Boston Estate Planning and Probate Lawyer & Attorney : Gosselin & Associates Law Firm : Serving Boston, Winchester, Hingham, Wellesley, Manchester

(From The Boston Globe) The cost of nursing-home care has risen 17 percent across the country over the past five years, a new survey shows. While the rate of increase was slightly lower in Massachusetts at 16 percent and even lower in Boston at 10 percent, the cost of care in Massachusetts was still well above the national average. One year in a nursing home private room costs $109,396 in Boston and $106,321 in other parts of Massachusetts. That compares to the national average of $76,460, according to the Cost of Care Survey conducted by Genworth Financial, a company based in Richmond, Va., that sells long-term care insurance. Alaska has the most expensive care, at $187,902, followed by New York City at $145,392. Connecticut is also more expensive than Massachusetts, at $119,678. The annual survey of long-term care also looked at the cost of assisted living, hourly home care, and adult day health care. In Boston a one-bedroom unit in an assisted-living facility cost $54,052 per year, in the rest of the state it cost $46,440, and an average of $36,090 in the rest of the country. Alaska again topped the list, at $54,809. The hourly rate for a home health aide was $23.40 in Boston, $22.41 outside Boston, and averaged $19.18 across the country. Adult day health care is a spot of moderation in Massachusetts. Five days a week cost $15,337 a year in Boston, $14,009 in the rest of Massachusetts, and an average of $15,236 nationally.

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I admire Roto Rooter. Few other businesses are so financially successful using a single tool - such as the spiraling drain cleaning tool. As an elder law and Medicaid attorney in Massachusetts I am starting to feel like Roto Rooter. New Medicaid regulations and qualifications have made it nearly impossible at the time of nursing home admission to protect an elder's assets. Despite the strict guidelines and pre-planning requirements of the Deficit Reduction Act and interim state and federal regulation, we are still winning the battle of family asset protection. If you are facing the spectre of paying the outrageous costs of a Massachusetts nursing home from your own funds please call Law for Life for a free telephone consultation to review your Medicaid asset protection options. Our phone number is (toll free) 877-325-6746 or 781-782-6000. We have offices throughout Massachusetts (Boston, Hingham, Wellesley, Winchester and serve the Worcester, Springfield, New Bedford/Fall River, Barnstable and Pittsfield areas through satellite and in-home appointments.

Often our only tool in Massachusetts is the Medicaid Qualifying Immediate Annuity, also called Single Premium Immediate Annuity (or SPIA). Although pooled income trusts have their place, we are not convinced that they will be available much longer as an emergency planning tool. These annuities are quite simple, the Medicaid applicant or their community spouse contributes a lump of funds to an annuity account with an insurance company and the insurance company returns the money to the annuitant over a fixed period of time consistent with their life expectancy under the HCFA life expectancy tables. When the annuitant dies then either the family or the Commonwealth of Massachusetts Division of Medical Assistance gets the funds depending very specific rules.

But there are several other options for elders and their families facing long term care financing and Medicaid qualification. There are exception for the principal residence where the nursing home resident's spouse is still living in the home. Same with siblings, minor, blind or disabled children. The other major exception is for children who are caregivers for their parents (the "caregiver exemption") in the two years prior to the elder's nursing home admission.

From an estate planning perspective and for non-real estate assets, our choices are more limited. There is the Medicaid Annuity (for which Law for Life is recognized as a Massachusetts source for the design and implementation of annuity based plans), but also the use of Special Needs Trusts that can be establish without disqualification for anyone in the Medicaid applicant's family. Disqualification for Medicaid is the term used by the Massachusetts Division of Medical Assistance (MassHealth) to describe the time period for which a Medicaid applicant or nursing home patient is ineligible for Medicaid benefits.

Of course, advance estate planning can solve a lot of these Medicaid qualification issues. If an elder client has good health, is generally under 80 years of age and has the wherewithal to pay annual premiums then Long Term Care Insurance is a great option. Premiums can be costly on a cash basis, but I have never had an elder law client that went on claim with Long Term Care Insurance complain about the benefits. The benefits are generally cash payments for home care and nursing home care. Many people call Long Term Care Insurance "nursing home insurance", but it is really much more than that as it includes a home care benefit that can be even more important to elders in need of services.

With the same foresight as an insurance applicant, elder law clients at Law for Life are often advised when they are healthy (I like to say "when you are still buying green bananas") to set up irrevocable trusts that preserve the step-up in tax basis and remove the elder law client's assets from inclusion in their resource calculation by MassHealth. The "trick" is that after setting up and funding these types of Medicaid trusts, the elder cannot qualify (or apply) for Medicaid for five years. At one time the waiting period was much shorter on transfers and trusts, but now it is a uniform five years before the trust's Medicaid protections kick in.

That's about it for asset protection and Medicaid qualification. It is imperative to speak with a competent elder law attorney such as us experts at Law for Life (our phone number is 781-782-6000 or toll free at 877-325-6746) regarding your personal situation as the regulations are very complex and change often during the year. Whatever you do, do not apply for Medicaid without speaking with an elder law attorney, no matter how much the nursing home pushes you to sign papers or an application company, such as Medi-Services encourages you to 'just get it done' - keep your pen in your pocket until you speak with an elder law attorney.

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The call came like all the others, a middle aged woman looking for help in navigating the maze of rules and regulations between bringing her father from his home of many years to what he always called "the waiting room", waiting to die of course.

She explained that she and dad had been together for 43 years since her mother died in a car accident when she was just 8. Dad's spirit was so crushed that his only daughter could not consider another choice - she needed to dedicate her life to caring for her depressed father. He did work, had saved some money, paid for the house, but not much was left after paying for nurse's aides, hospital beds and special medications. The only real monetary value was in the house which had a reverse mortgage put on years ago that has eaten away the home's equity along with a rapidly declining market. The house was ordinary with yellowed walls from the years of dad's smoking two packs of cigarettes a day.

In virtually all cases we are able to establish a Medicaid asset protection plan to conserve assets for the family - and not the nursing home. But here it was quite different. You see, the daughter was terminally ill with lung cancer and COPD, despite never putting a cigarette to her lips, but her devotion to her heavy smoking father came not only with the obvious prices of missed career, romance and a family of her own, but her very health. Dad was still in reasonably good health, driving to his Knights of Colombus meetings, taking in a Red Sox game at Fenway with a close friend from time to time, even driving to Mohegan Sun and Foxwoods from time to time to let it ride.

Since the daughter can no longer care for her father's daily needs (and he has been so conditioned to be waited on hand and foot so as to be completely incapable of doing household tasks for himself), she asked me to place him in a nursing home for the rest of his life since she herself needed nursing and hospice care. As I explained on the telephone that while nursing homes can accept anyone for residency and that MassHeath (the Massachusetts Medicaid service) can provide a myriad of taxpayer paid services, her father would not be eligible because he was not sick or even incapable of caring for himself, that unless they were to private pay, there would no way for him to be admitted to a nursing home.

The quietest moment of my legal career ensued.

The point here is that Medicaid qualification requires both financial qualification, which we hear about all the time, but also medical qualification. The state has in recent months not approved long term medical qualifications, but rather limited 90 day approvals are showing up more and more often. The consequence is ongoing reviews of patients who are clearly qualified for long term care - a true waste of already limited resources. The moral of this story and similar situations is to review potential calamity before things become a crisis. The crisis in this client's situation will result in the use of all the home equity to provide in-home services and a diligent search by A Place for Mom to find an appropriate PACE Assisted Living Placement with and Aid and Attendance Veteran's benefit. Law for Life is singularly focused on the needs of elders and their families in identifying and obtaining the most cost effective and financially conservative course of action possible.

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I admire Roto Rooter. Few other businesses are so financially successful using a single tool - such as the spiraling drain cleaning tool. As an elder law and Medicaid attorney in Massachusetts I am starting to feel like Roto Rooter. New Medicaid regulations and qualifications have made it nearly impossible at the time of nursing home admission to protect an elder's assets. Despite the strict guidelines and pre-planning requirements of the Deficit Reduction Act and interim state and federal regulation, we are still winning the battle of family asset protection.

 Of course, our one tool in Massachusetts is the Medicaid Qualifying Immediate Annuity, also called Single Premium Immediate Annuity (or SPIA). These annuities are quite simple, the Medicaid applicant or their community spouse contributes a lump of funds to an annuity account with an insurance company and the insurance company returns the money to the annuitant over a fixed period of time consistent with their life expectancy under the HCFA life expectancy tables. When the annuitant dies then either the family or the Commonwealth of Massachusetts Division of Medical Assistance gets the remaining funds depending on very specific rules.

 But there are several other options for elders and their families facing long term care financing and Medicaid qualification. There is an exception for the principal residence where the nursing home resident's spouse is still living in the home. This exception also applies to siblings, minor, blind or disabled children. The other major exception is for children who are caregivers for their parents (the "caregiver exemption") in the two years prior to the elder's nursing home admission.

 From an estate planning perspective and for non-real estate assets, our choices are more limited. Besides the Medicaid Annuity, Special Needs Trusts can also be used without disqualification for anyone in the Medicaid applicant's family. Disqualification for Medicaid is the term used by the Massachusetts Division of Medical Assistance (MassHealth) to describe the time period for which a Medicaid applicant or nursing home patient is ineligible for Medicaid benefits.

 Of course, advance estate planning can solve a lot of these Medicaid qualification issues. Generally, if an elder client is in good health,  under 80 years of age and has the wherewithal to pay annual premiums, then Long Term Care Insurance is a great option. Premiums can be costly on a cash basis, but I have never had an elder law client who had has a claim with her Long Term Care Insurance company complain about the benefits. The benefits are generally cash payments for home care and nursing home care. Many people call Long Term Care Insurance "nursing home insurance," but it is really much more than that as it also includes a home- care benefit.

 With the same foresight as an insurance applicant, elder law clients at Gosselin Law are often advised when they are healthy (or as I like to say "when you are still buying green bananas") to set up irrevocable trusts that preserve the step-up in tax basis and remove the elder law client's assets from inclusion in their resource calculation by MassHealth. The "trick" is that after setting up and funding these types of Medicaid trusts, the elder is not elegible for Medicaid for five years. At one time the waiting period was much shorter on transfers and trusts, but now, it is a uniform five years before the trust's Medicaid "protections" kick in.

That's about it for asset protection and Medicaid qualification. Whatever you do, do not apply for Medicaid without speaking with an elder law attorney, no matter how much the nursing home pushes you to sign papers or an application company, such as Medi-Services encourages you to 'just get it done' - keep your pen in your pocket until you speak with an elder law attorney. If you are facing the spectre of paying the outrageous costs of a Massachusetts nursing home from your own funds, please call Gosselin Law for a free telephone consultation to review your Medicaid asset protection options. Our phone number is (toll free) 877-325-6746 or 781-729-0313. We have offices throughout Massachusetts (Boston, Hingham, Wellesley, Winchester and serve Amherst, New Bedford, Barnstable and Pittsfield through satellite and in-home appointments.

 

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