Asset management for nursing home care

[Sue J]

My 85 year old Dad is currently in rehab in a nursing home after breaking his hip. I thought it was going well enough but my sister is concerned that he may not be able to return home and live alone, even with part time home health care. I like to keep thinking positively and I'm hopeful that he will still improve yet I'm aware that she may know more than I do.

She has been discussing with him that he may need to stay in the nursing home longer than his insurance covered rehab period. If he moves out of rehab and stays there he will be paying for it himself. He has limited assets (maybe 18 to 24 months of private pay in the nursing home) and Social Security but he asked us to find out how he can make sure that some of his assets go to us before it's all used to pay for his care, whatever level he ends up at.

I'm reading up on Medicaid rules and it looks like they have it pretty much locked up in terms of transfer of assets. I'm aware of the Medicaid 5 year look back period and the penalty period involved.

My sister is disappointed that he didn't plan better and take care of things like this earlier. I'm just overwhelmed by the possibility of him not recovering enough to be able to go home.

She's going to see if we can meet with the lawyer that her husband used with his parents. I'd like to know enough so that I can ask the right questions.

For those of you who have been through this what do I need to know before meeting with the lawyer? I'm thinking that it's too late and we have no options and it's a done deal.

 

[Nords]

Boy, did you just rip the lid off a can o' worms. I'll try to type fast before the mods have to shut down the political & ethical commentary.

First, your instincts are correct. It's a done deal.

If you're going to [-]waste time[/-] meet with a lawyer, then I think you want one who will do two things: (1) review all your father's work history (including military service, even if it's "just" being drafted) for benefits eligibility (like the VA) and (2) help you file the Medicaid application.

Frankly I think you're far better off starting with a geriatric care manager who can do much of this legwork for you (for a much smaller hourly rate) and who then will be able to bring in a lawyer as needed. The geriatric care manager can also do many more things that a lawyer can't, including engaging your father (as an outside authority) in a discussion of his options in a way that will preserve his dignity and your family harmony.

Personally, ethics & politics aside, I think it's a waste of time paying legal fees for advice on subverting the system. My understanding of the Medicaid bureaucracy is that it takes six months or more for approval, so it's best to start early. The risk of a legal shenanigan getting you locked out of Medicaid is far worse than spending down his assets.

I watched my Dad live "independently" for nearly two years with Alzheimer's. IMO it's a lose-lose situation from social isolation and a lack of peer pressure to exercise, show up for proper meals, and generally stay active. I believe that on his own my father lacked stimulation, engagement, proper nutrition, and safety. I think that all but a very small percentage of elders who want to "go home" have ended up changing their minds when they see what a skilled nursing facility or care facility offers. My Dad had a real emotional moment of relief when he realized he didn't have to be responsible for chores anymore. He didn't feel as if he was giving up any independence or dignity on that front.

If your Dad "goes home" then it's quite possible that you'll be spending his assets down far faster than the care facility would spend them. You'll either be stitching together a revolving door of care providers (and home maintenance/repair staff) or running yourselves ragged with emergency response. And then what if he falls again? The cycle repeats itself.

Your care facility choices are much better when your Dad is still a "private pay" customer. When he's private pay, nobody will ask for a list of his assets (at least nobody has asked me). Once he's in a place that he likes, and when his assets drop below $100K, then you start the Medicaid process. The care facility can't kick him out for failure to continue private pay. They can kick him out for behavioral issues or extended hospitalization, but once he's in as a private pay then Medicaid is not grounds for discharge.

Your sister may have an overly rosy view of what Medicaid offers. Your Dad's concern (and your sister's) for preserving his assets may be misplaced. Sounds to me like your Dad is doing a fine job of managing his assets. He could've spent even more of his money paying the premiums on long-term care insurance and ended up with the same net worth at about the same time.

If you think there's any possibility of sibling discord then I strongly recommend reading Jane Gross' "A Bitter-Sweet Season" to learn more about the issues with family caring for a parent. My brother and I are getting along fine in caring for my Dad but I'm beginning to understand that his caregiver burnout could be a much greater issue than I realized. I'm taking notes and we have things to discuss sooner rather than later. If the book's not at your local library then at least try her blog (Jane Gross - The New Old Age Blog - NYTimes.com). It went dark about six months ago but the material is still (unfortunately) relevant. She's a bit of a drama queen on her own but she's also a professional journalist who digs up a lot of facts & figures (and good advice) from credible sources.

Would your sister feel better if you suggested finding a geriatric care manager first, and then going to their lawyer next? Or at least having a free consultation with the lawyer?

As for the lawyer, you could ask about:
- Fees
- How to screen your Dad's history for VA benefits or other options
- How to file for Medicaid, and whether you really need a lawyer to do so
- Recommendations on who to hire as a geriatric care manager. If the lawyer doesn't know (or doesn't want to recommend anyone) then run away fast.

 

[Ally]

Having been through a mom who died from Alzheimer's and a dad who lingered with cancer, I fully agree with everything Nordstrom said.

 

[Huston55]

Sue-

Sorry to hear about your Dad. I'm currently going thru almost the same thing with my Mom. I second almost everything Nords listed above, and will add a few things.

1. I don't known what state you live in but, they will have an Agency on Aging; contact them immediately via their website then talk to a counselor. In my state, they are a wealth of info and advice. Read their material and talk to them. They can walk you thru the Medicaid process, help you find care givers and facilities, geriatric counselors and lawyers.

2. My sister and I used a lawyer to start, and I think it was money well spent. I think it all depends on the lawyer; I found ours thru our state's Agency on Aging. My Mom was very thorough at getting necessary legal docs in place (will, POA, medical directive, DNR, etc). You need to ensure you have these ASAP. Our POA has been essential in allowing us (mostly my dear sis) to get done what's required hassle free. We used the lawyer to validate these docs and for other advice.

3. If your Dad did serve on active duty and during a period of war (defined by law and definitions available in the net), then he may qualify for additional financial assistance. The VA website will guide you.

4. I don't know if it's always the case that, once in a private pay nursing facility, they cannot turn your Dad away when he's broke and on Medicaid. In my state, it seems to be more variable. Suggest you check this out and use it as one screening criteria when selecting a facility.

5. Sound like you and your sister have differing concerns but, no discord. I think it's very important that the two of you (and everyone else actively involved in your Dad's care) work harmoniously together. Family fights will make a bad situation catastrophic.

All the best to you.

 

[donheff]

+1 on Nords' advice.

 

[Sue J]

Boy, did you just rip the lid off a can o' worms. I'll try to type fast before the mods have to shut down the political & ethical commentary.

First, your instincts are correct. It's a done deal.

That's what I thought. And as a taxpayer, the idea of looking for ways around it makes me feel creepy.

It's my sister who is pushing for ways for him to avoid using up his money. This influence is coming from her husband, who successfully managed both of his parents through lengthy and expensive end of life issues. But there was a much larger pot of money and a longer time frame. More than 5 years before his parents needed help they established a family partnership of some kind and that's what he wants us to look into. Both of his parents are gone now and there was still money left for the heirs. They never used Medicaid.

My sister's latest rant is that Dad retired too early! He didn't make enough money! He didn't invest right! He retired at 59.5 and started collecting SS at 62, living off his investment income and SS very successfully for over 25 years. He and my Mom were comfortable and secure and had a really good time traveling and doing things they enjoyed for many years until they got older and travel got too difficult. I think he retired at the perfect age.

Nords, I so appreciate all the advice. I'm going to copy and save it in my "Dad" folder. I think you're on your way to your next book.

Huston55,

Thanks for your comments.

Dad was well prepared with a will, Durable POA for Health Care and a Durable General POA for Personal Affairs. He is a veteran from WWII and I have his VA card.

My sister and I are very different personalities but we get along well. She's a drama queen and usually needs to be the center of attention. She tends to suck all the oxygen out of a room. But in this situation she has been very focused on Dad and his care. We both realize how different we are but appreciate how much we need each other after losing our brother in 2006. So far there have been no fights, just some tension as we adjust to Dad's new circumstances. Also, I tend to bristle and resist when my BIL tries to tell us what to do. I do respect him because he's dealt with his parents and he is very smart. This eldercare/rehab/nursing home/Medicaid issue is all new to me.

I will look into Agency on Aging and VA benefits.

 

[Sarah in SC]

Sue, I sympathize with you on the real issue, as you've identified, that you have to deal with very different family members on the whole can o' worms, and who have very different perspectives than your own.
All I can say is ++1 on Nords' commentary and try to remember, when dealing with sis and BIL, that the goal is for your dad to be comfortable and relatively happy in his remaining years, and to retain your relationships as best you can. All the other stuff is just a distraction from the goal.

 

[donheff]

Sounds like your Dad would be popular around here. My BIL's parents did something like what your BIL's parents did. They put their assets in some sort of irrevocable family trust that becomes controllable by the kids after 7 years. But your dad doesn't have enough assets to make something like that sensible and it is too late in any event. I hope everything works out well for your Dad.

 

[Brat]

+++ Nords advice.

Your sister is spinning on what might have been. She likely had one set of expectations and is now seeing another. You need to gently get her to focus on the situation at hand and the resources on hand.

There is the personality behind the curtain, her husband. Ask your sister how she wants to handle him to avoid conflict.

I am sure your parents wanted to leave a legacy for you and your sister, acknowledge your father's desire but start talking about family treasures - not treasury.

Contact the VA to learn what resources they have that he might use. Even if you think he wouldn't use their services start the process of getting him in their system. The process can take time, at least it did for my brother, so that should his needs change you won't be scrambling.

 

[Sue J]

Update -

We met with an estate planning and probate lawyer today at the nursing home with my Dad. The lawyer reviewed my Dad's will, Health Care POA and Durable General POA and said that it was all fine.

I came with a few questions, mostly about if there was anything we needed to do concerning my Mom's death. About the only thing that needs to be done is to take the death certificate to the county property recorder to take her name off of their condo survivorship deed and have it be in his name alone. Then the lawyer recommended that he add a TOD affidavit (transfer on death) to the deed naming my sister and I. Here's a link about that TOD Affidavits - OHIO'S NEW TRANSFER ON DEATH AFFIDAVIT Dad should also do that with other assets like his IRA beneficiary designation and bank accounts. He explained that if assets transfer to beneficiaries then they don't have to go through probate.

My sister asked about the assets vs. Medicaid question and the lawyer said that he does not deal in that area. She asked if anyone else in his practice does that and he said no, so she asked for a referral which he gave us. It was pretty much a closed topic and she was fine with that and understood why. Both of our husbands were there but let the two of us do most of the talking.

My DH was interested in all this regarding my Dad, but also his own mother who is 82 and widowed. He's pretty sure she has LTC insurance which my Dad does not.

Dad was there but just listened. Right now his mind is on his physical therapy and what's for dinner.

I'll update my other topic about him with an update on how he's doing.

 

[Huston55]

Update -

We met with an estate planning and probate lawyer today at the nursing home with my Dad. The lawyer reviewed my Dad's will, Health Care POA and Durable General POA and said that it was all fine.

I came with a few questions, mostly about if there was anything we needed to do concerning my Mom's death. About the only thing that needs to be done is to take the death certificate to the county property recorder to take her name off of their condo survivorship deed and have it be in his name alone. Then the lawyer recommended that he add a TOD affidavit (transfer on death) to the deed naming my sister and I. Here's a link about that TOD Affidavits - OHIO'S NEW TRANSFER ON DEATH AFFIDAVIT Dad should also do that with other assets like his IRA beneficiary designation and bank accounts. He explained that if assets transfer to beneficiaries then they don't have to go through probate.

My sister asked about the assets vs. Medicaid question and the lawyer said that he does not deal in that area. She asked if anyone else in his practice does that and he said no, so she asked for a referral which he gave us. It was pretty much a closed topic and she was fine with that and understood why. Both of our husbands were there but let the two of us do most of the talking.

My DH was interested in all this regarding my Dad, but also his own mother who is 82 and widowed. He's pretty sure she has LTC insurance which my Dad does not.

Dad was there but just listened. Right now his mind is on his physical therapy and what's for dinner.

I'll update my other topic about him with an update on how he's doing.

SJ-

Glad to see you taking the next steps. Sounds like you and your sister are working together, which is good. I would still recommend you contact your state's agency on aging.

On my front, my sister, BIL and I are still working to get Mom's house emptied and ready to rent. Mom is currently living with DS and BIL, with some additional home help.

 

[Moemg]

Sue, If your Dad does not have Alzheimer's or needs a lot of nursing care he may be able to return home with help . My Mom who is 95 lived independently with a cleaning lady & a home health aide who I paid for and was not expensive . I paid $18 an hour and the woman would do anything shop, take my Mom to the Doctor's , do laundry , basically anything she was asked .Mom also had a life alert in case she fell .Seniors do better at home until they are disoriented or need assisted living beyond basic .

 

[meierlde]

One question occurs, if the estate is small enough beneficiary designations can eliminate the need for probate. The TOD takes care of the real estate which is one of the issues that could require probate. If you consider medicaid, think about pre-paying for a funeral as well, generally that does not count towards the medicaid limits. (My aunt did not do this and ended up on medicaid, and finally because she was a WWII veteran the state paid for the funeral (Nebraska).) Since her daughter was on SSI otherwise it would have fallen to the neices and nephews to pay for the funeral. (She had a local guardian who took her assets (house) for a ride as well).

 

[Nords]

Then the lawyer recommended that he add a TOD affidavit (transfer on death) to the deed naming my sister and I. Here's a link about that TOD Affidavits - OHIO'S NEW TRANSFER ON DEATH AFFIDAVIT Dad should also do that with other assets like his IRA beneficiary designation and bank accounts. He explained that if assets transfer to beneficiaries then they don't have to go through probate.

When the court appoints me the conservatorship of my father's assets, I plan on doing TODs on all his financial accounts. (He doesn't own any real estate.) I don't know if TOD counts for anything during probate or with the financial institution, but it'll certainly make things clear.

 

[meierlde]

When the court appoints me the conservatorship of my father's assets, I plan on doing TODs on all his financial accounts. (He doesn't own any real estate.) I don't know if TOD counts for anything during probate or with the financial institution, but it'll certainly make things clear.

If you do tod's then no probate may be needed if there is little but personal items left to take care of. Many states have a minimum amount to bother with an opening an estate, allowing a simpler proceedure to be used (lower lawyer fees) . You would have to check the amount in the state in question, but unless there is some valuable personal property, I would doubt that probate would be needed, since the TODs override any will. In the case of the TOD just provide the death certificate and the task is done. So yes the TOD's override probate.

 

[Leon44]

Unfortunately I am dealing with the same situation and I did go to an attorney. I'm told we have to spend down my mother's asset to $2,400 before Medicaid will take over.

All this got me thinking about my estae planning. Particularly for long term care. I'm not sure if I have enough assets to be self insured or should pay the high premiums for coverage. If I go with insurance, what age should I start getting it. Still in my 50's.

I would be curious to see how other members are planning for themselves.....now that we had to deal with our parents.

Any thoughts on you own plan for nursing home care?

 

[REWahoo]

Leon, if you go up to the Google search box near the top of the page and plug in "LTC" you'll find dozens of threads discussing the pros and cons of long term care insurance, self insuring, and having the taxpayers pick up nursing home costs via Medicaid.