Caring for an ailing family member is difficult work, but it doesn’t necessarily have to be unpaid work. There are programs available that allow Medicaid recipients to hire family members as caregivers. 

All 50 states have programs that provide pay to family caregivers. The programs vary by state, but are generally available to Medicaid recipients, although there are also some non-Medicaid-related programs. 

Medicaid's program began as “cash and counseling,” but is now often called “self-directed,” “consumer-directed,” or “participant-directed” care. The first step is to apply for Medicaid through a home-based Medicaid program. Medicaid is available only to low-income seniors, and each state has different eligibility requirements. Medicaid application approval can take months, and there also may be a waiting list to receive benefits under the program. 

The state Medicaid agency usually conducts an assessment to determine the recipient's care needs—e.g., how much help the Medicaid recipient needs with activities of daily living such as bathing, dressing, eating, and moving. Once the assessment is complete, the state draws up a budget, and the recipient can use the allotted funds to pay for goods or services related to care, including paying a caregiver. Each state offers different benefits coverage. 

Recipients can choose to pay a family member as a caregiver, but states vary on which family members are allowed. For example, most states prevent caregivers from hiring a spouse, and some states do not allow recipients to hire a caregiver who lives with them. Most programs allow ex-spouses, in-laws, children, and grandchildren to serve as paid caregivers, but states typically require that family caregivers be paid less than the market rate in order to prevent fraud. 

In addition to Medicaid programs, some states have non-Medicaid programs that also allow for self-directed care. These programs may have different eligibility requirements than Medicaid and are different in each state. Family caregivers can also be paid using a “caregiver contract,” increasingly used as part of Medicaid planning. 

In some states, veterans who need long-term care also have the option to pay family caregivers. In 37 states, veterans who receive the standard medical benefits package from the Veterans Administration and require nursing home-level care may apply for Veteran-Directed Care. The program provides veterans with a flexible budget for at-home services that can be managed by the veteran or the family caregiver. In addition, if a veteran or surviving spouse of a veteran qualifies for Aid & Attendance benefits, they can receive a supplement to their pension to help pay for a caregiver, who can be a family member. 

All of these programs vary by state. Contact your elder law attorney to find out what is available in your state. To find an attorney near you, go here: https://www.elderlawanswers.com/elder-law-attorneys.

For more information about these programs and other ways to be paid as a family caregiver, click here and here. 

A new report that combines nursing home quality data with a survey of family members ranks the best and worst states for care and paints a picture of how Americans view nursing homes.

The website Care.com analyzed Medicare's nursing home ratings to identify the states with the best and worst overall nursing home quality ratings. Using Medicare's five-star nursing home rating system, Care.com found that Hawaii nursing homes had the highest overall average ratings (3.93), followed by the District of Columbia (3.89), Florida (3.75), and New Jersey (3.75).  The state with the lowest average rating was Texas (2.68), followed by Oklahoma (2.76), Louisiana (2.80), and Kentucky (2.98). 

Care.com also surveyed 978 people who have family members in a nursing home to determine their impressions about nursing homes. The surveyors found that the family members visited their loved ones in a nursing home an average six times a month, and more than half of those surveyed felt that they did not visit enough. Those who thought they visited enough visited an average of nine times a month. In addition, a little over half felt somewhat to extremely guilty about their loved one being in a nursing home, while slightly less than one-quarter (23 percent) did not feel guilty at all. If the tables were turned, nearly half of the respondents said they would not want their families to send them to a nursing home. 

While the survey indicates that the decision to admit a loved one to a nursing home was difficult, a majority (71.3 percent) of respondents felt satisfied with the care their loved ones were receiving. Only 18.1 percent said they were dissatisfied and about 10 percent were neutral. A little over half said that they would like to provide care at home if they could. The most common special request made on behalf of a loved one in a nursing home is for special food. Other common requests include extra attention and environmental accommodations (e.g., room temperature). 

To read the full results of the survey, click here.

Traditionally, Medicaid has paid for long-term care in a nursing home, but because most individuals would rather be cared for at home and home care is cheaper, all 50 states now have Medicaid programs that offer at least some home care. In some states, even family members can get paid for providing care at home. 

Medicaid is a joint federal-state program that provides health insurance coverage to low-income children, seniors, and people with disabilities. In addition, it covers care in a nursing home for those who qualify. Medicaid home care services are typically provided through home- and community-based services “waiver” programs to individuals who need a high level of care, but who would like to remain at home. 

Medicaid's home care programs are state-run, and each state has different rules about how to qualify. Because Medicaid is available only to low-income individuals, each state sets its own asset and income limits. For example, in 2019, in New York an applicant must have income that is lower than $845 a month and fewer than $15,150 in assets to qualify. But Minnesota's income limit is $2,250 and its asset limit is $3,000, while Connecticut's income limit is also $2,250 but its asset limit is just $1,600. 

States also vary widely in what services they provide. Some services that Medicaid may pay for include the following: 

• In-home health care
• Personal care services, such as help bathing, eating, and moving
• Home care services, including help with household chores like shopping or laundry
• Caregiver support
• Minor modifications to the home to make it accessible
• Medical equipment

In most states it is possible for family members to get paid for providing care to a Medicaid recipient. The Medicaid applicant must apply for Medicaid and select a program that allows the recipient to choose his or her own caregiver, often called “consumer directed care.” Most states that allow paid family caregivers do not allow legal guardians and spouses to be paid by Medicaid, but a few states do. Some states will pay caregivers only if they do not live in the same house as the Medicaid recipient. 

To find out your Medicaid home care options, you should check with your elder law attorney. To find an elder law attorney near you, click here.

We’ve all heard the advice “It pays to shop around,” but this has never been more true than with the current market for long-term care insurance. 

Accordiing to the the latest industry figures, the spread between the lowest and highest cost for virtually identical coverage was as high as 243 percent.  “This is the largest spread I can recall in recent years,” said Jesse Slome, director of the American Association for Long-Term Care Insurance (AALTCI), an industry group that issues an annual Long Term Care Insurance Price Index. “It’s rare to see one policy costing more than twice another policy when both are large insurers but each company gets to set their own pricing and each has their own target market.”

Slome was referencing the results of AALTCI’s 2019 price index, which found that a married couple who are both 55 years old would pay an average of $3,050 a year combined for a total of $386,500 each of long-term care insurance coverage when they reach age 85. But the percentage difference between the lowest-priced and highest-priced policies for such a couple is 243 percent, meaning that a consumer could wind up paying more than triple what they might have paid for similar coverage.  Slome told ElderLawAnswers that the quoted premiums ranged from $2,898 to $9,932.

The price differences between policies for single people were lower but still significant, according to the index.  A single 55-year-old man can expect to pay an average of $2,050 a year (up from $1,870 in 2018) for $164,000 worth of coverage. But there is a 123 percent difference between the lowest-priced and highest-priced policies.  The same policy for a single woman averages $2,700 a year, down from $2,965 in 2018, although again the spread between the least and most expensive policies tops 100 percent.

For the first time, the index suggests ways for couples to save on their premium by electing less coverage or a “shared care” option.  Couples purchase 65 percent of policies, according to the AALTCI.  But clearly one of the best ways to save is to review the offerings of a number of different insurance companies.  “We really recommend the importance of talking to a specialist who is 'appointed' with multiple insurers,” Slome said.

For the association's 2019 index showing average prices for common scenarios, go here: http://www.aaltci.org/news/wp-content/uploads/2019/01/2019-Price-Index-LTC.pdf

For more about long-term care insurance. click here.

 

This is the last year that spouses who are turning full retirement age can choose whether to take spousal benefits or to take benefits on their own record. The strategy, used by some couples to maximize their benefits, will not be available to people turning full retirement age after 2019. 

The claiming strategy — sometimes known as “Claim Now, Claim More Later” — allows a higher-earning spouse to claim a spousal benefit at full retirement age by filing a restricted application for benefits. While receiving the spousal benefit, the higher-earning spouse’s regular retirement benefit continues to increase. Then at 70, the higher-earning spouse can claim the maximum amount of his or her retirement benefit and stop receiving the spousal benefit. To use this strategy, the lower-earning spouse must also be claiming benefits. Workers cannot claim spousal benefits unless their spouses are also claiming benefits. 

A 2015 budget law began phasing out the strategy. If you were 62 or older by the end of 2015, you are still able to choose which benefit you want at your full retirement age. However, when workers who were not 62 by the end of 2015 apply for spousal benefits, Social Security will assume it is also an application for benefits on the worker's record. The worker is eligible for the higher benefit, but he or she can't choose to take just the spousal benefits and allow his or her own benefits to keep increasing until age 70. 

The budget law’s phase-out of the claiming strategy does not apply to survivor's benefits and benefits on an ex-spouses record. Surviving spouses will still be able to choose to take survivor's benefits first and then switch to retirement benefits later if the retirement benefit is larger.  Ex-spouses who are divorced for two or more years can also file a restricted application for spousal benefits and wait to claim on their own record. 

For more information on Social Security benefits, click here.

Having a loved one with dementia can be scary, but if you add in a firearm, it can also get dangerous.  To prevent harm to both the individual with dementia and others, it is important to plan ahead for how to deal with any weapons. 

Research shows that 45 percent of all adults aged 65 years or older either own a gun or live in a household with someone who does. For someone with dementia, the risk for suicide increases, and firearms are the most common method of suicide among people with dementia. In addition, a person with dementia who has a gun may put family members or caregivers at risk if the person gets confused about their identities or the possibility of intruders. A 2018 Kaiser Health News investigation that looked at news reports, court records, hospital data and public death records since 2012 and found more than 100 cases in which people with dementia used guns to kill or injure themselves or others. 

The best thing to do is talk about the guns before they become an issue. When someone is first diagnosed with dementia, there should be a conversation about gun ownership similar to the conversation many health professionals have about driving and dementia. Framing the issue as a discussion about safety may help make it easier for the person with dementia to acknowledge a potential problem. A conversation about guns can also be part of a larger long-term care planning discussion with an elder law attorney, who can help families write up a gun agreement that sets forth who will determine when it is time to take the guns away and where the guns should go. Even if the gun owner doesn't remember the agreement when the time comes to put it to use, having a plan in place can be helpful. 

What to do with the guns themselves is a difficult question. One option is to lock the weapon or weapons in a safe and store the ammunition separately. Having the guns remain in the house–even if they are locked away–can be risky. Another option is to remove the weapons from the house altogether. However, in some states, there are strict rules about transferring gun ownership, so it isn't always easy to simply give the guns away. Families should talk to an attorney and familiarize themselves with state and federal gun laws before giving away guns. 

For more information about dementia and guns, click here and here.

The Centers for Medicare & Medicaid Services (CMS) has released the 2019 federal guidelines for how much money the spouses of institutionalized Medicaid recipients may keep, as well as related Medicaid figures.

In 2019, the spouse of a Medicaid recipient living in a nursing home (called the “community spouse”) may keep as much as $126,420 without jeopardizing the Medicaid eligibility of the spouse who is receiving long-term care. Called the “community spouse resource allowance,” this is the most that a state may allow a community spouse to retain without a hearing or a court order. While some states set a lower maximum, the least that a state may allow a community spouse to retain in 2019 will be $25,284.

Meanwhile, the maximum monthly maintenance needs allowance for 2019 will be $3,160.50. This is the most in monthly income that a community spouse is allowed to have if her own income is not enough to live on and she must take some or all of the institutionalized spouse's income. The minimum monthly maintenance needs allowance for the lower 48 states remains $2,057.50 ($2,572.50 for Alaska and $2,366.25 for Hawaii) until July 1, 2019.

In determining how much income a particular community spouse is allowed to retain, states must abide by this upper and lower range. Bear in mind that these figures apply only if the community spouse needs to take income from the institutionalized spouse. According to Medicaid law, the community spouse may keep all her own income, even if it exceeds the maximum monthly maintenance needs allowance.

The new spousal impoverishment numbers (except for the minimum monthly maintenance needs allowance) take effect on January 1, 2019.

For a more complete explanation of the community spouse resource allowance and the monthly maintenance needs allowance, click here.

Home Equity Limits:

In 2019, a Medicaid applicant’s principal residence will not be counted as an asset by Medicaid unless the applicant's equity interest in the home is less than $585,000, with the states having the option of raising this limit to $878,000.

For more on Medicaid’s home equity limit, click here.

Income Cap:

In order to qualify for Medicaid, a nursing home resident's income must not be above a certain level. Most states allow individuals to spend down their excess income on their care until they reach the state's income standard. But other states impose an “income cap,” which means no spend-down is allowed.

In 2019, the income cap in these states will be $2,313 a month.  For more on the income cap, click here.

 

 

Medicare's hospice benefit covers any care that is reasonable and necessary for easing the course of a terminal illness. It is one of Medicare's most comprehensive benefits and can be extremely helpful to both the terminally ill individual and his or her family, but it is little understood and underutilized. Understanding what is offered ahead of time may help Medicare beneficiaries and their families make the difficult decision to choose hospice if the time comes.

The focus of hospice is palliative care, which means helping people who are terminally ill and their families maintain their quality of life. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs while also supporting the terminally ill individual's independence, access to information, and ability to make choices about health care. 

To qualify for Medicare's hospice benefit, a beneficiary must be entitled to Medicare Part A, and a doctor must certify that the beneficiary has a life expectancy of six months or less. If the beneficiary lives longer than six months, the doctor can continue to certify the patient for hospice care indefinitely. The beneficiary must also agree to give up any treatment to cure his or her illness and elect to receive only palliative care. This can seem overwhelming, but beneficiaries can also change their minds at any time. It's possible to revoke the benefit and reelect it later, and to do this as often as needed.

Medicare will cover any care that is reasonable and necessary for easing the course of a terminal illness. Hospice nurses and doctors are on-call 24 hours a day, 7 days a week, to give beneficiaries support and care when needed. Services are usually provided in the home. The Medicare hospice benefit provides for:

• Physician and nurse practitioner services
• Nursing care
• Medical appliances and supplies
• Drugs for symptom management and pain relief 
• Short-term inpatient and respite care 
• Homemaker and home health aide services 
• Counseling 
• Social work service 
• Spiritual care 
• Volunteer participation 
• Bereavement services 

Services are considered appropriate if they are aimed at improving the beneficiary's life and making him or her more comfortable.

Because the beneficiary is electing palliative care over treatment, there are things the hospice benefit will not cover:

• Treatment to cure the beneficiary's illness. 
• Prescription drugs other than for symptom control or pain relief. 
• Care from a provider that wasn't set up by the hospice team, although the beneficiary can choose to have his or her regular doctor be the attending medical professional. 
• Room and board. If the beneficiary is in a nursing home, hospice will not pay for room and board costs. However, if the hospice team determines that the beneficiary needs short-term inpatient care or respite care services, Medicare will cover a stay in a facility. 
• Care from a hospital, either inpatient or outpatient, or ambulance transportation unless it arranged by the hospice team. The beneficiary can use regular Medicare to pay for any treatment not related to the beneficiary's terminal illness. 

To download Medicare's booklet on the hospice benefit, click here.  

 

The older the population gets, the greater the potential for elder abuse. States have laws in place designed to combat elder abuse, but some states are doing a better job than others. The consumer finance website WalletHub researched the protections in place in all 50 states and the District of Columbia to determine which states have the best protections against elder abuse. 

The prevalence of elder abuse is hard to calculate because the crime is underreported, but according to the National Council on Aging, approximately 1 in 10 Americans age 60 or older have experienced some form of elder abuse. In 2011, a MetLife study estimated that older Americans are losing $2.9 billion annually to elder financial abuse.

To determine its rankings, WalletHub compared the 50 states and the District of Columbia across three key areas: 
•    Prevalence of elder abuse in the state
•    Resources spent on preventing elder abuse and offering legal assistance
•    Protection against elder abuse through laws, the availability of eldercare organizations and services, the quality of nursing homes and assisted living facilities, and other factors

The survey found that Massachusetts, Wisconsin, and Nevada had the best protections overall while New Jersey, Wyoming, and South Carolina had the worst. Massachusetts, Wisconsin, and Nevada, along with Rhode Island and Arizona, all ranked high in total expenditures on elder abuse prevention. However, the states with the lowest rates of elder abuse, neglect, and exploitation complaints were Louisiana, New York, New Hampshire, Pennsylvania, and Michigan. 

WalletHub consulted with a panel of experts in social work, psychology, law, and gerontology on how to best protect seniors from abuse. Recommendations included incentivizing banks to report suspicious activity, requiring credit checks and background checks on caregivers, and providing more support to seniors to help them remain independent and be on the lookout for people trying to harm them. 

To see how your state compares in the WalletHub survey, click here. 

The new tax law makes it harder to claim a tax deduction for charitable contributions. While charitable giving should not be only about getting a tax break, if you want to reap a tax benefit from your contributions, there are a couple of options. 

The Tax Cut and Jobs Act, enacted in December 2017, nearly doubled the standard deduction to $12,000 for individuals and $24,000 for couples. This means that if your charitable contributions along with any other itemized deductions are less than $12,000 a year, the standard deduction will lower your tax bill more than itemizing your deductions. For most people, the standard deduction will be the better option. 

If you still want to maximize the tax benefits of charitable giving and you have the financial means, one option is to double your charitable donations in one year and then skip the donation the following year. For example, instead of giving $10,000 a year to charity, you could give $20,000 every other year and itemize your deductions in that year. 

Another way to concentrate charitable giving is to establish a donor-advised fund (DAF) through a public charity. A DAF allows you to contribute several years worth of charitable donations to the fund and receive the tax benefit immediately. The money is placed in an account where it can be invested and grow tax-free. You can then make donations to charities from the account at any time, in addition to adding to the account. As with any investment, you need to do research before establishing a DAF. Make sure you understand the fees involved and whether there are any limits on the charitable contributions you can make. You should consult with your financial advisor before taking any steps. 

If you are taking required minimum distributions from an IRA, another option is to donate those distributions directly to charity through a qualified charitable donation. The distributions won't be included in your gross income, which means lower taxes overall. The donation must be made directly from the IRA to the charity and different IRAs have different rules about how to make the distributions. 

For more information on how to maximize your charitable giving under the new tax law, click here.