Geriatric financial management & asset allocations

[Brat]

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.

 

[Nords]

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.

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.

 

[Nords]

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.

 

[Brat]

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.

 

[JakeBrake]

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.

 

[GregLee]

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.

 

[Brat]

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.

 

[JakeBrake]

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.

 

[chinaco]

...
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!

 

[Brat]

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.

 

[Nords]

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.

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.

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.

 

[Nords]

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.

 

[Walt34]

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.

 

[brewer12345]

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.

 

[rescueme]

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...

 

[MichaelB]

A change of address to Hawaii raises a potential state tax liability or health care law regulation issues. The concern about the facility not forwarding promptly is legit. A change of address to the designated POA works best. Some financial institutions allow duplicate statements to be mailed to a different address, but not health care or gov't. Until he has a permanent address, I would use the brother with the POA.

 

[SteveL]

A few things no one has mentioned yet:
1) Safe Deposit Box....when I took over my FIL's affairs we looked in his box, and found several matured $5000 muni bonds. Took 9 months to collect via Schwab.
2) ADLs will continue to be important after the LTC runs out. The IRS allows medical deductions for care, but not for living expenses. Fortunately, the facility billed separately for the room and board.
3) Theft is an issue in all of these facilities. Not just money, but anything valuable can disappear. Jewelry, IPOD's etc.
4) To reaffirm one thing that was said earlier, as screwy as it seems, some states require a trustee or conservator to follow "Modern Portfolio Theory". In CA, this meant that we had to get an hourly CFA to write a letter with the AA included to put the file as a CYA and or submit if requested.

Alz. cannot be diagnosed at present without an autopsy. The fact that both long and short term memory are impacted might suggest another cause for the dementia. There are at least 7 known causes. This might be important because the progression is different.

Finally, it is important to have some doctor examining all the drugs and their interactions. My father was given some things that conflicted resulting in a temporary crazy spell during which he whacked a care giver. When the drug thing was fixed he was back to normal, but had a forever after "possible violent" label attached making finding a residence difficult.

 

[Dancer373]

Nords, I hope your father continues to be comfortable and I think you and your brother are doing a wonderful job of taking care of his affairs. Your dad is a lucky man to have sons like you!!

 

[Nords]

This is all going to work out eventually, but it's turning into a marathon instead of a 400-meter heat. I'd appreciate any advice from those who've had to work through the system with their loved ones.

John Hancock is grumbling about turning down the claim.

Three months ago when I filed the claim, I was given the number of supervisor "Mary" who explained the process. She advised calling her only when I had more than a basic question. So now when I call the 1-800 number I get claims service. As my questions are asked, I might get transferred to clinical services or policy services. Over the last month those "services" have started giving conflicting info or answers like "Gee, I don't know why this hasn't been approved". So I finally called Mary.

Last Friday Mary said that Hancock "might not be able" to approve the claim. She says a typical care center's Medicare code information provided on the claim form (UB-04) is usually fairly pessimistic, even dire. They want things to look as bad as possible so that Medicare will pay them. Yet Dad's UB-04 is not considered bad enough to cover three of the six ADLs. The "help" he gets bathing & dressing is more supervisory, not assistive.

The "minimum data set" (MDS, https://www.cms.gov/IdentifiableDataFiles/10_LongTermCareMinimumDataSetMDS.asp) and "mini-mental state exam" (MMSE, What is the Mini Mental Status Examination (MMSE) for Alzheimer’s Disease?) are two other claim forms. Again according to the first he isn't in bad enough shape, and according to the second his memory's too good. Part of the MMSE is giving the subject three words to remember. They're asked to recite them. A few minutes after that they're asked to recite them again. Dad got all three. For cognition to be considered "impaired", even getting two correct is borderline.

Yet from everything I read on the Internet, and from the time I spent with Dad in the hospital (admittedly not at his best), and from my brother's frequent visits, and even from a letter Dad surprisingly wrote us last week: his cognition is absolutely impaired. He can't "get through the day". Even if he was set up in another apartment with daily visitors, his nutrition and socialization would quickly go off a cliff-- again. If he left his lodgings then he wouldn't be able to find his way back. Even worse, he'd try to drive a vehicle. He spent nearly 30 years in a nuclear engineer's sales job, selling nuclear plants to utility companies by explaining very complex concepts to business people. He's disarmingly charming, polite, agreeable, and able to bluff his way through any conversation. It took our lawyer nearly 30 minutes to realize that (regrettably) Dad's not mentally capable of agreeing to a financial POA. The MMSE exam is superficial enough to assess most of the subjects, but in this case it's not detailed/long enough to really determine that Dad can't handle his affairs.

Mary says the claim hasn't been denied-- yet. She says that the tests are shortened versions of full-blown (expensive) tests, and the short versions don't always capture the full story. She said that Dad's declining weight could be interpreted as another symptom of impaired cognition. (It's a symptom, although researchers don't seem to understand why.) She said that if he's on certain medications (blood pressure?) then needing supervision to take them might indicate inability to handle another activity of daily living. So next week I'll be spending a few more hours on the phone querying the care facility on the trivia of ADLs and medications.

Mary said she'd ask her supervisor to pay for a more detailed onsite assessment, which is not normally approved. While she's doing that, she advised that we line up a neurologist (not "just" a psychologist) for a neuropsych evaluation.

Even if this drags out for another month or two, the good news is that Hancock will pay retroactive to the 100-day exclusion period (which ended 15 July). If Dad ends up in a hospital for some other crisis, though, that kicks off another round of Medicare eligibility which would be followed by skilled nursing rehab and another 100-day exclusion period. At $214/day, these expenses add up.

I'm concerned that Hancock doesn't seem to have a clear-cut end to the claims process. If this does drag out for another month or two with no definitive answer, then I don't want to be accused of not properly submitting a claim or not processing it quickly enough. I guess I'd rather have a faster "Sorry, no" followed by a statement of what needs to happen before it can be resubmitted, plus an explanation of the appeals process. But I suspect I'll get that "Sorry, no" answer within the next couple weeks.

So I called our geriatric care manager for a neurology appointment and alerted my brother that he might have to drive Dad to the appointment. (Which upsets Dad like a young child getting lost at the shopping mall.) I asked our lawyer to hustle up on the guardianship/conservatorship petition and her own psychologist's mini-mental state exam (part of the petition). And while we're waiting, I guess we're also going to pay another month or two of long-term care expenses out of Dad's assets.

Ironically, Hancock's policy-services call center affirmed that the policy's 20-year 5% inflation rider is still accruing for another 18 months. (Or until the claim starts paying out.) So for every month that they won't pay their current $240/day limit, it rises by another daily buck or so. Yet the claims supervisor says that the onsite assessment is usually considered too expensive to be approved. I pointed out this financial inconsistency and was told that the medical criteria are considered more important than the financial ones. Riiiight.

Mary said that Hancock administers thousands of policies, from dozens of companies bought by Hancock over the years, with many different forms of coverage. She said that I wouldn't always get consistent or correct answers from the call center. I said that sort of advice would just encourage me to call only her from now on.

Frankly (even without the long-term care insurance) Dad's pension, SS, and savings will probably last longer than he does. But it's disheartening to have the finish line jerked out from under your feet-- and to be told that he's going to have to pony up more thousands of bucks to "prove" what you already know.

 

[Brat]

Do you have a copy of your Dad's LTC policy? If not, get one.

Make a list of the requirements for benefits and original date of the policy.

My recollection is that your father lives in CO and probably purchased the policy in CO. Call the CO Insurance Commissioner's office for information on their expectations of time-frames for response from Hancock. You might ask them also for any regulations that define 'assistance' with ADLs.

Send a letter to Hancock asking them, based on those contractual requirements, which ones your father meets or hasn't met based on documentation they have received. I would give them a reasonable drop-dead date to respond that lines up with state requirements. Start developing a paper trail.

With that you know what documentation you might need to resolve this matter.

My parent's policy was with GE but it was old and didn't pay out much. Maybe that is why they didn't give us grief when applying for benefits.

 

[MichaelB]

The lack of a denial is telling. It sounds like Hancock does have a clear cut goal - this is one way an organization says "no" without saying "no". They probably do have thousands of different policies, but that's not your problem, regardless of how hard they try to make it so. Most financial institutions are not subject to penalties for this type of behaviour, and there are people that give up and walk away.

You might contact the facility administration where your father is to discuss this with them. A face to face meeting usually works, perhaps your brother can arrange one with your help which you can then follow up on by phone. Ask what experience they have with Hancock that may apply to your situation. There is no doubt this is an issue they deal with (probably frequently) and unless there is something specific in his policy that is unique, they should be able to tell you if it covers his care now. In fact, if it were clearly a problem they probably would have let you know when he was first admitted. Even if his coverage is not clear cut, they may help to find a way to reassess so that he meets the required criteria. The people in the administrative office probably know exactly what is needed to qualify and the physician overseeing his care should be able to assist.

If the facility supports your claim, escalating within Hancock may be required. If there is a claims window deadline, a letter documenting the contacts so far is advisable just to establish that timelines have been met.

 

[brewer12345]

Definately contact the state insurance department and get what information you can. I would also find out how you go about filing an official complaint with the department so that you know how to make it stick if it comes to that.

 

[Dreamer]

My office manager said that her DH had to contact a lawyer, when her MIL's LTC was denied. It was approved then.

Some one should file to be Representative Payee for his social security benefits. If something as simple as a letter is returned, his SSA record will be put in suspense (checks stopped).

Good luck with everything and I agree that your father is lucky to have such caring sons.

 

[Nords]

I'm starting all those steps this week, especially if they drag their feet on the independent assessment. It's possible that Hancock will come up with a better answer when they have time to talk amongst themselves.

The claims staff need to understand what type of advocate they're dealing with. I suspect that they get a lot of overworked, stressed-out people who haven't had the time to educate themselves and are just trying to juggle family responsibilities. OTOH I have plenty of time and a fair amount of financial resources to devote to this. Eventually some CPA is going to look at the ammunition piled up on both sides of the situation and realize that approving the claim is cheaper than litigation.

 

[clifp]

Eventually some CPA is going to look at the ammunition piled up on both sides of the situation and realize that approving the claim is cheaper than litigation.

When I was helping to sort out my grandfathers estate (My grandmother, with dementia, was swindled by the former trust officer of the Church that handled the estate) I used a similar tactic. I one point I mentioned that I was retired, independently wealthy, and my best friend was litigation attorney. It got a bit of attention, although ultimately we ended up hiring attorney and suing.


Best of luck.