Geriatric financial management & asset allocations

[Nords]

Great thread for anyone who is starting down this track. Things are very well covered here and your Blog is most appreciated and well written. I would add a couple of issues that did not get mentioned.

Thanks-- I'm working on a blog post that will go up sometime in the coming months. I'll add your comments to the list!

 

[Brat]

I concur with Safe Harbor's points 2 & 3.

However, (there are always 'howevers') the quality of care can change over time, particularly when there is a change of managers. What is now a locally owned and managed facility can be sold to someone who doesn't have the same standards. ALWAYS review Medicare's nursing home reports of skilled nursing facilities. Don't be influenced by pretty buildings.

 

[MBAustin]

Excellent thread, thanks for all the updates. I hope never to be in this difficult of a situation with my mother or DH's father, but it's good to know where to find some practical "been there" information.

 

[chinaco]

When my mother started having problems (but was still in reasonably good health), I made an appointment with an attorney and we got her will updated, created the POAs for finance and health and living will.

So when I needed to step in and help... that was taken care of.

 

[chinaco]

Nords.


You did uncover a situation that many LTCi owners have not contemplated. If the health problem is related to dimentia, families may be in a waiting period before they can utilize the insurance due to how they would qualify for benefits.

 

[DangerMouse]

We are going through something similar with MIL at this time and have to say it has been a nightmare.

MIL will not give either child POA or allow them to be listed on her financial accounts as she is of the mind that everyone wants what is hers. This is so ridiculous as both her children have only ever given rather than taken. However, I think doing so threatens her as she believes she is sharper than what she is.

It sure does make things much harder than they need be.

 

[Col. Klink]

Great Thread

Great thread for anyone who is starting down this track. Things are very well covered here and your Blog is most appreciated and well written. I would add a couple of issues that did not get mentioned.

1. Nords father had no IRA but if your parent does don't forget (especially the first year) to make the RMD on time or the penalties are huge!

2. Don't let your parent continue to get mail directly in a situation with dementia. They are prone to mail fraud and will pay anything that looks like a bill.

3. Get your parent in a progressive care facility as soon as possible. They may likely require this and it is disturbing for them to be moved to a new facility because the old one can't handle them. Make sure the facility has skilled nursing as they will likely someday need it.

4. Don't plan for dementia to progress to death in 5 years. Some dementias patients go on for decades. As was said earlier Alzheimer's can only be diagnosed after death and there are many forms of dementia.

5. Make financial arrangements when your parent is still capable. For me a POA and joint accounts have worked well.

6. Getting your parents LTC to pay is only the start of the battle. It will require month by month diligence and effort to get the checks.

It's not easy getting old! But it's better than the alternative.

This has been a terrific thread, that I only found today. I found Safe Harbour's advice as quoted to be right on target. I am the administrator of a nursing home that focuses on care of persons with end stage dementia, the comments that I am reading are the realities we deal with daily with our families. It is heartbreaking to watch the decline and death of a loved one. However, a person with ALZ or vascular dementia is not in pain (unless there are comorbidities) and many enjoy their life in the NH taking part in activities and living for the activity and the day. Toward the end, palliative care is provided to residents that are in pain and, if desired, hospice or pastoral care offered to families.

I do have a point #6 to add to Safe Harbour's list. #6 keep track of the NH residents net worth and insurance. When the net worth declines to $50,000, it is time to begin the application process for Medicaid with the State Department of Social Services. This is a really good time to use the services of an eldercare attorney if you have not done so already. Finally, #7 - don"t attempt to transfer assets to other family members or trusts. There is a five year federal look back period that imposes significant penalities for doing so, and at least here in CT., they catch people doing it all the time.

One last point regarding Brats comment of using Nursing Home Compare to check out the quality of a nursing home. NH Compare is an attempt to make nursing home selection simple by using a five star system based on state survey results. Nursing home selection, particularly for those afflicted with ALZ or other dementias is far from simple. State survey agency results vary widely from state to state, and even the best facilities can have an incident triggering a bad survey (and vice versa). Visit the nursing homes, ask to meet the Director of Nursing or Medical Director, Administrator, Therapeutic Rec Director, and Dietary Director. Also, ask your doctor as he or she may be an attending physician at local nursing homes. Finally, support the Alzheimers Association by attending classes, support groups, and fundraisers in your state.

 

[chinaco]

We are going through something similar with MIL at this time and have to say it has been a nightmare.

MIL will not give either child POA or allow them to be listed on her financial accounts as she is of the mind that everyone wants what is hers. This is so ridiculous as both her children have only ever given rather than taken. However, I think doing so threatens her as she believes she is sharper than what she is.

It sure does make things much harder than they need be.

She could get the POA documents ready and not distribute them to her children... and retain control of the documents so they will be available if a crisis occurs.

If not, when the time comes (if it does) they will probably have to do it through the court.... get guardianship, which is more complicated (IMO).

 

[DangerMouse]

She could get the POA documents ready and not distribute them to her children... and retain control of the documents so they will be available if a crisis occurs.

If not, when the time comes (if it does) they will probably have to do it through the court.... get guardianship, which is more complicated (IMO).

Things operate a bit differently in Oz where MIL is resident. When the time comes, if she has not allocated a POA the court will appoint a guardian from the Public Trustee, it will not be a family member. What that will mean is all control will be lost over finances, every decision that needs to be made will be made by someone operating on a commission basis.

 

[Sue J]

Thanks for going into so much detail, Nords. I'm taking notes as my parents are 85 and 83 and still living in their own apartment.

I've asked my Dad if he needs any help and he says they are fine so far. He still drives and they go out every day. I think he feels that if he slows down he will lose all momentum and get stagnant and homebound.

I recently asked if he still handles all his finances and he said he writes checks and mails all the bills and manages his investments with his accountant overseeing what he does. I think he was glad that I asked.

They updated their wills 5 years ago when my brother died and I know they have living wills.

Looks like the next step should be POAs. My dad could handle everything if my mom became incapacitated but she could not handle anything if something happened to him.

 

[Nords]

Thanks, and I have a question plus a comment.

I am the administrator of a nursing home that focuses on care of persons with end stage dementia, the comments that I am reading are the realities we deal with daily with our families. It is heartbreaking to watch the decline and death of a loved one.

You have the most credibility I've read about on this board so far (in addition to the posters who've gone through this with their families). I've read through a couple dozen Alzheimer's & dementia websites, and I'm having a hard time figuring out the signposts & timelines from mid-stage on. Most of them seem to take refuge in generalities and broad time ranges. Many of them are so vague as to be useless.

I know there are concerns about liabilities & legalities, as well as protecting feelings, but I'd rather have low expectations based on good data so that I can be relieved instead of unpleasantly/abruptly surprised. Is there a website that'll present a more clinical, perhaps even harsh, factual chronology? I'm looking for a more specific, even technical/detailed, list of symptoms that a family could use as a guideline... such as "If your loved one is showing X symptoms then Y will probably occur within the following Z months." I'd also like to know how other medical conditions (chronic high blood pressure, repaired duodenal ulcer, poor/weak physical condition) affect the symptoms & timeline. Short of sitting down with a geriatric nurse or doctor, is there any other way to read up on this? I don't mind calling a local nurse who'd discuss it with me, but I'd rather be ready to have a conversation with her instead of a tutorial.

One last point regarding Brats comment of using Nursing Home Compare to check out the quality of a nursing home. NH Compare is an attempt to make nursing home selection simple by using a five star system based on state survey results. Nursing home selection, particularly for those afflicted with ALZ or other dementias is far from simple. State survey agency results vary widely from state to state, and even the best facilities can have an incident triggering a bad survey (and vice versa). Visit the nursing homes, ask to meet the Director of Nursing or Medical Director, Administrator, Therapeutic Rec Director, and Dietary Director. Also, ask your doctor as he or she may be an attending physician at local nursing homes.

This sounds great-- in theory and with advance prep time. Even if I'd devoted my ER time to studying the facility choices, it would have been for an event that wasn't likely to occur for another 12-18 months. When it finally happened, it turned out we were looking in the wrong location anyway.

For example, my father's city has 10 facilities ranked at 4-5 stars (out of five). Visiting 10 of them, and talking with 30-40 people, is unlikely to happen. (I don't think I visited that many condos with my first realtor.) If your loved one is in the surgical recovery ward of the hospital, and the discharge coordinator is calling you for the third time that morning, then a more likely number for visits & discussions is "zero". You're going to go with the first 4/5 star place to have an available bed, whether that's AAAA Best Care Facility or ZZZZ Not Actually Indicted, Inc.

My Dad's case involved a 250-mile transfer. The town hospital's discharge coordinator had no idea, so she literally printed out the Internet website list of the city's facilities and handed them to me. I passed them to our town geriatric care manager (roughly $100/hour) who phoned her network counterpart in the city for an extended discussion (at another $100/hour). By the time we were done we'd narrowed the list down to four places, the city care manager had set up my brother for a tour (and explained to him how to understand what he was seeing), and made sure the facility was really ready to receive.

If I was doing this again, hopefully with a year or two of advance warning, my first call would be to a geriatric care manager in my chosen city. I'd ask for a short list of 4-5 star facilities and tour three of them, hoping to have my parent's name on their files. Then when it was time I'd call back the care manager for an update, pick a place, and get the move started.

 

[old woman]

My mom got tired of taking care of herself. She put my brother on all of her accounts years ago. She never was big on financial stuff but dad forced her to deal with things before he died. Then she kinda forgot that CDs send you a notice when it is time to renew so she didn't want CDs because she might forget. My brother offered to remind her, she got arthritis and so had him make out checks for her and he was a signer on her accounts so could sign them.

She still has her check book and makes choices but lives at my brother's house now. Her rent covers all food and they provide laundry service and housekeeping so she doesn't have to do anything. She loves it like when she wanted to take us all to dinner she just told him to pay with her credit card so she didn't have to do anything.

I have been doing her taxes almost 25 years, I do electronic filing so she doesn't even need to sign the return.

Now interest rates are too low and my brother talked her in to going to Edward Jones. I am not sure I agree but he is doing the daily care of mom and is honest so I won't have an opinion.

She is 84 and taking life easy. She even gave up driving so just asks when she wants to go somewhere.

She signed a POA and gave me a copy, she wanted one because her boyfriend got one for his son.

Her mom died 4 years ago after fighting her daughters every attempt to help her so mom is giving control to us entirely. She said if we think she needs assisted living let her know and she will go.

 

[Col. Klink]

Stages of Alzheimers

Nords: The following websites are useful to learn about the progression of Alzheimer's Disease:

www.alz.org/stages

www.alzinfo.org/clinical-stages-of-alzheimers

I also recommend (and use for training and with support groups) the following emmy award winning documentary from produced by PBS:

The Forgetting - A Portrait of Alzheimers

Information about the show is at www.pbs.org/theforgetting/about/index.html

Getting in touch with your states chapter of the Alzheimer's Association is one of the best moves anyone caring for someone with ALZ can make. They can tell you about NH's that are actually taking a holistic approach to working with people having the disease as opposed to simply having a "locked Alzheimer's unit".

Kind regards, Klink

 

[kcowan]

Is this thread a sticky yet? I don't need the info until I qualify!

 

[Brat]

If an elderly adult is facing surgery or is getting frail I think family should start looking at care facilities in advance of need. As Nord mentioned most of us are scrambling just before patent discharge to find a long term care facility. I have been in that situation and it wasn't fun. My other issue with surgeons is that they don't prepare the patient for the possibility that they may need to recover in a skilled nursing facility for a while.

 

[Nords]

Thanks for the websites. I'll give those a look later tonight.

My other issue with surgeons is that they don't prepare the patient for the possibility that they may need to recover in a skilled nursing facility for a while.

I give Dad's surgeon a lot of credit for pulling his patented "I'm the doctor" act and telling him that he'd only be discharged to a skilled nursing facility. He said that returning home was not an option. Up until that point Dad had out-resisted both us sons and the geriatric care manager.

Two weeks into the SNF, Dad decided he never wanted to leave. He actually started agitating at us to get rid of his stuff and shut down his apartment.

Today I finished changing addresses. USPS has the blanket COA to my Hawaii address, of course, and I changed Dad's Social Security address to my brother's house. (Which is right by the care facility.) That will also take care of Medicare. The IRS and the state will wait until next year's tax returns (both for my brother's house), and the DMV won't need to care since Dad's not driving any more. Credit card addresses were changed online a few months ago.

I was able to do his pension servicing company over the phone-- the deposits still go to his checking account, but now the 1099s will come to me.

After that I flung caution to the winds and did both the Fidelity & Vanguard mailing address changes (online). Everything is still delivered electronically so those fund companies don't seem to care.

Now I'm waiting for various lawyers, psychologists, and property managers to get back to me. I think that can keep waiting until next week when my brother's back from his vacation.

 

[Nords]

Nords: The following websites are useful to learn about the progression of Alzheimer's Disease:
www.alz.org/stages

www.alzinfo.org/clinical-stages-of-alzheimers

Thanks-- the clinical stages page at Alz.org (Alzheimer's Association - Stages) is a good summary, and the tax brochure (http://www.alz.org/national/documents/brochure_taxes.pdf) will make that a lot easier to sort through.

The clinical stages page at AlzInfo.org was particularly detailed, and I appreciated seeing the most detailed time estimates yet.

 

[Nords]

I paid the psychologist's office another $1670 this morning (total cost $3670) and got the report this afternoon (12 pages, or a bit over $300/page at $250/hour).

This is the exam required by state law to determine the need for guardianship & conservatorship. I'm hoping to also use a copy to push John Hancock into approving the long-term care insurance claim.

The doctor spent nearly three hours interviewing Dad and having Dad demonstrate his ability to do things. Dad could remember his age and that he grew up on a farm and that he'd been married to Mom and that he had sources of income. He remembers his sons and sort of what we do and where we live. He couldn't remember when Mom died, where he'd lived before (as in five months ago), how long he'd been at the care facility, what kind of electrical/nuclear engineering work he'd done, or what kinds of income or investments he had. He doesn't remember anything about being hospitalized for the ulcer (which is probably a good thing to forget). The doctor must have been recording the interview because he wrote that Dad said things like "I get lost trying to remember beyond today and I don't remember where I lived before coming here", "A critical thing I need to tell you-- I seem to be normal, but I can't remember from one day to the rest and that bothers me and it's the reason I'm here-- and I'm very comfortable here", "My memory is not sharp and that's my biggest problem and has made me feel helpless; almost to tears". Then the doctor wrote "And he did have tears."

I'm not familiar with all the testing acronyms, but the doctor determined that Dad's senses and motor function are OK. However he can no longer remember the date to put on a check, balance a checkbook, recall a hypothetical doctor's appointment 10 minutes after being told about it, remember a five-item grocery list, or explain why he's receiving Social Security. He couldn't figure out how to dial 911 if he felt chest pains or who to call if the electricity goes out. He's forgotten basic first-aid skills and doesn't remember his medication times. He couldn't figure out how to get a cab or ride a bus.

Dad said he was "stumped" by the doctor asking him to discuss the statement "I look forward to tomorrow".

Dad's performance on "Independent Living Skills" was "low range". That assessment covers "memory/orientation", "managing money", "managing home/transportation", "health & safety", and "social adjustment". His score on the last section was "moderate" and all the others were "low". A low score means that he's "significantly impaired" and only capable of "dependent living". The doctor specifically said "he requires assistance in all of the areas of activities of daily living". Assistance in any three ADLs is a trigger for the insurance claim.

Dad's score on the first section of the mini-mental state exam was 17 out of 30, indicating "significant cognitive impairment". Anything below 23 is cognitive dysfunction. On the second section ("story memory") he got 4 out of 25. On the third section ("processing speed") he got 7 out of 35. The last two sections reflect "significant impairment in learning new information and in the processing speed of incidental learning".

My brother filled out a "Behavioral and Psychological Assessment of Dementia" form indicating how Dad's behavior has changed over the last five months. It uses behavior scores from "Never" to "Very Frequently" for at least 78 different behaviors from "appears fatigued" and "easily overwhelmed by changes in routine" to "screams or makes loud noises" or "urinates or soils on floor or furniture". The most significant changes were "does not recognize family members", "complains excessively", "states feeling helpless", "shows loss of pleasure in usual activities", "repeats statements and questions over and over again", "walks about aimlessly", "lost weight", and "sleeps excessively".

The doctor also quoted extensively from a biography I'd written to help him determine when Dad was bluffing and when he was telling the facts. As the doctor noted, Dad makes a great first impression.

The doctor concluded that Dad is an "incapacitated person" and "unable to manage property & business affairs". He recommended appointing an unlimited guardian and an unlimited conservator.

Our lawyer said "I believe it should help considerably with the LTC insurance application as well." She says she'll file the petitions next week.

I'll fax the report over to John Hancock. This should give them all they need to cover their assets and stop wasting everyone's time arguing over the details. I sure hope we're in the home stretch.

 

[Brat]

Before you send it to LTC folks: would he write a separate report addressing the ADLs if you sent him a copy of your Dad's policy? "Unable to manage property & business affairs" doesn't address what they are looking for.

 

[W2R]

Nords, I am so sorry. It's got to hurt to see this in black and white. Getting the test done was a necessary step, and it looks like it has been completed successfully, but it has to be so hard on you. When everything is done, maybe you can take it easy on yourself for a while and give yourself some time to handle the impact of seeing a statement like this.

 

[chinaco]

This discussion got me thinking about our LTCi policies.... It has been years since I looked at the details of it. So I dug one out of the files to look at the qualification...

For benefit qualification it states:

In order to receive benefits, you must first be assessed by an assessor and confirmed as having a chronic illness or disability. A chronic illness or disability is one which there is:

1) A loss of the ability to perform, without substantial assistance, at least two activities of daily living. The loss must be expected to continue for 90 day. Activities of daily living are bathing, dressing, eating, toileting, and transferring.

Or

2) A severe cognitive impairment which requires substantial supervision to you from threats to health or safety.

...

then it goes into more detail about the process to get coverage and an appeals process.

That second qualifier on the safety part... is a pretty low hurdle for anyone with dementia.... even in the earlier stages. Staying at home alone and perhaps starting a fire by not turning off the stove or any number of things... or walking out of the home and wandering off.


If your father's policy has that type of wording in the qualification terms... I think you will get approved.

If the courts say he is not capable... and approve guardianship... you have even more independent opinion and proof.


People need to carefully inspect the contract for the rules to qualify. Dementia is becoming very common because people are living longer. It would be terrible to spend all that money on an LTC policy and still wind up spending huge amounts of money out of pocket. Frankly, I can't remember how much I scrutinize that part of it. We bought those quite a while back. My education on the system (with my parents) and really looking closely at how our LTC (in the US) system works... occurred after we purchased the policies.

I wonder if that is common language in most contract now days.

 

[Safe Harbour]

Chinaco, This is common language, with the required number of activities of daily living being either 2 or 3. The wording I think most important to check is where the benefit will be paid. Some policies still say "Nursing Home". This rules out an assisted living facility or at home. That's kind of a nasty surprise for some people.

 

[chinaco]

Chinaco, This is common language, with the required number of activities of daily living being either 2 or 3. The wording I think most important to check is where the benefit will be paid. Some policies still say "Nursing Home". This rules out an assisted living facility or at home. That's kind of a nasty surprise for some people.

I have heard some older policies are not as flexible.

Our policy covers alternatives to NH... at a reduced rate (e.g home health care, day care, assisted living). It actually covers quite few things I would not have considered.

I hope and pray I will never need it.

 

[Nords]

Before you send it to LTC folks: would he write a separate report addressing the ADLs if you sent him a copy of your Dad's policy? "Unable to manage property & business affairs" doesn't address what they are looking for.

The claims processor's last offer (on 15 July) was to ask her boss for permission to do an onsite assessment of my Dad... a more detailed one than the care facility's MDS/MMSE. I've heard nothing from the claims processor since she said she'd take this step.

If our version of Hancock's onsite assessment doesn't meet their standards, then for a fee I'm pretty sure the ($250/hour) psychologist and the ($275/hour) lawyer would be happy to help.

I'm hoping that my ($0/hour) time on the phone with the claims processor will be a triumph of logic & persistence over bureaucracy. Otherwise they're gonna spend far more than the claim's $318K value in its defense.

I'm beginning to think that John Hancock may be holding all the money, but they certainly seem to be in the minority for common sense. Maybe they're using the wrong definitions for ADLs. By their criteria a household pet would not qualify for long-term care because the pet is capable of eating & toileting and requires no assistance with those ADLs. However left to its own devices and without the assistance that provides the food & toilet facilities, we wouldn't think that the pet had a very good life.

Hancock has other "bureaucracy" issues that make BofA look like Berkshire Hathaway. For example, the doctor's office e-mailed me the report as a PDF. They did so after I'd signed a HIPAA permission form and then they didn't worry about Dad's patient info going through an unencrypted e-mail system.

Not so for John Hancock, who only operates by fax.

I've never owned a fax machine and I don't think I ever will. I can't remember the last time I had to dial out on my fax modem, but it's been at least two years because that's when my desktop "upgrade" from WinXP to Vista removed my fax capability. Last year I did an entire PenFed mortgage refi, with nearly two dozen attachments adding up to over 100 pages, via e-mail & scanned PDFs. My SSN was splashed all over unsecure e-mail. But then PenFed's just concerned about ID theft, not patient privacy.

John Hancock does not do e-mail because of HIPAA concerns. I don't even have any e-mail addresses for their people because they don't hand them out and they've only corresponded by phone/snail mail. But Dad's psychologist report has to go to Hancock and I figured a fax would be faster than snail-mail. (I was wrong.) So a couple days ago I upgraded my eFax account to transmit as well as receive ($16.95/month), figuring that a month's fees for one fax would be cheaper than going the "buy a fax or have OfficeMax send it" route. I have yet to try to "downgrade" my eFax service when I'm done with faxing-- I don't even know if it can be done.

Let's say that you want to send a document to someone at Hancock. A few decades ago you would've sent it by snail mail. In the 1980s if you were in a real hurry then you might've upgraded to FedEx (if you had that person's actual address and not just the corporate mail room). Up through the 1990s a fax was your best bet.

I sent a fax to Hancock on Thursday night. The processor called Friday to say that she wouldn't see it for a week and to give me her "personal" fax number so that I could send it again.

Here's what happens when you "fax" someone at Hancock:
1. You print out the PDF.
2. You annotate each page of the PDF with the loved one's full name, policy number, claim number, SSN, and DOB.
3. You re-scan the PDF (with your annotated data).
4. You log in to your eFax account, fill out their HTML form for a cover sheet, and upload your PDF.
5. An hour later eFax tells you the number's still busy. You re-send at 8:30 PM HST (2:30 AM in Boston) and finally get it through.
6. eFax converts your HTML & PDF to the equivalent fax tones and sends them to what must be Hancock's sole fax machine.
7. A minimum-wage employee takes each sheet out of the fax machine and... scans them into a PDF. For all I know, Hancock's fax machine is actually in Bangalore or Hanoi.
8. The PDF is (hopefully) filed under the right claim number and is uploaded to Hancock's "secure" computer network for the staff's use. Apparently this takes about a week. I coulda used a snail-mail stamp for that result.

Or... you get that employee's personal fax number and repeat steps 1-6.

Hancock does not allow employees to permit us to sign a HIPAA waiver.

Hopefully this claims processor will call back Monday with an update. If they're not inclined to approve the claim then I think I'll pay the lawyer to handle the appeals process. I'm pretty sure the lawyer has a fax machine. At $275/hour I bet it's a nice one.

Nords, I am so sorry. It's got to hurt to see this in black and white. Getting the test done was a necessary step, and it looks like it has been completed successfully, but it has to be so hard on you. When everything is done, maybe you can take it easy on yourself for a while and give yourself some time to handle the impact of seeing a statement like this.

I think the worst part for Dad right now is knowing that he can't remember. Cruel irony that it's one of the few things he can remember. Maybe in a few months that won't be a problem any more.

The "good" news is that he appears to have total faith in us sons (even though he doesn't recognize me) to handle his affairs.

I should point out that my sympathy lies with this memory loss happening to anyone ("Flowers for Algernon"), but not so much with my father in particular. I'm probably carrying enough baggage for an entire squad of skycaps, but my father spent the last 25 years turning himself into a hermit at the expense of ties to family (particularly his only grandchild), friends, and acquaintances. "Giving up" his independence by keeping an updated POA file would have cost him a few notary fees. Doing it this way is over $6000 so far and no end in sight.

My spouse is joint, JTWROS, and/or POD on everything we own or control. Accounts, web addresses, logins, and passwords are all on hand in a passworded file. If I woke up incapacitated tomorrow she'd be able to open that file folder (it's her password) and carry on within an hour. My brother's my only other living relative, and if he someday ends up living alone and wants this sort of backup then he knows the rules.

 

[nwsteve]

John Hancock does not do e-mail because of HIPAA concerns. I don't even have any e-mail addresses for their people because they don't hand them out and they've only corresponded by phone/snail mail. But Dad's psychologist report has to go to Hancock and I figured a fax would be faster than snail-mail. (I was wrong.) So a couple days ago I upgraded my eFax account to transmit as well as receive ($16.95/month), figuring that a month's fees for one fax would be cheaper than going the "buy a fax or have OfficeMax send it" route. I have yet to try to "downgrade" my eFax service when I'm done with faxing-- I don't even know if it can be done

Nords
Another option to consider, if you need to deliver multiple page docs is to look at the USPS Priority Mail with return receipt request. You get timely (not sure what the parameters are from the islands but on Mainland, it is 3 business days) delivery PLUS absolute confirmation of dated receipt.

I appreciate the time you have devoted to sharing your experiences with JH. It certainly adds another critical variable to the whole LTC debate of do I or don't I. It more like if I do, will they ever pay and if so who is going to make sure!
Thanks again
Nwsteve