Vicki J. Bowers, B.C.S., CELA Florida Bar Board Certified Elder Law Attorney

Certified Elder Law Attorney –National Elder Law Foundation

Veterans Administration Accredited Attorney 4540 Southside Boulevard, Suite 603 Jacksonville, Florida 32216 Phone: 904-998-0724

COST OF CAREGIVING Medical Financial Emotional Physical

Is your family prepared?

Factors impacting long term care needs Age 70% of people 65 or older can expect to use some form of

long term care during their lives But ….while 1/3 may never need it, 20% will need > 5 years!

Over age 65 = 35% chance of nursing home, 20% >5 years

Older you are = more likely to need care

Between ages 40-50, 8% have disability requiring long term

care Age 90 or over – 69% need long term care

Gender Women outlive men on average by 5 years

Average time of need for long term care Women = 3.7 years; Men = 2.2 years Much longer with certain incapacities

Women more likely to live alone when older

Those who live alone = more likely to need long

term care

Health

Chronic Conditions Family History

Lifestyle

Poor Diet

Exercise Routine

Important considerations….

What type of care is needed

Skilled nursing care

Assisted Living - Memory Care

Independent with some assistance

Medication management

What type of support is needed / available

How to pay for it

Medical Considerations Level of Care Activities of Daily Living (“ADLs”) Normal management of life without causing harm

to oneself or others Eating (Feeding oneself) Dressing Toileting (Continence) Bathing Transferring

Inability to perform 2 or more = needs

assistance

Incidental /Instrumental Activities of Daily Living Cooking Cleaning Running Errands Shopping Taking Medications Emergency response (dial 911 etc) Pet Care Telephone

“Convenience Services”

Mental Incapacity

Memory Loss Alzheimer’s or other Dementias

Traumatic Brain Injury

Complete vs. Partial

Who Determines Mental Incapacity?

Inability to provide “informed consent” Attending physician evaluates you If not sure, another physician evaluates you Medical record is documented The health care surrogate, attorney in fact with

health care authority is informed or a proxy is named

Physical Incapacity Injury - Accident

Stroke

Illness / Disease-Related

Complete vs. Partial

Eyesight

Hearing Loss

Ambulation

Care Options Home Care

Family Support

Adult Day Care

Independent Living Facility

Assisted Living

Skilled Nursing Home Care

Congregate Living

Safety at Home – the Preferred Alternative Professional Caregivers vs. “Family Friend”

Family Assistance

Life-Alert Systems

Alarm Systems

Community Transportation

Cameras

Hearing Devices

Visual Aids Prescription Reminders

Daily Logs

Home Safety - - Handrails, non-slip flooring

Lift Chairs or other Special Furniture

Fire and other safety risks

Home Health Care Home Health Care Company

Companion Services

Certified Nurse’s Assistant (“CNA”)

Registered or Licensed Nurse

Overnight Care

Average length of home care = 3 years

Independent Living Facilities

Independent apartment or patio home Kitchen facilities

Pets allowed

Community Dining

Housekeeping

Laundry

Assisted Living Group Living Settings

Individual or Shared Rooms

Social and Recreational Activities

Assistance with personal care and services, ADLs

Meals, laundry, housekeeping, medication assistance

Generally, no medical care

Monthly rent

Skilled Nursing Care Comprehensive Care Services

24-Hour

Nursing Care

Supervision

Memory Care

Secure Units

Cost of Care

Nursing Home = $250+ per day, room and board only Assisted Living - $2,500 ++++ monthly Home Health Care – hourly or daily Adult Daycare - $70/day avg Caregiver burnout – the Greatest Cost!

Costs of Care Florida Nursing

Home Private Rate

Nursing Home Semi Private Rate

ALF Home Health Aide

Home maker Services

Adult Day Care

Jax $223 $206 $3,266 $19 $17 $61

Miami $328 $267 $3,356 $16 $16 $50

Orlando $262 $238 $3,271 $19 $19 $61

Rest of State

$242 $219 $3,161 $18 $17 $62

State Avg.

$259 $230 $3,234 $18 $17 $60

Who Pays? Nobody!

Self-Funded (Private Pay) Savings Reverse Mortgage Long Term Care Insurance

Health Insurance - No

Medicare - Limited-Restorative-not LTC

Medicaid - Limited

Veterans’ Benefits – maybe

Long Term Care Insurance

Age of Applicant Health of Applicant

Elimination Period

Coverage: Nursing Home Care Assisted Living Home Health Care

Long Term Care Insurance Triggers to Coverage Daily Benefit – Reimbursement/Flat Rate Policy Maximum Benefit Inflation Protection Tax Considerations Spouse Shared Policies Partnership Program Policies Life Insurance Products

Medicare Skilled Nursing for Rehabilitation Days only 3 Day Hospital Admission 100 Day maximum Benefit 60 day break in service to start new benefit Co-pay after day 20 = $140 (2013)

Medicare – Age 65 or Disabled per SS (26 month wait)

DOES NOT PAY FOR LONG TERM CARE !!

Rehabilitation only:

3 night hospital Admission

20 days Rehab at 100%

80 Days Rehab with co-pay

Rehab stops = Medicare stops paying!

60 day break required to start new benefit period

Medicare A Hospital Skilled care - Nursing Home (Rehabilitation) Home Health Hospice No charge for this coverage through SS

Medicare B Medically necessary services to treat or diagnose Preventative services for early detection no charge for this if provider accepts assignment Clinical research Ambulance Durable Medical Equipment

Medicare B (cont.) Mental Health – inpatient/outpatient/partial hospitalization Second opinions before surgery Limited outpatient prescription drugs There is a charge for Medicare B Coverage

Medicare HMOs Good News/Bad News

Less expensive premiums Limited skilled/rehabilitation benefits Provider networks Medicaid will not be secondary payers to HMO

Medicare Supplemental Policies (Medigap) A Medicare supplement insurance Must have Medicare A and B (not an HMO (Medicare Advantage)) sold by private companies can help pay some of the health care costs that Medicare doesn't cover, like copayments, coinsurance, and deductibles

Medigap Policies There is a monthly premium in Addition to Part B Individual coverage Guaranteed renewable even if you have health problems

Medigap Policies (cont.)

Some Medigap policies sold in the past cover prescription drugs, but Medigap policies sold after January 1, 2006 aren't allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Part D Plan (Prescription Drugs)

It's illegal for anyone to sell you a Medigap

policy if you have a Medicare Medical Savings Account (MSA)

Medicare D Each Medicare Prescription Drug Plan has its own list of

covered drugs (called a formulary). Many Medicare drug plans place drugs into different

"tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a

drug in a higher tier. If your drug is on a higher tier and your prescriber thinks

you need that drug instead of a similar drug on a lower tier, you can request an exception to get a lower copayment.

Medicaid - Needs-Based Income and asset limits N/A for Independent Living Very limited for Assisted Living Pays for Skilled Nursing Care Individual also pays toward care

Assets that do not count for Medicaid eligibility Homestead - in Florida (equity limit may apply)

Automobile

Irrevocable funeral plans

Cemetery plots

IRAs if taking Required Minimum Distributions

(counts as income payable for care)

Assets that do not count for Medicaid eligibility (cont.)

Additional assets under certain circumstances Seek the advice of an Elder Law Attorney DO NOT MAKE GIFTS/TRANSFERS TO BECOME MEDICAID ELIGIBLE !!!

Don’t forget VA Benefits! Available for Veterans and Surviving Spouses

Service-connected injury not necessary

Can help with Assisted Living Expenses

Can help with at-home medical expenses

Can pay Family Caregivers!

Duval County VA Service Office 904-630-3680

Wartime veterans Surviving spouses of

wartime veterans The key is to qualify

and to APPLY FOR IT !!

There is Money Available For

Requirements for Extra Money

90 days Active Service – at least One Day Wartime (or widow of wartime Veteran)

Discharge other than dishonorable Medical expenses Based on household income and assets Assistance needed

• Service Connected Disability compensation is not limited by Veteran’s income or assets

• Surviving Spouse/ Dependents may be eligible for Dependency and Indemnity Compensation (DIC)

V.A. Disability Compensation

Inability to dress/undress Inability to keep

oneself presentable Inability to bathe oneself

Inability to take

medications Inability to feed oneself

What Aid & Attendance Means

Income for Veteran Administration Purposes (IVAP)

Determining Eligibility For Aid and Attendance

Gross Household Income

–Out of Pocket Medical

Income for VA purposes (IVAP)

MAPR is the maximum available pension depending on the need of the claimant

Maximum Available Pension Resource (MAPR)

The VA will not pay anything toward needs-based benefits if IVAP is greater than the MAPR

The Importance of Calculating Income

MAPR is $23,388 If IVAP is zero or less Veteran qualifies for entire amount

Couple’s Gross Income: $45,000 UME (Unreimbursed Medical Expenses): -49,000 IVAP: ($ 4,000) MAPR: -23,388 Maximum Pension Allowed: $ 23,388

Married Veteran in Need of Aid & Attendance

Couple’s Gross Income: $45,000 UME: -10,000 IVAP: $35,000 MAPR: -23,388 Maximum Pension Allowed: $ 3,612

If IVAP is greater than MAPR Benefit to Veteran will be reduced

What if UME was less than their income?

FREE VA medical (no co-pay) and FREE prescription through VA pharmacies for

formulary drugs

Additional Benefits

Unlike Medicaid, the VA doesn’t have a set asset limit.

This is where the greatest need for planning exists.

Limits on Net Worth

Residence Burial Policies/plans

Some life insurance policies

Personal property

Assets VA does NOT count

Residence Burial Policies/plans

Some life insurance policies

Personal property

Assets VA does NOT count

Family Medical Leave Act

12 Weeks Unpaid Leave (can use paid leave as substitution for unpaid)

Benefits must continue/Job Protected

Birth/Adoption/Foster child

Employee serious health condition

Care for spouse, child, parent with serious health condition

Caregiver Burnout Emotional Rollercoaster

Irritable

Immune System Deficiency

No Personal Time – Guilty Complex

Self-Neglect

SUPER HERO………….

Loss of Employment Paying for Care and Needs Depression Exhaustion Sleep Deprivation Higher Mortality and Physical Issues Marital and Family Dynamics

2/3 of Caregivers are Women 14% of caregivers are over age 65 !

At least 20 hours per week

80% are unpaid

Caregiver burnout is a leading cause of nursing home placement, when run-down caregivers become too depleted to manage caregiving demands.

Questions?

Thank you !!

Vicki Joiner Bowers, PA 4540 Southside Boulevard, Suite 603 Jacksonville, Florida 32216 Phone: 904-998-0724 Visit our Website to learn more:

www.bowerselderlaw.com