Major Breakthrough in Medicare Coverage for Chronic Illnesses

hands of old and youngFor years we have accepted the fact that Medicare will only cover physical therapy for patients who are continuing to improve. When my mother broke her hip the therapists informed her doctor that Medicare coverage for rehabilitation would cease after only three weeks of therapy. They told us that she would have to return to her assisted living residence even though she was still not able to walk. Their conclusion: She was no longer improving and it was likely she would never walk again.

Of course this was complicated by the fact that she had dementia and couldn’t remember the exercises they had prescribed for her a few minutes after she left the therapy room. But we accepted their conclusion without making a fuss and she has been in a wheelchair for the last five years.

But a major change has recently occurred in Medicare. One that has been kept very quiet but will have a huge impact on patients who have chronic illnesses. Medicare officials updated the agency’s policy manual in January. This is the rule book for everything Medicare does.  They stated that Medicare will now pay for physical therapy, nursing care and other services for beneficiaries with chronic illnesses like Multiple Sclerosis, Parkinson’s and Alzheimer’s disease in order to maintain their condition and prevent deterioration.

This dramatic change is due to the settlement of a class-action lawsuit filed in 2011 against Kathleen Sebelius , the Secretary of Health and Human Services by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson’s Action network and the Alzheimer’s Association. The settlement affects care from skilled professionals for physical, occupational or speech therapy and home health and nursing care, for patients in both traditional Medicare and private Medicare Advantage plans.

The change will have the greatest impact on seniors who want to avoid having to go into an institution to get care. People with chronic illnesses like Parkinson’s or MS may be able to get the care they need and stay in their own homes.

Existing eligibility criteria for Medicare rehabilitation benefits have not changed however. To be admitted to a rehab. facility or nursing home for covered care the patient must have spent three consecutive midnights in the hospital as an admitted patient and the patient must be referred by a Doctor’s order prescribing skilled nursing home care not custodial care.

For home health coverage, the beneficiary must have a Doctor’s order for intermittent care ( every few days or weeks) provided by a skilled professional or outpatient therapy, social work services or a visiting nurse. Beneficiaries receiving skilled services at home are also eligible for home health care aides for assistance with bathing, dressing and other daily activities.

The settlement also provides for a review of claims that were denied in the past three years solely because patients were not improving. Officials have posted a form on the Medicare site to repay beneficiaries for the care they paid for themselves. This form must be submitted by July 23, 2014 for claims that were denied from Jan. 18, 2011 to Jan. 24, 2014. Claims denied between Jan. 25, 2013 and Jan. 23, 2014 must be submitted by Jan. 25, 2015


Join the War Against Alzheimer’s

losing one's memory

losing one’s memory

Nearly half of all seniors who need some form of long term care, from help at home to institutional care, have dementia. That’s from the World Alzheimer Report which came out a few weeks ago.

The report further states that cognitive impairment is the strongest predictor of who will move into a care facility in the next two years. That is 7.5 times greater than people stricken with cancer, heart disease or other chronic ailments.

More than 35 million people worldwide, including 5 million in the U.S., are estimated to have Alzheimer’s. Unless some miracle cure is found these numbers are expected to double by the year 2050.

Unfortunately the U.S. is investing only $400 million a year in Alzheimer’s research. But the disease’s financial toll is estimated to be $200 billion per year. Compare that to the budget of the National Cancer Institute, part of the Department of Health and Human Services. For the last 6 years it has had a budget of $4.9 billion per year.

It’s time for caregivers, advocates and families stricken by Alzhemier’s to come to together to demand a push to end this brain disease. The world’s governments and researchers came together to turn the AIDS virus from a death sentence to a chronic disease and the same force of will can turn Alzheimer’s around.

If you want to get a clear picture of what Alzhemier’s is like from the patient’s perspective I suggest you read Lisa Genova’s book, “Still Alice” or read Dr. David Hilfiker’s blog, “Watching the Lights Go Out.” He is a retired physician who was diagnosed with Alzheimer’s in September, 2012, Lisa Genova’s book is fictional but was based on her experiences working with support groups for people who contracted the disease.

During my 33 years as a financial advisor I met with many couples and strongly recommended that they put together a long term care plan while they were healthy. I was emphatic when I suggested that they consider buying long term care insurance to protect themselves. Most people don’t realize that medicare will not cover the custodial care that an Alzheimer’s patient will require. It is only available for up to 100 days if a person is expected to recover from an illness or injury.

Long term care insurance covers cognitive impairment from Alzhemier’s or other forms of dementia. Time and time again people told me that long term care insurance was too expensive. But all they had to do was to talk to a few of my clients who discovered that the cost of care was much more expensive! Here in New England care in a residence that focused on those with mental impairment averages more than $8000 per month and in some cases is over $10,000 a  month.

The Coming Caregiver Crisis

Caregiver CrisisOne third of the families in the United States provide long term care for a disabled or elderly family member. Two thirds of these caregivers are women. And one half of them are working.

These family caregiver are critical for the elderly to remain in their homes  when disability strikes. More than two- thirds (68 percent) of Americans believe that they will be able to rely on their loved ones to meet their long term care needs when they require help, but this belief may collide with the reality of dramatically shrinking availability of family caregivers.

According to an AARP study, in 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.

By 2030, the ratio is projected to decline sharply to 4 to 1; and it is expected to further fall to less than 3 to 1 in 2050, when all boomers will be in the high-risk years of late life.

If fewer family members are available to provide everyday assistance to the growing numbers of frail older people, more people are likely to need institutional care—at great personal cost—as well as costs to health care programs. Greater reliance on fewer family caregivers to provide home- and community-based services could also add to costs borne by family members and close friends—in the form of increasing emotional and physical strain, competing demands of work and caregiving, and financial hardships.

The decades of the 2010s and 2020s will be a period of transition, as boomers age out of the peak caregiving years and the oldest boomers age into the 80-plus high-risk years.

The departure of the boomers from the peak caregiving years will mean that the population aged 45–64 is projected to increase by only 1 percent between 2010 and 2030. During the same period, the 80-plus population is projected to increase by a whopping 79 percent.

It is critical that families begin the conversation now to create a long term care plan for elderly family members. Do not wait for it to become an immediate crisis. The family must have a serious meeting to answer the following three questions.

  1. If mom or dad becomes incapacitated, where will they live?
  2. Who will take care of mom or dad if they need custodial care? 
  3. How will they pay for this care?

The answers to these questions will form the basis for a long term care plan. If family members disagree regarding the answers to these questions, compromises must be made. The entire family must come to a consensus that everyone can live with or risk the disintegration of the family.

9 Critical Steps to Protect Your Aging Parents

  1. Review all life insurance policies, annuities and IRA accounts to verify primary and contingent beneficiaries. List account numbers and contact information
  2. Establish Durable Power of Attorney and name appropriate person to hold that power
  3. Identify Health Care Proxy and describe extent of care desired through a living will (I suggest you use Five Wishes form from
  4. Discuss long term care plan with parents
  5.  Review will and any trust agreements to determine if still relevant and confirm who executor/executrix and trustee is.
  6. List all bank and investment accounts, identifying account numbers and who the legal account holder is.
  7. Identify all internet based accounts, listing web address, user name and password. List beneficiary for each account.
  8. Identify all key professional contacts including, attorney, financial adviser, accountant, banker and spiritual adviser. Note desired contact information.
  9.  Maintain a record of where all the above forms, documents and information are stored. I suggest using either a three ringed notebook or a web based dropbox for storage. make sure your spouse and children know the location of these records

Do You and Your Aging Parents Have a Digital Estate Plan?

ImageYou may be comfortable that your have your estate plan in order. You have a will, a durable power of attorney, a living will and a health care proxy. But do you have a digital estate plan?

In the past, we kept albums full of snapshots, vinyl records and shoeboxes full of correspondence. Now our photos are all on Flickr and IPhoto, our music is downloaded from ITunes and our correspondence is email via Yahoo or Google. Naomi Cahn, a law professor at George Washington University, stated that most adults have 20-25 accounts on the internet. And many of those accounts are for banking or investments.

Have you given instructions to your family on what to do with your internet accounts if you should die? And do they even know how to access those accounts? User names, passwords, internet addresses?

The family of Ricky Rash, a 15 year old who committed suicide in 2011, discovered how difficult it was to recover information from their deceased son’s internet account. In an effort to understand why he had taken his own life, they requested but were refused access to his Facebook account.

Facebook claimed that according to the Stored Communications Act of 1986 – the federal law that governs the protection of a person’s electronic data – even the account of a minor is protected from access by his parents or anyone else.  Other sites and providers interpret the legislation this way, making access all but impossible.

There are only five states that have taken any steps to help recover the internet data of a deceased person—Indiana, Idaho and Oklahoma legislation covers social media and blogging accounts, while Connecticut and Rhode Island legislation covers only email.

What does this mean for you? It is critical that you create a digital estate plan. The listing of internet accounts needs to be comprehensive. Information must include:

  • the name of the account
  • the contents of the account
  • the URL address
  • username
  • password
  • instructions for the disposition of the account including the person to oversee such disposition.

I have created a new spreadsheet to gather this information. Email me at and I will send it to you.

There is a whole new industry that has been created to service your digital estate including, a new digital estate planning service. You can create an account and then enter your user names, passwords and wishes for each of your digital assets. You can specify an heir for each account; Legacy Locker will provide heirs with information after the account holder’s death is verified.

There are also online memorial services to celebrate your client’s life, including, and These services enable your clients to create their own memorials before they pass away. Facebook and Twitter also offer these services for family members.

The importance of having a digital estate plan will increase as more and more of our assets (and access to assets) are online. Gradually laws will evolve to give family members access to deceased loved ones’ accounts. It is important to prepare your clients for the disposition of their digital assets now so that family members will not be unpleasantly surprised when they attempt to uncover them.

If you want to explore digital estate planning in more detail read Evan Carroll’s excellent book Your Digital Afterlife.  This book was the source of many of the sites I mention in this article.

How to be by the bedside

  • When one of your parents is very sick, you may not know what to do or expect. The time you spend with them by their bedside is very important. It is time that you will never forget. You may find it very difficult and very uncomfortable to be there but you will be glad you did it when it is over.

People are very different in how they handle serious illness. You are just going to have to let them deal with it in their own way. They may just act the way you have always known them or they may seem like a totally different person to you. A lot depends on the type of illness they have and whether or not recovery is possible.

Your loved one may be afraid of dying, tired all the time, confused, unwilling to have visitors, afraid to be alone, not wanting to talk, restless, depressed, or wanting to talk all the time. None of these actions are unusual. The best thing you can do is to be prepared for the unexpected. Your primary goal should be to make them as comfortable as possible.

Just being there with your parent is the most important thing you can do. Do not worry about saying the right thing. You may even admit, “Mom, Dad, I don’t know what is the right thing to say to you. I just know that I want to be with you and I am happy to be here.”

If your parent is sick they may want you to hold their hand, softly stroke their hair, read to them, play some music for them, show them photographs, tell them family stories, listen to them, pray with them or just sit quietly with them. Try not to upset them and assure them that they aren’t a burden to you.

Be conscious of how long you stay. After awhile you will get a sense of how long is appropriate. If you notice them starting to close their eyes or lose concentration, it’s time to go. In most cases I would suggest not staying longer than an hour. Frequent visits are much more important than long visits. Don’t be offended if they tell you they want to be alone. Having family members visit you requires a lot of energy and can be very draining to those who are ill.

As difficult as it may seem, imagine that this is the last conversation you may have with them. This will help you say everything you need to say.

Do Not Resuscitate?

Many of us mistakenly believe that if we have gone to the trouble of having our parents complete a living will and have had an attorney prepare an advance directive identifying a health care proxy for them we have covered all the bases. But this is not the case!

Advance Directives and living wills are not accepted by Emergency Medical Services (EMS) as legally valid forms. If a patient has a living will that states that they do not wish to be resuscitated but does not have an appropriately filled out state sponsored form that is co-signed by a physician, the Emergency Medical Technician (EMT) will attempt resuscitation. This is a little known fact to many patients and primary care physicians that can cause patients to be resuscitated even if their family has given instructions not to do so. Although this law is currently being evaluated for a constitutional challenge it is still in place.

A do not resuscitate document is a binding legal document that states resuscitation should not be attempted if a person suffers cardiac or respiratory arrest. A DNR does not affect any treatment other than that which would require intubation or CPR. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatment.

The DNR documentation is especially complicated since each state has its own specific approved form. The DNR form for residents of the State of Arizona is required to be printed on orange paper or it is not valid.  The Massachusetts form can be obtained from the Department of Emergency Services and can be downloaded from the site:  It provides for a bracelet to be applied to the patient’s wrist.

It is imperative that you contact your state health and human services department to determine what form is approved in your state. The form must be signed by the health care proxy ( sometimes called the health care agent) or a durable power of attorney and cosigned by a physician. It is recommended that the original DNR form be kept in safe place, and that copies be kept in places that will be readily available to EMS personnel