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Every year the Social Security Administration publishes its list of Supplemental Security Income & Spousal Impoverishment Standards that are adjusted for inflation. These standards define the minimum and maximum amount of resources and income limits that an individual and/or their spouse can have in order to be on Medicaid. Here are the new numbers for 2021 (also available on the Medicaid Website):
Income Cap Limit for an Individual: $2,382.00 per month
Resource Cap for an Individual: $2,000 per month (same as previous year)
Minimum Monthly Maintenance Needs Allowance (MMNA): $2,155.00
Maximum Monthly Maintenance Needs Allowance: $3,259.50
Community Spouse Resources:
Minimum Resource Standard: $26,076.00
Maximum Resource Standard: $130,380.00
Home Equity Limits:
The expense of nursing home care can devastate a family’s resources as expenses for a nursing home rise. Currently, a stay at a skilled nursing facility can easily cost $15,000 or more per month. It seems hard to fathom how a couple can survive on the above thresholds, especially if there is a “Community Spouse” (i.e. spouse living in the community). There are strict rules for the use of income of the spouse on Medicaid and an even stricter limit for resources. These rules are complex and hard to navigate. However, with the proper legal guidance and direction, you can help plan for your or your loved one’s nursing home care costs, or plan to receive home and community-based waiver services. Whether you or a loved one is looking to qualify for Medicaid or continue to remain eligible for Medicaid to supplement the cost of long-term care, Rao Legal Group is here to help! Contact us via our website at www.EstateElderPlanning.com or call our office at 609-372-2855 to see how we can help you!
Amidst an ongoing pandemic, you may have heard some well-meaning declarations urging you to make sure your health care documents are in order. However, there are many kinds of health care documents, and it can be difficult to know what you need and what gaps there may be in any documents you already have prepared. This article is not intended to serve as legal advice, but it may provide an overview of the available types of health care documents so that you are prepared to speak to an attorney about ensuring you have a plan in place that is comprehensive and accurately represents your wishes.
The first and most general document is the HIPAA waiver. The Health Insurance Portability and Accountability Act (HIPAA) sets national standards for the protection of personally identifiable health information. Because of this Act, doctors and other health care professionals are limited as to who they may share health information with, including family members of their patients. A HIPAA waiver authorizes doctors, hospitals, and long-term care facilities to disclose protected health information to certain individuals named in the document. A public health emergency does not mean HIPAA no longer applies; while certain jurisdictions have adjusted guidelines to allow doctors to communicate with those involved in the coordination of care, without a waiver in place, communication is not guaranteed. Executing a HIPAA waiver when competent makes clear who you want your doctors and other caretakers to speak to and give advice regarding your care. Without one, family and friends may be unable to receive information from doctors while you are being treated, which can add additional stress and uncertainty to a situation that is already stressful for your loved ones.
While many advanced health care directives include a section for HIPAA rights, if this is separated out into a stand-alone document, then not everyone who you may name in a HIPAA waiver needs to be or should be able to make health care decisions on your behalf. In that case, to give someone that power, you should execute a Health Care Power of Attorney (HCPOA). A power of attorney is a document that allows named people to act in your place. Many people are familiar with this kind of document as it relates to finances (authorizing someone to deal with your bank on your behalf, organize to have your bills paid, etc.), but it exists for your healthcare too. A HCPOA names someone who can legally make decisions about your care with health care providers. Depending on what powers you include, this document may authorize them to consent to (or refuse to consent to) your medical treatment, hire or fire medical personnel, make decisions about the best medical facilities for you, visit you when visiting is otherwise restricted, gain access to your medical records, and get court authorization if a hospital or doctor refuses to honor your own wishes or your authority as the authorized representative. A HCPOA does not automatically authorize someone to consent or refuse consent to organ donation, as the document’s authority terminates upon your death. However, in some states as in New Jersey, you may choose to draft the document in a way that covers authority over the disposition of your body. Additionally, you may even choose to have your healthcare representative make end-of-life decisions if you do not want to execute a Living Will (see more on that below) which shifts the responsibility over to one or more doctors. Therefore, the importance of this document is immense. Instead of only relying on doctors who you may have a limited or no relationship with, you can designate someone you trust to carry out your wishes regarding end of life if you are unable to. Although most states allow family members to step in as care coordinators (with an order of preference usually beginning with the spouse), a lack of this document can still be problematic and cause unnecessary tension and stress on the family in deciding the best course of action thereby taking precious time away from coping with your illness.
Complementing the two above documents, especially if you have particular intentions on end-of-life decisions, is the Living Will. The Living Will lays out specific directions about types of treatment you want or do not want should you go into a terminal state where there is no meaningful chance of your recovery. It can be as comprehensive or as limited as you want, depending on your preferences of different types of treatment. Typical procedures mentioned in a Living Will might be blood transfusions, CPR, dialysis, use of a respirator, surgery, or palliative care. Particularly amidst the continued spread of the COVID-19 pandemic and as people realize that they may not desire to be put on a respirator should they be hospitalized with this illness (where a number of people who need to be hospitalized end up on respirators), you should consider whether you want to revisit these preferences noted in this document. This is especially important when you may not have communicated your preferences to your HCPOA. Without a Living Will, the person making health care decisions on your behalf will have to guide those decisions. It’s a significant burden that you will be imposing on him or her so you should make thoughtful decisions. You should speak to both your elder care attorney and members of your family to decide the pros and cons of executing a Living Will, and if one should be included in your plan. Having this important discussion ahead of time will allow you to decide whether or not entrusting family with this decision is a good idea.
Finally, there is another document called the POLST or Practitioner Orders for Life Sustaining Treatment. Similar to a Living Will, this is also a directive for a specific method of care during the end of life stages; however, a POLST is typically executed somewhat later on than a Living Will might be. They are generally intended for patients who are at risk of a life-threatening clinical event or who may experience a life-threatening clinical event while already under facility care (thus, most facilities have long-term residents sign one upon entry). It is a form made legal with a signature from you (or your agent) and your doctor that is portable between different medical institutions like hospitals and nursing homes, or even to your home, without needing to be changed each time. Every state has its own form, but there is some reciprocity across states. POLST forms are often filled out by a nurse or social worker when someone is admitted to the hospital and the patient is at risk of significant deterioration; this is what makes them so important right now. In June 2020, ventilators have become vitally necessary for many patients suffering from severe cases of COVID-19. At-risk groups such as the elderly or those with underlying medical conditions have difficulty coming off a ventilator, and some people would rather die in dignity than spend weeks or months on a ventilator or other artificial life-extending device. However, if that person does not have proper documentation directing their health providers to follow their wishes—if they don’t tell a doctor or loved one that they don’t want a ventilator—the patient will be put on a ventilator if the situation arises and it is necessary to prolong life.
When we consider health care documents from these perspectives, it is clear that a lack of articulated intentions results in stress, confusion, and poor health outcomes (where a positive health outcome is measured by patient satisfaction with care as well as physical health). The creation of advanced health directives is an action taken to protect both yourself and your loved ones from unnecessary grief in the future. Planning for incapacity, no matter the source of the incapacity, is a vital part of any sound estate plan that is unfortunately sometimes overlooked until it is too late. The best thing you can do to prepare yourself and your loved ones is speak to a specialized estate planning attorney to implement your own advanced health directives. Rao Legal Group, LLC (“RLG”) is committed to providing comprehensive estate plans which always include advanced health care directives and financial powers of attorney to help you and your loved ones plan for incapacity. We are only a phone call away.
- 1. https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html
- 2. https://www.nolo.com/legal-encyclopedia/living-will-power-of-attorney-29595.html
- 3. https://www.nolo.com/legal-encyclopedia/living-will-power-attorney-medical-issues-29536.html
- 4. “Importance of POLST During the COVID-19 Pandemic” webinar given by Goals of Care Coalition of New Jersey
It’s hard to believe that the holiday season is well behind us and we are into the first week of February! This post was originally scheduled for a January submission but due to a recent good interruption last week (my attendance at the Heckerling Conference on Estate Planning in Orlando, Florida), there was a slight delay. Stay tuned for my musings of the conference in the coming weeks. Thank you!
We all know that people download Wills off of Legal Zoom thinking that “some” plan in place is better than none at all; rather than incur the expense of engaging an attorney, their thought is to come up with a quick solution to ensure their family’s protection. The problem with this approach is that one may actually be causing more harm than good. For ex. if all a person created was a Last Will & Testament, then what happens if that person got hit by a truck and went into a coma for several months or years? What does the family do when they need to pay bills, run the household or just take care of the incapacitated person? Any good estate planning attorney will offer as part of the estate planning package along with a Last Will & Testament, a broad and robust Financial Power of Attorney as well as a Health Care Directive naming an Authorized Representative to make decisions upon incapacity.
Okay, so I know you are thinking: “Fine – I’ll just download these Powers of Attorney and I am all set. From what you say, these documents are all I need to cover me then, right?” Not so fast! Drafting your own legal documents with the help of Legal Zoom or other online software tools is like trying to fix your car using a manual. I don’t know about you but I know I will not get very far fixing a carburetor using a manual.
There are specific powers in a power of attorney that we look for when we help families – from the Medicaid planning perspective, I am looking for certain powers of the agent to help an aging parent or spouse set up trusts or apply for government benefits; for banks, I want to ensure that the agent has all of the proper authority under the document that banks are looking for; gift giving provisions are hugely helpful where there is a taxable estate and assets need to be transferred out of the estate when someone is incapacitated but where death may be imminent.
Finally, most people are clueless when you talk to them about the difference between probate and non-probate assets. To give you some perspective – let’s talk about a widowed surviving spouse who takes it upon himself to draft all of the required documents discussed above and gets them properly signed, witnessed & notarized. And let’s also say that this individual was savvy enough to ensure that his two minor children do not get the assets from his estate outright but rather he designed the Will to put those assets into a trust for his children until age 30. Now let’s assume that this individual has a primary residence that he owns “joint tenants with a right of survivorship or JTWROS” with his brother and the only other asset he has is a significant life insurance policy where he has named his children as primary beneficiaries in equal shares on the designated beneficiary form. Imagine this individual’s surprise when he is told that his beautifully designed Will cannot work as intended because at his death, these assets would bypass the Will and be handed to the named beneficiaries directly! These are red flags that a good estate planner will point out and take it upon himself or herself to ensure that the documents are designed in a way that fulfill the Testator’s objectives.
It’s difficult to understand the work estate planning attorneys do on the back-end. Although I have heard people stating this quite often, good estate planning is never about simply “copying & pasting” or using “boiler-plate” documents. Each family’s situation is unique and even the most straightforward family situation may present nuances that are unique only to that family. My job is to ensure that you or your family never have to spend wasted money undoing mistakes and hopefully never have to enter a court of law to contest or dispute the provisions contained within the documents.