Planning for a Loved One with Dementia

Having the conversation about dementia with a loved one is never easy says The Tribune-Democrat’s recent article entitled, “Dealing with dementia | Planning ahead: ‘Have the conversation.’” But, it is important to discuss the future and ensure your loved one is well-cared for.

First, it is important not to wait too long to have this conversation.  Once there is a diagnosis or symptoms, it’s time to act.  Dementia and similar diseases are degenerative so they won’t get better on their own.  Delay in confronting this issue won’t make things better, and can limit your options on how to address it.

Plus, you want to get as much input from your loved one with dementia as you can.  As the disease progresses, they will have a harder time making their own choices, considering their situation and offering direction and preferences for their own welfare.  This could be everything from living arrangements, care plans, estate planning, to bucket list items.  Starting early includes your loved one as much as possible and preserves their own wishes and choice.

Next, address the legal documents and define the future care. Of course, you should have an estate plan in place long before this.  But, dementia will affect a person’s capacity which may make them unable to create a new plan.  So, this may be the last, best opportunity to review and update the estate plan.

You should especially review the incapacity planning documents such as powers of attorney or trusts.  These documents can help prevent the person from being placed in guardianship by the court, which is an expensive, difficult process for families. When granted, the court appoints a decision-maker, taking away the individual’s ability to make decisions – either in whole or in part. This court oversight continues throughout the individual’s life or until capacity returns.

You especially want to review who your fiduciaries are (such as your agent to make financial decisions for you) and the powers you’ve given them.  For example, if you want to use Medicaid to help pay for your long-term care, the power for your agent to make gifts may become important where it wasn’t 15 years ago when you first executed the power of attorney.

Similarly, it is important to update your medical powers of attorney and directive to physicians, as well as discussing your wishes and preferences with your agent.  These documents appoint a person to make medical decisions on your behalf if you can’t, including end-of-life care.  Having the conversation with your agent about your preferences will prepare your agents to make those decisions and relieve the burden of worrying they are making the wrong decisions.

As a final point here, you should discuss the future care plan with your loved one. Is the plan to live at home?  Will family assist with care?  Will in-home care workers be hired to assist, or is an assisted living or nursing home a better idea?   What’s more, how do you pay for it?  It is often important to discuss these question with your financial advisor and an elder law attorney so that you can make an informed choice.  You may also consider whether and how to use Medicaid or other long-term care programs to help pay for future care.  The answers to these questions also impact your estate planning.

Reference: The Tribune-Democrat (July 29, 2023) “Dealing with dementia | Planning ahead: ‘Have the conversation’”

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Retaining Assets While Being Medicaid Eligible

Medicaid is a program with strict income and wealth limits to qualify, explains Kiplinger’s recent article entitled “You Can Keep Some Assets While Qualifying for Medicaid. Here’s How.” This is a different program from Medicare, the national health insurance program for people 65 and over that largely doesn’t cover long-term care. In this system, clients often have a goal of retaining assets while being Medicaid eligible.

If you can afford your own care, you’ll have more options because all facilities (depending on the level of medical care) don’t take Medicaid. Even so, couples with ample savings may deplete all their wealth for the other spouse to pay for a long stay in a nursing home. However, you can save some assets for a spouse and qualify for Medicaid using strategies from an Elder Law or Medicaid Planning Attorney.

You can allocate as much as $3,259.50 of your monthly income to a spouse, whose income isn’t considered, and still satisfy the Medicaid limit. Your countable assets must be $2,000 or less, with a spouse allowed to keep half of what you both own up to $130,380. Countable assets include things like cash, bank accounts, real estate other than a primary residence, and investments.  However, you can keep a personal residence, personal belongings (like clothes and home appliances), one vehicle (2 for married couple), engagement and wedding rings and a prepaid burial plot.  There are more detailed rules for countable and exempt assets, but suffice it to say most things count.

If you have too much income over the $2,382 income per month for the application, you can use a Miller Trust aka Qualified Income Trust for yourself, which is an irrevocable trust that’s used exclusively to satisfy Medicaid’s income threshold. If your income from Social Security, pensions and other sources is higher than Medicaid’s limit but not enough to pay for nursing home care, the excess income can go into a Miller Trust. This allows you to qualify for Medicaid, while keeping some extra money in the trust for your own care. The funds can be used for items that Medicare doesn’t cover.

However, your spouse may not have enough to live on. You could boost a spouse’s income with a Medicaid-compliant annuity. These turn your savings into a stream of future retirement income for you and your spouse and don’t count as an asset. You can purchase an annuity at any time, but to be Medicaid compliant, the annuity payments must begin right away with the state named as the beneficiary after you and your spouse pass away.

These strategies are designed for retaining assets while being Medicaid eligible for married couples; leaving an asset to other heirs is more difficult. Once you and your spouse pass away, the state government must recover Medicaid costs from your estate, when possible. This may be through a a claim on your probate estate (usually means the house) before assets go to heirs, reimbursement from a Miller Trust or other items.  That is a topic unto itself, albeit an important one, so see here for more information on Medicaid recovery.  https://galligan-law.com/protect-assets-from-medicaid-recovery/

Note that any assets given away within five years of a Medicaid application date still count toward eligibility. Property transferred to heirs earlier than that is okay. One strategy is to create an irrevocable trust on behalf of your children and transfer property that way. You will lose control of the trust’s assets, so your heirs should be willing to help you out financially, if you need it.

Reference: Kiplinger (May 24, 2021) “You Can Keep Some Assets While Qualifying for Medicaid. Here’s How”

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Can I Afford In-Home Elderly Care?

Most clients prefer to age at home. However, in-home elder care costs add up quickly, so be aware of other affordable housing options.

Staying at home isn’t always affordable, according to a recent US News and World Report article. The article, entitled “Can You Afford In-Home Elderly Care?”, says about 80% of seniors are concerned about being able to afford home health care costs, based on a 2019 SCAN Health Plan survey. Paying for personalized in-home senior care can add up quickly and isn’t always easy on a senior’s tight income.

If you’re thinking about in-home elderly care, review these criteria to determine what costs to expect and the different payment options available for this type of care.

Find Out the Services Included in Home Care for the Elderly. In-home care can vary a lot, depending on your health conditions and needs. You might get helpers if you’re recovering at home from an illness or injury, and you could also have home care workers help you with daily activities, such as preparing meals and personal hygiene. Home care services often include rides to and from appointments, monitoring heart rate and blood pressure and in-home physical and cognitive therapy sessions.

Think about the Level of Care Needed. If you can do most daily activities on your own, but could use help with certain activities, such as cooking or cleaning, home care might be a wise option. Home care is focused on the service, and it’s supposed to help those who are living on their own as long as possible. When more care is required, moving to a place with more health support may be necessary. People who have significant needs may often look to assisted living as an alternative. Assisted living facilities offer more services, like 24-hour emergency care and ongoing supervision for seniors with Alzheimer’s, dementia, or other disabilities, although funding options may be limited.

Check Out the Cost of In-Home Senior Care. Homemaker services cost about $22.50 per hour on average and include tasks to help a person with daily duties like laundry, grocery shopping and light housework. A home health aide charges an average of $23 per hour, and may help with administering medicine at scheduled times, supervising and monitoring chronic illnesses and helping with walking aids. Of course, the exact cost of these services depends on where you live and the amount of help you need. The monthly cost for in-home care ranges from $4,290 for homemaker services to $4,385 for home health aide care. This typically costs more than the monthly median cost for an assisted living facility—but less than the median cost per month for a room at a nursing home facility.

Know Your Insurance Coverage. If you’re on Medicare, you may be able to get coverage for some short-term home services. To do so, a doctor will need to indicate that skilled nursing care is needed for a short period of time. Medicare will cover speech therapy, occupational therapy, or physical therapy. You can also use it to help with the purchase of durable medical equipment and safety additions to your home. However, Medicare won’t typically cover long-term home care services.

Medicaid will cover some health services at home, like cleaning and meal preparation, rides to and from medical visits and personal care if you are financially eligible.  Depending on the program, it provides some care and services in the home to those who need it medically. If you have long-term care insurance, some in-home services may be covered by your policy.

Look at Other Payment Methods. If your insurance won’t cover in-home care, you might have to pay out-of-pocket. One way to lower costs, is by asking family members to help. If you need to hire more help over time, the cost for services will increase accordingly. If that doesn’t work, they may help pay for in-home elderly care.

Additionally, people often overlook government benefit options, such as Medicaid or Veterans’ benefits such as Aid & Assistance.  People wrongly assume they aren’t eligible for the benefits, and miss out on funds available to them.  See here for a fuller description of this issue.  https://galligan-law.com/medicare-basics-what-to-know/

Reference: US News and World Report (June 10, 2020) “Can You Afford In-Home Elderly Care?”

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