Author Archives: Administrator

House Calls Provide Better Care and Save Money. Why Don’t More Use Them?

October 8, 2019

Only a fraction of older adults eligible for home-based primary care are being served
By  Beth Baker  September 13, 2019

Margaret Birt, then 62, had routine surgery in 2006. But in the recovery room, she had complete cardiac arrest. Initially in a vegetative state, Birt regained much of her cognition. Her life, however, was never the same. She was left with no physical capabilities, needing constant care.

Rather than ending up in a nursing home, though, Birt lives at home in Wheaton, Ill. with her husband, Maurice. She receives primary medical care there, covered by Medicare, from Dr. Thomas Cornwell and his team at Northwestern HomeCare Physicians. They perform exams, chest x-rays and blood draws — all in the comfort of Birt’s home. “We’re very fortunate,” says her husband. Cornwell is also CEO of the Home Centered Care Institute, dedicated to mentoring and training home-based providers.

In addition to her Medicare-covered primary care, Margaret Birt requires 24-hour help from caregivers that the couple must pay for out-of-pocket. Without the generous long-term care policy purchased years ago, Maurice Birt says, he would be bankrupt.

House Calls: A Cost-Saving Measure

“Home-based primary care focuses first on a vulnerable and disenfranchised population, often older adults with multiple chronic conditions who also experience problems with basic activities of daily living [such as walking or dressing],” says Dr. Bruce Leff, director of The Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine. “They are what payers refer to as ‘high need, high cost.’”

Prior to January 1, 2019, health providers had to document the medical necessity for why a house call was needed instead of an office visit. Medicare has since eliminated this requirement. Now it is at the provider’s discretion where a patient is seen, explains Cornwell.

“The main difference is house calls could not be done prior to this year for the convenience of patients who could easily get to the office. Now they can. Having said this, most house call programs have as their mission to serve patients who otherwise cannot get to a provider’s office,” notes Cornwell.

It may seem counter-intuitive, but giving these vulnerable patients individualized primary care at home saves money for the nation’s health care system, according to studies by Department of Veterans Affairs and the Centers for Medicare and Medicaid Services (CMS), among others.

“Now there is strong evidence that home-based care results in better care outcomes and better experience of care by patients and by caregivers, who often have a lot put upon them,” says Leff, who is working with colleagues to develop quality standards for home-based primary care. “It also has a pretty robust effect on reducing health care costs.”

The John A. Hartford Foundation (a Next Avenue funder) awarded Leff and colleague Dr. Christine Ritchie, in partnership with the Home Centered Care Institute and the American Academy of Home Care Medicine, a $1.5 million grant to foster and expand home-based primary care.

“What we’re focusing on is a population who is really in need,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. “Even if the adult son could get mom to the doctor’s office, the average primary care practice is not equipped to handle the patients. The doctors don’t have time, and often [the patients] have psychosocial issues.”

Patients with dementia may experience fear and anxiety at a doctor’s office, for example, and be disruptive to others in the waiting room.

At least 2 million older adults would benefit from home-based primary care, according to Health Affairs. Because these patients have difficulty getting to an office visit, they frequently end up in emergency rooms or hospitals. Per-patient savings range from $1,000 to $4,000 annually through reduced hospital and nursing home stays, emergency room trips and specialist visits, according to research cited by the American Academy of Home Care Medicine.

According to the American Academy of Home Care Medicine, the CMS Independence at Home Demonstration, part of the Affordable Care Act, estimated that Medicare would save $10 to $15 billion total over a 10-year period if home-based primary care were extended nationally to those on Medicare who are homebound.

Benefits to Patients and Families

For patients with chronic conditions, in addition to the convenience of home-based primary care, “The biggest benefit is that the care is very well coordinated,” says Dr. Zia Agha, chief medical officer of West Health, a research and policy center focused on improving care delivery to older adults.

“You have a team of providers who are working together to provide services to you. There is a tremendous emphasis on delivering palliative care. We see a lot of these patients where mom used to be in the ER or hospital ten times a year, and now she has not had a single hospital admission,” says Agha. “That is the biggest advantage, to be helped at home and have the right care to allow them to have quality of life, and not be on aggressive medical services.”

Geriatrician Dr. Carla Perissinotto, medical director of UCSF Care at Home at the University of California, San Francisco, stresses that home-based primary care is person-centered by definition. “When you are in someone’s home, you [as the doctor] are not the center, it is the person,” she says. “It is on their territory. You have to be comfortable with a change in the dynamic.”

For example, she says, “In the clinician’s office, you very clearly know as a patient where you’re supposed to sit. When I go into someone’s home, I wait for them to tell me where to sit.”

She recently had a medical resident ask her what to do about a patient who was stuck in the hospital and becoming increasingly delirious, begging to go home. The hospital did not want to keep him and no nursing home would take him.

“I said, ‘Has anyone thought of taking him home?’” says Perissonotto. “’I can see him at home, we can get home physical therapy. Has anyone applied for in-home support services?’” Two days later, he was back at home where he and his wife have lived happily for 18 months.

“We’re spending billions and no one has asked, what are the barriers to being at home? That’s not rocket science,” Perissinotto says.

“I see this is mostly a high-touch field. But in order to provide quality care, you have to have high-tech capability,” Cornwell adds. “With my smartphone, I can do an EKG within a minute. We have x-ray services, lab services, ultrasound in the home to check things like blood clots in the legs or abdominal pain. I can have more done in the home with smart technology than most can do in the office. It’s having the technology that enables truly quality care.”

Obstacles to Expanding At-Home Care

Despite the growing evidence that home-based primary care is superior in terms of cost and quality for those with complex needs, only a fraction of eligible older adults are being served.

Huge swaths of the country have no home-based primary care, especially in rural areas in Idaho, Montana, the Dakotas and other states.

Most people who are homebound live at least 30 miles from a home-based practitioner. Experts point to two major obstacles: reimbursement and lack of physicians.

Providers of primary care at home, including physicians, nurse practitioners and physician assistants, see roughly six to 10 patients a day, compared to office-based physicians who see up to 25. Providers receive a modest amount more per house call (Medicare pays $10 to $30 extra), which usually does not cover the time spent driving or coordinating the care of these complex patients. In the traditional payment model, this has meant much lower salaries for home-based practitioners (unless they are subsidized by a health system), making it hard to attract doctors to the field.

But that is changing. The fee-for-service model is giving way to value-based payments, a flat-fee per patient for primary care, including home-based. Here, high-quality care is incentivized and more complex cases receive higher reimbursement. In January 2020, providers in 26 regions may voluntarily opt for this method of payment. Medicare also recently eased some of the record-keeping burdens on physicians making house calls by not requiring them to justify every home visit.

Beyond the reimbursement challenges, many doctors barely know of the field’s existence. Residency programs often do not require rotations in home-based medicine or even in geriatrics.

“When I say I’m a geriatrician, I don’t get ‘Wow, you must be brilliant’ like I would if I said ‘I’m a neurosurgeon,’” says Perissinotto. “A lot of it is how we as a society value older adults. And it’s exposure. We have to explain it’s very challenging work and it’s amazing.”

“If you’re going into medicine not with a procedural focus [such as surgery], but to have a relationship with the patient for many years, you find a home in home-care medicine,” says Feorene. “You’re seeing the patient’s surroundings, you get to know the elder’s story. We’re often there in the last three years of life, and we’re making a difference in that final chapter. For those providers looking for a Marcus Welby relationship with the patients, this delivers in spades.”

The field is growing. Feorene’s organization, the American Academy of Home Care Medicine, has 900 members, half of them physicians, one-quarter nurse practitioners and physician assistants and the rest being social workers and nurses.

Nurse practitioners are “flocking to the field,” he says.

To spread the word and develop best practices, the Home Centered Care Institute in 2017 created a national network of Centers of Excellence that includes the Cleveland Clinic, University of California, San Francisco and four others.

Cornwell urges consumers to ask their physicians and health systems to support home-based primary care and the new value-based payment programs.

“It would be wonderful to have a groundswell,” he says.

Who’s Charging What for Trust Services?

October 8, 2019

Trust fees are headed higher according to our pricing survey completed this week. Some firms work strictly from a rate card. Others decide what your client will pay when the business is placed on the table. Either way, it’s good to know what the “market value” of trust services.

There’s still a fair amount of mystery surrounding exactly what’s baked into each of those basis points. “It’s never as simple as just lining up the fees,” says Mike Flinn, a Phoenix-based trust consultant. “Once you start drilling down into the basis points, it becomes pretty clear that different firms really do different things,” he added. To find out where the sizzle hits the steak for various types of trust company, The Trust Advisor conducted a survey below of what they’re charging.

Who’s Charging What for Trust Services
Trust Company State Trust account minimum Minimum annual fee First $1 million Next $2 to $3 million $3 to $5 million Above $5 million
Advisory Trust DE $500,000 $3,000 0.50% 0.40% 0.30% 0.25%
Bryn Mawr Trust DE $1 million $6,000 0.60% * 0.45% Neg.
The New Hampshire Trust Company NH None $3,000 0.90% 0.55% 0.45% 0.35%
Northern Trust IL & DE $5 million $20,000 0.40% 0.40% 0.40% 0.20%
Reliance Trust GA None $3,000 0.60% 0.35% 0.35% 0.35%
Santa Fe Trust NM None $4,000 0.75% 0.75% 0.50% 0.35%
Saturna Trust Co. NV None $1,000 0.50% 0.50% 0.50% 0.40%
Summit Trust Co. NV $100 $100 1.00% 0.80% 0.70% Neg.
Wealth Advisors Trust Company SD None $4,000 0.50% 0.50% 0.42% 0.35%
Wilmington Trust DE $1 million $8,000 0.60% 0.40% 0.40% 0.25%
* Breakpoint is $2 million.

One thing we discovered: if you just want a no-frills account, Flinn adds, it’s probably going to cost at least $3,000 a year. “That’s really the minimum anyone can comfortably charge.”

“Maybe $2,500,” he conceded. “But at that level, it’s going to be very difficult to stay in the business.”

While $3,000 happens to be what Advisory Trust charges on the low end, it does seem to be an informal sweet spot within the trust industry. Other companies that start at that level include New Hampshire Trust and Georgia-based Reliance Trust.

There are companies that charge small accounts less (Nevada’s Summit Trust will go as low as $100 a year), but plenty start their fees at $4,000 and up. It all depends on the size of account they’re courting and what makes economic sense, Christopher Holtby, president of Wealth Advisors Trust Company, told me.

“Hitting the sweet spot is part art, part science,” he explains. “There are very specific things that every trust has to do, and everything else is extra.”

Good scale for big fish

Northern Trust doesn’t publish its fee scale, but president Dan Lindley was kind enough to give The Trust Advisor a peek.

Although the $20,000 minimum fee looks steep at first, it makes a lot more sense when you consider that Northern Trust isn’t really interested in personal directed trust accounts with less than $5 million in assets. For a client with that kind of wealth, the $20,000 translates into at most 40 basis points a year—pretty low by industry standards.

(Really big clients get institutional-strength discounts. Once a Northern Trust account grows beyond $30 million, the company will only charge 5 basis points: $500 a year per $1 million.)

The upshot is that by concentrating on high-end clients, a white-glove firm like Northern Trust can build a lot of sizzle into its steak, even though the cost per dollar of AUM is comparable to what bare-bones vendors charge.

“Northern Trust in Delaware charges a reasonable, competitive fee and in return provides comprehensive services to our directed trust clients backed by more than 120 years of experience as a fiduciary,” Lindley told me.

Other high-end trust companies argue that at this level, it’s pointless to advertise your fees because high-net-worth clients and their advisors are happy to pay for the service.

Some vendors refused to participate in the survey because they either work on an a la carte basis (Peak Trust) or figure out what to charge once they see the trust paperwork (Commonwealth Trust). As Peak Trust founder Douglas Blattmachr told me, it’s pointless to advertise how much a generic offering would cost when the fact is that at this level, one size fits none.

“It really does depend on what the client wants us to provide,” he says.

When asked to present a benchmark, he estimated that a relatively bare-bones Peak Trust account might charge 50 basis points a year or an annual minimum of $3,500. That’s about where vanilla Commonwealth trusts start, Jim McMackin, who runs the company’s marketing, told me.

Splitting smaller pies

Naturally, it’s going to cost extra if the trust company also manages the underlying assets. But there are a lot of vendors out there that are happy to offload the investment responsibilities and knock a bit off their fees in return.

Companies like Wealth Advisors Trust, Advisory Trust and Santa Fe Trust, cater exclusively to investment advisors looking for a place to refer their clients who need to open a trust.

Account minimums tend to be relatively low—Wealth Advisors Trust and Santa Fe Trust can theoretically start a trust with as little as $1—but expenses can be a little higher to cover the fixed cost of administering these tiny trusts.

For example, Santa Fe Trust accepts very small accounts, but according to its published fee scale it will still charge them at least $4,000 a year. At an annual fee of 75 basis points, this suggests that a trust really needs to have more than around $533,000 in it to “earn out” that $4,000 minimum fee.

By comparison, Wealth Advisors Trust’s scale “earns out” at a slightly higher level ($800,000 in the account), which indicates that its platform is built to support a somewhat more affluent clientele. Others on our list (Advisory Trust, Reliance, Saturna, New Hampshire Trust) justify their minimums at lower levels.

Whatever happens, says Kathy Roberts, the CEO of Santa Fe Trust, small accounts shouldn’t be loss leaders.

“We don’t take a trust that isn’t going to be profitable,” she told me.  While she’ll take on a tiny trust if the grantor insists, she warns that advisors should recognize that the trust company will pass on the cost of running it and sometimes it just doesn’t make sense.

Where we go from here

Most of the people I talked to say the cost of running a trust has already gone about as low as it can go.

Mike Flinn from Advisory Trust and Douglas Blattmachr of Peak Trust agree that the cost of fiduciary compliance and routine service probably isn’t going any lower than around $3,000 per trust any time soon, especially given the current trend toward higher regulation.

“It’s expensive to be a fiduciary,” Blattmachr acknowledged in our conversation. “So that provides a floor on what people can offer.”

But beyond that level, technology keeps improving and letting efficient trust companies bring down their overall cost proposition. Blattmachr says low-end players can use technology to better serve the mass market. Kathy Roberts of Santa Fe Trust agrees.

Either way, Christopher Holtby of Wealth Advisors Trust told me that there’s always room for enthusiastic competitors.

“Wherever fees go,” he says, “there are going to be a lot more entrants in the trust service business.”

Scott Martin, contributing editor, The Trust Advisor.  

Beneficiary Advocates Raise Alarms Concerning Roll-Out of New Medicare Plan Finder and Revision of Medicare Marketing Rules

October 8, 2019

Washington, DC ─ Justice in Aging, Medicare Rights Center, Center for Medicare Advocacy and the National Council on Aging sent a joint letter to Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), on August 27, 2019, urging the agency to address concerns regarding changes to the Medicare Plan Finder (MPF) tool and the 2020 Medicare Communications and Marketing Guidance (MCMG).

The four organizations expressed appreciation for CMS’s efforts to update these resources to better support beneficiary decision-making, while raising concerns that the revisions may instead have the opposite effect. The groups urged CMS to mitigate adverse consequences by closely monitoring the roll out and functionality of the new MPF tool, providing enrollment relief as needed, and by rescinding the updated MCMG in its entirety.

Earlier today, CMS unveiled long-awaited updates to MPF—the federal government’s primary enrollment assistance tool for Medicare Advantage and Part D plans. While the new site includes a number of improvements, the groups are concerned that its late-August launch date may not give third-party assisters, like State Health Insurance Assistance Programs (SHIPs), adequate time to learn the new tool before Fall Open Enrollment begins. And that coupled with recent legislative and regulatory changes set to take effect this year, the truncated MPF launch timeline may generate demand for enrollment assistance that these chronically underfunded programs are unable to meet.  Further, CMS has stated that there will be no back-up system in place or ability to revert to the current “legacy” system during the upcoming Fall Open Enrollment period.

The Medicare Communications and Marketing Guidelines (MCMG) is a set of rules that govern the selling and promotion of Medicare Advantage and Medicare Prescription Drug plans. Revised each year, these guidelines help ensure that people with Medicare have accurate information about a plan’s costs and benefits as well as adequate protections against inappropriate marketing practices. The 2020 revisions, however, effectively disregarded the regular process for stakeholder input and introduce changes that primarily ease the burden on plans and downstream entities while at best doing little to benefit or protect consumers and at worst increasing the likelihood consumers will experience harm.

Apparently in direct conflict with current law, the revised MCMG weaken the distinction between “marketing” events, which are designed to steer or attempt to steer beneficiaries toward a plan or limited set of plans; and “educational” events, which are designed to inform beneficiaries about Medicare Advantage, Prescription Drug, or other Medicare programs. In addition, the revisions removed several disclaimers required of plans, including a short one alerting Spanish speakers of the availability of translations of certain important plan communications. The burden on plans of including the two-line notice was miniscule, but the need to alert limited-English proficient beneficiaries that they can receive help is great.  Further, the revision failed to include provisions outlined in the draft version that would have limited the aggressive marketing of plans referred to as D-SNP look-alikes. These Medicare Advantage plans, which are not subject to the oversight that CMS and states impose on plans designed to serve the complex needs of dual eligibles (people with both Medicare and Medicaid), are being marketed almost exclusively to this population. CMS has itself identified this marketing as a significant problem but abandoned its proposal to address its concerns in the guidelines.

Kevin Prindiville, Executive Director of Justice in Aging stated: “CMS’s harmful updates to the Marketing Guidelines are a step backward, leaving consumers more vulnerable to aggressive marketing tactics and making it more difficult for them to request important health information in their language. The hasty roll out of plan finder changes will only add to the challenges of this year’s Open Enrollment season.

Judith Stein, Executive Director of the Center for Medicare Advocacy, noted, “The revisions to the Marketing Guidelines cater to Medicare private plans and those who sell them, rather than being in the best interest of Medicare beneficiaries, those who assist them, or in furtherance of an equitable Medicare program. CMS should rescind these changes, and should ensure that beneficiaries are not hindered by a delayed roll out of a completely new Plan Finder format, with no back-up system in place.”

Frederic Riccardi, President of the Medicare Rights Center, stated: “Based on our experience assisting people with Medicare and their families, we know how challenging it can be for beneficiaries to make the best coverage decision for their unique circumstances. CMS must ensure that its tools and resources are developed, distributed and updated in ways that maximally support this decision-making process.”

Read the letter here.

How Not to Grow Old in America

October 8, 2019

The assisted living industry is booming, by tapping into the fantasy that we can all be self-sufficient until we die.


Assisted living seems like the solution to everyone’s worries about old age. It’s built on the dream that we can grow old while being self-reliant and live that way until we die. That all you need is a tiny bit of help. That you would never want to be warehoused in a nursing home with round-the-clock caregivers. This is a powerful concept in a country built on independence and self-reliance.

The problem is that for most of us, it’s a lie. And we are all complicit in keeping it alive.

The assisted living industry, for one, has a financial interest in sustaining a belief in this old-age nirvana. Originally designed for people who were mostly independent, assisted living facilities have nearly tripled in number in the past 20 years to about 30,000 today. It’s a lucrative business: Investors in these facilities have enjoyed annual returns of nearly 15 percent over the past five years — higher than for hotels, office, retail and apartments, according to the National Investment Center for Seniors Housing and Care.

The children of seniors need to believe it, too. Many are working full time while also raising a family. Adding the care of elderly parents would be a crushing burden.

I know this fantasy well. When my parents, who were then in their 70s, were unable to take care of themselves, I bought an apartment in Brooklyn that was big enough to fit them, in addition to my husband and our two young children. But then my husband lost his job in the Great Recession, and we could no longer afford the mortgage.

The only solution I could think of was to move. I took a job in India, where the dollar goes farther, so I could rent an apartment big enough to fit us all and hire helpers to care for my parents and children while my husband and I worked.

Back then, I, too, dreamed about those assisted living facilities. My parents seemed so bored and lonely in my house. And it was hard for us to keep up with their ballooning needs. They grew so enormous that I eventually had to quit my job.

As I struggled to support my parents, assisted living became a private dream for my own old age.

Now that I am back in the United States, I have been thinking about assisted living again. My dad died in 2017, after living with us for nine years, and my 83-year-old mother now lives in New York City with my sister. Would assisted living offer our mother better care and relieve the pressure on my sister, who works full time while raising a young daughter?

Sadly, I’ve discovered the answer is no.

The irony of assisted living is, it’s great if you don’t need too much assistance. If you don’t, the social life, the spalike facilities, the myriad activities and the extensive menus might make assisted living the right choice. But if you have trouble walking or using the bathroom, or have dementia and sometimes wander off, assisting living facilities aren’t the answer, no matter how desperately we wish they were.

“They put their money into the physical plant. It’s gorgeous,” said Cristina Flores, a former home health care nurse who has a Ph.D. in nursing health policy, lectures in the gerontology program at San Francisco State University and runs three small group homes for the elderly.

But when it comes to direct care, the facilities are often lacking. “The way they market everything is, it’s all about autonomy and independence, which are important concepts,” she said. Families and residents don’t realize that these facilities are not designed to provide more than minimal help and monitoring. Even those that advertise “24-hour” monitoring may have someone present round-the-clock on the premises, but may not have sufficient staff to actually monitor and assist the large number of residents.

“People’s defense against something horrible happening is, ‘Well, they have a right to be independent,” she said. “‘Yes, he did walk up the stairs with his walker and fall down and die, but he had a right to do that.’ That’s a horrible defense. You don’t just allow people to do unsafe things.”

Most residents of assisted living need substantially more care than they are getting. Half of those residing in assisted living facilities in the United States are over the age of 85, the Centers for Disease Control reports. And this trend is accelerating. The number of people 85 years of age and older in the United States will nearly triple to about 18 million by 2050, according to the Census Bureau.

“When you say nursing home, people say, ‘Yuk,’” said Eric Carlson, the directing attorney for Justice in Aging, a national advocacy group for low-income older Americans. “When you say assisted living, a lot of people say, ‘That sounds good.’ Nobody realizes the system is broken.” When something bad happens to a resident of an assisted living facility, “They just think it was that facility that was horrible,” he says.

Part of the problem is a lack of regulation. Nursing homes are regulated and inspected and graded for quality to ensure that residents receive adequate care. The federal government does not license or oversee assisted living facilities, and states set minimal rules. Nursing homes are required to have medical directors on staff who review patient medications regularly, while there is usually no such requirement in assisted living.

Not surprisingly, complaints against assisted living facilities are mounting in courts around the country.

In June of last year, Claude Eugene Rogers, an 83-year-old retired Marine, suffered from heatstroke at an assisted living facility in Roseville, near Sacramento. He died a few days later. A state investigation said that he had been left on an outside patio in his wheelchair for one hour and 45 minutes or longer that morning, when local temperatures reached 93 degrees Fahrenheit. The state in July moved to revoke the facility’s license to operate, which it is fighting to retain, while denying any wrongdoing.

His family was devastated. They had chosen assisted living when his dementia grew more severe and his wife was no longer able to care for him at home. “We thought it was a nice place and the people there could provide great care and the other residents there would be friends for my dad,” his son, Jeffrey Rogers, told me.

Bonnie Walker, 90, who also suffered from dementia, wandered undetected out of an assisted living facility in South Carolina sometime after midnight in July 2016. According to a lawsuit, her remains were found eight hours later in a pond nearby, and her pacemaker was recovered from inside an alligator that lived on the property.

Her family, after struggling to care for her at home, had taken her to assisted living believing she would be safer. They visited her daily and took her home on Sundays. “My grandma deserved to have us there” when she died, her granddaughter, Stephanie Weaver, told me, “not to go the way she did.”

Ruth Gamba, 96, fell three times during her first month in a memory care unit of an assisted living facility in Fremont, Calif., her family said in a lawsuit against the facility. Memory care units are supposed to provide closer monitoring and care of patients with dementia. But in Mrs. Gamba’s most recent fall, she broke her hip and fractured her toes, her family said in the lawsuit.

Her son, Peter Gamba, a television editor in Los Angeles, told me that he and his sister moved their mother into the facility because it promised round-the-clock monitoring. More than 40 percent of people in assisted living have some form of dementia. Construction of memory care units in assisted living facilities is the fastest-growing segment of senior care. But assisted living, even memory care units, often aren’t the right place for people with dementia. In most states, there’s no requirement that these units be staffed with enough people or that they be properly trained.

Assisted living has a role to play for the fittest among the elderly, as was its original intent. But if it is to be a long-term solution for seniors who need substantial care, then it needs serious reform, including requirements for higher staffing levels and substantial training.

That will raise prices, and assisted living already costs between about $4,800, on average, each month, and nearly $6,500 if dementia care is needed, according to the National Investment Center, a group that analyzes senior housing reports.

Perhaps the United States can learn from Japan, which is a few decades ahead of us in grappling with how to care for its rapidly aging population. Japan created a national long-term-care insurance system that is mandatory. It is partly funded by the government but also by payroll taxes and additional insurance premiums charged to people age 40 and older. It is a family-based, community-based system, where the most popular services are heavily subsidized home help and adult day care. Japanese families still use nursing homes and assisted living facilities, but the emphasis is on supporting the elder population at home.

We need to let go of the ideal of being self-sufficient until death. Just as we don’t demand that our toddlers be self-reliant, Americans need to allow the reality of ourselves as dependent in our old age to percolate into our psyches and our nation’s social policies. Unless we face up to the reality of the needs of our aging population, the longevity we as a society have gained is going to be lived out miserably.

As Mr. Gamba told me, “There’s going to be lots and lots of old people dying left and right with nobody attending to them.”

And there’s a pretty good chance, I believe, that among those languishing there will be you and me.


Grandparents Raising Grandchildren May Qualify for the Earned Income Tax Credit

October 8, 2019

Raising a grandchild can be tough financially, but grandparents should be aware that there is a tax credit available that could help them. Working grandparents who are supporting their grandchildren may qualify for the earned income tax credit, which could reduce the amount they pay in taxes by thousands of dollars or allow them to receive a refund.

The earned income tax credit is a benefit for working people with low to moderate incomes and dependents, and this includes grandparents.  (Taxpayers without a dependent may also qualify, but it is more difficult.) To be able to claim the tax credit, you must be raising a child who meets the following criteria:

  • Is your son, daughter, adopted child, stepchild, foster child, brother, sister, half brother, half sister, step-sister or a descendent of any of them, such as a grandchild or niece or nephew
  • Is younger than 19 at the end of the year, younger than 24 and a full-time student at the end of the year, or any age and permanently and totally disabled
  • Lives with you for more than half the year

In addition, to qualify for the tax credit your income must be below certain limits, depending on how many dependents you have. The limits for 2019 are as follows:

  • One child.  Filing as an individual, your income must be less than $41,094. Filing jointly, your income must be less than $46,884.
  • Two children. Filing as an individual, your income must be less than $46,703. Filing jointly, your income must be less than $52,493.
  • Three or more children. Filing as an individual, your income must be less than $50,162. Filing jointly, your income must be less than $55,952.

The maximum amount of the tax credit also depends on how many dependents you have. In 2019, the following are the maximum credit amounts:

  • $6,557 with three or more qualifying children
  • $5,828 with two qualifying children
  • $3,526 with one qualifying child

For more information from the IRS about the tax credit, click here.

Medicaid’s Asset Transfer Rules

October 8, 2019

In order to be eligible for Medicaid, you cannot have recently transferred assets. Congress does not want you to move into a nursing home on Monday, give all your money to your children (or whomever) on Tuesday, and qualify for Medicaid on Wednesday. So it has imposed a penalty on people who transfer assets without receiving fair value in return.

This penalty is a period of time during which the person transferring the assets will be ineligible for Medicaid. The penalty period is determined by dividing the amount transferred by what Medicaid determines to be the average private pay cost of a nursing home in your state.

Example: If you live in a state where the average monthly cost of care has been determined to be $5,000, and you give away property worth $100,000, you will be ineligible for benefits for 20 months ($100,000 / $5,000 = 20).

Another way to look at the above example is that for every $5,000 transferred, an applicant would be ineligible for Medicaid nursing home benefits for one month. In theory, there is no limit on the number of months a person can be ineligible.

Example: The period of ineligibility for the transfer of property worth $400,000 would be 80 months ($400,000 / $5,000 = 80).

A person applying for Medicaid must disclose all financial transactions he or she was involved in during a set period of time — frequently called the “look-back period.” The state Medicaid agency then determines whether the Medicaid applicant transferred any assets for less than fair market value during this period.  The look-back period for all transfers is 60 months (except in California, where it is 30 months).  Also, keep in mind that because the Medicaid program is administered by the states, your state’s transfer rules may diverge from the national norm.  To take just one important example, New York State does not apply the transfer rules to recipients of home care (also called community care).

The penalty period created by a transfer within the look-back period does not begin until (1) the person making the transfer has moved to a nursing home, (2) he has spent down to the asset limit for Medicaid eligibility, (3) has applied for Medicaid coverage, and (4) has been approved for coverage but for the transfer.

For instance, if an individual transfers $100,000 on April 1, 2017, moves to a nursing home on April 1, 2018, and spends down to Medicaid eligibility on April 1, 2019, that is when the 20-month penalty period will begin, and it will not end until December 1, 2020.

In other words, the penalty period would not begin until the nursing home resident was out of funds, meaning there would be no money to pay the nursing home for however long the penalty period lasts.  In states that have so-called “filial responsibility laws,” nursing homes may seek reimbursement from the residents’ children. These rarely-enforced laws, which are on the books in 29 states, hold adult children responsible for financial support of indigent parents and, in some cases, medical and nursing home costs.  In 2012, a Pennsylvania appeals court found a son liable for his mother’s $93,000 nursing home bill under the state’s filial responsibility law.


Transferring assets to certain recipients will not trigger a period of Medicaid ineligibility. These exempt recipients include the following:

  • A spouse (or a transfer to anyone else as long as it is for the spouse’s benefit)
  • A trust for the sole benefit of a blind or disabled child
  • A trust for the sole benefit of a disabled individual under age 65 (even if the trust is for the benefit of the Medicaid applicant, under certain circumstances).

In addition, special exceptions apply to the transfer of a home. The Medicaid applicant’s home may be transferred to the individuals above, and the applicant also may freely transfer his or her home to the following individuals without incurring a transfer penalty:

  • A child who is under age 21
  • A child who is blind or disabled (the house does not have to be in a trust)
  • A sibling who has lived in the home during the year preceding the applicant’s institutionalization and who already holds an equity interest in the home
  • A “caretaker child,” who is defined as a child of the applicant who lived in the house for at least two years prior to the applicant’s institutionalization and who during that period provided care that allowed the applicant to avoid a nursing home stay.

Congress has created a very important escape hatch from the transfer penalty: the penalty will be “cured” if the transferred asset is returned in its entirety, or it will be reduced if the transferred asset is partially returned. However, some states are not permitting partial returns. Check with your elder law attorney.

New Rule May Make It Harder for Medicare Beneficiaries to Receive Home Care

October 8, 2019

It may become harder for Medicare beneficiaries to find home health care due to a new rule from the Centers for Medicare and Medicaid Services (CMS). Although the rule changes the way home health care providers are reimbursed, it could affect patient care as well.

Starting in January 2020, Medicare will reimburse home health agencies at a lower rate when they care for patients who have not been admitted to a hospital first. CMS estimates that it will pay home health agencies approximately 19 percent more for a patient who hires the home health agency directly after leaving a hospital than a patient who was never in the hospital or was only an outpatient.  (The Center for Medicare Advocacy calculates that the disparity could be as high as 25 percent.)

In part due to pressure from Medicare to reduce costly inpatient stays, hospitals often do not admit patients, but rather place them on observation status to determine whether they should be admitted. These patients, if not admitted to the hospital for at least three nights, are not eligible for Medicare reimbursement of a limited amount of skilled nursing care and typically head home instead to continue care with Medicare’s home health care benefit.

But a home health agency that cares for a patient who was in the hospital under observation will be reimbursed as if the patient had been an outpatient. This lower reimbursement rate means that home health agencies may be reluctant to provide care for patients who were under observation status or who haven’t been in a hospital at all.

If you are hospitalized, it is important to learn whether you are admitted or under observation. Hospitals are required to provide notice to patients if they are under observation for more than 24 hours.

For more information about the new rule from the Center for Medicare Advocacy, click here.

Medicare Prescription Drug Premium to Drop Slightly in 2020

October 8, 2019

courtesy of NAELA eBulletin:

Monthly charge for Part D enrollees will decline for third year in a row

En español | The average monthly premium for Medicare Part D prescription drug plans will decrease from $31.83 this year to $30 in 2020, the Centers for Medicare and Medicaid Services (CMS) announced late Tuesday. This is the third straight year that premiums will decline.

The actual amount beneficiaries will pay in 2020 will vary depending on which prescription drugs they take, what plan they select and where they live. How much participants will pay out of pocket for their drugs also depends on the deductibles and copays that different plans charge.

CMS officials say that the three years of declining monthly charges will add up to $1.9 billion saved in premium costs for beneficiaries. In addition, enrollment in Part D plans has grown by 12.2 percent since 2017, in keeping with increases in Medicare enrollment as the number of older adults has risen. Federal officials say they have made changes to the program that have increased competition among Part D plans, including requiring plans to provide more information about drug price increases, allowing generic drugs to be substituted for brand names more quickly, and changing certain rules that have expanded the number of plan options available to Part D enrollees.

Medicare open enrollment begins Oct. 15 and lasts through Dec. 7. During that period, beneficiaries can evaluate their current coverage and decide whether to keep their plans or enroll in different ones. Final Part D premiums as well as premiums and deductibles for the other parts of Medicare are typically released in the fall.

Medicare’s New Plan Finder Could Boost Insurers’ Advantage Enrollment

October 8, 2019

courtesy of NAELA eBulletin:
Bruce Japsen Senior Contributor

Myriad upgrades to the way seniors choose Medicare health plans and drug coverage online could boost already fast-growing private Medicare Advantage enrollment.

Calling the upgrades  the first in a decade, the Centers for Medicare & Medicaid Services (CMS)  Tuesday announced a new “Medicare Plan Finder” on the government’s web site that allows 60 million seniors and others with Medicare coverage to shop and compare Medicare Advantage and Medicare Part D drug plans.

“The new Plan Finder walks users through the Medicare Advantage and Part D enrollment process from start to finish and allows people to view and compare many of the supplemental benefits that Medicare Advantage plans offer,” CMS said in a  statement Tuesday morning.

CMS said seniors can compare pricing and plan options between original Medicare, supplemental policies and Medicare Advantage plans. And they can also “compare up to three drug plans or three Medicare Advantage plans side-by-side,” CMS said.

The upgrades will be welcome to seniors, but also to health insurance companies as they invest billions of dollars in their own upgrades and medical care provider networks to offer seniors private Medicare Advantage coverage.

“CMS’ Medicare Plan Finder redesign could boost Medicare Advantage enrollment by reducing the complexity of the purchase process,” says Andrew Kadar with L.E.K. Consulting, which has projected enrollment of seniors in private Medicare Advantage plans could reach 70% of those eligible for federal health benefits for the elderly between 2030 and 2040, a new report shows.

Enrollment in Medicare Advantage plans surpassed 22 million in 2018, which is 35% of total Medicare beneficiaries.

The new plan finder and related technology upgrades come ahead of annual open enrollment when seniors begin in October to choose their plans for 2020. The new plan finder also comes as health insurers including Anthem, CVS Health’s Aetna health insurance unit, Cigna, Humana and UnitedHealth Group are expanding sales of Medicare Advantage plans into new states, counties and regions. Meanwhile, several startups and new entrants including Bright Health and medical care provider plans are also expanding while some companies like Oscar Health, best known for sales of individual Obamacare coverage, are going to be selling Medicare Advantage for the first time.

Medicare Advantage plans provide extra benefits and services to seniors, such as disease management and nurse help hotlines, as well as some plans providing vision and dental care. But the Trump administration via CMS has changed the rules for Medicare Advantage plans to allow them to cover more supplemental health benefits beyond what Medicare Advantage typically covers.

Though open enrollment is more than a month away, CMS wants seniors and others to try out the plan finder and offer feedback in the meantime.

“We want consumers to have the best tool possible when open enrollment begins on October 15,” CMS Administrator Seema Verma said. “Try it out and let us know what you think.”

Agency did not conduct required oversight of program for those with disabilities

October 7, 2019

courtesy of NAELA eBulletin:
The Washington Post

August 14

Health and Human Services officials have failed to conduct required visits of independent living programs for thousands of people with intellectual and physical disabilities, the agency’s Office of the Inspector General found.

The Administration for Community Living, created within HHS in 2012, administers two independent living programs, which aim to help people with disabilities find housing services, job opportunities and other resources. By law, ACL must carry out compliance reviews of at least 15 percent of the programs that receive federal funding and in at least one-third of the states that receive the funding. The inspector general found ACL has not conducted such visits since it assumed oversight of the programs five years ago.

ACL said it could not conduct the reviews because of limited funds for travel. The office is given a set amount of funding to administer grants to independent living programs and monitor them, but OIG determined it did not set aside enough money to conduct its oversight activities.

“The problem is that these organizations, they’re not large. They’re serving beneficiaries that need a lot of services,” said Mike Barton, assistant regional inspector general for audit services. “These on-site visits would help to ensure the services are being provided, but it’s not being done.”

ACL contends it provides proper oversight through a program it piloted that monitors compliance activities, outcomes, fiscal operations and reports from the programs’ operations.

But disability advocates maintain that visits are critical to ensure the programs are not only operating most effectively, but adequately serving a diverse set of beneficiaries who rely on the services to live independently.

“You have to make sure that independent living programs are serving the full breadth of the disability community,” said Nicole Jorwic, senior director of public policy for the Arc, which advocates for people with intellectual and developmental disabilities.

OIG conducted its audit after receiving a hotline tip that ACL was not carrying out its oversight.

“Because current technology enables ACL to thoroughly review most program components, on-site reviews can be reserved for more complex situations or concerns that require physical inspection,” an ACL spokesperson said in a statement. “This cost-effective approach to monitoring allows us to focus resources on services that directly support people with disabilities.”