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Dementia and Guns: A Tragedy Waiting to Happen

It’s common for families of those with Alzheimer’s and other forms of dementia to realize that at some point, their loved one shouldn’t be allowed to drive. But fewer people know that they should exercise the same level of caution when it comes to restricting their loved one’s access to firearms.

This was one of the findings of a May 2018 study published in the Annals of Internal Medicine covering firearm ownership among Alzheimer’s patients. The study noted that even though 89% of Americans support restricting access to firearms for those with mental illness, there’s been little attention focused on limiting firearm access among elderly dementia patients. Currently there are no federal gun laws prohibiting the purchase or possession of firearms by persons with dementia. And only two states—Hawaii and Texas—have laws restricting gun access for dementia patients.

A ticking time bomb

This lack of attention comes despite an increasing number of incidents involving elderly dementia patients shooting and killing family members and caregivers after confusing them for intruders. And with so many Baby Boomers now entering retirement age, this dangerous situation could get much worse.

In fact, the number of people with dementia is expected to double to around 14 million in the next 20 years, with the vast majority of those over age 65. Nearly half of people over 65 either own a gun or live with someone who does. So it’s clear that firearm safety should be a top priority for those with elderly family members—even if they don’t currently show any dementia signs.

Just talking about restricting someone’s access to guns can be highly controversial and polarizing. Many people, especially veterans and those in law enforcement, consider guns—and their right to own them—an important part of their identity. Given this, the study’s authors recommended that families should talk with their elderly loved ones early on about the fact that one day they might have to give up their guns. Physicians suggest bringing up the topic of firearms relatively soon after individual’s initial dementia diagnosis.

This discussion should be similar to those related to driving, acknowledging the emotions involved and allowing the person to maintain independence and decision control for as long as it’s safe. Even though this can be a very touchy subject, putting off this discussion can literally be life threatening.

All part of the plan

Since it relates to so many other end-of-life matters, this discussion should take place as part of the overall estate planning process. One way to handle the risk is to create a legally binding agreement laying out a “firearm retirement date” that’s similar to advance directives addressing the elderly relinquishing their driving privileges.

Such an agreement allows the gun owner to name a trusted family member or friend to take ownership of their firearms once they’re reached a certain age or stage of dementia. In this way,the process may seem more like passing on a beloved family heirloom and less like giving up their guns. Moreover, the transfer of certain types of firearms must adhere to strict state and federal regulations. Unless the new owner is in full compliance with these requirements, they could inadvertently violate the law simply by taking possession of the guns.

In light of this risk, you should consider creating a “gun trust,” an estate planning tool specially designed to deal with the ownership of firearms. With a gun trust, the firearm is legally owned by the trust, so most of the transfer requirements are avoided, making it a lot easier for family members to manage access after the original owner’s death.

Indeed, gun trusts can be a valuable planning strategy even for gun owners without dementia. Speak with us to see if a gun trust would be a suitable option for your family. A matter of life and death

If you have an elderly family member with access to guns, you should consult with us as your Personal Family Lawyer® as soon as possible. We can not only offer guidance on the the most tactful ways to discuss the matter, but also help you set up the appropriate estate planning strategies to ensure the firearms are properly secured and transferred. Given the grave risks involved, managing the elderly’s access to firearms should be taken every bit as seriously—if not more so—as managing their ability to operate motor vehicles. The safety of both your loved one and everyone who cares for them depends on it. Contact us today to learn more about your options.

This article is a service of attorney Myrna Serrano Setty. Myrna doesn’t just draft documents, she ensures you make informed and empowered decisions about life and death, for yourself and the people you love.That’s why we offer a Planning Session, during which you will get more financially organized than you’ve ever been before, and make all the best choices for the people you love. You can begin by calling our office today to schedule a Family Wealth Planning Session and mention this article to learn how to get this $500 session at no charge.

How to Appeal a Medicare Prescription Drug Denial

If your Medicare drug plan denies coverage for a drug you need, you don’t have to simply accept it. There are several steps you can take to fight the decision.

The insurers offering Medicare drug plans choose the medicines — both brand-name and generic — that they will include in a plan’s “formulary,” the roster of drugs the plan covers and will pay for that changes year-to-year. If a drug you need is not in the plan’s formulary or has been dropped from the formulary, the plan can deny coverage. Plans may also charge more for a drug than you think you should have to pay or deny you coverage for a drug in the formulary because it doesn’t believe you need the drug. If any of these things happens, you can appeal the decision.

File An Exception Request

Before you can start the formal appeals process, you need to file an exception request with your plan. The plan should provide instructions on how to request an exception. The plan must respond within 72 hours or 24 hours if your doctor explains that waiting 72 hours would be detrimental to your health.

5 Steps Appeals Process

If your exception is denied, the plan should send you a written denial-of-coverage notice and a five-step appeals process can begin.

  1. The first step in appealing a coverage determination is to go back to the insurer and ask for a redetermination, following the instructions provided by your plan. You should submit a statement from your doctor or prescriber that explains why you need the drug you are requesting, along with any medical records to support your argument. If your doctor informs the plan that you need an expedited decision due to your health, the plan must notify you within 72 hours. For a standard redetermination, the plan must notify you within seven days.
  2. If you disagree with the drug plan’s decision, you have the right to reconsideration by an independent board. To request reconsideration, follow the instructions in the written redetermination notice you receive from the insurer. You have 60 days from the redetermination notice to request reconsideration. An independent review entity (IRE) will review the case and issue a decision either within 72 hours or seven days. If you receive a negative decision, you can keep appealing.
  3. The third level of appeal is to request a hearing with an administrative law judge (ALJ), which allows you to present your case either over the phone or in person. To request a hearing, the amount in controversy must be at least $160 (in 2018). The amount in controversy is calculated by subtracting any amount already covered under Part D, and any deductible, co-payments, and coinsurance amounts applicable to the Part D drug at issue, from the projected value of the drug benefits in dispute. Your request for a hearing must be sent in writing to the Office of Medicare Hearings and Appeals (OMHA). The ALJ is supposed to issue an expedited decision within 10 days or a standard decision within 90 days.
  4. If the ALJ does not rule in your favor, the next step is a review by the Medicare Appeals Council. The appeal form must be filed within 60 days after the ALJ’s decision. You will need a statement explaining why you disagree with the ALJ’s decision. The appeals council will issue an expedited decision in 10 days or a standard decision within 90 days.
  5. The final step is review by a federal district court. To be able to request review, the amount in controversy must be $1,600 (in 2018). Follow the directions in the letter from the appeals council and file the request in writing within 60 calendar days.This article is service of attorney Myrna Serrano Setty. Myrna doesn’t just draft documents, she guides her clients so that they can make the best decisions for themselves and their families. Contact Myrna at (813) 514-2946 to schedule your elder law consultation today.

Case Study: Two Brothers Fighting Over Long-Term Care

A recent New Jersey appeals court case shows how important it is for families to come up with a long-term care plan before an emergency strikes. The case involves two brothers who got into a fight over whether to place their mother in a nursing home – a dispute that resulted in one brother filing a restraining order against the other.

Brother vs. Brother

R.G. was the primary caregiver for his parents and their agent under powers of attorney. After R.G.’s mother fell ill, R.G. wanted to place his mother in a nursing home. R.G.’s brother objected to this plan, but R.G. went ahead and had his mother admitted to a nursing home without his brother’s consent. R.G.’s brother sent angry and threatening texts and emails to R.G. as well as emails expressing his desire to find a way to care for their parents in their home. Eventually the men got into a physical altercation in which R.G.’s brother shoved R.G.

R.G. went to court to get a restraining order against his brother under the state’s Prevention of Domestic Violence Act. The trial judge ruled that R.G. had been harassed and assaulted and issued the restraining order. R.G.’s brother appealed, arguing that R.G. did not meet the definition of a victim of domestic violence.

What is Domestic Violence?

In R.G. v. R.G. (N.J. Super. Ct., App. Div., No. A-0945-15T3, March 14, 2017), a New Jersey appeals court reversed the trial court, ruling that R.G.’s brother’s actions did not amount to domestic violence. According to the court, there was insufficient evidence that R.G.’s brother purposely acted to harass R.G., ruling that “a mere expression of anger between persons in a requisite relationship is not an act of harassment.”

Keep This From Happening in Your Family

If the brothers had sat down with their parents before they needed care to explore options and determine their parents’ wishes, this drawn-out and costly dispute might have been totally avoided. Putting a long-term care plan into place can help avoid family conflicts like this one.

To start planning for long-term care, talk to us to help you design the best plan for you.

 

5 Reasons to Hire an Attorney for Medicaid Planning

Many seniors and their families don’t use a lawyer to plan for long-term care or Medicaid, often because they’re afraid of the cost. But a qualified lawyer can help you save money in the long run as well as make sure you are getting the best care for your loved one.

Instead of taking steps based on what you’ve heard from others, doing nothing, or enlisting a non-lawyer referred by a nursing home, you can hire an elder law attorney. Here are a few reasons why you should at least consider this option:

#1 No conflict of interest

When nursing homes refer the families of residents to non-lawyers to assist in preparing the Medicaid application, the preparer has dual loyalties, both to the facility that provides the referrals and to the client applying for benefits. To the extent everyone wants the Medicaid application to be successful, there’s no conflict of interest. But it’s in the nursing home’s interest that the resident pay privately for as long as possible before going on Medicaid, while it’s in the nursing home resident’s interest to protect assets for the resident’s care or for the resident’s spouse or family. A lawyer hired to assist with Medicaid planning and the application has a duty of loyalty only to the client and will do her best to achieve the client’s goals.

#2 Saving money

Nursing homes can cost as much as $15,000 a month in some areas, so it is unusual for legal fees to equal the cost of even one month in the facility. It is not difficult to save this much in long-term care and probate costs. And most attorneys will consult with new clients at little or no cost to determine what might be achieved before the client pays a larger fee.

#3 Deep knowledge and experience

Professionals who work in any field on a daily basis over many years develop both the depth and breadth of experience and expertise to advise clients on how they might achieve their goals, whether those are maintaining independence and dignity, preserving funds for children and grandchildren, or staying home rather than moving to assisted living or a nursing home. Less experienced advisers, however well intentioned, can’t know what they don’t know.

#4 Malpractice insurance

While we should expect that every professional we work with will provide outstanding service and representation, sometimes things don’t work out. Fortunately there is a remedy if an attorney makes a mistake because almost all attorneys carry malpractice insurance. This is probably not the case with other advisers in the Medicaid arena.

#5 Peace of mind

While it’s possible that when you consult with an elder law attorney, the attorney will advise you that in your situation there is not much you can do to preserve assets or achieve Medicaid eligibility more quickly, the consultation will provide peace of mind that you have not missed an important opportunity. In addition, if obstacles arise during the process, the attorney will be there to work with you to find the optimal solution.

Medicaid rules provide multiple opportunities for nursing home residents to preserve assets for themselves, their spouses and children and grandchildren, especially those with special needs. There are more opportunities for those who plan ahead, but even at the last minute there are almost always still steps available to preserve some assets. It’s always worth checking out whether these are steps you would like to take.

 

Medicare’s Treatment of the Two Main Hospital Stay Options

Hospital patients who need additional care after being discharged from the hospital are usually sent to either an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF). Although these facilities may look similar from the outside, Medicare offers very different coverage for each. While you may not have complete say in where you go after a hospital stay, understanding the difference between the two facilities can help you advocate for what you need and know what to expect with regard to Medicare coverage.

Inpatient Rehabilitation Facility vs. Skilled Nursing Facility

An IRF can be either part of a hospital or a stand-alone facility that offers intensive physical and occupational therapy under the supervision of a doctor and nurses. IRFs offer a minimum of three hours a day of rehabilitation therapy. But a SNF provides full-time nursing care. Patients also receive physical and occupational therapy, but the care is generally less intensive and specialized than in an IRF.

IRFs and Medicare

Medicare Part A covers a stay in an IRF in the same way it covers hospital stays. Medicare pays for 90 days of hospital care per “spell of illness,” plus an additional lifetime reserve of 60 days. A single “spell of illness” begins when the patient is admitted to a hospital or other covered facility, and ends when the patient has gone 60 days without being readmitted to a hospital or other facility. There is no limit on the number of spells of illness. However, the patient must satisfy a deductible before Medicare begins paying for treatment. This deductible, which changes annually, is $1,364 in 2019.

After the deductible is satisfied, Medicare will pay for virtually all hospital charges during the first 60 days of a recipient’s hospital stay. If the hospital stay extends beyond 60 days, the Medicare beneficiary begins shouldering more of the cost of his or her care. From day 61 through day 90, the patient pays a coinsurance of $341 a day in 2019. Beyond the 90th day, the patient begins to tap into his or her 60-day lifetime reserve. During hospital stays covered by these reserve days, beneficiaries must pay a coinsurance of $682 per day in 2019.

To qualify for care in an IRF, you must need 24-hour access to a doctor and a nurse with experience in rehabilitation. You must also be able to handle three hours of therapy a day (although there can be exceptions).

SNFs and Medicare

Medicare’s coverage of skilled nursing care is more limited. Medicare Part A covers up to 100 days of “skilled nursing” care per spell of illness. Beginning on day 21 of the nursing home stay, there is a copayment equal to one-eighth of the initial hospital deductible ($170.50 a day in 2019).

But the conditions for obtaining Medicare coverage of a nursing home stay are quite stringent. Here are the main requirements:

  • The Medicare recipient must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; “observation status” does not count) that itself lasted for at least three days (not counting the day of discharge).
  • The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
  • The patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered “skilled,” nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse or licensed practical nurse. Moreover, such care must be delivered on a daily basis. (Few nursing home residents receive this level of care.)A new spell of illness can begin if the patient has not received skilled care, either in an SNF or in a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care during that 60 days.

Keep in mind that some or all of Medicare’s deductibles and co-payments for both IRF and SNF care may be covered by Medicare supplemental insurance, also called Medigap coverage.

 

Important Changes in Veterans’ Long-Term Care Benefits

It’s now harder than ever for veterans to qualify for long-term care benefits.

Recently, the Department of Veterans Affairs (VA) finalized new rules that make it more difficult to qualify for long-term care benefits. The rules establish an asset limit, a look-back period, and asset transfer penalties for claimants applying for VA pension benefits that require a showing of financial need. The main benefit for those needing long-term care is Aid and Attendance.

The VA offers Aid and Attendance to low-income veterans (or their spouses) who are in nursing homes or who need help at home with everyday tasks like dressing or bathing. Aid and Attendance provides money to those who need assistance.

Currently, to be eligible for Aid and Attendance a veteran (or the veteran’s surviving spouse) must meet certain income and asset limits. The asset limits aren’t specified, but $80,000 is the amount usually used. However, unlike with the Medicaid program, there historically have been no penalties if an applicant divests him- or herself of assets before applying. That is, before now you could transfer assets over the VA’s limit before applying for benefits and the transfers would not affect eligibility.

New Regulations in Effect October 18, 2018

Not so anymore. The new regulations set a net worth limit of $123,600, which is the current maximum amount of assets (in 2018) that a Medicaid applicant’s spouse is allowed to retain. But in the case of the VA, this number will include both the applicant’s assets and income. It will be indexed to inflation in the same way that Social Security increases. An applicant’s house (up to a two-acre lot) will not count as an asset even if the applicant is currently living in a nursing home. Applicants will also be able to deduct medical expenses — now including payments to assisted living facilities, as a result of the new rules — from their income.

Three-Year Look-Back Provisions

The regulations also establish a three-year look-back provision. Applicants will have to disclose all financial transactions they were involved in for three years before the application. Applicants who transferred assets to put themselves below the net worth limit within three years of applying for benefits will be subject to a penalty period that can last as long as five years. This penalty is a period of time during which the person who transferred assets is not eligible for VA benefits. There are exceptions to the penalty period for fraudulent transfers and for transfers to a trust for a child who is unable to “self-support.”

Under the new rules, the VA will determine a penalty period in months by dividing the amount transferred that would have put the applicant over the net worth limit by the maximum annual pension rate (MAPR) for a veteran with one dependent in need of aid and attendance. For example, assume the net worth limit is $123,600 and an applicant has a net worth of $115,000. The applicant transferred $30,000 to a friend during the look-back period. If the applicant had not transferred the $30,000, his net worth would have been $145,000, which exceeds the net worth limit by $21,400. The penalty period will be calculated based on $21,400, the amount the applicant transferred that put his assets over the net worth limit (145,000-123,600).

The new rules went into effect on October 18, 2018. The VA will disregard asset transfers made before that date. Applicants may still have time to get through the process before the rules are in place.

Veterans or their spouses who think they may be affected by the new rules should contact their attorney immediately.

This article is a service of the Law Firm of Myrna Serrano Setty, P.A. We don’t just draft documents, we guide our clients to make the best choices for themselves and their loved ones.

Estate Planning Mistakes Seniors (Including You or Your Parents) Can’t Afford to Make

couple, elderly, man

It’s no secret that many of us put off estate planning. But once you or your parents reach senior status, you really can’t afford to put it off any longer. Unfortunately, without proper planning, seniors can lose everything, even if they have family to look after them. Having a will isn’t enough.

More and more, the media is highlighting stories of seniors being taken advantage of, and even being targeted by unscrupulous professional guardians. The New Yorker  recently published an article about many seniors in Nevada that were targeted by professional guardians, had their rights and property stripped away, and were isolated from their own families.

While planning for your incapacity and death can be scary, it’s even scarier to think of all the horrible things that can happen to your family if don’t have the right planning in place.

Here are a some of the most common mistakes that seniors make:

Mistake #1: Not creating advance medical directives

In your senior years, health care matters become much more relevant and urgent. At this age, you can no longer afford to put off important decisions related to your medical needs. How do you want your medical care handled if you become incapacitated and can’t communicate your wishes? And at the end of life, how do you want your medical care handled? You can address both of these situations with a Designation of Health Care Surrogate and a Living Will.

With the Designation of Health Care Surrogate, you appoint a health care decisionmaker that can step in for you when you can’t make your own health care decisions. With the Living Will, you provide guidelines for what medical care you want or don’t want at the end of your life. You can even include other instructions, such as who can visit you.

Mistake #2: Relying only on a will

Many people mistakenly believe that a will is the only estate planning tool they need. While wills are definitely one key aspect of estate planning, they come with some serious limitations:

● Wills require your family to go through probate, which is open to the public, can be time consuming and expensive.
● Wills don’t offer you any protection if you become incapacitated and unable to make legal and financial decisions.
● Wills don’t cover jointly owned assets or those with beneficiary designations, such as life insurance policies.
● Wills don’t shield assets from your creditors or those of your heirs.
● Wills don’t provide protections or guidance for when and how your heirs take control of their inheritance.

Mistake #3: Not keeping your plan current

Far too often people prepare a will or trust when they’re young, put it into a drawer, and forget about it. But your estate plan is worthless if you don’t regularly update it when your assets, family situation, and/or the laws change.

We recommend you review your plan at least every three years to make sure it’s up to date and immediately amend it following events like divorce, deaths, births, and inheritances. And if you have a trust in place, you need to make sure that you’re using it properly. Many people who have trusts aren’t using them effectively, leaving their property vulnerable to probate or mismanagement.

Mistake #4: Not pre-planning funeral arrangements

Although most people don’t want to think about their own funerals, pre-planning these services is a key facet of estate planning, especially for seniors. By taking care of your funeral arrangements ahead of time, you not only eliminate the burden and expense for your family, you’re able to make your memorial ceremony more meaningful, as well.

In addition to basic wishes, such as whether you prefer to be buried or cremated, you can choose what kind of memorial service you want—simple, elaborate, or maybe none at all. Are there songs you want played? Prayers or poems recited? Do you have a specific burial plot or a spot where you want your ashes scattered?

Pre-planning these things can help relieve significant stress and sadness for your family, while also ensuring your memory is honored exactly how you want. It’s important that you take care of your estate planning immediately and avoid these common mistakes. Our firm can walk you step-by-step through the process, ensuring that you have everything in place to protect yourself, your assets, and your family.

This article is a service of attorney Myrna Serrano Setty. Myrna doesn’t just draft documents, she helps her clients make informed and empowered decisions about life and death, for themselves and the people they love. Contact Myrna today at (813) 514-2946.