Assets You Can Have to Still Qualify for Medicaid

Medicaid is health insurance that helps people who can't afford medical care pay for their medical expenses.

Medicaid is designed for low-income people age 65 and older. (Certain people younger than age 65, particularly those who have disabilities, can also qualify for Medicare, but they must meet certain criteria.)

Many people feel that because they own a home or have some assets that they can't qualify for Medicaid help with their nursing home and doctor's bills. The truth is there are a variety of assets people can own and still qualify. It's just a matter of knowing the rules, and making a plan to meet those requirements.

Here are the asset limits for those applying for Medicaid. They include:

• Cash – You can possess $2,000 cash that will not be counted as an asset in determining your Medicaid eligibility.
• Home – There is a $500,000 exclusion toward your home, meaning that if your home is valued at $500,000 or less at the time of your application, your home is excluded as an asset. Some states use the higher permitted exemption of $750,000.
• Car – Up until recently, you could exclude only one car at a value of $4,500 or less, however that law has been changed. Now, one automobile of ANY current market value is excluded on your application.
• Funeral and Burial Funds – If you have a pre-planned funeral or memorial arrangement, the entire value of that plan is excluded. If you do not, a separate bank account that contains $1,500 toward funeral expenses can be excluded. If you have pre-purchased burial plots, you can exclude not only the costs of the plot for the applicant, but for the entire family, and still be eligible for Medicaid.
• Property – According to federal law, any real or personal property that is essential to self-support, regardless of value or rate of return, is excluded. That could include farms, rental properties and other real estate investments that generate income necessary for self-support. For rental income, however, the property must generate at least 6 percent of its value annually in order to qualify for the exclusion.
• Life Insurance – Only the cash value of a life insurance policy owned by the applicant is counted, thus, all term policies are ignored.

There are so many other rules that can benefit those who aren't sure they'll have enough when the time comes. The key is to plan now and act now. These laws exist for your protection, and avoiding the discussion and the planning necessary to take care of the potential complications just because it is an unpleasant topic will only result in a more unpleasant conversation when you realize you're not ready when the worst happens. That can be a very expensive dilemma. Peace of mind right now, however, won't cost a dime, and could save you hundreds of thousands of dimes later.

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Stepping into the Leadership Role

Alzheimer's disease and related forms of dementia involve a progressive loss of one's memory, thinking, language, and self-care skills. Someone with dementia eventually loses the capacity to be completely independent, and others must step up to provide assistance. A special brand of leadership is called for. At least one person must assume overall authority for ensuring the person's well-being. Much work is involved in addressing basic physical needs like food and shelter as well as the emotional, social, and spiritual needs. You need not be afraid of taking on this important leadership role, although it may feel awkward at first. Quite simply, the person with dementia needs your help. If possible, it is best to share this role with someone else willing to help and support your efforts.
Whether the person with dementia is your spouse, parent, sibling, or in-law, a shift in the balance of power must occur in your relationship. You may feel uncomfortable at first with the term "power." Yet the dynamics of power, influence, and authority exist in every relationship and can be used constructively. The change in power balance derives from the fact that the impaired person needs protection from the risks imposed by the brain disease. Unfortunately, this person no longer enjoys intellectual equality and control over decision-making diminishes. Your role in the relationship must change in corresponding ways.

Anyone who assumes responsibility in a relationship is exercising more power than the other person. This does not mean, however, that the dignity of the person with dementia should be diminished or ignored. On the contrary, preserving one's dignity becomes the utmost priority. In taking leadership, your job is not to dominate the other person's life, but to help minimize one's disabilities and maximize one's remaining abilities. Ultimately, the leadership role is about meeting the needs of the other person in a profoundly intimate way.

Knowing how and when to help out completely, partially, or not at all also requires you to think on your feet. Sometimes it may seem more efficient for you to take over a task completely. At the same time, by doing so you may be ignoring one's remaining abilities. You may reason, "I can do something in half the time it takes her so I might as well do it by myself," even though the person with dementia may derive satisfaction from performing the same task. At the other extreme, you may assume that a certain task can be done independently, causing the person with dementia to struggle needlessly. You may think, "She can still get dressed by herself" when, in fact, she may silently wish for help with this stressful task. Understanding the different levels of dependence and independence requires insight into the other person's needs and preferences.

A good metaphor for the changing relationship between you and the person with dementia is the relationship between two dance partners. When a couple dances, the roles of leader and follower are orchestrated. A good leader dances in a way that enables the follower to be led almost effortlessly. The leader's cues may be so subtle that the follower may not appear to be led at all. The couple dances together gracefully as each partner cooperates in playing his or her part. In your relationship with a person with dementia, you may be called on to change roles from follower to leader.

It may take a long time for you to learn a new set of "dances moves," even though you may know that a different way of relating is now required. The sooner the shift in roles takes place, however, the better it will be for the person with dementia. If you are assertive without being domineering, helpful without being overbearing, and kind without being patronizing, then the person with dementia is likely to respond well to your good intentions. Be patient with yourself as you learn how to be a gentle leader.

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Home Care or a Congregate Setting: Which is Best for your Parent?

Many children of older adults have heard their parents implore them to: "Please never put me in a nursing home!" Unfortunately, some of us find ourselves faced with a difficult decision when our parents become debilitated by disease or compromised with memory impairment issues.

Today there are congregate settings, assisted living and supportive living programs in particular, that offer alternatives to the nursing home. However, while aesthetically more pleasing than most nursing homes, these options still are often viewed by older adults to be inferior to receiving care at home. But before one can conclusively say that care provide by a paid care giver in one's own home is the best option, there are many factors to consider:

1. Home care is costly, and except when the care required qualifies for Medicare reimbursement, most home care services must be paid for privately. A good long term care insurance policy will cover home care but not many older adults own such policies. Home care, if needed 24 hours a day, seven days a week will likely cost about the same as a nursing home stay and perhaps more than assisted living.
2. The level and type of socialization your parent experiences will vary greatly from care provided at home to care provided in a congregate residential setting. In most cases when 24-hour care is needed, there will be two live-in caregivers assigned to a case. Many great friendships have been formed between caregivers and clients but the social life of the client in a home care setting will be very narrow. In a residential setting (nursing home, assisted living, supportive living, or continuing care retirement community), the person will be exposed to other older adults and staff and who can provide a rich social experience.
3. The individual attention in a home setting can provide an opportunity to focus on favorite activities but the array of cultural experiences should be broader in a congregate setting.
4. Proper nutrition can often be accessed more readily in a congregate setting but attention to favorite foods might be more readily facilitated with home care.

From my own personal and professional experience, I have found that most people wait too long before electing assisted living care. A well-run assisted living facility can offer a wonderful living experience, often in an elegant setting. The cultural activities available on-site and through scheduled outings can make for a rich experience. The dining program is often very upscale and offers great variety.

However, when a person residing in assisted living begins to requires skilled care, avoiding nursing home placement can only be accomplished by augmenting current care with paid caregivers. For those with unlimited resources this can be the best alternative.

Honoring mom and dad's wishes for end of life care is paramount. Have the conversation well before a need exists so you can be sure that you are doing the right thing for them if the time comes when they need assistance with daily activities.

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Comfort Care for Advanced Dementia

The prestigious medical journal, Archives of Internal Medicine, published a study last month showing that a significant portion of Medicare expenditures for people with advanced dementia is spent on aggressive treatments that could have little clinical benefit. Researchers found that 30 percent of Medicare expenditures for people with advanced dementia were for hospitalizations during their last year of life.

A few days after reading this research study, I visited a man caring for his wife, terminally ill with Alzheimer's disease, at their suburban Chicago home. Ten years ago, at age 61, she began showing symptoms of her disease. She had tried desperately to hide her memory impairment from others. However, she had a high profile job and eventually was forced to take disability leave. For his part, the husband tried to deny the seriousness of her problems until she wandered away from home and got lost for many hours. He sought out the best medical care but after a couple of years, he realized the limits of medicine. He concluded that medicine might actually hasten her decline with unnecessary tests and ineffective treatments. He chose instead what one might call a "soft approach" to her disease.

He learned to accept her symptoms and create meaningful moments for her through simple, pleasurable activities. Instead of focusing on elusive medical treatments, he focused on giving her the best possible care. His goals were to make her happy and to give her the best quality of life. He also began to take care of himself, understanding that his own welfare affected her, for better or worse. He joined a church choir and played lots of golf. He downsized to a smaller, less expensive home. And he hired two caregivers who shared his goals for his wife. One of the caregivers, a compassionate woman in her 20s, was present during my visit. She happily recounted many ways they had found to connect with her over the years, despite progressive decline in her abilities.

The woman with Alzheimer's disease was now bedridden. She had not spoken a word in more than a year. She had been enrolled in hospice for nearly two years, long after she was expected to die. Her breathing had become labored in recent days but measures were being taken to keep her comfortable. The husband said that no extraordinary steps would be taken to sustain her life. Admission to a hospital was not necessary. Long ago he had given up on aggressive medicine in favor of comfort care. He and the caregivers were at peace with this choice. He wished for her to die with dignity in the safety and comfort of their home. He got his wish just two days later.

Whether people with advanced dementia remain in their own home or reside in a care facility, it is possible for them to live and die in comfort. It takes a concerted effort on the part of many people to make this a reality. In this case, the husband had the courage to lead this great effort to its peaceful end. I was privileged to witness his love in action.

Dementia Signage for the Home

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