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Old 04-16-2011, 04:49 PM   #21
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My sympathies are with you as you, your family and your dad travel into the future. I can't give you more financial advice than you've already received, and can only say to be prepared for your relationship to change to you and your brother being the parents, while your dad becomes very childlike. Be patient with him. My mom died of Alzheimers in 2006.
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Old 04-16-2011, 05:29 PM   #22
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Ah, dementia is incidental to his hospitalization and discharge to a nursing facility.

Evidently the admissions specialist of the care facility doesn't expect Medicare to approve many days of care. There is no reason to 'save days' for coverage later.

Read page 14 & 15 of the following: http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf

Once things have settled down you and your brother may want to research hospice care. It may not be indicated yet but when it is indicated you may not be in any position to think this through.
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Old 04-16-2011, 06:14 PM   #23
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One idea I didn't notice in the posts so far is to send your brother a periodic statement of accounts.

I saw DW's father and uncles break off contact with each other due to suspicions, misunderstandings and assumptions. The situation changed over an extended time (grandma lived into her 90's). "I'm glad brother is taking care of the money" evolved into "I wonder what brother is doing with the money" to "I'm sure brother is raiding grandma's cookie jar". Nothing changed for the worse on the financial side during this time, but the brother managing the money didn't always keep his brothers up to date on balances, spending, etc.
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Old 04-16-2011, 07:51 PM   #24
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Ah, dementia is incidental to his hospitalization and discharge to a nursing facility.
Evidently the admissions specialist of the care facility doesn't expect Medicare to approve many days of care. There is no reason to 'save days' for coverage later.
Read page 14 & 15 of the following: http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf
Well, IMO the dementia led directly to the duodenal ulcer, but we're all treating the dementia as an incidental discovery after the surgeon saved his life.

Thanks for the PDF, I misinterpreted the care specialist's comments. I also have "Medicare for Dummies" on request at our local library. I hadn't intended to study up on this subject for at least another 14 years...

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Once things have settled down you and your brother may want to research hospice care. It may not be indicated yet but when it is indicated you may not be in any position to think this through.
Done that, along with a backup care facility that has a full Alzheimer's memory-care unit. I think it's worth keeping in touch with the care manager just to update that list. We're ready. At least I think I have the emotional distance to stay ready, and hopefully my brother can hang in there on the front lines.

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One idea I didn't notice in the posts so far is to send your brother a periodic statement of accounts.
It's early days yet for us, and I've been giving him the big picture, but not even to the level of detail in this thread. Right now he's genuinely not interested in the money aspect (as in "don't want to know") but I expect that to change over the upcoming years. However although he's petitioning for guardianship & conservatorship, I think I'll end up being the one who talks to the care facility and Hancock about the money.

I just put Dad's checking account online this morning. The bank's CD rates are, to put it politely, not quite in the same league as NFCU or PenFed or USAA. I don't plan to have Dad (or my brother) sign any more checks and I'll use Fidelity's online billpay instead of the bank (if they even offer billpay). I guess we'll be moving the checking account's balance back to Fidelity (which is not anything to crow about either) and only use the checking account as a drop box for his pension/SS.
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Old 04-26-2011, 06:56 PM   #25
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Dad's still happy with his care facility. He had given them his $50 cash to start his trust-fund account, so now I have the billing info to keep that topped off.

I think the Medicare "skilled nursing facility" care has ended and he's started the "long term care" phase. The care facility has his Medigap insurance info, which made the billing department very happy, and we're starting on the LTC policy claim.

It's interesting how an Alzheimer's "diagnosis" has taken root. When Dad walked into the hospital ER nearly two months ago, they called a gastrointestinal surgeon who became "Dad's doctor" for the next 11 days. During that time he'd visit once or twice a day for a 10-20 minute conversation. By the time I showed up to talk about vascular dementia, the GI surgeon had the opinion that it was Alzheimer's because both Dad's short-term and long-term memories are affected. (Yep, that's for sure.) That diagnosis went into the charts and it's been accepted as gospel by the rehab facility, which is happy to offer Alzheimer's care so long as Dad doesn't become a physical threat.

He wears an ID bracelet that includes a RFID chip. If he goes through an entrance the chip sets off a perimeter alarm. He's strolled the neighborhood in groups with the staff, and he says that if he tried it on his own he wouldn't be able to remember his way back. The staff would take him walking 2-3 times/day if he wanted. So as long as he's in conscious control of himself he's unlikely to wander.

I called John Hancock today to start the LTC claims process. A specialist is calling back in 3-5 business days to do the diligence. I think the care facility's doctor & nursing staff actually handle the "activities of daily living" questions, and thank goodness for that. The reality is that my father is more or less capable of bathing, dressing, and feeding himself-- for now. He can probably still cook and buy groceries and keep an apartment clean and even drive. He's just not capable of handling anything that requires analysis or memory or long-term thinking. It's especially dangerous if he has to remember whether he's taken his BP medication or has to remind himself that ulcer survivors shouldn't drink alcohol. I don't know if LTC includes some sort of blanket "Alzheimer's diagnosis" or if we'd have to refile the claim when the syndrome renders him incapable of handling enough ADLs.

The care facility is the ideal environment for him now. He reads the newspaper every morning. (I don't think it matters what newspaper or what date, or even if it's different from yesterday's paper.) He strolls the corridors all day having one conversation after another with everyone. (During his working days he probably used to "manage by walking around".) He's great with the nursing staff (he was married to an RN for over 25 years). Next morning he starts all over again, with pretty much the exact same conversations with the same people. He reads a paperback book every week, maybe even a different one. But he's happy.

I think it'll come down to my brother and the care facility parsing the policy's fine print until JH agrees with their assessment.

I suspect that my Dad's bank manager has busted me. He probably knows her personally in his small town. She noticed that his last dozen checks have been written out by me, and in the hospital his signature wasn't exactly what you'd call "firm". She left voicemail for him about a week ago and I finally got back to her. I explained the situation to her and she suggested that we "talk about adding signatures to the account". She didn't even bother asking to speak to him or how to reach him. They've probably seen this a gazillion times before-- elderly client, lets his bank balance drift up over a few years, suddenly the checks look different, suddenly he signs up for the website account and shuts off snail mail. However they got nothin' that would justify freezing the account, thus pissing off a customer who'd promptly close it, maybe even seriously inconveniencing a long-term client. They're getting the use of a nice chunk of cash while paying practically zero interest for it. And frankly, if they were the adult child in my shoes then they'd be doing pretty much the same thing.

But I have all his bills online now and will be using his Fidelity account to pay them. He's had his Fidelity account linked to that checking account for years, too, so I don't think the bank can object to ACH transfers initiated by Fidelity. When I'm back in his small town to shut down Dad's apartment, I'll stop by the bank to introduce myself and start whatever POA paperwork they feel comfortable with. I'd rather leave his pension & SS deposits continuing to go to the bank rather than trying to redirect them to another account.

Dad had an apartment lease through the rest of 2011, but the manager completely understands the situation and has also probably seen it a gazillion times before too. They'll let him out of the lease with just a note citing medical issues. I think we'll do that in June.

I'm interested in any suggestions for dealing with John Hancock or LTC in general, or any pitfalls for the unsuspecting. So far the care facility has treated us all wonderfully, and I suspect JH is too big to get picky with us.
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Old 04-26-2011, 11:36 PM   #26
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I had to deal with GE. As long as they received the paper work they needed they were cool. Now and again they needed a form from the care facility to verify that Mom/Dad were still alive and their ADLs were not significantly improved all was well. The CSRs were very competent and supportive when I contacted them although when the nursing home wasn't immediately responsive their system spit out threatening letters.

See if they will send both you and your brother copies of any letters they send. That way if you miss something your brother can backstop any issue. Also, since bro will be dealing with the facility he can walk his copy of the letter to their administrator.

It was an old LTC policy, at best Mom & Dad broke even, but all parties lived up to their commitments.
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Old 04-27-2011, 12:17 AM   #27
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See if they will send both you and your brother copies of any letters they send. That way if you miss something your brother can backstop any issue. Also, since bro will be dealing with the facility he can walk his copy of the letter to their administrator.
Good idea, thanks. I'd be thrilled if these guys would work through e-mail PDFs or even faxes to my eFax number. The care facility's billing rep was happy to get Dad's 34-page hospital records as a PDF. I guess she should be able to e-mail me their rate summary or spreadsheet.

That Medicare pub you recommended was a good read, too, when I went through it again with LTC in mind. The transition from "skilled nursing" to "custodial care" made sense, along with Medicare's limits. Maybe that's as complimentary as it gets with Medicare pubs.

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It was an old LTC policy, at best Mom & Dad broke even, but all parties lived up to their commitments.
I see this as Dad's winning lottery ticket. It not only pays for 2-3 years of care but lets that many more months of pension/SS accumulate in his accounts before the withdrawal faucet has to crank open.
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Old 05-03-2011, 09:59 AM   #28
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Hmm. If the care facility is happy with Medigap insurance then I'll have to ask them about Dad's Medco prescription plan for his blood pressure medication. I don't know how that's being handled because the hospital put him on their BP meds and then the care facility picked that up somehow when he transferred to their rehab. I guess the first issue would be to make sure that the care facility actually has him on some sort of BP meds in the first place.

After two phone calls to John Hancock, my skeptical cynicism is slowly giving way to cautious optimism. But it's early days yet.

The claims processor surprised me with a call the next morning. I guess they've seen the whole bell curve on these discussions and they're very good at handling the emotions as well as the info. They have their forms and their requirements but they try to do as much of that as possible between JH and the care facility while leaving the family alone unless absolutely necessary.

They also use contractors to periodically check up on Dad's condition. JH fusses about making sure the care facility provides the right doctor/nurse for the contractor to talk with so that there's no confusion over Dad's abilities. Apparently during earlier stages of Alzheimer's, especially with medication, there's occasionally enough improvement during rehab for the insurance company to declare the person "capable of independent living" and suspend payments. This just starts the appeals process but it might even result in having to leave the care facility. "Luckily" no one seems to think that Dad will ever be capable of living independently again. He had dementia symptoms as far back as Sep 2009 and lived independently at least one month longer than he should have. Not that we could persuade him to do it any other way.

JH asked for the care facility to fax them a Medicare "UB-04" form to establish the start date of the LTC policy's 100-day exclusion period. They'll do their verifications during this period so that they're ready to pay up starting the 101st day in late June. Medicare paid for the rehab, but I think Dad will be financially responsible for about 60 days of that 100.

Actually the insurance payments seem to be made in arrears. The issue is that the IRS allows a deduction if the insurance is paid after the expense is incurred. If it's paid beforehand then there's no tax benefit. So every month the care facility has to fax an invoice to JH for them to scan, process, and pay. JH is terrified of screwing up HIPAA, so they only work by snail mail and fax. No e-mail and certainly not a "secure" website for uploading scanned documents. Several admonishments to write the claim number & policy number at the top of every sheet of paper.

Dad bought the policy in Dec 1992. After the 100-day period it pays out $100/day up to $120K total coverage. He also bought a 5%/year inflation rider for 20 years. Now in 2011, after 100 days, Hancock will pay up to $240/day for a total benefits limit of $288,794. They're still researching whether the inflation rider continues to boost the benefit for the full 20 years or if it stops when the claim is made.

During the last 18 years Dad's paid about $610/year in premiums, ~$11K overall, but I don't those prices will ever be seen again. For some reason JH still wants him to pay the July semi-annual policy premium, but I'm not arguing.
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Old 05-03-2011, 10:32 AM   #29
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In most cases the policy provides that the policy premiums cease once the policy holder is receiving benefits. It may be that someone wants to make sure he doesn't loose coverage if he briefly 'recovers'. Find a copy of the policy to see what it says. If it does have a waiver of premium provision you can always request a rebate once he is on the acute slope and there is no question that he will not recover.

Even if he has some of his ADLs improve don't move him from the facility. The change of environment is very disruptive.

The care facilities in Oregon are required to use an institutional pharmacy. While in theory you can provide your own meds as a practical matter it is impossible. An institutional pharmacy dispenses in those bubble cards so it is easy for the facility to see whether or not a resident has received a med on time (and unused meds can be returned to the pharmacy). They also must comply with the script orders from the physician. Obtain a list of the meds he is currently using and verify with his regular physician that it is OK. Not all generics for a med behave the same so if a generic is prescribed ask for the name of the manufacturer. This is true for even over the counter medications (I have seen that even with Slo Niacin used by my husband). I have no medical credentials, just managing parents through many years of long term care. It is a balancing act assuring that the meds are helping as intended and not getting ripped off. In my experience health care pharmacy managers try to dodge medical reimbursement for patients in LTC if they can. I had to battle Blue Cross Basic once because they wouldn't approve an institutional pharmacy.. once I threatened to go to OPM they found a work-around.
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Old 05-03-2011, 12:56 PM   #30
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I admiited my mother to a lockdown alzheimer's assisted care unit. It had to be a lockdown unit because her mind was gone, but she was in great physical condition for an 86 year old woman and this is not a good combination. Her LTC policy by Conseco was paying most of her bill. The assisted care facility said I could buy and furnish her meds or they would, but all meds had to be in individual blister packs. I found this to be a problem, so I let them handle. Either way her Medigap policy paid for her meds. She suffered a kidney infection and had to go to a hospital. Her overall condition declined, never to improve, and she was admitted to a skilled nursing facility directly from the hospital. At first Medicare paid the nursing home. she received the maximum Medicare LTC benefit. I forget how long that was. However, after Medicare LTC ran out, I had to totally restart the process with her Conseco LTC policy. This was a major pain in the you-know-what. The daily rate at the nursing home was over twice the daily rate at the assisted care facility. Both the assisted care unit and the nursing home operated "banks" for the residents, But I did not open accounts because my mother could not deal with money from the first day. As I recall her main extra bill was from the beauty parlor.
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Old 05-03-2011, 01:20 PM   #31
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At first Medicare paid the nursing home. she received the maximum Medicare LTC benefit. I forget how long that was.
My mother got 100 days Medicare (+ supplemental) in a skilled nursing facility for physical therapy. I believe there is no Medicare LTC coverage.
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Old 05-03-2011, 01:58 PM   #32
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Medicare has an annual skilled nursing benefit after discharge from a hospital. The number of days is limited and even then it stops if the patient is not improving. For example, if the patent has had hip replacement surgery or repair of a broken bone the discharge to skilled nursing is for physical therapy. If the patient fails to participate in physical therapy or improvement stops medicare payments cease even if there are benefit days remaining.

It is often difficult to get dementia patients to participate in physical therapy, it hurts and takes a lot of effort.

Some of the older LTC policies paid only after the insured was hospitalized or was admitted to a nursing home within x number of days after hospitalization as a result of the reason for hospitalization. Some then re-set the waiting period even on re-admission. Also, they paid only if the facility is licenced as a nursing home, not an intermediate (convalescent) or assisted living facility.
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Old 05-03-2011, 02:33 PM   #33
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My mother got 100 days Medicare (+ supplemental) in a skilled nursing facility for physical therapy. I believe there is no Medicare LTC coverage.
Quoting from page 28 of "Medicare and You - 2011" "Skilled nursing facility care includes semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies that are medically necessary after a 3-day minimum inpatient hospital stay for a related illness or injury. an inpatient hospital stay begins the day you are formally admitted with a doctor's orders and doesn't include the day you're discharged. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn't cover long-term care or custodial care."

The doctors, hospitals, and nursing homes that I have worked with know Medicare very well and they know how to maximize patients' benefits.
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Old 05-03-2011, 03:46 PM   #34
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The care facilities in Oregon are required to use an institutional pharmacy. ...
Different state but that was I experienced with a parent.

That was another source of profit for the NH!
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Old 05-03-2011, 05:24 PM   #35
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The requirement of an institutional pharmacy became a HUGE barrier when my mother needed pain pills as she was dying.. on a holiday weekend. The hospice people couldn't understand why they couldn't (wouldn't) deliver them.
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Old 05-03-2011, 08:25 PM   #36
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In most cases the policy provides that the policy premiums cease once the policy holder is receiving benefits. It may be that someone wants to make sure he doesn't loose coverage if he briefly 'recovers'. Find a copy of the policy to see what it says. If it does have a waiver of premium provision you can always request a rebate once he is on the acute slope and there is no question that he will not recover.
I'll take a look at that. I'm wondering if they charge a monthly premium but only collect semi-annually, so if he starts benefits in July they want a premium for July-Dec paid in June because he's not "receiving benefits" yet. Luckily it costs me nothing to ask the question, especially if we can keep the 5% policy rider going through its 20-year term.

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Even if he has some of his ADLs improve don't move him from the facility. The change of environment is very disruptive.
No problem there. Dad really likes the place, and having to bring about the change of environment would be even more disruptive for my brother & me. We're keeping a geriatric care manager on standby just in case we someday get "the call" from the current facility that they can no longer care for Dad. I'm hoping that his RFID bracelet is good enough but I suspect that locked doors are the only guarantee.

I was all over the ADLs when I first read the policy, but the clause that really matters is "cognitive dysfunction". Of course he'll eventually lose the ADLs as well but he's currently OK on all of them. I just don't see how he could improve his cognition if the medications are not recommended for ulcer patients.

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The care facilities in Oregon are required to use an institutional pharmacy. While in theory you can provide your own meds as a practical matter it is impossible.
I think I'm going to get told that it's logistically impossible to use Medco-- even if it's cheaper-- unless the care facility is directly reimbursed by them. But I'm not trying to save nickels here, only to make sure that I don't blissfully ignore an unclaimed benefit.
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Old 05-31-2011, 12:54 AM   #37
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Dumb question for you elder-care experts: what should we put on Dad's change-of-address cards?

I have his mail forwarded to my Hawaii address for another few months under a "temporary" order. Everything that goes to his apartment now is going to me. However we expect to shut down his apartment in a few weeks, so I'm going to need to fill out permanent changes of address.

I have three choices of mailing addresses:
- The care facility he's at now and expects to be at for some months
- My brother's address (a few blocks away from the care facility)
- My address on Oahu

Dad doesn't want to be "bothered" by the mail anymore. My brother and I would prefer that everything come out here to me for further action. I don't expect Dad to get much mail once we shut down the apartment and the utilities, so most of his mail would be from Social Security, Medicare, insurance, his pension company, and the federal/state government. Whenever I can I'm going to sign up for online notification/websites and shut off the snail mail.

I suspect that the IRS, Social Security, Medicare, and the insurance company would raise an eyebrow if his address changed to Oahu. Maybe the pension company would care too. I know the state wants his actual physical location (he's already received a notification for jury duty). However I worry that something sent to the care facility would sit in a box for a week or two before someone got around to distributing it, or Dad would put it away in a drawer and forget about it.

How did you guys handle these questions?

Otherwise things are chugging along. My brother was told that one of Dad's medications wasn't on the insurance company's formulary, so it took a month for them to realize that and shift it to a different med. That bill went to my brother's mailing address (which I need to fix) and it looks like a $100 mistake on the facility's part. But it gives me a chance to ask the care facility about their progress on the long-term care claim paperwork and their "price list". Then I can follow up with John Hancock and find out if they have any issues with the LTC claim.
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Old 05-31-2011, 05:54 AM   #38
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It was easier for me to deal with my mother's mail because I lived about 10 miles away at the time. I just drove over once a week and went through it.

Given your reservations about the reliability of the care facility staff I'd say send it to your brother, assuming you can rely on him to open the mail, read it, and let you know of anything important.

Failing that, then I'd have it all sent to Oahu.
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Old 05-31-2011, 06:54 AM   #39
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Who has power of attorney? Your brother, if I recall? Assuming I remember right, I would have the mail sent to your brother's address. If we are talking a small amount of mail it should not be a big deal.
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Old 05-31-2011, 07:15 AM   #40
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I suspect that the IRS, Social Security, Medicare, and the insurance company would raise an eyebrow if his address changed to Oahu. Maybe the pension company would care too. I know the state wants his actual physical location (he's already received a notification for jury duty). However I worry that something sent to the care facility would sit in a box for a week or two before someone got around to distributing it, or Dad would put it away in a drawer and forget about it.

How did you guys handle these questions?
I doubt if any federal or private company scans and comments on where they think anybody should be living (hey, for family support, you could be living anywhere).

For my disabled (adult) "child", even though he lives in an apartment not near us, I keep his "legal address" as my address. I do this for a variety of reasons, such as SS communications (I'm his "representative payee" for his SSD, since the government will not allow him direct access to funds), along with items of which you mentioned, such as jury duty/summons info. For jury duty (both local & federal), it takes my involvement to supply the necessary info (a letter from his doctor) to confirm his inability to serve, and since he can't "communicate" on his own, he needs somebody to intervene (be it me while I'm alive, or his trust attorney after I'm gone). However the important thing to remember is that if I would have his "official address" moved to where he actually lives, these kinds of things would fall through the cracks.

We've already worked out with our (elder law) attorney that they will receive all mailings, assuming we pass before our son does; that's part of the trust arrangements we have already made.

It's quite simple (well, simple for me, since I've already done it). Have the mail sent to the address of the person who is/will be responsible for making the decisions, at the time of the mailing. That's all you need to do.

BTW, I still have my son's apartment utility bills sent to him at his apartment address. However, since I set it up for direct debit pay from his disability account, the bills will never be "past due", and I can still see the billing info on-line. However, things such as his car insurance is sent to my address (along with all vehicle registration/license renewals) to ensure that I can make sure they are paid (not by me, but from his accounts).

Anyway, I'm sure you can look at what I do currently when looking at your father's needs, along with the necessity to "manage" the info...
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