June 8, 2021
In Part One, I described the crises that lead to both my parents needing care at the same time. After three weeks in the ICU, dad was transferred to a skilled nursing facility for rehabilitation. It is amazing how much every-day functioning a person can lose when they are stuck lying in a bed for weeks. Even simple tasks that we take for granted, like bending down to pull on socks or climbing over the tub side to get in and take a shower or walking more than 100 feet were challenging.
The transfer to skilled nursing was not without its bumps. While dad is competent to make his own healthcare decisions, he was still on heavy doses of morphine. They consulted him, sort of, about where he would be transferred but not in a meaningful way. It was important to my brother and I that dad be close to mom. I knew that mom’s facility had a really good physical therapy department and I spoke with them about whether they had a bed available, which they did. So far so good. But, when I talked to dad’s nurse, she indicated he was going to a different facility; one that was across town and not as highly thought of as where mom was. I had discussed with the hospital discharge planner/social worker that I would like to be in the loop regarding dad’s discharge, but that didn’t happen until it was almost too late. After a frantic flurry of phone calls – and the planets aligning just right – dad was transferred to the same facility as mom. It would make things so much easier for my brother that they were both at the same place.
Now nearly six weeks later, dad is physically ready to go home; but, he can’t be discharged until the doctor changes his antibiotics from IV form to pill form. Because the antibiotic must be administered every eight hours, it was not possible to find a home health agency willing to provide the supervision. We’re keeping our fingers crossed that at dad’s next doctor visit at the end of the week the medication can be changed. Dad is really itching to be home and out of the nursing home.
Getting the “Wrong” Medical Diagnosis Can Cost You a Bundle. The majority of Dad’s medical bills, and stay in the hospital and nursing home, will be covered forby Medicare; however, mom is a different story. Since mom needs help with activities of daily living, such as bathing, dressing, toileting, and mobility– rather than help recovering from an injury or illness - none of her costs in the nursing home will be paid by Medicare. Currently, we are paying $10,000 per month for her care! Unfortunately, many people think that when we get old Medicare pays for everything. The truth is that Medicare only pays when you can be made better. As soon as the care you need is only custodial Medicare no longer pays. This is a huge problem for many people, including my parents.
Finances. As soon as the initial crisis was stabilized, with my brother’s help, I gathered mom and dad’s financial information. It wasn’t a very pretty picture. While they have always done OK, they are far from wealthy and don’t have a big nest egg – just like many of the families I work with. But their nest egg is larger than allowed for Medicaid qualification.
I did a little research regarding Maine’s version of Medicaid – MaineCare - and quickly decided that reaching out to a Maine elder law attorney would be a wise thing to do. While I am thoroughly versed in the ins and outs of planning and qualifying for California’s version of Medicaid – Medi-Cal – each state has their own take on it. I also knew that things would be more difficult, because mom and dad have very little planning in place; mom has a very basic and inadequate financial power of attorney and dad doesn’t have anything.
So, we will be taking the long, hard road, one that includes a trip to court to get authority to take mom’s name off accounts. We will also be evaluating available spend down options.
Good planning, completed sooner, would have made things smoother, allowed quicker qualification for Medicaid, made a difficult situation easier, and would have brought a sense of peace of mind. What does good planning look like? In terms of the legal documents the following should be included:
Advance Healthcare Directive: An AHCD allows you to select trusted persons who will make healthcare decisions for you. Such decisions range from where care should take place, whether or not to authorize tests and procedures, and if you should include end-of-life decisions like Do Not Resuscitate orders.
HIPAA Authorization: HIPAA is a law that protects your medical information from being shared. Unfortunately, the prohibition on sharing extends to family members including spouse and children. The HIPAA Authorization allows you to select trusted persons who can talk to your doctor and other medical providers. It does not give any authority to make medical decisions for you.
Durable Financial Power of Attorney: This allows you to select trusted persons who will make financial decisions for you. A thorough power of attorney can even allow your trusted person to engage in additional planning on your behalf.
Will: A will allows you to select trusted persons to wrap up your estate and transfer it to whomever you wish. It can also include sophisticated provisions to leave assets to a surviving spouse, but in a manner that will not impact the survivor’s’ eligibility to qualify for Medicaid.
Trusts: A trust is a legal entity that can help you centralize management of your finances during periods of incapacity, and pass assets to your loved ones on your death without going through the probate process, and minimize certain taxes. It comes in many varieties depending on what you desire to accomplish.
A final piece of any good long-term care or aging plan is a thorough discussion of how the long-term care system works, what Medicare does and does not pay for, and planning options if Medi-Cal (Medicaid) looks like it will be needed.
A Few Helpful Professionals: Geriatric Care Mangers (GCMs) are the best friend of anyone doing long-distance caregiving. They can save you a lot of leg work and are the go-to professional for identifying resources for seniors, such as home health agencies, care facilities, in-home care, elder-friendly doctors, and evaluating the senior’s care needs. For more information on Geriatric Care Managers and Aging Life Care Professionals visit https://www.aginglifecare.org/.
Elder Law Attorneys can help you create a good estate plan, educate you regarding long-term care, and help you plan for Medicaid qualification. They have connections with GCMs, care placement agencies, and other resources. An excellent resource for locating elder law attorneys is the National Association of Elder Law Attorneys (naela.org).
Also, when a health situation raises its head, make friends with the nurses caring for your loved one. They are a wealth of information, often more patient and accessible than the doctors, and can provide you with helpful insights. Don’t be timid about asking questions, especially if you don’t understand the medical jargon.
If you live in the state of California and would like assistance in sorting through all of the steps and processes above, please contact The Chubb Law Firm at916-241-9661 to schedule a Discovery Meeting.