UW Retirement Association Presentation

January 22, 2013

"You're Only Old Once"

Planning to Age in Place1
Julie A. Short JD
Haskins Law LLC
3866 Johns Street
Madison, WI 53714
(608) 237-6673

Copyright 2013. Attorney Julie A. Short. No part of this presentation or outline may be reproduced without the
express written permission of the author.

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Copyright 1986 by Dr. Suess and A.S. Geisel.

Dedication:

"With Affection for and Affliction with the Members of the Class of 1925"

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"One day you will read in the National Geographic of a faraway land with no
smelly bad traffic. In those Green-pastured mountains of Fotta -Fa-Zee everybody
feels fine at a hundred and three 'cause the air that they breathe is potassium free
and they chew nuts from the Tutt-a-Tutt tree.
And you'll find yourself wishing you were out there in Fotta-Fa-Zee and not here
in this chair in the Golden Years Clinic on Century Square for Spleen
Readjustment and muffler repair.
Just why are your here? You're not feeling your best..."

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"You've come in for an Eyesight and Solvency Test.

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"When at last we are sure you've been properly pilled, then a few paper forms must
be properly filled so that you and your heirs may be properly billed."











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Youre Only Old Once

Planning Ahead to Age in Place"
I. Introduction: What is aging in Place?

Aging in Place is growing older without having to move

According to the Journal of Housing of the Elderly it is not having to move from
one's present residence in order to secure necessary support services in response
to changing need.

Some 70% of seniors spend the rest of their life in the place where they celebrated
their 65th birthday (Seniorresource.com)

II. What are the Challenges to Aging in Place?

A. Functional
Some increased physical limitations
Transportation issues
Correlation with increase in age with need for assistance with daily activities
Age related health conditions (Alzheimers disease, Diabetes)
B. Financial
Earned income less to non-existent
Primary source of income for individuals over age 65 is Social Security
Lack of financial assistance for non-medical / custodial services as well as vision
and dental care
Exorbitant cost of long-term care and insurance
C. Social
Family and friends often far away
Some social isolation due to transportation / rural areas
Childrens ability to assist limited by employment / childcare

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Scenario One: Aunt Jane Needs Help At Home

Aunt Jane is 92, lives alone in an apartment building with other seniors in
Madison. She lost her husband four years ago. She is mentally very strong
but has balance issues and needs a walker. Just recently, she has had some
undiagnosed digestive problems and is very weak and needs assistance
bathing (getting in and out of the tub) and sometimes needs assistance to get
out of bed and/ or a chair. Her mobility difficulties have contributed to her
having difficulty preparing meals and eating and drinking which only make
her more weak and frail. Her income is $2,000 month. Aunt Jane would like
services to assist her with shopping, meal preparation and to shower at least
three days a week. Given her low income she would like help paying for these
services. Aunt Jane has original Medicare Part A and Part B.

I. Question One: Will Medicare Part B help Aunt Jane pay for the home health care
assistance she needs?
A. Medicare Home Health Services/ Provided under Part B*
i. A physician has signed or will sign a care plan.
ii. The patient is homebound
This criterion is met if leaving home requires a considerable and taxing
effort which may be shown by the patient needing personal assistance, or
the help of a wheelchair or crutches, etc. Occasional but infrequent "walks
around the block" are allowable. Attendance at an adult day care center or
religious services is not an automatic bar to meeting the homebound
requirement.
iii. The patient needs skilled nursing care and /or Physical Therapy on an
intermittent basis
Intermittent means for as much as every day for recurring periods of 21
days if there is a predictable end to the need for daily care to as little as
once every 60 days
Skilled care: Physical or speech therapy; Care that requires
administration or supervision by a Nurse or therapist. CNA and or
custodial care is not skilled care
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iv. The care must be provided by, or under arrangements with, a

Medicare-certified provider.
v. The care must be medically necessary. All Medicare benefits only
apply if covering a medical expense that was incurred due to medical
necessity.
vi. All Part B services require a 20% co-pay.
*As a general rule Medicare Part B covers outpatient medical care. Exceptions include
observation care at a hospital and prescription medicine services required to be provided
in a doctor's office.
The monthly premium for most people is in 2013 is $104.50 (For individuals with annual
incomes of $85,000 or less / $170,000 for a married joint return)
** Annual enrollment period January 1, 2013 to March 31, 2013 every year.

I. Answer Number One: Probably Not. Although Aunt Jane has mobility issues because she
is able to ambulate most of the time with a walker she is probably not homebound. If she gets
to a point where she cannot get out of a chair and needs to use a wheelchair, she would be
homebound. If Aunt Jane was homebound, she would still need to receive skilled care to
benefit from home health care under Medicare Part B. If a physician prescribed physical
therapy with a goal of increasing Aunt Jane's physical abilities to get her back to being able to
use a walker, Medicare Part B should pay for some home health services. Another potential
area of assistance that might meet this criteria would be the need to be evaluated by a nurse at
home to ensure proper hydration and nutrition if tied to a specific diagnosis and treatment plan to
mitigate or eliminate her digestive problems. But the care would only be skilled if needed to be
monitored by a nurse. If she received home health services she would need to satisfy her annual
Part B deductible of $147 (2013), if she had not already paid for any other Medicare Part B
services.

II. Question Two: What if Aunt Jane had a Medicare Supplemental (Medigap) Policy.
Would that help her pay for home health services?
A. Medigap policies are available to individuals with original Medicare and cover copays, deductibles and co-insurance. Some cover services not covered in original
Medicare (unusual). Most Medigap policies do not pay benefits unless Medicare benefits
were paid or would have been paid but for a deductible. Medigap covers the 20% co-pay
that applies with every Medicare Part B covered service.
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B. Medigap policies are regulated in WI and they must cover Home Health Care.
1. Up to 40 home care visits per year in addition to those provided by Medicare
(with no increase in premium). Must offer coverage for 365 visits but can charge
an additional premium.
2. Note that the underlying criteria is the same as above with original Medicare
Part B; Physician prescribed plan, homebound, intermittent skilled care that is
medically necessary.
C. Medigap policies are guaranteed renewable no matter how bad your health gets as
long as coverage is maintained for example, this could be lost if opt out of Original
Medicare to elect a Medicare Advantage plan.
II. Answer Number Two: Probably not. Aunt Jane will only receive financial assistance for
home health care under her Medigap policy if she first qualifies for and receives Medicare home
health services under Medicare Part B, as discussed above, unless her Medigap plan specifically
provides for Home Health services not covered by original Medicare Part B (something to watch
for when shopping around). The Medigap policy will only help if there is a need for skilled care
as discussed above as;

Per State of Wisconsin guidelines home health Medigap required coverage is only
available if a Doctor certifies but for the care a stay at a Skilled Nursing Facility (SNF)
would be needed

Essentially Medicare will not pay for care that does not have a skilled care component
and thus will not finance assistive services / bathing assistance aka custodial care.

III. Question Three: Would Aunt Jane get assistance with these expenses if she had a
Medicare Advantage plan?
A. Medicare Advantage /aka Medicare Choice/ aka Medicare Part C
1. Opt out of original Medicare Part A and Part B and then through the Medicare
program (CMS /Centers for Medicaid and Medicare) you purchase a private
health plan; the Medicare Advantage Plan
2. Medicare Advantage plans are annual contracts and are not guaranteed
renewable as is required for Medicare supplement policies
3. The plan must meet minimum state and federal requirements for licensure,
benefits offered, access to providers, quality of care, and reporting and must
provide the same benefits as original Medicare
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4. Must continue to pay Medicare Part B premium in addition to the Medicare

Advantage plan premium
5. Statistics show that these plans generally do to provide better health coverage
for most individuals than with Original Medicare and generally they cost about
17% more for CMS to administer.

III. Answer Question Three: Medicare Advantage Home Health coverage is unlikely for Aunt
Jane as Medicare Advantage will only assist if the specific policy has coverage that would cover
custodial care as the same issues apply as to the need for skilled care etc. Medicare Advantage
does not have to provide more than Original Medicare thus the standards will be the same unless
the policy expressly adds this coverage component (something to keep in mind when shopping).
Note use of Medicare Advantage precludes the use of a Medigap policy because Medigap only
supplements original Medicare. When reviewing a Medicare Advantage plan one should ensure
that there is coverage for co-pays, deductibles and co-insurance and if not evaluate the savings
and determine if original Medicare with a Medigap policy would be better/ more affordable.

IV. Question Four: Will Medicaid Help Aunt Jane?

IV. Answer to Question Four: No. Medicaid has an asset and income test. Aunt Janes
income of $2,000 is over the Medically needy limit of $591.67 per month. If Aunt Jane was on
SSI (supplemental security income), she would qualify, even though SSI income of $678 a
month is above the medically needy limit as WI ties MA to SSI. If Aunt Jane had regular
medical expenses that are high she could qualify for Medicaid through a deductible plan but her
assets would have to meet Medicaid criteria.
Ex. Aunt Jane can own a home and a car and any personal property but could not have an IRA,
and/ or bank accounts, and /or CDs, and or investments and /or cash value life insurance with a
combined value over $2,000.

V. Question Number Five: What if Aunt Jane could not afford to pay her Medicare
premiums?
V. Answer Number Five: She could get assistance under a program called QMB (Qualified
Medicare Beneficiary) if she meets the following qualifications. She will not as her income is
above $11,170 per year.
A. QMB / Medicaid pays all Medicare premiums, deductibles and co-insurance
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B. Eligibility: 1. Countable incomes below 100% of Federal Poverty Levels (FPL/

$11,170 per year for a single person);
2. Countable resources below $6,940 for an individual and $10,410 for a couple
VI. What if Aunt Jane has long-term care insurance? Will a long-term care insurance
policy pay for the home health services she wants?
A. What type is her policy?
Three types
1. Long-Term Care Insurance Policies: Cover both institutional (nursing home or
other facility) care and care in the community (home health care or other
community-based services).
2. Nursing Home Insurance Policies: Cover only institutional care, such as in a
nursing home.
3. Home Health Care Insurance Policies: Cover only community care, such as
home health care or care in an assisted living facility and or a community-based
residential facility (CBRF).
C. Mandatory Home Health Coverage in WI LTC Ins Policies: policies that include
home health care benefits must pay for community-based (home health) care
Whether or not you have an acute medical problem.
Even if the services are not provided by a Medicare-certified agency or
provider.
Even if you were not previously in a hospital or nursing home
VI. Answer to Question Number VI: If aunt Jane had a LTC Insurance policy and or a
health insurance policy she may be able to get some benefits to cover home health and
assistive services if the policy language does not have any exceptions or exclusions for
coverage that would preclude benefits. Policies often require certification of a health care
provider (defined) that a certain number of functional limitations exist (referred to
inability to do activities of daily living). When submitting a claim it is essential to meet
each and every written requirement of the policy.
VII. What community resources might be able to provide assistance for Aunt Jane?
VII. Answer to Question VII: In Madison and Dane county there are some wonderful
community resources:
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A. Area Agency on Aging of Dane County serves individuals who are age 60 and over
and/or their family members by providing information and assistance in accessing
services that will help older adults stay in their own homes and communities.

Dane County has 16 Senior Center Focal Points with Case Manager Services

B. Possible Services to Assist Aunt Jane:

Home assistance with light housekeeping, laundry, lawn care, and minor home
repairs.

Examples of other community-based services include: congregate and home

delivered meals, caregiver support, and help with benefit questions.

Many of these services are provided free or on a donation basis/ funded under the
Older Americans Act

C. Elderly Benefit Specialist Program

Elder Benefit Specialists provide free advocacy and assistance adults age 60
or older with public and private benefits including Medicare, Medicaid, Social
Security retirement, Supplemental Security Income, FoodShare, and
SeniorCare. They provide information on program eligibility criteria,
assistance applying for benefits, and appealing benefit denials.

D. SAIL / Supporting Active and Independent Lives (sailtoday.org)

SAIL is a non-profit membership organization of people over age 55 in the
Madison area. Members join as they wish to remain active independent in
their own homes and maintain social connections. SAIL assist in finding and
screening resources.
Membership includes referral to prescreened service providers; daily
automatic check-in service, house checks, wellness services and social events
and clubs. members-helping-members, volunteer opportunities, discounts and
other services.
E. Naturally occurring retirement communities (NORC)

A NORC is a community or neighborhood where residents remain for years, and

age as neighbors, until a Naturally Occurring Retirement Community develops. A
NORC may refer to a specific apartment building, or a street of old single family
homes where residents have stayed and aged.

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In a NORC it is possible to band together and to develop, or seek help to develop,

access to services to aid those needing assistance, thereby retaining the highest
quality of life for all residents as they age. SAIL is one example of one
manifestation of this idea.

F. Share the Care / See Sharethecare.org

mission is to improve the quality of life of person who are seriously ill or
disabled or experiencing the challenges of aging and to reduce stress,
depression, isolation and economic hardship often suffered by their family
caregivers.
The paradigm is that family and friends pool resources / efforts to ease the
burden on the family caregivers and those without family or friends nearby.
This pooled resource center is called a station.
caregiving responsibility tends to fall upon one or two family members often
resulting in caregiver burnout, isolation of those in need of care and high rates
of institutionalization for patients lacking adequate social supports
Madison LBGT community has created a Share the Care Station

Scenario 2: Aunt Jane Needs Help Paying for Long-term Care

Aunt Jane trips while using her walker to go get her mail and breaks her hip.
The hospital has cared for her for five days and now is discharging her to a
skilled nursing facility (SNF) for rehabilitation services. Aunt Jane wants to
be sure that she receives all of the assistance she can to pay for her
rehabilitation stay, as she has been told the cost of staying at the SNF is $250
per day.
Question I. What benefits will Aunt Jane receive under Medicare to help her pay for her
hospital and SNF stay?
Answer to Question I: Before Medicare Part A will pay for her hospital stay, Aunt Jane will
have to pay a deductible for Days 160 of $1,18 4 for each benefit period in 2013. A new
benefit period begins if an individual has been out of the hospital for at least 60 days. Once the
deductible has been satisfied there is a$296 per day co-payment for inpatient hospital services for
days 61-90. There is 60 days of lifetime reserve that can be used to cover some of the cost for
days 91-150 ($592 per day co-pay). After that there are no Medicare benefits.

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At the SNF, if Aunt Jane Qualifies for Medicare Part A coverage*, days 1-20 are covered in full
but then there is a $148.00 per day co-payment for skilled nursing facility services after the 20th
day; No coverage after 100 days.
* note the existence of the three day qualifying hospital stay ( Observation status stays in the
hospital do not count issue) / medically necessary/ daily skilled care/ beware of the
improvement issue
Question II: Will Medicaid Pay for Aunt Jane's stay?
Answer to Question II: Maybe....The monthly cost of Aunt Janes care in the SNF is At least
$7,500. This exceeds her income of $2,000 so she qualifies on an income basis. The issue will
again be her assets as discussed above.
Question III: If Aunt Jane's husband was still alive, would it change how the Medicare or
Medicaid rules are applied?
Answer to Question III: Medicare. There would be no impact upon Aunt Jane's Medicare
coverage as a result of her husband still being alive. Marriage can help with eligibility if one
spouse does not work enough to acquire his or her own Medicare coverage. Thus, if Aunt Jane
did not work enough to acquire her own Medicare coverage, and then her Medicare coverage
would be dependent and derivative upon that of her husband. Once a person is eligible for
Medicare there are no issues as to income and assets (unless individual or couples have annual
income in excess of $85,000 / $170,000) as Medicare is not a means tested program but rather a
government run insurance program. High income individual do have to pay premiums for
Medicare Part A and Part B depending upon their annual income. See Medicare.gov.
As for Medicaid, if aunt Jane was applying and she had a spouse living in the community, it
would change the rules significantly as Spousal Impoverishment Protections would apply
allowing Jane's husband to possibly retain more income and both of them more assets but note
that within one year of a spouse qualifying for Medicaid the title of all the assets are to be in the
name of the spouse in the community.
A. Community Spouse Asset Share (CSAS): 1/2 of all countable assets between
$50,000 - $117,920 (home, car, burial funds are not counted)*
B. Community Spouse Income Allocation/ Minimum Monthly Maintenance Allowance
(MMMNA):
Unless a larger amount is ordered by a fair hearing or court, the maximum
allocation is the lesser of :
$2,898 or
$2,521.67, plus excess shelter (housing expenses in excess of $756.50)
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Example. If Janes husband had an income of $2,000 per month, Aunt Jane would be able to
shift at least $521.67 of her income to her husband. Remember once a person is on Medicaid, all
of his or her income, except for a personal needs allowance of $45 and the cost of any medical
insurance, is paid to the state as a cost of care contribution.
In this example, Aunt Janes income would be treated as follows:
$2,000
(45.00) Personal Needs Allowance
(104.50) Medicare part B Premium
(30.00) Medicare part D Premium
(120.00) Medicare Supplemental Insurance Premium
(521.67) MMMNA
1,178.83 Aunt Janes monthly Cost of Care Contribution

*Determining which assets are countable and not countable is very complicated and the list
of assets that are not counted is extensive and changes frequently. The same goes for
income considerations and calculating the cost of care contribution. Note that it is possible
to get more income allocated to a community spouse but that requires the assistance of a
knowledgeable attorney and a court appearance. Consultation with an elder law attorney
who is knowledgeable of Medicaid rules is essential. Keep in mind when paying over
$7,000 per month for a SNF stay, paying an elder law attorney often pays for itself in
savings.

WARNING: THE INFORMATION IN THIS OUTLINE IS IN SUMMARY FORM AND

IS CURRENT AS OF THE DATE PRESENTED. TITLE 19 LAW CHANGES
DRASTICALLY, FREQUENTLY, RAPIDLYAND SOMETIMES EVEN
RETROACTIVELY. MEDICAID, MEDICARE BENEFITS AND FEDERAL POVERTY
LEVEL NUMBERS CHANGE ANNUALLY. IF ANY SIGNIFICANT AMOUNT OF
TIME PASSES BETWEEN THIS PRESENTATION AND YOUR NEED FOR
INFORMATION CONCERNING TITLE 19 BENEFITS, IT IS IMPERATIVE THAT
YOU CHECK ON THE LAW BEFORE MAKING APPLICATION.

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Top 10 Tips
1. Execute Advance Directives and Powers of Attorney for Health Care and Finances.
2. Participate actively in discharge planning between care settings.
3. Engage in estate planning and financial planning before a crisis occurs. Review the plan on
an annual basis at tax time.
4. Create a crisis kit/box: See sample list attached.
5. Make modifications to your residence to make it accessible.
6. Educate yourself about local Aging Network resources: If in Wisconsin, meet your local
elderly benefit specialist or at least know how to contact the county elderly benefit specialist.
7. Take full advantage of any public benefits for which you may be eligible: Medicare Premium
and cost assistance (QMB discussed above), SNAP, Energy Assistance, Homestead credit.
8. Review your Medicare Prescription Drug coverage options (do not forget Senior Care) and
your Medicare Advantage plan, if applicable, every year.
9. If you are a veteran, educate yourself about all veteran's benefits to which you may be entitled.
Aid and Attendance benefits and other VA benefits are highly underutilized. Get to know your
county veteran's service office and /or consult with a VA accredited attorney.
10. Be an advocate for yourself and appeal Medicare and LTC Insurance denials when coverage
is denied due to failure to improve, observation status or the care being not medically necessary.

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Resources:
Dane County Aging Unit / ADRC / Elderly Benefit Specialists (EBS)
Dane County Elder Benefit Specialist Program
Aging & Disability Resource Center of Dane County
2865 N. Sherman Ave.
Madison WI 53704
Phone: 608-240-7474
Fax: 608 240-7401 Email: aaa@countyofdane.com
How to local an EBS Statewide

To locate Elder Benefit Specialists from throughout the State of Wisconsin, go to:
www.dhs.wisconsin.gov/aging/EBS/counties.htm .

Wisconsin Bar Association: Lawyer Referral and Information Service

Refer to an attorney in your area who has indicated an interest in your type of legal
situation. Attorneys referred through LRIS agree to charge no more than $20 for the first
consultation up to one half hour.
Call us: (800) 362-9082 or (608) 257-4666 (in Dane County and outside of Wisconsin).
Monday through Friday from 8AM to 5PM.
Medicareadvocacy.org: terrific website with non legalese and detailed description of Medicare
coverage and how to handle denials and appeals.
WisPACT.org: Wisconsin's Poled and Community Trust for individual with disabilities and
their families.
Seniorresource.com: Good basic description of Aging in Place
NAELA.org: Good list of Elder Law Attorneys in Wisconsin but note, not all good elder law
attorneys are members
Medicaid Handbook: Only available online. This is what the State uses when reviewing the
MEH rules. http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm
Medigap Helpline: 1-800-242-1060. Call regarding Medicare Insurance, employer coverage,
subsidies; Medigap and Medicare Advantage Plans and long term care insurance. Publications
are also available.
Medicare Part D helpline: Wisconsin Prescription Drug Helpline at 1-800-242-1060. Operated
by the Board on Aging and Long-Term Care.
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