Elder Law 1 final - National Law Institute · 2017-03-20 · Nursing care and aides, but not...

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Thursday,May4,2016

ElderLawfortheNon-ElderLawAttorneyPartI:

ProtectingYourClientandYourself

Copyright©2016WeissLawGroup,PLLC

Overview

I. ChangingDemographics&TheCostofAging

II. MedicareandMedicaid

III.PowerofAttorney/StatutoryGiftsRider

IV.HealthCareProxyandLivingWill

V. ElderLawCaseStudy

VI. Resources


I.ChangingDemographicsandTheCostofAging

ChangingDemographicsinAmerica

• Today,about1ofevery7Americansis“older”(65+).

• Ifyou’re65yearsoldtoday,youraveragelifeexpectancyisanother20.5yrs (F)or17.9yrs (M).

• Inthenext25years,thepopulationaged85+isprojectedtotriple(from6millionto14.6million).

Source:AgingStatistics,AdministrationonAging,Dept.ofHealth&HumanServices,http://www.aoa.gov/Aging_Statistics.(PrincipalsourcesofdatafortheProfilearetheU.S.CensusBureau,theNationalCenterforHealthStatistics,andtheBureauofLaborStatistics.)


LeadingCausesofDeath(65+)

1.Heartdisease 3.Stroke 5.Influenza/pneumonia2.Cancer 4.Respiratorydisease 6.Alzheimer’s

Alzheimer’sDiseasein2016:• Anestimated 700,000Americansage65+willdie.• 5.2millionAmericans65+haveanAlzheimer’sdiagnosis(2/3arewomen)• By2050,thisnumberisexpectedtoincreaseto16million .

http://www.cdc.gov/nchs/data/ahcd/agingtrends/06olderpersons.pdf.

Sources:Alzheimer’sFactsandFigures,Alzheimer’sAss’n,http://www.alz.org/facts/overview.asp#quickFacts.YelenaGorina,DonnaHoyert,HaroldLentzner,andMargieGoulding,TrendsinCausesofDeathamongOlderPersonsintheUnitedStates,U.S.Dept.ofHealthandHumanServices,CentersforDiseaseControlandPrevention,http://www.cdc.gov/nchs/data/ahcd/agingtrends/06olderpersons.pdf.


TheCostofAgingOver70%ofthe65+populationwillrequirelongtermcareservices(“LTC”).

MedianAnnualCost:

Sources:2015CostofCareSurvey,GenworthLifeInsuranceCompany,2015.

Nation-wide N.Y. N.J. Conn. Florida

HomeHealthAideServices $45,760 $52,624 $48,506 $50,336 $41,184

Assisted Living Facility $43,200 $49,200 $68,700 $66,900 $37,800

NursingHome(Semi-PrivateRoom) $80,300 $131,758 $116,800 $146,000 $87,600

NursingHome(Private Room) $91,250 $136,437 $127,750 $158,775 $96,725


OlderAmericansActReauthorizationActof2016

• SignedbyPres.ObamaApril19,2016• Reaffirmsnation’scommitmenttothehealthandwell-beingofolderadults• Createsnewsupportformodernizingmultipurposeseniorcenters• Highlights importanceofaddressingeconomicneeds• Requiresthathealthpromotion&disease preventioninitiatives beevidence-based• Promoteschronicdiseaseself-managementandfallsprevention• Supportsstrongerelder justiceandlegalservicesprovisions,neededclarityforcaregiversupportandAging&DisabilityResourceCenters,andnewopportunitiesforintergenerationalsharedsites• NolimitplacedonappropriationsforOAA

Sources:OlderAmericansActReauthorizationActof2016,Pub.Law114-144(2016)S.192- OlderAmericansActReauthorizationActof2016,availableathttps://www.congress.gov/bill/114th-congress/senate-bill/192.

II.Medicare&Medicaid

N.Y./Region.Medicaid Shift Fuels Rush forProfitable ClientsByNinaBernstein,May8,2014.


MedicareDefined

FederalprogramestablishedunderTitleXVIIIoftheSocialSecurityAct

Persons65+Disabledpersonsunder65PersonswithEndsStageRenalDisease

CentersforMedicareandMedicaidServices(Dept.HealthandHumanServices)

WhatisMedicare?

Whoiseligible?

WhoadministersMedicare?


MedicareOptionsforSeniorsInpatienthospitalandrehabilitationcareHospiceservices

Physicianandoutpatientmedicalservicesequipment,supplies

MedicareAdvantage(combinesPartsA&B)

Prescriptiondrugs

Planvariations

PartA

PartB

PartC

PartD

Other


• MedicareSupplementPlans(“Medigap”)areNOTMedicare!Theyareprivateinsurance!

• AllMedigapplansarecreatedequal!• MedicareAdvantagePlans• MedicareSupplementInsurancePlans• MedicarePrescriptionDrugPlans

MedicareSupplementPlans


MedicaidRegulatorySchematic

Federal

- 42USC§ 1396etseq.(a/k/aTitleXIXofSocialSecurityAct)– establishedMedicaidprogram,authorizedgrantstostates[whichhavediscretioninconstructingtheirownMedicaidprogram].Seealso42CFR§ 430etseq.

State– programs

- Musthave1agencyresponsibleforadministeringMedicaid(NYagency:NYSDept.ofHealth(“DOH”))- Musthavestate-specificplanapprovedbyFed.Dept.OfHealth&HumanServices(DHHS)(§1902ofSocialSec.Act).

ManagedLongTermCare

- MLTCplansaccreditedbyNYSDOHtocoordinatedelivery,quality,costofcare.


ResearchingMedicaidIssuesFederal– Dept.ofHealth&HumanServices• TitleXIXSoc.SecurityAct(42USC§ 1396)• OmnibusReconciliationActs• AffordableCareAct• 42CFR§ 430,etseq.• CenterforMedicare&MedicaidServices• CMSRulings(bindingadministrativedirectivesthatclarify,interpretcomplexorambiguousprovisionsoflaw/regulationsrelatingtoMedicare,Medicaid)

• ApprovedStateMedicaidplan

State– NYSDept.ofSocialServices• NYSDept.ofHealth• OfficeofTemporaryandDisabilityAssistance(“OTDA”)– responsibleforFairHearings(ALJrulings)

• LocalMedicaiddistricts(e.g.,NewYorkCityHumanResourcesAdministration(“HRA”))

• MedicalInsuranceandCommunityServicesAdministration(“MICSA”)–administermedicalprograms

• MedicalAssistanceProgram(“MAP”)–determinewhichindividualsareeligibleforMedicaid;administerHomeCareServicesProgram


ResearchingMedicaidIssues(Continued)

StateGuidance• AdministrativeDirectives(“ADMs”)– bindingdirectivesofpolicyandprocedurestothe58localMedicaiddistricts(i.e.,15OMM/ADM-11)

• GeneralInformationSystemNotices(“GIS”)– provideimmediatedirectionaboutcurrentOTDAprogrampolicyandprocedures(i.e.,GIS15MA/011)

• MedicaidReferenceGuides(“MRGs”)– DOH’sguidetoassistdistrictsindeterminingMedicaideligibilityforbenefits

• NYHealthAccess:http://wnylc.com/health/


BREAK


TransitiontoManagedCareAFederal/Statepartnershipprogramprovidinghealthandlongtermcareinsurancebenefitsforeligibleenrollees.

AhealthinsuranceplanorhealthcaresystemaccreditedbyNYSDept.ofHealthtocoordinatethedelivery,qualityandcostofcare,alsoknownasan“MLTC”.

TraditionalMedicaid

ManagedMedicaid


MedicaidDefinedFederal/StatepartnershipprogramprovidingmedicalbenefitsEstablishedunder42USC§ 1396etseq.,42CFR§ 430etseq.

Eligibilityisbaseduponfinancialneedandmedicalcondition(notage)

Asof2013CenterforMedicareandMedicaidServices(DepartmentofHealthandHumanServices)andNYHealthandHumanResourcesAdministration

WhatisMedicaid?

Whoiseligible?

WhoadministersMedicaid?

18Copyright©2016WeissLawGroup,PLLC

MedicaidProgramsforSeniors

Institutional/NursingHomeCare

Community BasedHomeCare

Waiver&OtherPrograms

Longterm,nursinghomecare(medicalequip.,supplies)MedicalservicesnototherwisecoveredbyinsuranceRoomandboardNursingcareandaides,butnotprivateduty

Homeattendant,homehealthaide,privatedutynursingAssistedliving,adultdaycare,mealsMedicalequipment,supplies,somehomemodificationsPodiatry,audiology,dental,optometry,andothersNon-emergencymedicaltransportation

ConsumerDirectedPersonalAssistanceProgram(“CDPAP”)Update4/1/16:parentcanserveasPA(GIS16MA/006)

EPIC(PrescriptionDrugBenefits)andothersNursingHomeTransitionandDiversionProgram(“NHTD”)

Update3/30/16:programextendeduntilJan2018Copyright©2016WeissLawGroup,PLLC

InstitutionalMedicaidEligibility:2016MedicaidResource&IncomeAllowances

Institutional/NursingHomeCareApplicantResourceAllowance $14,850.00CommunitySpouseResourceAllowance $119,220.00

ApplicantIncomeAllowance $50.00CommunitySpouseIncomeAllowance $2,980.50


CommunityBasedMedicaidEligibility:2016MedicaidResource&IncomeAllowances

CommunityBasedCare(HomeCare,etc.)ApplicantResourceAllowance $14,850.00CommunitySpouseResourceAllowance $21,750.00

ApplicantIncomeAllowance $825.00CommunitySpouseIncomeAllowance $1,209.00


CalculatingIncome

Whatcountsas“Income”?

Includesboth“earned”&“unearned”income

SSI,VA,Union(benefits)Disabilitybenefits,unemploymentInsurancePension&retirementfundsDividends&interestAnnuityandtrustpaymentsRentalincomeCapitalgainsEmployment(tips,wages,salary,bonus)In-kindincome(goods/services)

Examples


CalculatingResources

Whatcountsasa“Resource”?

Anythingofmonetaryvaluethatcanbeconvertedintocash.“Exempt” v.“Nonexempt”:amountsthatMedicaidwill/willnotinclude incalculationofapplicant’sassets

RealEstatePersonalpropertyCash,moneymarketandbankaccountsStocks&bondsAnnuities,IRAs,pensionsLifeInsurancepoliciesBurialfund&pre-paidfuneraltrust

Examples


Whatresourcesare“exempt”?

“Exempt”Resources

Primaryresidence(withexceptions)

Automobile

Lifeinsurance*

Burialfundsintrustupto$1,500

Holocaustsurvivor&ghettopensions

QualifiedIRAs(MRDplans)


BudgetingExample• Ms.M,awidow,livesaloneinaco-opvaluedat$700k.Eachmonth,shereceives$1kinSocialSecurity,and$400fromherqualified-IRA(whichhas$600kremaining).Asidefromherhome,heronlyotherassetsareherIRA(whichsheearnedwhileworking),Checkingaccountwith$8kandSavingsaccountwith$10k.

• CanMs.MqualifyforCommunityMedicaid?• CountableResources:$8k+$10k=$18k ($14,850limit)

CountableIncome:SocialSecurity 1,000.00IRAMRD 400.00

Deductions: - MedicarePartBPremium - 104.90- Incomededuction(foraged,blind,disabled) $- 20.00_____MEDICAIDINCOME $1,275.10 ($825limit)


MedicaidAssetPlanning:SpousalRefusalSpousemayrefusetopayforhealthcareneeds&supportoftheirlegallyrecognizedpartner

SpousalrefusalappliestocommunityMedicaidapplicantsaswellastoinstitutionalMedicaidapplicants(GIS14MA/025)

Medicaid inNYStateBudget2016– 2017(S.6407-C/A.9007-C):• Keeps SpousalRefusal intact• Keeps"SpousalImpoverishment"Resource Allowanceat$74,820insteadofreducingitto$23,820. Thisistheamountofresourcesa"wellspouse"maykeepwhentheotherspouse isinaMLTCplan,waiverprogram,oranursinghome


MedicaidAssetPlanning:SpendDown

Whatisa“SpendDown”

TheamountthatincomeexceedseligibilitylimitsafterreductionforMedicarePartBandotherhealthinsurancepremiums&medicalcarecosts

HealthcareexpensesPrepaymentsofhousingexpensesLegalfeesBurialtrusts/prepaidfuneraltrustReimbursement(NY- nofiliallawsrequiringadultchildrentocareforindigentparents)

Examples


MedicaidAssetPlanning:AssetTransfersAllowed when transfers are for fair market value

“Look Back Period”: Penalty applies to institutional applicants for transfers madewithin 60 month period prior to date of filing application and date that applicantotherwise qualifies forMedicaid

• Precise, complex calculation• Penalty period = # of months calculated using value of the "uncompensatedtransfer" divided by "regional rate" in effect on date application is filed orrequest for increase in nursing home benefits is made

Exceptions for transfer penalty if transfer is to spouse, disabled child (directly, or toSNT)


MedicaidAssetPlanning

AccountManagement

PromissoryNote/Loan

Jointaccounts,intrustaccounts,accountsnotforconvenienceofapplicant(bonafide)

Institutional– 5yearlookbackapplies

Institutional– usedtoshelterapercentageofassetsandreducepenaltyperiod

Gifting



RealEstate PrimaryhomeexemptforcommunityMedicaid,notforinstitutionalMedicaid

Exceptions:• Intenttoreturnhome• Dependentwithspecialneeds• Childlivingwithparentandprovidingsupportenablingparenttoremainathomeforaperiodofnolessthan2years.


MedicaidAssetPlanning:Trusts

Sources:SupplementalNeedsTrusts,NYLAGEvelynFrankLegalResourcesProgram,updatedMarch2016(availableathttp://www.wnylc.com/health/afile/5/9/).

Importanceofproperlydraftingtrustdocumentation!Considerlongtermcareimplications,varioustaximplications.

IntheMatterofFrancesFlanneryv.Zucker (N.Y.Sup.Ct.,App.Div.,4thDept.,No.TP15-01033,Feb.11,2016).

MedicaidAssetPlanningPooled IncomeTrusts

42USC§1396(d)(4)(C))

ForindividualswhoreceivemonthlyincomegreaterthanallowedbyMedicaid“Excessincome”deposited intotrust;thisamountisdisregardedwhendeterminingMedicaideligibility.FundsmanagedbyNYStatecharteredfund(masteraccount)withseparateaccountforeachparticipant(joinderagreement).Fundsmaybeusedforsupplemental needs(i.e.,adaptiveequipment,education,transportation,supplies)notprovidedbyMedicaidUponbeneficiary’sdeath,remainingbalanceofaccountremainsintrusttobenefitspeoplewithdisabilities.


MedicaidAssetPlanningFirstPartySpecialNeedsTrusts

(42U.S.C.1396p(d)(4)(A)

Createdwithassetsownedbybeneficiary;establishedbyparent,grandparent,legalguardian,courtorderforthebenefitofadisabledindividual;mustbeunder65yrs old

*Pendinglegislation:SpecialNeedsTrustFairnessActof2015(S.349,H.R.670):authorizesindividualwithadisability,whohascapacity,tocreatehis/herownSNT

FundsmaybeusedforsupplementalneedsnotprovidedbyMedicaid

Trustisdraftedbyprivateattorneyorfinancialinstitution;privatelymanagedbyfinancialinstitutionorbyaNYScharteredtrust

Upondeathofbeneficiary,Medicaidpayback;balanceofremainingassetsdistributedinaccordancewithtrustterms



ThirdPartySpecialNeedsTrusts

Establishedwithfundsfromsomeoneotherthanthepersonwithadisability

Typicallyusedbyparentsforchild’sbenefit

NoMedicaidpaybackrequirement

Grantorhascompletecontroloverselection ofthetrustremainderbeneficiaries

MaybeIndividualSNTorpooledSNT(seenextslide)


PooledSpecialNeedsTrust

Forindividualswhoreceiveunexpectedsumofmoney(e.g.,inheritance,lawsuitaward)

FundsusedforsupplementalnotprovidedbyMedicaid

FundsmanagedbyNYStatecharteredfund(masteraccount)withseparateaccountforeachparticipant(joinderagreement).

Fundsarepooledwiththefundsofotherdisabledpersons

Uponbeneficiary’sdeath,remainingbalanceofaccountremainsintrusttohelppeoplewithdisabilities.

III.PowerofAttorneyandStatutoryGiftsRider

PowerofAttorney/StatutoryGiftsRider

Legaldocumentusedbyaperson(“Principal”)todelegateauthoritytoanotherperson(“Agent”)tomakefinancial,property,andotherlegaldecisionsforthePrincipal.

AddedtoaPOAandgrantsagentauthoritytomakegiftsonprincipal’sbehalf.

Essentialforelderplanning,taxplanningandprotectsagentfromaccusationsofself-dealing.

StatutoryGiftsRider(SGR)NYGen.Ob.Law§5-1514

PowerofAttorney(POA)NYGen.Ob.Law§5-1501,etseq.


Recommendations

• Donotuseinternetform!• NotallPOAsarealike– customizePOAtofityoursituation,appointanagentyoutrust.• SGRessentialforelder,estateandtaxplanning.• Olderclientstendtohaveoutdatedforms.• Appointmentofagents.• Useofmonitor


LegislativeUpdate– ProposedChangesRevertbacktoone,singleform;eliminateprovisionsrelatingtoSGR

Expandagent’spowertomakeannualgiftsfromcurrent$500to$5,000withoutrequiringtheinsertionofamodificationtotheform

Clarifyagent’sobligationtokeeprecordsorkeepreceipts

Clarifyagent’sauthoritywithregardtofinancialmattersrelatedtohealthcare

Change“exactwording”to“substantiallyconforms”andallowforOptionalsectionsoftheformtobeintentionallyomitted

• Berrian vSienaColl.,129A.D.3d1004,12N.Y.S.3d240(2dDep't2015)(upholdingsummaryjudgmentdismissingacomplaintsignedbyanagentunderPOAstating,“[s]tatutory shortform[POA]andnonstatutory [POA]mustcontaincertain ‘exactwording’inorder‘tobevalid’….”)

IV.HealthCareProxyandLivingWill

HealthCareProxyandLivingWill

Legaldocumentusedbyaperson(“Principal”)todelegateauthoritytoanotherperson(“Agent”)tomakehealthcaredecisionsforthePrincipal.

ProposedHealthCareProxyRegistryBill– (S.S6081;A6307)

HealthCareProxy(HCP)

N.Y.Pub.HealthLaw§§ 2980,etseq.

Legallyrecognizedexpressiononintentmadebyacompetentadultstatinghis/herwisheswithrespecttofuturehealthcaredecisions,includingtheuseoflifesustainingmedicaltreatment,artificialnutritionandhydration,andothers.

LivingWill10NYCRR§400.21(b)(3)


V. ElderLawCaseStudy

VI.Resources• U.S.Dept.ofHealthandHumanServices– AdministrationforCommunityLiving:http://acl.gov/get_help/help_older_adults/index.aspx

• NYCDepartmentfortheAging:http://www.nyc.gov/html/dfta/html/home/home.shtml• NationalAssociationofAreaAgenciesonAging:http://www.n4a.org/• SocialSecurityAdministration:http://www.ssa.gov/• NewYorkStateDepartmentofHealth– AdvanceDirective:http://www.health.ny.gov/professionals/patients/health_care_proxy/index.htm

• Dept.ofHealth,HealthCareProxy:https://www.health.ny.gov/forms/doh-1430.pdf• HIPAAonNYHealthAccess:www.wnylc.com/health/10


MiraB.Weiss,Esq.425MadisonAvenue,Suite901NewYork,NY10017

[email protected](646)395-3851

WeissLawGroup,PLLC

ChelseyB.Axel,Esq.425MadisonAvenue,Suite901NewYork,NY10017

[email protected](646)395-3851


Elder Law 1 final - National Law Institute · 2017-03-20 · Nursing care and aides, but not...

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