Long-Term Care: How to Plan & Pay for It

By Attorney Joseph L. Matthews, Nolo Press

Finding the right kind of long-term care, in the right place, often requires making difficult decisions in difficult times. Long-Term Care helps you understand the many alternatives to nursing facilities and shows you how to fit the care you need to the funds you have available.

Learn how to:

• Arrange Home Care
  Understand what home care can do, what kind of care is available where you live, and how to arrange for services.
• Find a Non-Nursing Facility Residence
  Learn about the many varieties of independent living and assisted living residential care communities, and how to choose one that matches your needs and budget.
• Choose a Nursing Home
  If you need a nursing facility, find out what to look for and how to assess the quality of care.
• Get the Most out of Medicare, Medicaid and Other Benefit Programs
  Understand the regulations concerning benefit programs, what they cover and how to qualify for them.
• Evaluate Long-Term Care Insurance
  Find out whether long-term care insurance is a good investment for you.
• Protect Some of Your Assets
  Avoid draining your life savings and losing your home as you cover the costs of long-term care.

Table of Contents

Introduction

• A. What Is Long-Term Care?
• B. Threshold Issues of Long-Term Care
• C. How This Book Can Help

1. Making Decisions About Long-Term Care

A. Getting Started

• 1. Get Help From Others
• 2. Assess Medical Needs
• 3. Evaluate Personal Needs and Capabilities
• 4. Learn About Family Leave Laws

B. Make a Realistic Family Commitment

• 1. Staying at Home
• 2. Moving in With Family
• 3. Entering a Residential Facility

C. What Can You Afford?

• 1. Medicare, Medicaid, and Insurance
• 2. Determine Income and Assets

D. Geriatric Care Managers

• 1. Where to Find Geriatric Care Managers
• 2. Evaluating a Geriatric Care Manager

E. Other Legal and Financial Matters

• 1. Health Care Directives
• 2. Durable Powers of Attorney for Finances
• 3. Wills
• 4. Living Trusts

2. At-Home Care

A. What Is Home Care?

• 1. Independence
• 2. Financial Savings
• 3. Quality of Care

B. How to Find Home Care Services

• 1. Friends and Relatives
• 2. Hospital Personnel
• 3. Physicians
• 4. Nursing Registries
• 5. National, State, and Local Agencies and Organizations
• 6. Senior Centers
• 7. Volunteer Organizations

C. Services Provided

• 1. Medical Services
• 2. Medical and Safety Equipment and Supplies
• 3. Nonmedical Personal Care

D. Kinds of Providers

• 1. Full-Service Agencies
• 2. Support-Care Agencies
• 3. Independent and Informal Arrangements

E. What to Look For

• 1. Certification
• 2. Reputation
• 3. Services and Flexibility
• 4. Personnel Standards
• 5. Matters of Less Significance

F. Getting Started

• 1. Developing a Care Plan
• 2. Getting Regular Providers
• 3. Supervising and Reviewing Your Care

G. Costs of Home Care

• 1. Sliding Scale (Income-Based) Fee Policy
• 2. Cost Depends On Skill Level
• 3. Beware the Hidden Charges

H. Financing Home Care Through Reverse Mortgages

• 1. Drawbacks of Reverse Mortgages
• 2. Protecting Your Interests

I. Cashing in a Life Insurance Policy

• 1. Accelerated or Living Benefits
• 2. Viatical Settlements

J. Supplements to Home Care

• 1. Meals-On-Wheels
• 2. Adult Daycare and Respite Care
• 3. Senior Centers
• 4. County Health Screening
• 5. Family Education Programs
• 6. Additional Services

3. Organized Senior Residences

A. Independent Living

• 1. The Basics
• 2. Costs
• 3. Rules and Restrictions

B. Assisted Living

• 1. The Basics
• 2. Costs
• 3. Rules and Restrictions

C. Combination Residential Facilities

• 1. Extended Care Residences
• 2. Continuing Care Retirement Communities (CCRCs)

4. Long-Term Care Facilities

A. Levels of Care

• 1. Hospital-Based Skilled Nursing Facilities
• 2. Skilled Nursing Facilities
• 3. Intermediate Care Facilities
• 4. Custodial Care Facilities

B. Choosing the Right Facility

• 1. Ownership and Management
• 2. Cost
• 3. The Facility
• 4. Services and Activities
• 5. Other Residents
• 6. Staff
• 7. Food
• 8. Family Involvement
• 9. Decision Making

C. Your Written Contract

• 1. What Your Agreement Should Cover
• 2. Other Matters to Understand

5. Care for Elders With Alzheimer's Disease

A. The Symptoms and Stages of Alzheimer's

• 1. Early Stage Alzheimer's
• 2. Middle Stage Alzheimer's
• 3. Late Stage Alzheimer's

B. Home Care for Alzheimer's

• 1. Care in a Family Home
• 2. Home Care in an Organized Senior Residence

C. Residential Care Facilities for Alzheimer's

• 1. Physical Space
• 2. Other Residents
• 3. Staff Skills
• 4. Family Participation
• 5. Special Programs for Alzheimer's Residents
• 6. Incontinence
• 7. Medication and Other Medical Care

6. Medicare and Veterans' Benefits

A. Medicare Coverage for Long-Term Care

• 1. Skilled Nursing Facility Care
• 2. Home Health Care

B. Veterans' Benefits for Long-Term Care

• 1. Eligibility for Veterans' Benefits
• 2. Home Health Care Coverage
• 3. Nursing Facility Care Coverage

7. Medicaid Coverage for Long-Term Care

A. Eligibility for Medicaid

• 1. Home Care: Income and Asset Limits
• 2. Income and Asset Rules for Long-Term Care Facilities

B. What Medicaid Pays For

• 1. Medicaid-Certified Providers Only
• 2. Home Care Coverage
• 3. Long-Term Care Facility Coverage

C. Finding Out About Medicaid in Your State

D. If You Are Denied Medicaid Coverage

8. Medicaid and Asset Protection

A. Medicaid Rules on Transfer of Assets

• 1. Penalized Transfers
• 2. Transfers to a Trust
• 3. Permissible Transfers

B. Strategies to Protect Your Assets

• 1. Transfers 36 Months Before Medicaid Application
• 2. Investments in Your Home
• 3. Investing in Other Exempt Assets
• 4. Transferring Nonexempt Assets to at-Home Spouse
• 5. Transferring Assets to Children or Others
• 6. Medicaid and Divorce
• 7. Special Long-Term Care Insurance Available in Some States

9. Protecting Choices About Medical Care and Finances

A. Health Care Decisions

• 1. Types of Health Care Directives
• 2. What You Can Cover in Your Health Care Directives
• 3. Choosing Your Health Care Agent
• 4. Making Your Documents Legal
• 5. When Your Documents Take Effect
• 6. Revoking a Document
• 7. Where to Get Health Care Directive Forms
• 8. What to Do With Your Completed Documents

B. Financial Decisions

• 1. Granting Authority to Your Attorney-in-Fact
• 2. Deciding When Your Durable Power of Attorney Should Take Effect
• 3. Finalizing and Changing Your Documents

C. Guardianships and Conservatorships

• 1. Financial Conservatorship or Guardianship
• 2. Full Guardianship

10. Long-Term Care Insurance

A. Risks and Benefits

• 1. The Odds of a Long Nursing Facility Stay
• 2. The Performance of Long-Term Care Insurance
• 3. Improvements in LTC Insurance
• 4. The 5% of Income Rule
• 5. Finding Long-Term Care Policies

B. Warnings About Insurance Practices

• 1. Beware of Pretty Promises
• 2. Beware of Brochures and Agents
• 3. Beware of Mail-Order and Limited-Time-Only Policies
• 4. Check the Company's Reliability Rating
• 5. Examine the Policy

C. Extent of Coverage

• 1. Custodial Care Nursing Facilities
• 2. Assisted Living Facilities
• 3. Home and Community Care

D. Coverage Conditions and Exclusions

• 1. Prior Hospital or Skilled Nursing Facility Stay
• 2. Preexisting Condition Exclusion
• 3. Benefit "Triggers"

E. Premiums

• 1. Initial Premium Cost
• 2. Premium Hikes
• 3. Waiver of Premiums

F. Benefit Amounts

• 1. Flexible Benefit Pay-Out
• 2. Elimination or Waiting Period
• 3. Inflation Protection

G. Refund Provisions

• 1. Nonforfeiture Provisions
• 2. Reduced Paid-Up Provisions
• 3. Death Refunds
• 4. Survivorship Provisions

11. Elder Fraud

A. Why Elders Are Targets

B. Who Commits Elder Fraud

• 1. Con Artists
• 2. Family Villains, Neighbors, and So-Called Friends
• 3. Paid Caretakers and Residential Staff

C. Elder Frauds

• 1. Home Repair, Improvement, or Maintenance
• 2. Asset Protection, Tax Shelters, Financial/Estate Planning
• 3. Refinancing, Home Equity Loans, and Reverse Mortgages
• 4. Quick Buck Investments
• 5. Sweepstakes and Contests
• 6. "Recovery" Schemes
• 7. Exploitive Control Over Finances and Decision Making

D. Where to Get Help

• 1. Home Repair or Improvement
• 2. Investment Fraud
• 3. Deceptive Sales or Advertising Practices
• 4. Undue Influence and Control Over an Elder

Appendix: Resource Directory

• Aging, State Agencies
• Alzheimer's Disease Organizations
• Caregiver Support Groups
• Home Care, Community Programs, and Senior Residences
• National Organizations
• State Associations
• Insurance-Long-Term Care
• State Departments of Insurance
• State Agencies On Aging
• Legal Assistance
• Licensing and Certification
• Nursing Facility License and Certification Offices
• Medicaid Assistance
• Nursing Facility and Alternative Residence Organizations
• Ombudsman Offices
• Reverse Mortgage and Home Equity Conversion Assistance
• Viatical Settlement Assistance