Setting up an ABLE Account and New Legislation
Q. Our son, Isaiah, has high-functioning Autism Spectrum Disorder, and we are thrilled to say that he was recently accepted into trade school. I heard from a friend at work about the ABLE Act. I don’t know much about it, but I’ve heard it may be something that can help my son with his education expenses without jeopardizing any other government benefits for which he may be eligible. However, the accounts are currently limited to $14,000 in deposits per year. Has there been any talk about increasing that amount, and can you tell me more about the guidelines to open an ABLE Account? Thanks!
A. The Achieving a Better Life Experience Act, or ABLE Act, enables people with disabilities to establish special accounts where they can save up to $100,000 without jeopardizing SSI and other Medicaid benefits. What makes these accounts unique is that Medicaid eligibility is not affected by any level of funds accrued in the accounts.
Similar to 529 college savings accounts, ABLE accounts are offered through state-sponsored programs. Initially, the law required savers to open an account in the state where they lived, but legislation approved in 2015 changed that rule, so consumers can choose a plan sponsored by any state. That means they can open an account as soon as any state offers one and will have a variety of investment options, just as participants in the 529 college plans do. Currently, Nebraska, Ohio, and Tennessee have programs available and at least a dozen more state programs (including Virginia) are expected before the end of the year.
New Legislation Being Considered to Increase ABLE Account Deposit Amount Limits
As mentioned above, yearly contributions to ABLE accounts are capped at the annual gift-tax exclusion — $14,000 for now — and can grow to $100,000 without putting SSI benefits at risk. If the account exceeds the total cap, SSI benefits would be suspended until the balance is spent down. That would change under legislation known as the ABLE to Work Act that’s now headed before the full Senate.
The ABLE to Work Act calls for people with disabilities who are employed to be allowed to save their earnings up to the federal poverty level — currently $11,770 for a single person — in their ABLE accounts above and beyond the existing cap, nearly doubling their annual savings allowance.
A separate measure that also won committee approval — the ABLE Financial Planning Act — would allow families to rollover money saved for an individual with a disability in a 529 college savings plan to an ABLE account.
A third tweak to the ABLE Act, that would allow people with a disability that onsets by age 46 to qualify for an account, has not yet been considered. At present, the ABLE Act only applies to those with a disability that occurs before turning age 26.
Setting Up an ABLE Account
In Virginia, ABLE savings trust accounts will be administered by the Virginia College Savings Plan to facilitate the saving of private funds for paying the qualified disability expenses of certain disabled individuals. Again, these accounts will not be available in Virginia until the end of 2016. To take advantage of ABLE accounts offered through programs in other states in the meantime, these are some guidelines:
● Age limitation: The ABLE Act limits eligibility to individuals with significant disabilities with an age of onset of disability prior to 26 years of age.
● What ABLE accounts can be used for: ABLE accounts can assist individuals and families in saving and paying for the education, housing, transportation, employment training, support, assistive technology, personal support services, health, prevention and wellness, financial management, administrative services, and other expenses.
● Exclusion from taxable income (federal): Earnings on contributions to ABLE accounts are exempt from federal income tax.
● Exclusion from taxable income (state): Earnings on contributions to ABLE accounts will also be excluded from Virginia taxable income.
● Account Size Limits: If the assets in an ABLE account reach $100,000 and the beneficiary is receiving SSI benefits, monthly SSI benefits will be placed in suspension. If the assets in the ABLE account drop back below $100,000, the SSI cash benefits resume. No re-application is necessary.
● Rollovers: As more states adopt and implement the accounts, you can always roll the assets from your current account over to a new state plan.
● Number of accounts: Beneficiaries can have only one ABLE account. This is a key difference from college 529 plans. Therefore, friends and relatives will need to pool their contributions into one account with contributions not exceeding the annual limit.
● Qualifying disability expenses: A “qualified disability expense” is any cost related to the designated beneficiary as a result of living with a disability. This may include education, housing, transportation, employment training, support services, health care expenses and even administrative services that help improve the health, independence and quality of life of the beneficiary.
● Choosing a state: Look for low internal expenses and ongoing costs, good investment options with minimal fees and commissions and determine what the account minimums are to set up an account.
Medicaid Eligibility
A beneficiary will not lose eligibility for Medicaid based on the assets held in the ABLE account, even during the time that SSI benefits are suspended (as described above for an account with over $100,000). However, under the ABLE Act, when the qualified beneficiary dies (or if he/she is no longer disabled), any remaining assets in the ABLE Account are used to “pay back” any state Medicaid plan up to the value of Medicaid services provided to the beneficiary. The payback is calculated based on amounts paid by Medicaid after the creation of the ABLE Account. This is a MAJOR drawback for most families who might otherwise want to fund a Special Needs Trust without giving up the right to allow other family members to ultimately benefit from any remaining assets. The National Academy of Elder Law Attorneys is fighting to ensure that the best parts of the ABLE legislation are preserved while proposing amending the Medicaid payback requirement.
Why a Special Needs Trust is Still Recommended
Unlike an ABLE Account, assets remaining in a properly established Third Party Special Needs Trust are not recoverable by Medicaid at the time of the beneficiary’s death if the trust was funded using the assets of a parent or other third party. This allows the creator to provide for a secondary beneficiary. Therefore, an ABLE account should NOT be used as a substitute for a Third Party Special Needs Trust, but rather only a limited substitute for a First Party Special Needs Trust. A special needs trust is recommended to protect a disabled individual’s financial future. Also known as Supplemental Needs Trusts, this type of trust preserves legal eligibility for federal and state benefits by keeping assets out of the disabled person’s name while still allowing those assets to be used to benefit the person with special needs. Read more here.
Special Needs Planning
Aside from changes to the ABLE Act, the U.S. House of Representatives approved separate legislation this month impacting savings options for those with disabilities. The Special Needs Trust Fairness and Medicaid Improvement Act would allow people with disabilities to establish their own first party special needs trusts. Under existing law, individuals must rely on other family members or petition a court in order to save money through a trust regardless of their own abilities.
“This is a fundamental issue of equal protection under the law for those who are facing life-changing disease or disability,” said U.S. Rep. Glenn Thompson, R-Pa., who sponsored the bill. Similar legislation passed the Senate last year, but due to some changes, the bill approved by the House will now return to the Senate.
Since The Special Needs Trust Fairness and Medicaid Improvement Act has not been enacted yet, it is vitally important for parents to take the right steps to ensure their child will be financially secure and cared for in the event of death or disability of the parent, including:
◾Hiring an attorney who is experienced in creating special needs trusts, such as myself;
◾Clearly spelling out your wishes for the disbursement of trust funds within the trust document;
◾Finding someone you can trust that has your child’s best interests at heart to serve as trustee and/or
◾Hiring an institutional trustee that has a reputation for utilizing social workers and case managers to monitor the welfare of beneficiaries and determine how trust funds should be spent.
This month is National Special Needs Law Month. When it comes to special needs planning, The Law Firm of Evan H. Farr, P.C. can guide you through this process. If you have a loved one with special needs, call one of our offices to make an appointment for a no-cost consultation:
Fairfax Special Needs Attorney: 703-691-1888
Fredericksburg Special Needs Attorney: 540-479-1435
Rockville Special Needs Attorney: 301-519-8041
DC Special Needs Attorney: 202-587-2797
Critter Corner: Federal Initiatives for Autism
Dear Commander Bun Bun,
My son has Autism Spectrum Disorder. I know there are lots of private initiatives out there to raise money and awareness. What I don’t know is whether there are any federal initiatives that may be in progress. Are you aware of any?
Thanks!
Ina Sheatives
—
Dear Ina,
On the Autism Speaks Website, they have details on some of the current federal initiatives for autism. Below are highlights about them:
Medical Research and Innovation: H.R. 6 (The Century Cures Act)
H.R. 6 received broad bipartisan approval in the U.S. House
● It would establish an $8.75 billion fund for the NIH to support biomedical research to accelerate the discovery, development and delivery of new treatments for all, including those with autism.
● It would direct the NIH Director to require those whose research is fully funded by NIH to share their data and would help organize collaborative research through a clinical trial data system.
● It would also require the Food and Drug Administration (FDA) to incorporate patient experience into regulatory decision-making.
● It also requires the FDA to advance the development of personalized medicine, which holds promise for individuals diagnosed with autism.
The U.S. Senate is considering companion legislation which has already received approval from the Senate Health, Education, Labor and Pensions Committee (HELP).
Safety and Wandering Prevention S.2614/H.R. 4919 (Kevin and Avonte’s Law)
The legislation has already been passed in the U.S. Senate and is now being considered by the U.S. House of Representatives.
● The legislation would reauthorize the expired Missing Alzheimer’s Disease Patient Alert Program and include new provisions to support people with autism.
● It would help families locate missing loved ones who have autism or other conditions that may cause them to wander.
● It would allow Justice Department grants to be used by law enforcement agencies and nonprofits for education and training programs to prevent wandering.
Support Family Caregivers S. 1719 and H.R. 3099, also known as the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act
The RAISE Act has already been approved by the U.S. Senate and is currently being considered by the House of Representatives.
● It would direct the US Secretary of Health and Human Services to develop and implement a National Family Caregiving Strategy to support family caregivers, including the many who support individuals with autism.
For more federal initiatives for autism, visit the Autism Speaks website.
Hop this helps!
Commander Bun Bun
What Happens to a Surviving Spouse’s Social Security Benefits After the Death of His/Her Spouse?
By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Elder Care Attorney
What happens to Social Security benefits when someone dies? Specifically I am talking about the entitlements of a surviving spouse.
These benefits are commonly referred to as survivor benefits. Other family members, such as disabled children (provided the disability began before age 22), may be entitled to survivor benefits but this post will focus on the surviving spouse.
Generally, the surviving spouse is entitled to 100% of the deceased spouse’s Social Security benefit provided it is greater than his/her own benefit. In other words, the surviving spouse will receive either his/her own benefit or the deceased spouse’s benefit, whichever is great, but not both. The surviving spouse will also receive a one-time death benefit payment of $255.
Additionally, the surviving spouse must be age 60 or older or 50 or older provided he/she is disabled from a disability that began no later than 7 years after the deceased spouse’s death. The surviving spouse must have been married to the deceased spouse at least 9 months and is not currently remarried where the marriage occurred before he/she turned age 60.
An ex-spouse may also collect survivor benefits under certain circumstances. The ex-spouse must have been married to the deceased ex-spouse at least 10 years. The age 60 or age 50 with a disability requirements are the same as the married surviving spouse. Finally, the ex-spouse must not be remarried in a marriage that occurred before age 60.
To discuss your NJ Elder Care matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing consultations if you are unable to come to our office.
How Does Medicaid Treat Your Grandchild’s 529 College & Education Plan?
By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Medicaid Attorney
Our office prepares and files many, many Medicaid applications each year throughout all 21 counties of our state. We routinely go over the assets a client has left to spend down. That’s when we sometimes find that a parent/grandparent has set up a 529 plan(s) for grandchildren. “Do we have to spend the money in these accounts on Dad’s care before qualifying for Medicaid”, we are asked.
529 plans are college savings plans named after the section of the federal law that establishes them. These plans allow a parent, grandparent – or really anyone – to transfer money into an investment account which is established for the benefit of a child, to be used for that child’s college expenses.
There are gift and estate tax advantages to these plans. Individuals may make contributions of up to $14,000 per person per year to a 529 plan. The gift and tax laws will allow a person to accelerate contributions so that he/she can contribute as much as $70,000 in one year for each beneficiary. This contribution will be considered as having been made over a 5 year period so that no gift tax will be triggered.
The advantage is that these contributions and the growth of these account(s) are removed from the estate for estate tax purposes. But, as I have stated so many times to clients and prospects, don’t confuse the gift and estate tax laws with the Medicaid rules. The outcomes can be very different. 529 plans are another example of that.
So, is a 529 plan a countable asset subject to Medicaid’s spend down rules? As with most things Medicaid related the answer is a bit complicated.
While the value of a 529 plan is removed from the contributor’s estate for estate and gift tax purposes, the owner and custodian of the account still has the ability to revoke it and pull the assets back and therein lies the problem for Medicaid.
If the applicant is the owner and custodian then he/she has not made a transfer of assets out of his name for Medicaid purposes. The money in those 529 plans is countable and must be spend down. That means the money must be spent for the person’s needs and not his/her granddaughter’s education.
On the other hand, if he/she sets up the account(s) but names someone else – an adult daughter for example – as the owner and custodian then he or she has no control over the accounts. The daughter may be able to revoke them but the applicant cannot. In that case, for Medicaid purposes, he made a transfer for less than fair value. So is he then “out of the woods”? Possibly but we need to know more.
The next question is when did he/she make the contributions to the accounts? If any were made in the last 5 years, they would be subject to Medicaid’s 5 year look back and would result in a Medicaid penalty.
In each individual case we need to examine how the 529 plan works and who the account owner and custodian are. As with any Medicaid questions there isn’t a “one size fits all” answer.
To discuss your NJ Medicaid matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing consultations if you are unable to come to our office.
Seniors balk and Social Security backs off text messaging requirement
By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Elder Care Attorney
It’s good to keep up with the times, but the Social Security Administration (SSA) found itself too far in front of many people it serves.
Seeking to enhance online protections, the agency required “my Social Security” account holders to use a password sent to them via text message.
That was a problem for some older folks who don’t text message and don’t plan to.
“Who’s the youngster who dreamed up the idea of text messaging for senior citizens,” Franklin, 73, and Janice Moses, 70, of Arlington, asked in an email to the Federal Insider.
SSA officials got the message, not sent by text, and reversed course. Text messaging is no longer required.
“Our aggressive implementation inconvenienced or restricted access to some of our account holders,” said Mark Hinkle, an SSA spokesman. “We are listening to the public’s concerns and are responding by temporarily rolling back this mandate. As before July 30 (when the text messaging requirement began), current account holders will be able to access their secure account using only their username and password.”
Text messaging remains an authentication option and the agency continues to “highly recommend the extra security” it provides, but it is not mandatory. SSA is developing an alternative method that will be available within six months.
Sen. Susan Collins (R-Maine), chairwoman of the Senate Special Committee on Aging, praised the agency’s decision. “I was troubled that the policy would have placed a high burden on seniors, many of whom do not own a cell phone,” Collins said in a statement released Monday. “While the Social Security Administration should develop ways to enhance security to prevent fraud, they must take into account the needs of seniors and ensure that they have easy access to their accounts.”
On Friday, she and Sen. Claire McCaskill (Mo.), the committee’s top Democrat, sent a letter to Carolyn W. Colvin, SSA’s acting commissioner, that said the agency’s security concerns must be balanced with a realistic understanding of its clients.
“According to a 2014 study from Pew Research Center, almost a quarter of people age 65 and older in the United States do not have a cell phone,” they wrote.
Perhaps more to the point, that report, based on 2013 data, indicated just 18 percent of the seniors used smartphones, which are better equipped for texting.
“In addition, a significant number of Americans lack access to reliable cell phone service,” the senators added. “On top of both of those factors, many disabled and older Americans receiving Social Security are not as technologically savvy as other segments of the population.”
But don’t think old folks are the only ones technologically challenged. That also applies to SSA’s cyber systems.
The agency’s website showed a notice on Aug. 2 that “due to high volume of traffic, users may have experienced problems receiving security codes,” Collins and McCaskill said in the letter. “The identification methods effectively locks users out of their own accounts and could prevent them from accessing necessary information or making important account changes.”
Rep. Elijah E. Cummings (D-Md.) blamed Republicans for SSA’s outdated cyber system, as he noted the 81st anniversary, Aug. 14, of the date President Franklin D. Roosevelt signed the Social Security Act of 1935. It created the program that eventually serves almost all Americans.
“Senseless budget cuts have already resulted in extended wait times for seniors calling Social Security’s 800 number, reduced operating hours at the field offices visited by more than 40 million Americans annually, and delays that are averaging more than 500 days for the more than one million Americans waiting for adjudicative hearings,” he said in a statement. “Underfunding the Social Security Administration has also affected the agency’s efforts to modernize its 40-year-old IT infrastructure and address evolving cyber risks.”
To discuss your NJ Elder Care matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing consultations if you are unable to come to our office.
Veterans May Have a Higher Risk of Getting Alzheimer’s
Currently, 1 in 9 Americans over the age of 65 (44 million people worldwide) live with Alzheimer’s disease. These numbers are staggering! Even more startling, is research cited in the Los Angeles Times that reveals that veterans with Post Traumatic Stress Disorder (PTSD) are 60% more likely to develop Alzheimer’s or a late form of dementia. In addition, the study found that those who developed dementia also tended to develop it about two years earlier than veterans who hadn’t had brain injuries.
The study, which is featured in the journal “Neurology” and supported by the U.S. Department of Defense and the National Institutes of Health, involved 188,784 veterans aged 55 and older who were free of dementia at the study’s start. Their average age was 68. All had visited a V.A. hospital when the study began, and again about nine years later. They were given tests to look for signs of dementia and assessed for other mental health and medical problems. Of the veterans, 1,229 had suffered a traumatic brain injury, or TBI, during service. During the study’s nine-year follow-up period, 196, or 16 percent, developed Alzheimer’s or another form of dementia. In comparison, about 10% of those without a brain injury were given a dementia diagnosis.
Additional findings:
• Veterans who had had brain injuries were 60% more likely to develop dementia than those without a brain injury.
•Many of the veterans who had had traumatic brain injuries (TBI) never developed dementia. And some of those who had never had a serious brain injury developed dementia. But overall, veterans with TBI tended to develop dementia about two years earlier (around age 78) than those without a TBI.
•The researchers controlled for factors like diabetes, high blood pressure, depression and alcohol abuse, all of which can increase dementia risk.
•The researchers also found that the risk of dementia was higher in veterans with TBI who also had depression, post-traumatic stress disorder or blood vessel disease than in those with either TBI or these other conditions alone.
•Alzheimer’s researchers have become concerned that brain injuries, possibly even mild to moderate concussions, can cause brain inflammation that then triggers the development of Alzheimer’s in those who may already be at increased risk of the disease.
•The findings show a correlation between brain injury and Alzheimer’s; however, they cannot prove a cause and effect relationship.
Another study found that Veterans who have experienced PTSD are twice as likely as those without PTSD to develop dementia.
Veterans: Be Proactive and Protect Yourself
With risk factors increased to such a degree, it’s important that Veterans know how to protect themselves and their loved ones when it comes to Alzheimer’s disease. Here are a few tips to keep in mind:
•Know what constitutes a “senior moment” and what doesn’t. As we age, many of us experience brief bouts of forgetfulness or confusion. Forgetting an appointment here and there may not be a problem, but if forgetfulness disrupts your day-to-day life or if you experience “confusion with time or place,” it’s possible your senior moments indicate something more serious. If you’re experiencing these warning signs, or if you notice them in a loved one, don’t hesitate to see a doctor.
•Make brain health a priority. If you are at a higher risk for developing Alzheimer’s (if your relatives had or have the disease or if you are a veteran who had a TBI or has PTSD), know that the disease isn’t inevitable. When you take steps to nurture your brain health, you may be able to delay the disease or, at the very least, slow its progress. These are six things you can do to help you maintain your brain health:
1. Regular exercise
2. Healthy diet
3. Mental stimulation
4. Quality sleep
5. Stress management
6. An active social life
•Know and Claim Your Well- Earned Benefits. Depending on the level of care needed, the costs of managing one’s Alzheimer’s can be quite expensive. As a veteran, you may be eligible for certain benefits through VA, including some provisions for home-based primary care, nursing home services, and more. The VA program has a little known benefit called Aid and Attendance and Housebound Improved Pension that can be especially helpful in paying for in-home care.
Nearly 69% of veterans are unaware of the benefits available to them, meaning that veterans are paying more for senior care services than they should. Additionally, more than 1/3 of Americans over the age of 65 are wartime veterans or the spouses of wartime veterans, qualifying them for Aid & Attendance.
This Special Pension program provides benefits that can reduce the cost of care for veterans and surviving spouses who require assisted living services. The program can provide up to:
Single sick Veteran ~ $21,466 per year / $1,788 per month
Healthy Veteran with sick spouse ~ $16,851 per year / $1,404 per month
Married sick Veteran ~ $25,448 per year / $2,120 per month
Married, Both Veterans sick ~ $34,050 per year / $2,837 per month
Surviving Spouse – $13,794 per year / $1,149 per month
Are You or Your Loved One a Veteran?
If you or a loved one is a US veteran or the spouse of a veteran, you may be eligible for this Special Pension program and you could potentially save yourself hundreds of thousands of dollars.
Here at the Farr Law Firm, we work with veterans and their spouses to evaluate whether they qualify for this Special Pension program and/or Medicaid, and we deal with all the paperwork. As an Accredited Attorney with the U.S. Dept. of Veterans Affairs and Certified Elder Law Attorney, I understand both the Veterans Special Pension program and the Medicaid program and the interaction between both benefit programs. Please call us to make an appointment for a no-cost initial consultation:
Fairfax Veteran’s Attorney: 703-691-1888
Fredericksburg Veteran’s Attorney: 540-479-143
Rockville Veteran’s Attorney: 301-519-8041
DC Veteran’s Attorney: 202-587-2797
P.S. Another benefit of being a veteran is a 10% discount off all services at the Farr Law Firm. We hope to see your family soon!
Critter Corner: Who Are the Oldest Living Man, Woman, and Pet Bunny?
Dear Commander Bun Bun,
I have read that it has become more common for people to live to be over 100. I am just curious — do you know who the oldest living man and woman are, what they say their secret is, and who the world’s oldest pet bunny is? Thank for your research!
Al Duss-Twanns
—-
Dear Al,
Mbah Gotho, an Indonesian man, was born on December 31, 1870, according to the date of birth on his identity card. Indonesian officials at the local record office have confirmed Mr. Gotho’s birth date is genuine; however there is no independent, third-party verification of his claimed age, which is required to be recognized by the Guinness World Records. If it is true, it would make him a staggering 145 years old—and the oldest living man in recorded history!
Nevertheless, Mr. Gotho has outlived all 10 of his siblings, four wives, and even his children. His nearest living relatives are grandchildren, great grandchildren, and great-great grandchildren.
One of Mr Gotho’s grandsons said his grandfather has been preparing for his death ever since he was 122. In 1992 (24 years ago) he even bought a burial site close to the graves of his children.
Mr Gotho spends most of his time sitting and listening to the radio because his eyesight is too poor to watch television. He has had to be spoon-fed and bathed for the past three months as he has become increasingly frail. When asked what his secret to longevity is, Mr Gotho replied: “The recipe is just patience.”
The oldest living woman is Emma Morano, an Italian supercentenarian who is, at the age of 116 years, 298 days, one of the ten verified oldest people ever. When she received the news about being the oldest, she said “My word, I’m as old as the hills,” a caregiver confirmed.
Ms. Morano now lives in a small lakeside town near the Switzerland border, still in her own one-bedroom home. Doctors make house calls, but for a 116-year-old, her health is good.
As a teenager, a doctor told her to eat raw eggs for her anemia, and so she has every day since, according to a New York Times profile in 2015. She also eats minced meat and pasta daily.
According to Morano, leaving an unhappy marriage also helped her live so long. She separated from her husband in 1938 and never remarried. She kept busy working at a factory and then as a cook, and didn’t retire until she was 75 — 41 years ago.
Her physician, Carlo Bava, credits Morano’s longevity to genetics, but also to her emotional balance. “She is always very serene,” Bava said, “The beauty of Emma is that it is normal that she smiles, but also in difficulties, she is very decisive.”
As far as pet bunnies go, Hazel, a 16-year-old miniature grey rabbit set the world record for being the oldest living rabbit. I hope to surpass that age in the future!
Hope you enjoy this article!
Commander Bun Bun
How to Live Past 100
Q. This past year, I became interested in genealogy, and have been compiling my family tree using online resources. With some research, I found that generations before mine have included not-so-distant relatives who have lived past 100. My parents, unfortunately, both died in their 70’s. I wonder what my ancestors did right to live so long. I would like to replicate some of the habits of centenarians, so my family has a better chance of a long life ahead. Based on what you’ve read and heard from clients, do you have any suggestions to help?
A. Not long ago, someone who had lived to be 100 was a true rarity. Even today, those reaching 100 are contacted by the White House, and often the national and local media. Now, closer attention to good nutrition and access to better medical care are paying off, and living past 100 has become more common. In fact, one in 26 baby boomers is now expected to live to 100 and many more will reach the mid-to-late 90s, according to the book, Celebrate 100: Centenarian Secrets to Success in Business and Life. This week, as we celebrate National Centenarians Day, we recognize the 55,000 Americans aged 100 or over. In 1980, the number was 32,000.
Born just a decade or so after the turn of the century, centenarians were teenagers during the Great Depression, young people during World War II, and, for some, grandparents by the time the 1960s rolled around. Their stories are different, but they share common themes.
Understanding centenarians is important for seniors to become knowledgeable about the lifestyle choices that can influence longevity. To explore this topic further, let’s look at countries where seniors are living the longest, including Japan, and countries spanning the Mediterranean and East Asia, such as those with strong economies and healthcare systems. Here are some facts about aging in those countries:
- Diet: John Beard, director of Aging and Life-course at the World Health Organization (WHO) attributes longevity to diet. For instance, the diet in Japan includes plenty of fresh fish and vegetables, combined with low levels of meat and saturated fat. The diet in Southern Europe is a Mediterranean diet, that traditionally consists of a small amount of wine, fresh vegetables, olive oil and, again, little meat and saturated fat. A recent study found that people consistently consuming a Mediterranean diet were both physically and mentally healthier as they aged.
- Lifestyle: Active lifestyles into older years are the norm in Japan, helped by the country’s extensive rural landscape getting people outdoors, and further aided by a well-established health infrastructure. Beard believes that in countries such as Italy, Spain and France, cultures of physical activity and warmer climates have a role to play. In countries with cold, harsh winters, maintaining an active lifestyle becomes a challenge.
- Social Relationships: Sarah Harper, professor of Gerontology at the University of Oxford cites other reasons for Japanese longevity. “They tend to have a society which tends to promote a strong family set up and stress-relieving cultural activities,” she says. Furthermore, Japan has less social inequality than many other countries, enabling everyone to experience these benefits. Social relationships are important in Southern Europe, as well, and family ties are strong. This is helpful because when people have a greater sense of belonging to a community, or family, and maintain a healthy work-life balance, they stay healthy longer.
- Economy: In general, countries with a smaller wealth and class divide have a healthier aging population. For instance, “in Singapore, there’s a range of wealth and advantage; there are very few people at the bottom,” says Beard. “This uniformity means more members of the population can live the lifestyles needed to ensure good health — well into their eighties and beyond.”
- Good Health Programs: If entire populations can access good health programs — such as screening services — chronic conditions that generally affect older populations can be picked up early and treated before they’re irreparable.
For “secrets” on how to live past 100, read this recent CNN article about what people in Acciaroli, Italy are doing.
Centenarians May Be Living Longer, But Disease Takes its Toll
When looking at centenarians in the U.S. and other countries, life span is not necessarily matched by increases in “health span,” or time spent living in good health. Longer life spans have been accompanied by a tremendous increase in the disease burden due to Alzheimer’s disease. Alzheimer’s is now the number 12 cause of disease burden in the US, and the fourth leading cause of death. Its impact on health has become much more severe over the course of two decades; the number of years of life lost prematurely because of Alzheimer’s increased by 392 percent—far more than any other disease. Other wealthy countries have witnessed similar but not as dramatic increases.
How Do We Care for “the oldest of the old”?
Once people get to be centenarians or even beforehand if they are afflicted with diseases, such as Alzheimer’s, many will need help in their daily life. This is an “intense burden for the health care system in the U.S.,” says Kathrin Boerner, associate professor of gerontology at the University of Massachusetts Boston, adding that we are “totally not ready for it.”
Many of these seniors want to stay in their own homes, but that isn’t always possible. This makes it all the more important to plan in advance!
Hoping to Live Past 100? Plan for your future and your loved ones.
Luck and genetics play roles in longevity, of course, but you can’t control that. If you want to better your odds of hitting 100, focus on what you can do, such as eating healthy, exercising, and cutting down on stress. As you are taking care of yourself and enjoying your life, it is also a good idea to plan for your future and for your loved ones. Our firm is dedicated to helping protect seniors preserve dignity, quality of life, and financial security. If you have not done Long-Term Care Planning, Estate Planning, or Incapacity Planning (or had your Planning documents reviewed in the past several years), or if you have a loved one who is nearing the need for long-term care or already receiving long-term care, call us to make an appointment for a no-cost initial consultation:
Fairfax Elder Law Attorney: 703-691-1888
Fredericksburg Elder Law Attorney: 540-479-1435
Rockville Elder Law Attorney: 301-519-8041
DC Elder Law Attorney: 202-587-2797
Hospice Care for Healthier Patients. . . Something Isn’t Right!
Linda Rodgers was shocked to see her father in so much pain when she visited him at his hospice facility. In a letter she wrote to the editor of USA Today, she described how her father had his pain controlled by medication while in the hospital, before admission to hospice, but was in severe pain from Wednesday through Sunday in the hospice facility.
Linda described how the hospice nurse visited her father at the time of admission on Wednesday, slapped a pain patch on him, and never came back to adjust the pain medications to make sure his pain was controlled. Although he was suffering, the only visits he received were from an aide on Thursday and Friday morning for a brief period of time, but there was nothing done to assist him further. Linda was appalled that the hospice did not even try to control her father’s pain, which was so severe he could not be touched or moved once under the hospice’s services, and no services were provided on the weekend, even though all hospices are reimbursed by Medicare for services every day the patient is there.
Unfortunately, Linda’s father’s case is not at all unusual, but some hospices are better than others. Hospice is designed to be an alternative to regular medical care for people in the final months of life. Instead of continuing to try curing or delaying a fatal disease or condition, hospice ends curative treatment altogether, and is supposed to focus on pain control.
Hospice use is currently on the rise. In fact, today roughly half of older Americans who die have received some hospice care — which has created a boom in the industry. In 2012, Medicare spent more than $15 billion on hospice care. But, hospices are being scrutinized. . . and for good reason.
Medicare data suggests that for-profit hospices actively seek out healthier patients in order to book greater profits. One way they do so is by admitting a greater proportion of patients with diseases such as dementia or Alzheimer’s, where predicting the end of life is often uncertain. Nonprofits, in turn, are more likely to serve short-living patients, such as those with late-stage cancer, where death is imminent and the cost of care is more expensive.
The Washington Post investigated whether hospices are safe and how they sometimes decline to provide proper care. To conduct the study, The Washington Post analyzed the Medicare billing records for more than 2,500 hospice providers, obtained an internal Medicare tally of nursing care in patients near death, and reviewed complaint records against hundreds of hospice providers.
Let’s explore the findings uncovered by The Washington Post:
- Lack of information: About one in three hospice patients were not given key information about what the choice of hospice care entails at the time they enrolled, according to a report by the Office of Inspector General of the Department of Health and Human Services. In the investigation, government inspectors reviewed a random sample of the documentation that patients sign to indicate they want hospice care. In many cases, the patient was not informed that electing hospice meant that they intended to forgo a cure for their terminal illness — a critical distinction between hospice care and other health services. Hospices provide “palliative care” – which is designed to be care focused on the prevention and alleviation of pain and suffering. Some hospice families claim they were pressured into hospice treatment without fully understanding that doing so meant forgoing curative treatment, and that their loved one was mistreated or ignored.
- Lack of attention by physicians: According to The Washington Post, “In about 14% of cases, the physician who is supposed to approve the enrollment of a patient in hospice care paid only cursory attention to the matter. They provided scant information about the patient’s prognosis, and appeared to have limited involvement in determining that the [patient] was appropriate for hospice care,” according to the report.
- Patient neglect: Hospices provide care at home or inpatient care at a medical or nursing facility. However, when some home hospice patients encounter crises—including pain, breathing troubles, or seizures — and need sustained attention, they are sometimes not getting the assistance they need. According to The Washington Post investigation, one in six U.S. hospice agencies, serving more than 50,000 terminally ill patients, did not provide crisis care to any of their patients in 2012. In fact, at 445 hospices, a third or more of patients died without having seen a skilled nurse in the 48 hours before their death.
- Safety concerns: The typical hospice provider in the U.S. undergoes a full government inspection about once every six years, according to federal figures, making it one of the least-scrutinized areas of U.S. health care. By contrast, nursing homes are inspected a year, and home health agencies every three years. According to The Washington Post, “the dispersal of patients makes oversight difficult to begin with, but the infrequency of inspections means shortcomings are even less likely to be detected.”
- Rising discharge rates: Even though the obvious goal of hospice is care for their patients until death, more than one in three patients are released from hospice care while still alive, according to a new study funded by Medicare. This is a sign that patients may be leaving to seek treatment elsewhere. It is normal for hospice to release a small portion of patients before death (15%), but when the rate of patients leaving hospice care alive is double that level, it can signify either that agencies are driving the patients away with inadequate care, or enrolling patients in the first place who aren’t really dying — often in order to pad their profits.
- Lethal doses: With the surge of hospices enrolling patients who aren’t close to death, hospice patients who are not actively dying are nevertheless being treated with powerful pain-killers that are routinely used by hospice providers in order to ease suffering and at the same time hasten death. There are no statistics on how often such abuses may be occurring, but complaints from around the country illustrate the potential dangers of overdosing and drug dependency and addiction caused by enrolling a non-dying relative in hospice care.
- Quality of hospices: Though the federal government publishes consumer data about the quality of other health-care companies, including hospitals, nursing homes, and home health agencies, it provides no such information about hospices. State inspections are often unpublished and, when they are published, they are often hard to understand. So a family is typically choosing hospice care blindly with no idea if it is truly a good option for their loved one.
- Attitudes of nurses and clinicians: Nurses and clinicians who work for hospice providers feel powerless to change the system. Although they feel frustrated and may disagree with the aggressive treatment and whether it is necessarily warranted, they have to do what they are legally required to do.
Beginning in 2009, and continuing every year since, MedPAC has called on Centers for Medicaid and Medicare Services (CMS) to change the incentive structure to discourage the cherry-picking of longer-living patients. Just recently, CMS finally took the advice — in part. CMS proposed a new structure for this fiscal year that would pay providers about $40 less per day for each day a patient stayed on the service after 60 days. In a letter commenting on the proposal, MedPac described the adjustment as a “positive step,” and also “modest and incremental.”
Still, many hospice providers are failing to provide quality care for patients, and the industry suffers from safety concerns due to infrequent inspections, lack of crisis care, lack of reporting consumer data, admission of people who aren’t dying and who eventually get discharged, and other issues. Unlike hospices, nursing home facilities are inspected once a year and have much consumer data and research available to help you choose the right facility, making them (in most cases) a better choice for a loved one’s long-term care needs. However, the two are not mutually exclusive, because hospice care can and often is provided to patients residing in nursing homes.
Nursing homes in the DC Metro area cost $10,000-14,000 a month. To protect your family’s hard earned money and assets from these catastrophic costs, the best time to create your long-term care strategy is before you actually need long-term care. If you’re over 65, we recommend that you begin your asset protection planning now. Even if you are currently receiving services for yourself or a loved one, it’s still not too late to plan. Please call us to make an appointment for a no-cost initial consultation:
Fairfax Elder Law Attorney: 703-691-1888
Fredericksburg Elder Law Attorney: 540-479-1435
Rockville Elder Law Attorney: 301-519-8041
DC Elder Law Attorney: 202-587-2797
Critter Corner: Questions to Ask at a Nursing Home Interview
Dear Baxter,
My husband and I are evaluating nursing homes for his mother. We set up several tours. We are wondering if you could suggest questions to ask at these meetings? Thanks for your help!
Wanda Fine-Darytwan
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Dear Wanda,
When you visit a nursing home to check it out, it’s important to be prepared. It is a good idea to conduct tours of at least three separate facilities. Here are some basic questions to ask during the tour:
Problems or special needs:
•How would your home deal with my father’s [dementia, weight loss, disability following stroke, or ____________________ ].
Toileting
•How do you handle incontinence?
•How often do staff members help incontinent residents use the restroom?
•How many residents are in diapers?
•How many residents have indwelling catheters?
•Do you utilize condom catheters for male residents with urinary incontinence?
Nutrition
•How flexible is your menu—can residents make choices, or are all Monday meals the same, for instance?
•How do you identify residents who are losing weight?
•What do you do to make sure residents are eating, especially those who have lost interest in food?
•Can residents eat meals whenever they want, or are meals only at scheduled times?
•Are healthy snacks available?
•Does your home honor religious or cultural dietary restrictions? Could you show me a sample menu of a [gluten-free, dairy-free, Kosher, low salt, or ______________] diet?
•How do you ensure that your meals meet high nutritional standards?
Falls
•What do you do to prevent falls?
•How often do residents fall?
•What do you do when there’s a fall?
Health inspections
•Please show me your last three survey inspection reports.
•How has your home fixed any problems that were identified?
•How quickly were the problems addressed?
Medical care
•How often is a doctor on site?
•Are dental services available?
•How do you keep track of residents’ medical records?
•If you have computerized health records, have you ever had any problems with the system?
•Do residents receive preventive care such as annual flu and pneumonia shots?
•Does your home arrange for regular hearing or vision screening?
•If Mom has a medical need, who contacts the doctor?
•If Mom needs to see her doctor, who arranges for transportation?
•What hospital arrangements do you have for emergencies?
Staffing
•What is annual rate of your nurse and nurse aide turnover?
•What do you do to try to improve turnover?
•How often do you use agency temp nurses?
•What proportion of families would you say hire private nursing aides or sitters to supplement your staff?
•How often do nurses and aides update doctors on residents’ health status?
•What kinds of background checks do you perform prior to hiring?
•Do you have volunteer programs?
•Do you have a relationship with local schools or houses of worship?
Safety
•Do you have an emergency evacuation plan?
•Do you hold regular fire drills?
•Who helps residents with bathing?
•Do you do nightly bed checks?
•How often does the staff check on residents during the day?
Overall direction
•What improvements have you put in place in the past year?
•What other improvements are planned?
•Do you often have to put residents on a waiting list?
•Where would we direct our questions and concerns if we were to enroll our dad here?
Feel free to tailor these questions to your situation. And for an even more complete list of questions, please see our website at
https://www.farrlawfirm.com/wp-content/uploads/2014/06/NURSING-HOME-EVALUATION-TOOL.pdf
Hope this is helpful and that you find the right place for your loved one!
Sincerely,
Baxter