Long Term Care Insurance — It’s All about the Contract

If you purchased a long-term care insurance policy, (LTCI) make sure you keep that contract and the annual update notices in a safe, accessible  place and that you let your important persons know where they can find these papers. When it comes time that hands-on care, supervision and cueing are required, it will be necessary to scrutinize the contract to see just what conditions must be met to trigger the policy benefits. A Claim will have to be submitted with copious written proofs. medical records and opinions. No one has a crystal ball, but the stronger the evidence at the time the claim is submitted, the greater the likelihood that the claim will be approved so that benefits can start to flow.

A policy may say that the contract holder must require “substantial assistance in three or more of the Activities of Daily Living,” or perhaps two, or even four. The ADL’s are dressing/grooming, feeding, toileting, transfers/ambulation [with or without assistive devices], bathing, and continence. The policy holder’s needs could be the result of physical disability, or could be the result of severe cognitive impairment due to Alzheimers disease, Parkinsons disease or other dementias. Some policies cover in-home care; others only cover care in a skilled nursing facility (nursing home). The daily benefit is usually different depending on the setting. Some contracts require that in-home caregivers be licensed; others do not have that requirement. The length of the policy benefit is spelled out in the contract — five years? Lifetime? Only until a certain pool of benefit dollars is used up?

After the claim is filed, you can expect the insurance company to send out someone who will perform a functional assessment to see whether the criteria are met. As we have discussed in this space on the subject of applying for Medicaid (the PAS clinical screening) or arranging for in-home care services after Medicaid eligibility has been approved (interaction with the Case Manager from the Medicaid Managed Care Organization), self-advocacy and knowledge of the applicable standards are vital.

There is typically an elimination period such as sixty or ninety days once the claim is approved. Some policies then pay the benefit to the individual as a reimbursement, only after receiving additional proof each month that care was paid for in the prior month. This may require cooperation from the care provider, such as the nursing home or the assisted living facility or home care agency. Sometimes benefits can be assigned — some companies will pay the benefit to the facility or agency after receipt of a properly signed Assignment of Benefits. Other policies may just start paying benefits monthly after the benefits begin.

It’s all about the contract. The contract itself and information about the policy should be kept with your other important financial documents such as your power of attorney and list of assets, so that if the need arises, and your trusted person knows how to start.

For advice on elder care planning involving long-term care insurance benefits, and advice on claims issues, call us at ………. 732-382-6070

What to do when you think it’s time to refuse further treatment

If you are the Guardian of the Person or the designated Health Care Representative for a person who is extremely mentally incapacitated, there may come a time that you may face that most dreadful of decisions. You may wonder whether to treat all new medical crises. The person you are responsible for may have advanced Alzheimers or other dementia, may be incapable of expressing themselves, or may be functionally incapable of interacting in a knowing way or performing any physical act without assistance. This is a delicate matter. There are intertwining considerations of law, bioethics and even religion, and a heavy burden is placed on the health care decision-maker.

These decisions aren’t necessarily restricted to the ones involving life-preserving measures like installation of a gastric feeding tube, pacemaker, or respirator (ventilator), or decisions about whether to embark on kidney dialysis or performing major surgery such as a liver transplant or non-laporoscopic heart valve replacement. You may be faced with decisions about whether to hospitalize an incapacitated  patient for a new medical problem when the patient already has advanced and debilitating congestive heart failure or has become severely impaired by numerous complications of diabetes such as peripheral neuropathy, or extreme vision impairment. You may be wrestling with whether to subject the patient to chemotherapy or radiation treatment for newly-diagnosed cancer.

It is important to have a frank conversation with the primary physician who coordinates the care for the patient. What should be the overall goal for care at this point? If the underlying chronic conditions will never get better and will certainly continue to get worse, is it time to just keep the patient comfortable and as pain free as possible in their bed, and avoid hospitalization? Anecdotally, I have been told by nurses who have years of experience with patients who have long-term advanced dementias that they observe patients experiencing  disassociation and disorientation  each time the patient is hospitalized, and they report that although the treatment stabilizes the patient  for a short time, there may be no no overall improvement in the underlying degenerating condition . The health care decision-maker often feels that their patient is suffering as s/he goes through a new round of  tests, tubes, needles  and exams. Yet there is a natural assumption that if a person has a degenerating condition which periodically flares into a medical emergency (such as congestive heart failure or COPD), each new episode should lead to hospital admission for acute care.

If your patient is living in a nursing home, have a frank discussion with the treatment team, especially the nurse and doctor who have who primary responsibility for the patient. I have attended such meetings with my clients over the years, and they are difficult but important. Ask about how to obtain a Do Not Hospitalize (DNH) order and what it would cover. For instance, a fracture may need to be set outside of the nursing home. Find out about the broad array of comfort treatment that can be provided within the nursing home such as IV antibiotics and oxygen. Ask the doctor about issuing a DNR (do not resuscitate) order in the chart.  Make sure that the patient is never sent to the hospital without your advance notice and consent. Make sure that the treatment personnel do not give the patient any legal forms to sign. And complete a green POLST form for the chart which sets out your wishes for the goals of the patient’s care.

For advice and advocacy in carrying out your role as surrogate medical decisionmaker, call us at ….732-382-6070

Yes, we can still honor our aging parents

I wrote this piece in 2003 as a letter to the editor of the NJ Jewish News, at the death of my friends’ father, who was a charming man I’d really enjoyed knowing in his last twenty years. Something reminded me of him recently, so I thought I’d republish it here.

“Last week, I attended the funeral of the father of my close friends. He was 86 years old and died of complications of Alzheimer’s’ Disease. Over the past 7 years, his memory had grown increasingly impaired, and he was a bit unsteady on his feet. Sometimes he’d lose track of his ideas while he was talking. There came a point where he couldn’t prepare his own meals, drive or navigate. He reluctantly agreed to move to an Assisted Living residence. Yet he never sunk into that lonely despair that so often ruins the lives of frail elders. Why?

Mr. B’s four children took turns helping him out every weekend. They arranged for him to travel. They visited him a lot. They brought him to religious services and gave him an honored place at their dinner tables. They weren’t embarrassed by his increasing frailty – they were understanding. They lent him a hand and helped him remember what he needed to know. They continued to include him in their many celebrations with friends and relatives, even though he would sometimes just drift around in a sort of pleasant fog and not make much conversation. Despite his physical illnesses, Mr. B. was happy when he was surrounded by people, especially the people whom he’d always enjoyed, both young and old.

Mr. B. was happy because people helped him continue to do the things that had always been important to him. He continued to attend services regularly at the congregation he’d attended for 50 years. The other people there made sure that he retained as much as possible of the meaningful role he’d played in their services for decades.

Holidays, of course, have their special family rituals. Mr. B. retained his dignity as head of the family because his children enabled him to perform those rituals which he had customarily performed at these ceremonies. He could still  remember how to recite the blessings, even though he could not remember how to find his room down the hall.

Despite his diminishing abilities, this lucky gentleman was never cut off from the social life of his community and family. Too often, though, frail elders do find themselves dishonored, isolated and rejected.

It is our personal duty to give our parents honor and respect. Their weaknesses in their frail twilight years certainly don’t absolve us of that responsibility. If anything, the responsibility is even greater once the person cannot fully take care of himself.

It surely can be a challenge to keep our frail elders involved in our lives. We need to make special arrangements, to allow extra time, and to be very patient. The results of such inclusion will be dramatic, though. Not only will we enable our parents to live out their lives with dignity, joy and peace, we will be teaching the next generation a crucial lesson about how to care for their loved ones. Perhaps this will bode well for the future of all who grow old in this country.”

Call for advice on senior care and elder care planning, and strategies for a good old age … 732-382-6070

Family Trusts to protect assets for the next generation

Has this happened to you? There is often a point in a person’s life when he looks at his children and grandchildren, starts thinking about how hard he worked to build his house or his business or his savings and investments, and wonders as he ages whether he will be able to still provide a financial legacy for his children. In particular, he may be worried that if he ever develops Alzheimers Disease or requires nursing home care, there will be nothing left to pass on to the next generations. This is what asset transfer planning is all about.

Decisions about transferring assets need to take into account many variables, such as the age, health and income of the senior citizen and his ability to take care of his needs once assets have been transferred. Of course, he should be sure to consider the impact  of asset transfers on his later eligibility for Medicaid should he actually need nursing home care. Additional considerations would be the situation with the children or grandchildren themselves. Is the child at risk of divorce or pursuit by creditors? Are any of the family members disabled or dependent on government programs like SSI or Medicaid or DDD where eligibility depends on the finances? Is a child a spendthrift so that giving them assets will likely result in the assets disappearing in no time? Family trusts can be a very good method to set aside assets for the family members for the long term.

The beauty of a family trust is that the assets are controlled and managed by a trustee, which can provide a layer of protection for the beneficiary. The trust can be written in a way that deals with the unique issues in the family. Special needs restrictions can insulate the assets and preserve a beneficiary’s eligibility for Medicaid or other programs. And the trust can direct just who would receive that share of the trust assets in case of the death of a beneficiary, so that the assets don’t become part of the beneficiary’s estate.

While it may be more cumbersome for assets to be managed in a trust rather than just be transferred outright to family members, there are so many opportunities to provide extra protection that the aging family patriarch or matriarch may well want to consider the use of a family legacy trust for the long-term good of the family.

Call us for family asset protection planning, and estate & elder care trust planning … 732-382-6070


Behavioral Therapy Techniques Show Promise for Alzheimers’ Patients

If you are caring for a person with Alzheimers’ dementia, you are probably seeing a number of behavioral changes that are difficult to understand and challenging to respond to. These are sometimes called “neuropsychiatric symptoms,” and they span the spectrum from apathy and depression to wandering, disinhibition, irritable verbal onslaughts, agitated pacing, and hallucinations. Physicians sometimes have success in managing these symptoms by prescribing  medications to address anxiety, restlessness/agitation or psychosis. Studies are ongoing and there’s an excellent article about them by Jeffrey L. Cummings, M.D. in the Spring, 2016 issue of  AFA Care Quarterly.

Non-pharmacologic  interventions are the province of behavioral therapy. Caregivers can learn what triggers an agitated response and can avoid those triggers; they can learn to engage the patient in activities which increase socialization and stimulation while avoiding an increase in the patient’s confusion or distress. Each patient is of course unique, and a caregiver would be wise to keep notes of behavioral changes, stimuli and triggers, as well as what responses seem effective and which just made things worse. This is crucial information for the physician, as well as for other people who will be caring for the individual.

If your loved one needs to be placed in a nursing home, a full medical report is requested and it is important to discuss these behavioral issues as you work with the staff to develop the individualized care plan. The Nursing Home Resident’s Bill of Rights and federal Medicare and Medicaid laws require a skilled nursing facility to “provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care.” See 42 USC 1395i-3(b). It has to be an individualized plan. You will be helping the staff to do the best job for your loved one if you share with them what you know about him or her.

We advocate for nursing home residents in care planning meetings. For elder care advice and representation, call us at … 732-382-6070