. [1]  The suit was based on a law that states[2]

 (a) Liability. --

(1) Except as set forth in paragraph (2), all of the following individuals have the responsibility to care for and maintain or financially assist an indigent person, regardless of whether the indigent person is a public charge:

(i) The spouse of the indigent person.

(ii) A child of the indigent person.

(iii) A parent of the indigent person.

(2) Paragraph (1) does not apply in any of the following cases:

(i) If an individual does not have sufficient financial ability to support the indigent person.

(ii) A child shall not be liable for the support of a parent who abandoned the child and persisted in the abandonment for a period of ten years during the child's minority.

North Dakota has an old law adopted in 1877, which creates a duty to support a parent.  

“It is the duty of the father, the mother, and every child of any person who is unable to support oneself, to maintain that person to the extent of the ability of each.  This liability may be enforced by any person furnishing necessaries to that person.  The promise of an adult child to pay for necessaries furnished to the child’s parent is binding.”  North Dakota Statutes § 14-09-10

An article in the North Dakota Dickinson Press highlighted the potential that nursing homes are considering using this old law to recoup unpaid bills.[3]


[1] Health Care & Retirement Corp. of America v. Pittas, 2012 PA Super 96, 536 EAD 2011 (May 7, 2011)

[2]  23 Pa.C.S.A. § 4603.

[3]   “Nursing homes eye old law as tool to recoup unpaid bills” by Dave Olson, The Dickinson Press, June 23, 2012.


Friday, March 16, 2012

Hope is not a plan. Is it OK to have two house fires?

By Susan M. Graham, Certified Elder Law Attorney, Senior Edge Legal, Boise, Idaho 

I talked to a wife this week who has been a caregiver for her demented husband for years.  Recently he has taken to getting up in the night and using firewood stored by the fireplace to start fires on the hearth and in the firebox!  Fortunately, his wife noticed both times and put the fires out.  She is grateful for these miracles but sees no need to change how they live.  

Her desire is to continue to care for and keep him at home with no help.   This is a dangerous plan for both of them.

Fortunately, their children and doctor have taken notice and are working to make changes that will result in a safer environment for each of them with plenty of help.

Hope is not a plan.  That approach is living in a fantasyland unrelated to real world events associated with ageing.

Friday, October 14, 2011

A MacArthur Genius Grant is Awarded to An Elder Abuse Lawyer. Yeah!

By Susan M. Graham, Certified Elder Law Attorney, Senior Edge Legal, Boise, Idaho

Caregivers of the elderly have a legal as well as a moral obligation to provide proper care for their charge.  Allowing your 84-year-old mother to rot to death is considered illegal.

Attorney Marie-Therese Connolly received the MacArthur Fellowship, the so-called "genius" grant, and was awarded $50,000 in recognition of a career that focused on many forms of elder abuse, incuding physical and psychological abuse as well as the financial exploitation and wrongful deprivation of rights of the elderly.

One example of a case handled by Ms. Connolly involved Chris Wise, a caregiver for his mother who was sentenced to three years in prison.  Why?  Even though his mother said she did not want to go to a nursing home and wanted to die at home with dignity, there is nothing dignified about dying in a filthy bed, emaciated and covered in sores so deep that bone was visible.  In her last days he ignored her calls for help, and just turned up the sound of his music so he could more easily ignore her.

Of course this is unpleasant to imagine, but thankfully it is called to our attention so that we can be more vigilant in protecting our seniors.  Perhaps this will help move some state Legislatures, including Idaho, to strengthen their laws to protect the elderly.

Congratulations and thank you, Ms. Connolly, for your work to protect seniors.


Sunday, September 25, 2011

Ten Warning Signs of Alzheimer's

By Susan M. Graham, Certified Elder Law Attorney, Boise, Idaho

Did you know September 21, 2011 was Alzheimer's Action Day?  Many companies have taken action by educating their employees and customers about the 10 warning signs of Alzheimer's1 disease.  I want to share that information with you too so you can help others in your world.

1.  Memory loss that disrupts daily life.  One of the most common signs of Alzheimer's is memory loss, especially forgetting recently learned information.  Others include forgetting important dates or events; asking for the same information over and over; relying on memory aids [e.g., reminder notes or electronic devices] or family members for things they used to handle on their own.

     What's a typical age-related change?  Sometimes forgetting names or appointments, but remembering them later.

2.  Challenges in planning or solving problems.  Some people may experience changes in their ability to develop and follow a plan or work with numbers.  They may have trouble following a familiar recipe or keeping track of monthly bills.  They have have difficulty concentrating and taking much longer to do things than they did before.

     What's a typical age-related change?  Making occasional errors when balancing a checkbook.

3.  Difficulty completing familiar tasks at home, at work or at leisure.  People with Alzheimer's often find it hard to complete daily tasks.  Sometimes, people may have trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game.

     What's a typical age-related change?  Occasionally needing help to use the setting on a microwave or to record a television show.

4.  Confusion with time or place.  People with Alzheimer's can lose track of dates, seasons and the passage of time.  They may have trouble understanding something if it is not happening immediately.  Sometimes they may forget where they are or how they got there.

     What's a typical age-related change?  Getting confused about the day of the week but figuring it out later.

5.  Trouble understanding visual images and spatial relationships.  For some people, having vision problems is a sign of Alzheimer's.  They may have difficulty reading, judging distance and determining color or contrast.  In terms of perception, they may pass a mirror and think someone else is in the room.  They may not realize they are the person in the mirror.

     What's a typical age-related change?  Vision changes related to cataracts.

6.  New problems with words in speaking or writing.  People with Alzheimer's may have trouble following or joining a conversation.  They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves.  They may struggle with vocabulary, having problems finding the right word or call things by the wrong name [e.g., calling a "watch" a "hand-clock".]

     What's a typical age-related change?  Sometimes having trouble finding the right word.

7.  Misplacing things and losing the ability to retrace steps.  A person with Alzheimer's disease may put things in unusual places.  They may lose things and be unable to go back over their steps to find them again.  Sometimes, they may accuse others of stealing.  This may occur more frequently over time.

     What's a typcical age-related change?  Misplacing things from time to time, such as a pair of glasses or the remote control.

8.  Decreased or poor judgment.  People with Alzheimer's may experience changes in judgment or decision-making.  For example, they may use poor judgment when dealing with money, giving large amounts to telemarketers.  They may less attention to grooming or keeping themselves clean.

     What's a typical age-related change?  Making a bad decision once in a while.

9.  Withdrawal from work or social activities.  A person with Alzheimer's may start to remove themselves from hobbies, social activities, work projects or sports.  They may have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby.  They may also avoid being social because of the changes they have experienced.

     What's a typical age-related change?  Sometimes feeling wary of work, family and social obligations.

10.  Changes in mood and personality.  The mood and personalities of people with Alzheimer's can change.  They can become confused, suspicious, depressed, fearful or anxious.  They may be easily upset at home, at work, with friends or in places where they are out of their comfort zone.

     What's a typical age-related change?  Developing very specific ways of doing things and becoming irritable when a routine is disrupted.


1Source:  The Alzheimer's Association [alz.org]


Thursday, August 18, 2011

The National Senior Citizens Law Center Issues an Updated "20 Common Nursing Home Problems"

Susan M. Graham, Certified Elder Law Attorney

The average consumer knows more about credit cards, cell phones or renting an apartment or movie than they do about nursing home regulations.  This great guide is available by going to the NSCLC website.  This guide spotlights some of the most common illegal practices and explains strategies that residents and family members can use to avoid or reverse illegal procedures.

For example, being "difficult" is not a sufficient basis to evict a resident from a nursing home.

To access this helpful guide, go to the NSCLC website and click on "Publications."  You can print one copy for free.

Friday, June 17, 2011

Who Plans on Being a Caregiver? You?

Remember we all have a 70% chance of needing care before we die.  Not a pleasing thought.

The number of adult children over 50 who are caring for their parents is estimated to be 10 MILLION in 2008.

What does it cost the caregiver to provide this service to their parents?  A Wall Street Journal article on June 14, 20111 estimates the cost to the care providers who are 50+ averages over $300,000.  This comes from lost wages, pension and social security benefits.  There is no measure for the increased stress, depression, and other physical ailments experienced by the caregiver.

If you plan to be the caregiver, understand the personal, financial and physical cost to you.

There are planning options that may lighten the burden for a family caregiver.  Discuss your family situation with a Certified Elder Law Attorney to explore ways to make the best of a difficult family situation.


1 "Toll of Caring for Elderly Increases," by Kelly Greene, The Wall Street Journal, June 14, 2011, page D3.

Friday, June 3, 2011

New Report Reveals Over-Use of Anti-Psychotics in Nursing Homes

This spring, a family reported to me that a loved one in a nursing home had trouble getting her medications in balance.  She was placed in a hospital to help sort the problem out and after her stay, she was even worse and never spoke again.  What a tragedy.

"When a loved one moves into a nursing hone, the support of family and friends is particularly important.  This is especially true when the nursing home patient has dementia and can't adequately advocate on his or her own behalf.  A newly released report from the Office of the Inspector General for the Department of Health and Human Services makes clear just how crucial it is for families to monitor and ask questions about medications that such patients receive.

Source:  CNN Opinion (May 31, 2011) 

and the National Academy of Elder Law Attorneys

Full OIG Report

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