Medical science has made great strides in the last 30 years.  We are certainly living longer.  Illnesses and injuries that in the past resulted in death, now do not.  However, the recovery period can be a long one, especially for the elderly, whose recuperative abilities are not the same as younger patients.  As a result, patients remain hospitalized longer and bounce back and forth between nursing home and hospital, in so many cases.

That’s where the long-term acute care hospital or LTACH, comes in.  General hospitals are typically paid a standard fee for a diagnosis so they earn more for a quicker patient discharge.  At the same time, the patient may not quite be ready for a sub-acute facility in a nursing home, which focuses primarily on rehabilitation but can’t provide the medical care of a hospital.  The LTACH can bridge that gap.  Patients receive the benefit of physicians on duty around the clock as well as nurses, respiratory therapists, case managers, physical and occupational therapists, dieticians and pharmacists, all on staff.  LTACHs provide more nursing care than on a medical-surgical floor of a hospital but less than is provided in an intensive care unit.

Many LTACH patients use ventilators to breath and are recovering from multiple medical conditions such as heart failure, major surgery, etc.  They may have developed complications such as bed sores.  The specialty hospital can concentrate on weaning the patient off of the ventilator or providing wound care, for example, that can require weeks of care, that the general hospital won’t receive payment for.  For those on Medicare, LTACHs are covered under Part A.  The average stay in an LTACH is 25 days.

There are over 400 LTACHs nationwide and 8 in New Jersey.  Most are housed in general hospitals, however, some are freestanding, such as Select Specialty Hospital in Rochelle Park, New Jersey which is owned by the same company that also owns Kessler Institute, the facility that specializes in the treatment of spinal cord injuries.  The long term acute care hospital is definitely an option families should explore for their critically ill or catastrophically injured loved one.  It may very well improve the recovery process and increase the chance that a loved one can ultimately return home.

For further information and advice in any elder law matter, do not hesitate to contact me at (888) 800-7442, or info@fnlawyerinnj.com.

Medicare consists of four parts — Part A, Part B, Part C and part D. The majority of Medicare enrollees have Part A and Part B. In addition they may have an employer-sponsored supplement or a Medigap policy to go along with Part A and Part B. The fourth part of Medicare is Part D or prescription drug coverage. Most people think that the “D” in Part D is because of the word “drugs.” Actually it’s because there is a Part C. Part C is the Medicare Advantage program. It was started in 2003 as part of the Medicare Modernization Act — the same Act that created the Medicare Part D prescription drug coverage. Medicare Advantage Plans have been around for some time. Before 2003 they were known as Medicare + Choice Plans. With Medicare Advantage, Medicare pays a private insurance company to take over and administer someone’s Medicare benefits. That person is still a part of the Medicare system. He or she doesn’t leave the system. A person is simply now receiving his or her benefits from a Private company not the Government.

Medicare will be getting a massive stack of mail over the next few months.  From November 15, 2008 through December 31, 2008, those eligible for Medicare have the option to change existing Medicare Advantage Plans and/or Medicare Part D. This period is called the Annual Election Period or AEP.

There is also another period of time from January 1, 2009 through March 31, 2009 that is called the Open Enrollment Period or OEP. During OEP, a person can enroll in Advantage but cannot change Part D status, meaning if there is just a Part D, a change or cancellation to the drug Plan cannot occur at this time. If there is a Medicare Advantage Plan which includes Prescription Drug Coverage (MAPD), a change can be made by purchasing another MAPD. Or, if there is just prescription coverage, an MAPD can be purchased. Going the other direction from an MAPD to prescription coverage only, is not allowed.

On April 1, 2009 and thereafter, Medicare institutes a lock-in period. During this time, no changes to drug coverage or an MAPD are allowed. As with most government programs there are a few exceptions to the rule. If a person has moved out of the area the plan operates in, or if a person becomes a resident in any long term care facility, or if a person involuntarily loses coverage, that person can enroll for new coverage under a Special Election Period or SEP. Finally, most people who are eligible for or who are on Medicaid can change coverage whenever they choose.

So why the big deal? Why does someone need to be aware each year of what is going on? The reason is the insurance companies that sponsor the Medicare Advantage and the Part D Plans have the option to change what they offer each year. Changes may come as a result of directives from Medicare, from previous years’ claims experience, or from a multitude of other issues. Asking 10 people if there are pending changes to the plans they are in will result in 9 of them replying they have received notice of adjustments or premium changes. However, not all changes are for the worse. There are some instances where the plans have gotten better. Nevertheless, from year to year most plans will have changes. Sometimes a plan may pull out of an area thus forcing an individual to make an unwanted change.

Medicare allows the Advantage companies to start marketing their plans to the public on October 1 and the companies can release information on intended changes to existing plans. For any pending changes, a beneficiary should receive an Annual Notice of Change (ANOC.) Most people will receive this document in November. People need to take the time to review changes. They need to be aware of the plan they are in and the benefits it provides when they might need to use the coverage.

Medicare Advantage Plans can be a great fit for many Medicare enrollees. As with anything, one size does not fit all. During the six-week period when changes can be made, people owe it to themselves to evaluate their options. In the past, many Advantage Plan companies made a big push during this change period to move people out of existing plans and into new ones. Medicare has changed the rules on how companies can induce people to change. In the past, seniors were invited to attend presentations where they received free meals as an inducement to attend. Starting in 2009, only snacks can be provided. Preliminary indications are that pie and coffee are on the menu. Personally we like Pecan pie and free pie is good pie.

On the National Care Planning Council website, at www.longtermcarelink.net, is a link to all medicare approved advantage plans in every state. All the plans listed in an area can be found there. Finally, those people who need help or who are facing changes should contact Ms. Kim Wellington, Director of Community Outreach at Hanlon Niemann at kwellington@hnlawfirm.com, or Fredrick P. Niemann, Esq. at fniemann@hnlawfirm.com.

Many people find themselves responsible for paying for the care of their parents in old age. The parents did not plan it that way and the children did not see it coming. According to a just-released survey, these adult children of aging parents have found themselves vastly unprepared.

The survey found: 

• 63% of caregivers have no plan as to how they will pay for their parents’ care over the next five years.
• 62% say the cost of caring for a parent has impacted their ability to plan for their own financial future.

“With an estimated 34 million Americans providing care for older family members, the survey’s results indicate a financial crisis in the making,” says Joe Buckheit, Publisher of AgingCare, a website and online forum for family caregivers.

“Medicare only covers long-term care for a short time, and only under strict rules. Medi-gap insurance helps, but does not cover all costs. The burden of paying for long-term care often rests with the family,” Buckheit says.

“The caregivers’ lack of planning is impacting their own financial future.”

Long-term care costs are not the only expenses caregivers bear.

“Family members responsible for ailing loved ones provide not only hands-on care but often reach into their own pockets to pay for many daily expenses, including groceries, household goods, drugs, medical co-payments and transportation,” says Buckheit.

“Americans who are already strapped for cash by the rising price of gas and food are unable to afford these additional expenses.”

The survey found: 

• 34% spend $300 or more per month out of their own pocket for caregiving expenses.
• 54% have sacrificed spending money on themselves to pay for care of their parents.

Work Issues
Making matters worse, caring for aging parents often impacts adult children at their workplace as well. The survey found: 

• 43% have had to take time off work due to caregiving responsibilities.
• 48% say they are earning less money at work as a result of caregiving.
• 25% have been fired or had to quit their job as a result of caregiving.

Physical and Emotional Toll
Despite potentially making less money and doling out more, more than half of the caregivers surveyed are spending what equates to a full-time work week   • 40 hours or more  •  on caregiving duties  •  many in addition to their full-time careers outside the home. 

• 53% of caregivers provide care 40 or more hours per week.
• 37% provide care more than 80 hours per week.
• 21% say they never get a break from caregiving.
• 36% get a break of 5 hours or less a week.

The survey indicates that today’s caregivers face a triple financial threat: unplanned-for caregiving expenses, less money for their own needs and reduced time in the workplace.

American residents who are 85 and older will meanwhile triple in number from 5.4 million to 19 million by mid-century, the federal agency projects. A shrinking of the working-age population (i.e. those 18 to 64) is expected to occur along with the enlargement of the older population; working-age residents are expected to be 57 percent of all residents in 2050, down from 63 percent now.

The Census also projects the overall population of the U.S. will grow from roughly 305 million people today to 439 million in 2050.

America’s steep aging has signified to many policy analysts a need to reduce the cost of entitlement programs, particularly Social Security and Medicare.

“This certainly makes entitlement reform more urgent,” Michael Tanner, a senior fellow at the D.C.-based Cato Institute, told The Bulletin, noting entitlement spending could grow to become one third of gross domestic product by mid-century. “That’s not economically sustainable.”

Other observers, like Brookings Institution economist Gary Burtless, are less apprehensive.

“The situation for Social Security is not terribly dire,” he said. He said the higher pension benefits other rich western governments spend on their aging populations are important to consider for perspective. He also said these other countries face larger increases in their numbers of seniors.

Dr. Burtless said Medicare and Medicaid, which provide healthcare to the elderly and the poor, present more pressing concerns but not primarily because of aging but because of the advances in medicine that have caused costs to go up. In 1960, he said, personal healthcare expenditures made up 7 percent of personal spending overall.

That figure is 20.5 now and is expected to continue rising. Government currently pays 45 percent of Americans’ health expenses and that percentage is also projected to rise.

“That does represent a big problem,” he said.

Mr. Tanner said because the population is aging so rapidly, the constituency most wary of scaling back entitlement programs and instituting free-market reforms stands to gain political clout and make changes more difficult to implement.

“There’s always been a bias in favor of voting in favor of seniors’ benefits because seniors vote and young people don’t,” he said.

One political development Mr. Tanner found telling was Republican presidential candidate John McCain’s refusal to back either a GOP proposal to cut Medicare reimbursements to doctors and hospitals or a Democratic measure to cut reimbursements to Medicare Advantage insurers.

Mr. Tanner said lawmakers are in a constant balancing act between efforts to fully reimburse the medical community for the care they provide and attempts to hold down spending. He said the government could resolve the matter by funding patients or insurers instead of each individual medical procedure.

The Census study also projects that racial minorities, making up about a third of the U.S. population today, will constitute a majority in 2042 and reach 54 percent of the population by mid-century, or 235.7 million out of 439 million total U.S. residents. The percentage of nonwhite U.S. children, meanwhile, will rise to 62 in 2050, up from 44 percent today.

Seniors who get remarried are often concerned about what will happen to their assets if their new spouse enters the nursing home in the future. They are concerned that their hard-earned assets they saved could be lost. They also want to make sure that when they die their assets will go to their children. Although the prenuptial agreement will protect the senior’s assets from claims of his surviving spouse when he dies, the prenuptial agreement does not protect his assets from his spouse’s nursing home expenses. Seniors who have entered into second marriages are often surprised to learn that the prenuptial agreement that specified that their spouse had no claim to their assets does not prevent Medicaid from counting the assets of the spouse at home in determining Medicaid eligibility.

Medicaid is the governmental program that pays nursing home costs when a senior runs out of assets. Until the nursing home resident has less than $2,000 of countable assets, he must pay his own nursing home costs. When countable assets are less than $2,000, Medicaid will begin paying the senior’s nursing home costs.

However, just because the nursing home spouse has less than $2,000 in assets does not necessarily mean that the nursing home spouse will be eligible for Medicaid. Instead, despite the prenuptial agreement, Medicaid looks at the assets of both spouses. The rules for determining Medicaid eligibility are exactly the same for couples with prenuptial agreements and those without them.

This does not mean that all assets of both spouses must be used up before Medicaid will begin paying nursing home costs. Congress passed “spousal impoverishment rules” to keep the spouse at home from having to be completely impoverished before Medicaid payments kick in.

Under these rules, the amount that the at-home spouse can keep is based on the resources that the couple has at the time one spouse enters an institution. Resources are counted (often referred to as a “snapshot” of resources) as of the date a senior first begins a period of continuous institutionalization. This can be when a senior enters a nursing home or when he first entered a hospital. So, if a spouse first enters a hospital prior to a nursing home, the snapshot is taken based on the date of admission to the hospital, not the nursing home. The spouse at home is permitted to keep half of the couple’s countable assets as of the snapshot date, up to $101,640; but the spouse in the nursing home is limited to $2,000 of countable assets.

Many families are concerned that if a spouse enters a long-term care facility, then the marital home will be eventually lost. Medicaid has no intention of evicting the at-home spouse (also known as the “community spouse”). Nor does Medicaid require the at-home spouse to sell the home and apply the proceeds toward long-term care costs. However, Medicaid can, under the veil of estate recovery, place a “lien” of claim on the subject premises. When the community spouse passes away or sells the house, then Medicaid can demand to be reimbursed for all monies expended on behalf of the ailing spouse.