Monthly Archives: July 2019

Updated 2019 Spousal Impoverishment Standards

July 1, 2019

courtesy of NAELA eBulletin:

CMCS Informational Bulletin
DATE: May 30, 2019
FROM: Chris Traylor, Deputy Administrator and Director
Center for Medicaid and CHIP Services
SUBJECT: Updated 2019 Spousal Impoverishment Standards

This CMCS informational bulletin provides an update to the 2019 Supplemental Security Income (SSI) and Spousal Impoverishment Standards.

Click here for the complete CMCS Informational Bulletin

Researchers test vaccine they hope could stem Alzheimer’s

July 1, 2019

courtesy of NAELA eBulletin:

See video at Researchers work on anti-Alzheimer’s vaccine

Albuquerque, N.M. — Researchers at University of New Mexico researchers are working on a vaccine they hope could prevent Alzheimer’s disease, reports CBS Albuquerque affiliate KRQE-TV. UNM’s Health and Sciences Department Associate Professor Kiran Bhaskar, who’s been passionate about studying the disease for the last decade, says the work started with an idea in 2013.

“I would say it took about five years or so to get from where the idea generated and get the fully functioning working vaccine,” he said.

Bhaskar and his team started to test the vaccine on mice. It has not yet been shown if it works in people.

“We used a group of mice that have Alzheimer’s disease, and we injected them over a series of injections,” said PhD student Nicole Maphis. She said the vaccine targets a specific protein known as tau that’s commonly found in the brains of Alzheimer’s patients.

“These antibodies seem to have cleared (out) pathological tau. Pathological tau is one of the components of these tangles that we find in the brains of patients with Alzheimers disease,” she explained. The response lasted for months, according to UNM.

Those long tangles “disrupt the ability of neurons to communicate with one another,” the school points out, adding that tau is “normally a stabilizing structure inside of neurons.”

The mice were then given a series of maze-like tests. The mice that received the vaccine performed a lot better than those that hadn’t.

However, drugs that seem to work in mice do not always have the same effect in humans. A clinical trial involving people will be required to see if the drug helps in real life, and that’s a difficult and expensive undertaking — with no guarantee of success.

“We have to make sure that we have a clinical version of the vaccine so that we can test in people,” Bhaskar said.

Testing just a small group would cost the UNM Health Sciences Department $2 million. Right now, Maphis and Bhaskar are looking for partnerships to help them toward a clinical-grade vaccine.

Alzheimer’s affects almost a third of senior citizens and “is on the rise, currently affecting 43 million people worldwide,” UNM notes.

Editor’s note: This story has been updated to clarify that the vaccine has not yet been shown to work in humans.



July 1, 2019

courtesy of NAELA eBulletin:

Many older Americans and people with disabilities living in nursing homes benefit from the care of dedicated leadership and staff members devoted to the health, flourishing and overall well-being of their residents. Investigative reporting, however, continues to identify facilities that fall short of the care standards required of every one of our nation’s nursing homes. In such facilities, some residents have experienced outright neglect, such as going without proper nutrition or languishing in filthy conditions. Some older adults and people with disabilities have even experienced physical abuse, sexual assault and premature death.1

Alarmingly, recent state survey findings reveal a number of such cases. Over the course of several years, at just one facility in Pennsylvania, documented instances include an unnecessary hospitalization resulting from an avoidable pressure sore, an escaped resident with dementia, mismanagement of medications, unsanitary shower and bathroom areas and uncleaned oxygen tubes.2   Further, a years-long investigation conducted by PennLive revealed an unsettling pattern of poor care in select Pennsylvania nursing homes involving improper wound care, insect infestations, supply shortages and more.3   Unfortunately, these are not the only instances of drastically substandard care. This report examines federal oversight of our nation’s consistently poor-performing nursing homes.

Many documented cases of abuse and neglect occur in facilities affiliated with the federal Special Focus Facility (SFF) program.4   The SFF program is designed to increase oversight of facilities that persistently underperform in required inspections conducted by state survey agencies.5   As stipulated by federal law, the SFF program targets those facilities that “substantially fail” to meet the required care standards and resident protections afforded by the Medicare and Medicaid programs.6

For the rest of the report go to:   U.S. Senator Bob Casey (D-Pa.) and U.S. Senator Pat Toomey (R-Pa), June 2019, FAMILIES’ AND RESIDENTS’ RIGHT TO KNOW:  UNCOVERING POOR CARE IN AMERICA’S NURSING HOMES 

Cannabis use among older adults rising rapidly

July 1, 2019

courtesy of NAELA eBulletin:

Study is first state-wide investigation of cannabis use among older Americans and the outcomes they experience


AURORA, Colo. (May 30, 2019) – Cannabis use among older adults is growing faster than any other age group but many report barriers to getting medical marijuana, a lack of communication with their doctors and a lingering stigma attached to the drug, according to researchers.

The study, the first to look at how older Americans use cannabis and the outcomes they experience, was published this month in the journal Drugs & Aging.

“Older Americans are using cannabis for a lot of different reasons,” said study co-author Hillary Lum, MD, PhD, assistant professor of medicine at the University of Colorado School of Medicine. “Some use it to manage pain while others use it for depression or anxiety.”

The 2016 National Survey of Drug Use and Health showed a ten-fold increase in cannabis use among adults over age 65.

The researchers set out to understand how older people perceived cannabis, how they used it and the positive and negative outcomes associated with it.

They conducted 17 focus groups in in senior centers, health clinics and cannabis dispensaries in 13 Colorado counties that included more than 136 people over the age of 60. Some were cannabis users, others were not.

“We identified five major themes,” Lum said.

These included: A lack of research and education about cannabis; A lack of provider communication about cannabis; A lack of access to medical cannabis; A lack of outcome information about cannabis use; A reluctance to discuss cannabis use.

Researchers found a general reluctance among some to ask their doctors for a red card to obtain medical marijuana. Instead, they chose to pay more for recreational cannabis.

Lum said this could be driven by feeling self-conscious about asking a doctor for cannabis. That, she said, points to a failure of communication between health care providers and their patients.

“I think [doctors can] be a lot more open to learning about it and discussing it with their patients,” said one focus group respondent. “Because at this point I have told my primary care I was using it on my shoulder. And that was the end of the conversation. He didn’t want to know why, he didn’t want to know about effects, didn’t want to know about side effects, didn’t want to know anything.”

Some said their doctors were unable or unwilling to provide a certificate, the document needed to obtain medical marijuana. They also said physicians need to educate themselves on the latest cannabis research.

Some older users reported positive outcomes when using cannabis for pain as opposed to taking highly addictive prescription opioids. They often differentiated between using cannabis for medical reasons and using it recreationally.

“Although study participants discussed recreational cannabis more negatively than medical cannabis, they felt it was more comparable to drinking alcohol, often asserting a preference for recreational cannabis over the negative effects of alcohol,” the study said.

The researchers also found that despite the legalization of cannabis in Colorado and other states, some older people still felt a stigma attached to it.

“Some participants, for example, referred to the movie `Reefer Madness’ (1936) and other anti-marijuana propaganda adverts that negatively framed cannabis as immoral and illegal,” the researchers said.

The study adds to the growing literature on the diversity of marijuana use patterns in older adults, said co-author Sara Honn Qualls, PhD, ABPP, professor of psychology and director of the Gerontology Center at the University of Colorado Colorado Springs.

“Older adults who use marijuana are ingesting it in a variety of ways for multiple purposes,” she said. “This and other papers from the same project show growing acceptance of marijuana use for medical purposes by older adults, and a clear desire to have their primary health providers involved in educating them about options and risks.

Lum agreed.

She said Colorado, the first state to legalize recreational marijuana, provides a unique laboratory to gauge public attitudes toward cannabis.

“From a physician’s standpoint this study shows the need to talk to patients in a non-judgmental way about cannabis,” she said. “Doctors should also educate themselves about the risks and benefits of cannabis and be able to communicate that effectively to patients.”

The study co-authors include: Julie Bobitt; Melissa Schuchman; Robert Wickersham; Kanika Arora; Gary Milavetz and Brian Kaskie.

Federal employees soon will have more options to withdraw money from their retirement accounts

July 1, 2019

courtesy NAELA eBulletin:

By Eric Yoder   May 30

Current and former federal employees and military personnel soon will have more options when it comes to withdrawing money from their retirement accounts.

The Thrift Savings Plan is on schedule for a September launch of new account withdrawal options that will remove restrictions that have long been a sore point for many investors, TSP officials said Wednesday at a meeting of the program’s governing board.

Those changes — most applying to those who have left the government but some applying to those still working — result from legislation enacted in late 2017 that gave the TSP two years to carry them out. The Thrift Savings Plan is a 401(k)-style retirement savings plan for federal employees and military personnel, with 5.9 million account holders who had $591 billion on investment as of the end of April.

Although those who leave the government for retirement or other reasons may leave their accounts in place, the limited withdrawal choices have been cited as a main reason so many transfer the money to an individual retirement account or other tax-favored savings plan instead — 36 percent do so within a year.

In the most recent investor satisfaction survey, in 2013, withdrawal choices ranked the second-lowest among the seven features of the program that were rated.

Account holders are “going to have a lot better withdrawal options. They’ve been very limited in the past and I think it’s going to be very beneficial,” said board chairman Michael Kennedy, a managing director in the Atlanta office of Korn/Ferry International, a management consulting firm.

Although the Thrift Savings Plan is a federal agency, it is self-funding and operates much like a corporation, with a chief executive officer overseen by a governing board.

Currently, account holders who leave federal employment or active military duty have three basic withdrawal options that they can use alone or in combination: take a lump-sum cashout or transfer to another account, purchase an annuity, or draw out equal monthly payments.

However, only one partial withdrawal is allowed, and any second withdrawal choice must apply to the entire remaining balance. Further, for those who have both traditional pretax balances and “Roth IRA” after-tax balances, withdrawals must be taken proportionately from both.

Under the new policies, to be effective Sept. 15, those who separate from the government will be allowed to take partial withdrawals as often as once every 30 days, and those with both types of balances will be allowed to take the money from one or the other in addition to prorating.

Further, installment payments could be taken quarterly or annually in addition to monthly, and the amounts could be changed at any time rather than just once a year.

One change will affect current employees and active duty military personnel who are over age 59½ . They may now may take a one-time “age-based” withdrawal without a tax penalty, which forfeits the right to take a later partial withdrawal. Instead, up to four age-based withdrawals per year will be allowed, with no impact on post-separation withdrawals.

Ravindra Deo, executive director of the board, said the changes could motivate some investors to decide to stay with the Thrift Savings Plan since “they want more flexibility and this will give it to them.” He said that by transferring out, investors are passing up advantages including investment fees that are much lower than those charged by mutual funds and other investment vehicles.

However, some investors still may have good reasons to move their money out of the TSP, he said, including those with only small accounts they wish to close out and, by contrast, those with substantial savings plus other investments that they want to consolidate. For them, “I don’t know if this will make enough of a difference” to motivate them to stay, he said.

“This is going to be a great benefit for the program and the participants,” said Clifford Dailing, secretary-treasurer of the National Rural Letter Carriers’ Association. “This is a request that we’ve been hearing from our members for some time. Many of them have been putting their money in other investments where they could have better control.”

“I think some have been making bad decisions because of a misunderstanding that once they retire they need to withdraw the account and reinvest it, which is inaccurate,” added Dailing, chair of a separate advisory board of federal employee organizations that met jointly with the TSP’s board.

At the meeting, officials outlined plans to inform account holders about the new options through electronic newsletters, webinars and other communications. Investors will be encouraged to make any changes through a feature being developed for the TSP website, although new paper forms also will be offered.

“We’re trying to make sure we implement it and roll it out the right way,” Kennedy said. “We’ll have to do a real good job of educating people.”

Other changes ahead, officials said, include making mandatory the now voluntary use of two-factor authentication to access an account, offering target-date investment funds in five-year increments rather than the current 10 years, and increasing the default investment for newly hired employees from 3 to 5 percent of salary. The first of those is targeted for later this year, while the other two are projected for July and October 2020 respectively.

Tips on Creating an Estate Plan that Benefits a Child with Special Needs

July 1, 2019

Parents want their children to be taken care of after they die. But children with disabilities have increased financial and care needs, so ensuring their long-term welfare can be tricky. Proper planning by parents is necessary to benefit the child with a disability, including an adult child, as well as assist any siblings who may be left with the caretaking responsibility.

Special Needs Trusts
The best and most comprehensive option to protect a loved one is to set up a special needs trust (also called a supplemental needs trust). These trusts allow beneficiaries to receive inheritances, gifts, lawsuit settlements, or other funds and yet not lose their eligibility for certain government programs, such as Medicaid and Supplemental Security Income (SSI). The trusts are drafted so that the funds will not be considered to belong to the beneficiaries in determining their eligibility for public benefits.

There are three main types of special needs trusts:

  • A first-party trust is designed to hold a beneficiary’s own assets. While the beneficiary is living, the funds in the trust are used for the beneficiary’s benefit, and when the beneficiary dies, any assets remaining in the trust are used to reimburse the government for the cost of medical care. These trusts are especially useful for beneficiaries who are receiving Medicaid, SSI or other needs-based benefits and come into large amounts of money, because the trust allows the beneficiaries to retain their benefits while still being able to use their own funds when necessary.
  • The third-party special needs trust is most often used by parents and other family members to assist a person with special needs. These trusts can hold any kind of asset imaginable belonging to the family member or other individual, including a house, stocks and bonds, and other types of investments. The third-party trust functions like a first-party special needs trust in that the assets held in the trust do not affect a beneficiary’s access to benefits and the funds can be used to pay for the beneficiary’s supplemental needs beyond those covered by government benefits. But a third-party special needs trust does not contain the “payback” provision found in first-party trusts. This means that when the beneficiary with special needs dies, any funds remaining in the trust can pass to other family members, or to charity, without having to be used to reimburse the government.
  • A pooled trust is an alternative to the first-party special needs trust. Essentially, a charity sets up these trusts that allow beneficiaries to pool their resources with those of other trust beneficiaries for investment purposes, while still maintaining separate accounts for each beneficiary’s needs. When the beneficiary dies, the funds remaining in the account reimburse the government for care, but a portion also goes towards the non-profit organization responsible for managing the trust.

Life Insurance
Not everyone has a large chunk of money that can be left to a special needs trust, so life insurance can be an essential tool. If you’ve established a special needs trust, a life insurance policy can pay directly into it, and it does not have to go through probate or be subject to estate tax. Be sure to review the beneficiary designation to make sure it names the trust, not the child. You should make sure you have enough insurance to pay for your child’s care long after you are gone. Without proper funding, the burden of care may fall on siblings or other family members. Using a life insurance policy will also guarantee future funding for the trust while keeping the parents’ estate intact for other family members. When looking for life insurance, consider a second-to-die policy. This type of policy only pays out after the second parent dies, and it has the benefit of lower premiums than regular life insurance policies.

ABLE Account
An Achieving a Better Life Experience (ABLE) account allows people with disabilities who became disabled before they turned 26 to set aside up to $15,000 a year in tax-free savings accounts without affecting their eligibility for government benefits. This money can come from the individual with the disability or anyone else who may wish to give him money.

Created by Congress in 2014 and modeled on 529 savings plans for higher education, these accounts can be used to pay for qualifying expenses of the account beneficiary, such as the costs of treating the disability or for education, housing and health care, among other things. ABLE account programs have been rolling out on a state-by-state basis, but even if your state does not yet have its own program, many state programs allow out-of-state beneficiaries to open accounts. (For a directory of state programs, click here.)

Although it may be easy to set up an ABLE account, there are many hidden pitfalls associated with spending the funds in the accounts, both for the beneficiary and for her family members. In addition, ABLE accounts cannot hold more than $100,000 without jeopardizing government benefits like Medicaid and SSI. If there are funds remaining in an ABLE account upon the death of the account beneficiary, they must be first used to reimburse the government for Medicaid benefits received by the beneficiary, and then the remaining funds will have to pass through probate in order to be transferred to the beneficiary’s heirs.

Get Help With Your Plan
However you decide to provide for a child with special needs, proper planning is essential. Talk to your attorney to determine the best plan for your family.

Link of the Week: Elder Justice: What “No Harm” Really Means for Residents

July 1, 2019

courtesy of NAELA eBulletin:

The majority of nursing home violations are identified as causing “no harm” to residents, despite any harm the resident may have actually experienced. Sadly, the failure to recognize resident harm when it occurs too often means that nursing homes are not properly held accountable for resident abuse, neglect, and other forms of harm. In order to bring attention to the poor enforcement of the nursing home standards of care, and how it effects resident care, the Center for Medicare Advocacy and the Long Term Care Community Coalition publish Elder Justice: What “No Harm” Really Means for Residents. Each issue of our Elder Justice newsletter provides readers with real stories of resident pain, suffering, and humiliation from across the country. All of our examples were taken directly from Statement of Deficiencies on CMS’s Nursing Home Compare Website and all were cited as no-harm.

Note – the files below are .pdf files that are best viewed in any browser except Internet Explorer.

Vol. 2, Issue 2
Vol. 2, Issue 1
Vol. 1, Issue 12
Vol. 1, Issue 11
Vol. 1, Issue 10
Vol. I, Issue 9
Vol. I, Issue 8
Vol. I, Issue 7
Vol. I, Issue 6
Vol. I, Issue 5
Vol. I, Issue 4
Vol. I, Issue 3
Vol. I, Issue 2
Vol. I, Issue 1

Protecting Your House from Medicaid Estate Recovery

July 1, 2019

After a Medicaid recipient dies, the state must attempt to recoup from his or her estate whatever benefits it paid for the recipient’s care. This is called “estate recovery.” For most Medicaid recipients, their house is the only asset available, but there are steps you can take to protect your home.

Life estates
For many people, setting up a “life estate” is the simplest and most appropriate alternative for protecting the home from estate recovery. A life estate is a form of joint ownership of property between two or more people. They each have an ownership interest in the property, but for different periods of time. The person holding the life estate possesses the property currently and for the rest of his or her life. The other owner has a current ownership interest but cannot take possession until the end of the life estate, which occurs at the death of the life estate holder.

Example: Jane gives a remainder interest in her house to her children, Robert and Mary, while retaining a life interest for herself. She carries this out through a simple deed. Thereafter, Jane, the life estate holder, has the right to live in the property or rent it out, collecting the rents for herself. On the other hand, she is responsible for the costs of maintenance and taxes on the property. In addition, the property cannot be sold to a third party without the cooperation of Robert and Mary, the remainder interest holders.

When Jane dies, the house will not go through probate, since at her death the ownership will pass automatically to the holders of the remainder interest, Robert and Mary. Although the property will not be included in Jane’s probate estate, it will be included in her taxable estate. The downside of this is that depending on the size of the estate and the state’s estate tax threshold, the property may be subject to estate taxation. The upside is that this can mean a significant reduction in the tax on capital gains when Robert and Mary sell the property because they will receive a “step up” in the property’s basis.

As with a transfer to a trust, if you transfer the deed to your home to your children and retain a life estate, this can trigger a Medicaid ineligibility period of up to five years. Purchasing a life estate in another home can also cause a transfer penalty, but the transfer penalty can be avoided if the individual purchasing the life estate resides in the home for at least one year after the purchase and pays a fair amount for the life estate.

Life estates are created simply by executing a deed conveying the remainder interest to another while retaining a life interest. In many states, once the house passes to the remainder beneficiaries, the state cannot recover against it for any Medicaid expenses that the ife estate holder may have incurred.

Another method of protecting the home from estate recovery is to transfer it to an irrevocable trust. Trusts provide more flexibility than life estates but are somewhat more complicated. Once the house is in the irrevocable trust, it cannot be taken out again. Although it can be sold, the proceeds must remain in the trust. This can protect more of the value of the house if it is sold. Further, if properly drafted, the later sale of the home while in this trust might allow the settlor, if he or she had met the residency requirements, to exclude up to $250,000 in taxable gain, an exclusion that would not be available if the owner had transferred the home outside of trust to a non-resident child or other third party before sale.

Contact your attorney to find out what method will work best for you.

Medicare’s Different Treatment of the Two Main Post-Hospital Care Options

July 1, 2019

Hospital patients who need additional care after being discharged from the hospital are usually sent to either an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF). Although these facilities may look similar from the outside, Medicare offers very different coverage for each. While you may not have complete say in where you go after a hospital stay, understanding the difference between the two facilities can help you advocate for what you need and know what to expect with regard to Medicare coverage.

An IRF can be either part of a hospital or a stand-alone facility that offers intensive physical and occupational therapy under the supervision of a doctor and nurses. IRFs offer a minimum of three hours a day of rehabilitation therapy. An SNF, on the other hand, provides full-time nursing care. Patients also receive physical and occupational therapy, but the care is generally less intensive and specialized than in an IRF.

IRFs and Medicare

Medicare Part A covers a stay in an IRF in the same way it covers hospital stays. Medicare pays for 90 days of hospital care per “spell of illness,” plus an additional lifetime reserve of 60 days. A single “spell of illness” begins when the patient is admitted to a hospital or other covered facility, and ends when the patient has gone 60 days without being readmitted to a hospital or other facility. There is no limit on the number of spells of illness. However, the patient must satisfy a deductible before Medicare begins paying for treatment. This deductible, which changes annually, is $1,364 in 2019.

After the deductible is satisfied, Medicare will pay for virtually all hospital charges during the first 60 days of a recipient’s hospital stay. If the hospital stay extends beyond 60 days, the Medicare beneficiary begins shouldering more of the cost of his or her care. From day 61 through day 90, the patient pays a coinsurance of $341 a day in 2019. Beyond the 90th day, the patient begins to tap into his or her 60-day lifetime reserve. During hospital stays covered by these reserve days, beneficiaries must pay a coinsurance of $682 per day in 2019.

To qualify for care in an IRF, you must need 24-hour access to a doctor and a nurse with experience in rehabilitation. You must also be able to handle three hours of therapy a day (although there can be exceptions).

SNFs and Medicare

Medicare’s coverage of skilled nursing care is more limited. Medicare Part A covers up to 100 days of “skilled nursing” care per spell of illness. Beginning on day 21 of the nursing home stay, there is a copayment equal to one-eighth of the initial hospital deductible ($170.50 a day in 2019). However, the conditions for obtaining Medicare coverage of a nursing home stay are quite stringent. Here are the main requirements:

  • The Medicare recipient must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; “observation status” does not count) that itself lasted for at least three days (not counting the day of discharge).
  • The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
  • The patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered “skilled,” nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse or licensed practical nurse. Moreover, such care must be delivered on a daily basis. (Few nursing home residents receive this level of care.)

A new spell of illness can begin if the patient has not received skilled care, either in an SNF or in a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care during that 60 days.

Keep in mind that some or all of Medicare’s deductibles and co-payments for both IRF and SNF care may be covered by Medicare supplemental insurance, also called Medigap coverage.