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California Elder Law Resources, Benefits, and Planning: An Advocate's Guide

Protect the interests of your clients and their families with this guide covering resources and planning options.

 

 

 

Protect the interests of your clients and their families with this guide covering resources and planning options.

  • Medi-Cal eligibility and planning strategies
  • Other government benefits and resources
  • Financial management and health care decision-making
  • Planning to stay at home
  • Medicare appeals
  • Long-term care insurance
  • Reverse mortgages
OnLAW ES94630

Web access for one user.

 

$ 405.00
Print ES33630

2 looseleaf volumes, updated 8/19

 

$ 405.00
Add Forms CD to Print ES23637
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Protect the interests of your clients and their families with this guide covering resources and planning options.

  • Medi-Cal eligibility and planning strategies
  • Other government benefits and resources
  • Financial management and health care decision-making
  • Planning to stay at home
  • Medicare appeals
  • Long-term care insurance
  • Reverse mortgages

1

Elder Law Practice

Susanne B. Cohen

Priscilla Camp

  • I.  WHAT IS ELDER LAW?
    • A.  A Distinct Practice  1.1
    • B.  Needs of the Rapidly Expanding Elder Client Population  1.2
    • C.  Understanding of Aging Process Required  1.3
    • D.  Becoming Part of Network of Resources
      • 1.  Organizations Serving Elders  1.4
      • 2.  Professional Organizations and Bar Participation  1.5
      • 3.  Legal Resource Centers  1.6
  • II.  CREATING A SUITABLE OFFICE ENVIRONMENT
    • A.  A Comfortable Space  1.7
    • B.  Location and Accessibility  1.8
    • C.  Accommodating Physical Impairments  1.9
    • D.  Impact of Americans With Disabilities Act  1.10
  • III.  EMOTIONAL CONSIDERATIONS WHEN HANDLING INCAPACITY ISSUES
    • A.  Accommodating Client Emotions  1.11
    • B.  Working With Resistance and Denial  1.12
    • C.  Considering the Caregiver  1.13
  • IV.  OFFICE PROCEDURES
    • A.  Informing Elderly Client About Fees  1.14
    • B.  Eliciting Information  1.15
    • C.  Follow-Up Advice Letter  1.16
    • D.  Document Management  1.17
  • V.  EMPLOYMENT CONTRACT AND BILLING
    • A.  Fee Agreements  1.18
    • B.  Payment of Fees on Behalf of Elder Clients  1.19
    • C.  Hourly Versus Flat-Fee Billing  1.20
  • VI.  COMMON MISUNDERSTANDINGS OF LAW ENCOUNTERED BY ELDER LAW ATTORNEYS  1.21
  • VII.  MARKETING
    • A.  Professional Background of Practitioners  1.22
    • B.  Referral Sources
      • 1.  Service Providers  1.23
      • 2.  Other Professionals  1.24
      • 3.  First Responders  1.25
    • C.  Promotional Activity
      • 1.  Public Speaking Engagements  1.26
      • 2.  Media Coverage  1.27
      • 3.  Brochures, Handouts, Newsletters, Websites, and Blogs  1.28
      • 4.  Activity Within Legal Profession  1.29

1A

Introduction to LGBT Elder Law

Daniel R. Redman

  • I.  INTRODUCTION
    • A.  How to Use This Chapter  1A.1
    • B.  Vocabulary  1A.2
    • C.  Sexual Orientation, Gender Identity, and Gender Expression  1A.3
    • D.  Brief History of the LGBT Community  1A.4
    • E.  Social Science  1A.5
    • F.  Creating an LGBT-Welcoming Practice  1A.6
  • II.  TRANSGENDER ELDERS
    • A.  Introduction to Transgender Issues  1A.7
    • B.  Name and Gender Marker Changes  1A.8
    • C.  Form: Change of Gender Affidavit  1A.8A
    • D.  Form: Doctor’s Affidavit of Gender Transition  1A.9
    • E.  Coverage of Transition-Related Care  1A.10
    • F.  Conservatorship  1A.11
    • G.  Advance Health Care Directive  1A.12
    • H.  Disposition of Remains  1A.13
    • I.  Form: Transgender-Inclusive Language for Power of Attorney for Health Care/Advance Health Care Directive (AHCD)  1A.14
    • J.  Form: Disposition of Remains Worksheet  1A.15
  • III.  DIVERSE FAMILIES  1A.16
    • A.  Marriage  1A.17
    • B.  Out-of-State Marriages, Domestic Partnerships, and Civil Unions  1A.18
    • C.  International Marriage  1A.19
    • D.  California Registered Domestic Partnerships  1A.20
    • E.  City and County Domestic Partnerships  1A.21
    • F.  Families of Choice  1A.22
    • G.  Form: Hospital Visitation Authorization  1A.23
  • IV.  LGBT CONCERNS WITH PUBLIC BENEFITS  1A.24
    • A.  Medi-Cal  1A.25
    • B.  Medicare  1A.26
    • C.  Social Security  1A.27
    • D.  Supplemental Security Income (SSI)  1A.28
    • E.  Veterans’ Benefits  1A.29
    • F.  HIV/AIDS issues  1A.30
  • V.  ANTIDISCRIMINATION PROTECTIONS
    • A.  State Law  1A.31
    • B.  Federal Law  1A.32
  • VI.  LONG-TERM CARE  1A.33
    • A.  Discrimination in Long-Term Care  1A.34
    • B.  Nondiscrimination Protections  1A.35
  • VII.  LGBT ELDER SERVICES  1A.36
    • A.  LGBT-Focused Senior Housing and Services  1A.37
    • B.  Finding Inclusive Services  1A.38
    • C.  Advocacy Tips  1A.39
    • D.  Area Agencies on Aging (AAA)  1A.40
  • VIII.  FURTHER RESOURCES  1A.41

2

Ethical Considerations in Elder Law Practice

Marilyn D. Anticouni

  • I.  IMPORTANCE OF ETHICAL CONSIDERATIONS  2.1
  • II.  RULES OF PROFESSIONAL CONDUCT
    • A.  Sources of Authority  2.2
    • B.  Consequences of Violating Rules
      • 1.  Discipline by State Bar  2.3
      • 2.  Civil Liability for Malpractice  2.4
      • 3.  Invalidating Client’s Estate Plan  2.5
  • III.  DUTIES AND LIMITATIONS
    • A.  Duties to Client  2.6
      • 1.  Duty of Loyalty  2.7
      • 2.  Duty to Keep Client Confidences  2.8
      • 3.  Duty to Avoid Conflicts of Interest
        • a.  Avoiding Representation of Adverse Interests Generally  2.9
        • b.  Concurrent Representation of Multiple Parties  2.10
        • c.  Distinguishing Potential and Actual Conflict [Deleted]  2.11
        • d.  Degree of Disclosure Required  2.12
        • e.  Representing Client With Interests Adverse to Former Client  2.13
      • 4.  Duty to Client With Limited Mental Capacity  2.14
        • a.  California Law  2.15
          • (1)  Estate Planning Documents  2.16
          • (2)  Protecting Client From Elder Abuse, Undue Influence, or Fraud  2.17
          • (3)  California State Bar Formal Opinion No. 89–112  2.18
        • b.  ABA Model Rules  2.19
      • 5.  Duty to Act Competently  2.20
    • B.  Duties to Nonclient
      • 1.  No Duty to Adverse Party or if Arm’s-Length Transaction  2.21
      • 2.  Theories of Duty to Nonclient Elder  2.22
        • a.  Intended Beneficiary  2.23
        • b.  Foreseeable Third Party Reliance  2.24
        • c.  Fiduciary Duty  2.25
      • 3.  Client’s Goals as Breach of Duty to Nonclient  2.26
    • C.  Limitations on Donative Transfers  2.27
      • 1.  Presumption of Fraud or Undue Influence  2.27A
      • 2.  Certificate of Independent Review  2.27B
    • D.  Limitations on Dual Compensation in Trust Matters  2.28
  • IV.  ATTORNEY-CLIENT RELATIONSHIP
    • A.  Identifying the Client  2.29
    • B.  Creation of Attorney-Client Relationship  2.30
    • C.  Representing the Elder  2.31
      • 1.  Ethical Compliance Assured
        • a.  Duty of Loyalty Clear  2.32
        • b.  Advising Other Family Members That Their Interests Are Unrepresented  2.33
      • 2.  Family Participation in Consultations  2.34
      • 3.  Family Members as Agents or Advisers  2.35
      • 4.  Form: Sample Paragraphs in Engagement Letter Confirming Family Member’s Role  2.36
      • 5.  Payment of Attorney Fees  2.37
    • D.  Representing a Family Member  2.38
      • 1.  Obtaining Informed Written Consent of Former Elder Client  2.39
      • 2.  Conditioning Representation on Elder Having Independent Counsel  2.40
      • 3.  Providing Written Disclaimer of Representation to Elder  2.41
      • 4.  Preventing Overreaching by Family Member
        • a.  Avoiding Undue Influence  2.42
        • b.  Avoiding Breach of Fiduciary Duty to Elder  2.43
        • c.  Refusing Representation or Limiting Representation  2.44
      • 5.  Payment of Attorney Fee  2.45
    • E.  Representing Family Member and the Elder  2.46
      • 1.  Risk of Undue Influence and Breach of Ethics  2.47
      • 2.  Practical Problems in Dual Representation  2.48
      • 3.  Form: Potential Conflicts Disclosure and Waiver  2.49
    • F.  Leaving Client’s Identity Ambiguous  2.50
  • V.  MENTALLY INCAPACITATED CLIENTS
    • A.  Standards and Tests for Legal Capacity
      • 1.  Due Process in Competence Determinations Act  2.51
        • a.  Evidence to Support Finding of Unsound Mind or Incapacity  2.52
        • b.  Ability to Communicate Decision and Understand Its Consequences  2.53
      • 2.  Specific Statutes Regarding Capacity  2.54
        • a.  Testamentary Capacity  2.55
        • b.  Capacity to Contract, Convey, or Make Agency Appointments  2.56
        • c.  Capacity to Create or Modify a Trust  2.57
        • d.  Capacity to Manage Personal and Financial Affairs and to Make Medical Decisions  2.58
      • 3.  Provisions in Estate Planning Documents  2.58A
    • B.  Attorney Assessment of Client Capacity
      • 1.  Evaluation Under Statutory Standards  2.59
      • 2.  Mental Status Assessment  2.60
      • 3.  Analysis of Hypothetical Situations
        • a.  The Clearly Mentally Incapacitated Client  2.61
        • b.  The Disputably Mentally Incapacitated Client  2.62
        • c.  The Partially Incapacitated Client  2.63
      • 4.  Physical Incapacity Distinguished  2.64
  • VI.  SCOPE OF REPRESENTATION
    • A.  Importance of Defining Scope of Representation  2.65
    • B.  Certificate of Independent Review to Qualify Transfer to Disqualified Person  2.66
    • C.  Termination of Representation  2.67

3

Surrogate Financial Management

Monica Dell’Osso

  • I.  INTRODUCTION  3.1
  • II.  CLIENT AND CAPACITY ISSUES  3.2
  • III.  MAJOR OPTIONS FOR SURROGATE FINANCIAL MANAGEMENT
    • A.  Revocable Living Trust  3.3
      • 1.  Selection of Trustee
        • a.  Client as Trustee  3.4
        • b.  Financial Institution as Trustee  3.5
        • c.  Another Individual as Trustee  3.6
        • d.  Cotrustees; Successor Trustees  3.7
      • 2.  Tax Consequences of Creation of Revocable Living Trust  3.8
    • B.  Conservatorship of the Estate  3.9
      • 1.  Types of Conservatorships  3.10
      • 2.  Nomination, Appointment, and Registration of Conservator
        • a.  Court Appoints  3.11
        • b.  Client May Nominate  3.12
        • c.  Professional Conservator Must Be Registered (Through June 30, 2008) [Deleted]  3.13
      • 3.  Selection of Nominee
        • a.  Individual as Conservator  3.14
        • b.  Private Professional Conservator  3.15
        • c.  Attorney as Conservator  3.16
        • d.  Trust Company as Conservator  3.17
        • e.  Co-Conservators  3.18
    • C.  Durable Power of Attorney for Property Management (DPAP)  3.19
      • 1.  Types of DPAP
        • a.  General Versus Limited DPAP  3.20
        • b.  Immediately Effective Versus Springing DPAP  3.21
        • c.  Determining Incapacity Under Springing DPAP  3.22
          • (1)  Impact of HIPAA and CMIA  3.22A
          • (2)  Alternatives to Using Springing DPAP  3.23
      • 2.  Selection of Agent
        • a.  Factors to Consider  3.24
        • b.  Joint Agents  3.25
        • c.  Successor Agent  3.26
  • IV.  SELECTING APPROPRIATE LEGAL DEVICE FOR SURROGATE FINANCIAL MANAGEMENT
    • A.  Comparative Analysis of Major Legal Options
      • 1.  Revocable Living Trust  3.27
        • a.  Burden of Trust Formalities  3.28
        • b.  Continuity of Management of Assets  3.29
        • c.  Minimizing Problems of Dealing With Third Parties and Out-of-State Assets  3.30
        • d.  Expense  3.31
      • 2.  Conservatorship of the Estate  3.32
      • 3.  Durable Power of Attorney for Property Management (DPAP)  3.33
        • a.  Problem of Third Party Acceptance  3.34
        • b.  Other Drawbacks to Use of DPAP  3.35
    • B.  Coordinated Use of Multiple Legal Devices for Surrogate Financial Management  3.36
    • C.  Potential Conflicts Between Devices for Surrogate Financial Management  3.37
    • D.  Community Property Issues  3.38
  • V.  OTHER OPTIONS FOR SURROGATE FINANCIAL MANAGEMENT
    • A.  Community Property Management by Spouse  3.39
    • B.  Joint Tenancy
      • 1.  Management Features  3.40
      • 2.  Joint Tenancy Solely for Property Management Purposes Inadvisable  3.41
    • C.  Representative Payee  3.42
      • 1.  Eligibility for and Selection of Representative Payee for Social Security Benefits  3.43
      • 2.  Payee Duties and Responsibilities  3.44

4

Health Care and Personal Decision Making

Fay Blix

  • I.  IMPORTANCE OF ADVANCE HEALTH CARE DECISION MAKING
    • A.  End-of-Life Care and the Elderly  4.1
    • B.  Terri Schiavo Case  4.1A
  • II.  ROLE OF ATTORNEY IN AIDING CLIENT  4.2
    • A.  Identifying the Client  4.3
    • B.  First Appointment With Client  4.4
    • C.  Assessing Client Capacity
      • 1.  Attorney’s Role  4.5
      • 2.  Due Process in Competence Determinations Act  4.6
    • D.  Issues to Discuss With Client Regarding Comprehensive Advance Health Care Directive  4.7
      • 1.  Choice of Agent  4.8
        • a.  Coagents  4.9
        • b.  Alternate Agents  4.10
      • 2.  Encourage Client to Discuss Medical Issues With Physician  4.11
      • 3.  Importance of Power of Attorney for Those in Alternative Relationships  4.12
      • 4.  Eliminating Individual’s Power to Petition  4.13
      • 5.  Out-of-State Issues  4.14
      • 6.  Advising Client About Actions to Take After Signing  4.15
    • E.  Advising Client About Postdeath Planning Issues  4.16
      • 1.  Client Research About Funeral Homes and Cemeteries  4.17
      • 2.  Death Certificate Information  4.18
      • 3.  Obituary Information  4.19
      • 4.  Eulogy Writing Exercise  4.20
      • 5.  Notebook of Instructions  4.21
  • III.  FEDERAL LAW
    • A.  Federal Case Law  4.22
    • B.  Patient Self-Determination Act  4.23
      • 1.  Education Campaign  4.24
      • 2.  Definition of Advance Directive  4.25
    • C.  Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standards  4.26
  • IV.  CALIFORNIA CASE LAW
    • A.  Seminal Cases  4.27
    • B.  Conservatorship of Wendland  4.28
  • V.  CALIFORNIA HEALTH CARE DECISIONS LAW  4.29
    • A.  Advance Health Care Directives (AHCDs)
      • 1.  Purpose and Operation  4.30
      • 2.  Definitions  4.31
      • 3.  Impact on Existing Documents  4.32
      • 4.  Who Can Be a Health Care Agent  4.33
      • 5.  Signing, Witnessing, and Notary Requirements  4.34
      • 6.  Witnessing Requirements for Residents of Skilled Nursing Facilities  4.35
      • 7.  Scope of Agent’s Authority  4.36
        • a.  Postdeath Authority  4.37
        • b.  Limitations on Agent’s Authority  4.38
      • 8.  Revocation  4.39
      • 9.  Duties of Health Care Professionals  4.40
      • 10.  Immunities and Liabilities  4.41
      • 11.  California AHCD Used in Other States; Out-of-State Instruments  4.42
      • 12.  Judicial Proceedings Under Prob C §4766  4.43
        • a.  Who May File Petition  4.44
        • b.  Eliminating Authority of Person to Petition  4.45
      • 13.  Types of Forms  4.46
        • a.  CMA Form  4.47
        • b.  Statutory Forms  4.48
        • c.  Attorney-Drafted Form  4.49
    • B.  Health Care Surrogates  4.50
    • C.  Request Regarding Resuscitative Measures  4.51
      • 1.  Forms for Request Regarding Resuscitative Measures
        • a.  DNR Order  4.51A
        • b.  POLST Form  4.51B
        • c.  When Treatment Preferences in POLST Form Must Be Followed; How They May Be Modified  4.51C
      • 2.  Relationship of DNR Order, POLST, and AHCD  4.52
      • 3.  Required Language and Signatures  4.53
      • 4.  Protection From Liability for Health Care Provider  4.54
      • 5.  DNR Order and POLST in Institutional Settings  4.55
      • 6.  DNR Order and POLST in Residential Care Facilities for the Elderly  4.56
      • 7.  DNR Order and POLST in Home Care Settings  4.57
  • VI.  OTHER CALIFORNIA STATUTES CONFERRING DECISION-MAKING AUTHORITY  4.58
    • A.  Conservatorships
      • 1.  Conservator’s Powers  4.59
      • 2.  Selection of Conservator of the Person  4.60
      • 3.  Nomination and Appointment of Conservator of the Person  4.61
      • 4.  Private Professional Conservator Must Be Licensed  4.61A
      • 5.  Conservatorships and PAHCs Compared
        • a.  Court Supervision  4.62
        • b.  Third Party Reliance  4.63
      • 6.  Relationship Between Conservator and Agent  4.64
      • 7.  Special Powers for Conservators of Persons With Major Neurocognitive Disorder  4.65
    • B.  Petition to Authorize Specified Treatment  4.66
      • 1.  Who May File Petition  4.67
      • 2.  Findings and Court Order  4.68
    • C.  Skilled Nursing Facility’s Authority  4.69
  • VII.  OTHER SPECIFIC HEALTH CARE ISSUES
    • A.  Informed Consent and Right to Participate in Decision Making
      • 1.  Requirement of Informed Consent  4.70
      • 2.  Capacity to Give Informed Consent  4.71
      • 3.  Special Rules for Residents of SNFs and RCFEs  4.72
        • a.  When Notice to Families Is Required  4.73
        • b.  Other Special Rules for Residents of RCFEs  4.74
      • 4.  Exceptions to Requirement of Informed Consent Applicable to Residents of SNFs and RCFEs
        • a.  Emergency Situations  4.75
        • b.  Use of Psychotherapeutic Drugs  4.76
      • 5.  Testing Without Patient Consent  4.77
    • B.  Pain Patient’s Bill of Rights  4.78
    • C.  Aid in Dying
      • 1.  Overview  4.78A
      • 2.  Oregon, Washington, Montana, Vermont, and New Mexico Law  4.78B
      • 3.  California Law  4.78C
        • a.  Requirements for Requesting Aid-in-Dying Drug  4.78D
        • b.  Requirements for Physician Receiving Request for Aid-in-Dying Drug  4.78E
          • (1)  Documenting Request for Aid-in-Dying Drug  4.78F
          • (2)  Determining Qualification for Aid-in-Dying Drug  4.78G
          • (3)  Dispensing Aid-in-Dying Drugs  4.78H
  • VIII.  POSTDEATH ISSUES  4.79
    • A.  Autopsies
      • 1.  Discretionary Autopsies  4.80
      • 2.  Mandatory Autopsies  4.81
      • 3.  Autopsy Authorization  4.82
      • 4.  Autopsy Performance  4.83
      • 5.  Access to Autopsy Report  4.84
    • B.  Anatomical Gifts
      • 1.  Revised Uniform Anatomical Gift Act  4.85
      • 2.  California’s Uniform Anatomical Gift Act  4.86
        • a.  Possible Recipients  4.87
        • b.  Actions Required of Department of Motor Vehicles  4.88
        • c.  Methods to Make, Amend, Revoke, or Refuse to Make Anatomical Gift
          • (1)  Making Gift Before Donor’s Death  4.89
          • (2)  Documenting Refusal to Make Gift  4.90
          • (3)  Amending or Revoking Gift Authorized During Life  4.91
        • d.  Third Party’s Postdeath Actions
          • (1)  Third Party’s Authority When No Instructions by Donor  4.92
          • (2)  Limitations on Third Party’s Authority to Authorize Gift  4.92A
          • (3)  Revocation of Postdeath Gift  4.92B
        • e.  Responsibility for Locating Documentation of Gift or Refusal to Make Gift  4.92C
        • f.  Actions by Doctor, Hospital, and Organ Procurement Agency  4.92D
      • 3.  Federal Law  4.93
    • C.  Planning for Funeral, Burial, or Cremation  4.94
      • 1.  Federal Law  4.95
      • 2.  California Law  4.96
      • 3.  Veterans’ Benefits  4.97
      • 4.  Planning for Burial  4.98
        • a.  Casket  4.99
        • b.  Burial Vault or Grave Liner  4.100
        • c.  Embalming  4.101
        • d.  Body Preparation  4.102
        • e.  Facility Use  4.103
        • f.  Transportation  4.104
        • g.  Professional Fee  4.105
      • 5.  Cemeteries  4.106
        • a.  Cemetery Plots  4.107
        • b.  Mausoleum Crypts  4.108
        • c.  Additional Cemetery Costs  4.109
      • 6.  Planning for Cremation  4.110
        • a.  Cremation Process  4.111
        • b.  Disposition of Cremains  4.112
          • (1)  Scattering Ashes  4.113
          • (2)  Exotic Options  4.114
      • 7.  Prepaid Funeral Contracts  4.115
        • a.  Client Questions for Seller  4.116
        • b.  Alternatives to Prepaid Contracts  4.117
        • c.  Review Existing Contracts  4.118
  • IX.  DEATH AWAY FROM HOME  4.119
    • A.  Death in Another State  4.120
      • 1.  Shipping the Body: Practical Considerations  4.121
      • 2.  Cremation or Body Donation  4.122
    • B.  Death Outside the United States
      • 1.  Initial Steps  4.123
      • 2.  Disposition of Remains  4.124
  • X.  FORMS
    • A.  Form: Sample Questions for Client to Consider Before Meeting With Attorney  4.125
    • B.  Form: Sample Physician Statement Regarding Capacity  4.126
    • C.  Form: Issues for Client to Discuss With Physician  4.127
    • D.  Form: Sample Letter to Physician About AHCD  4.128
    • E.  Form: Sample Letter to Clergy About AHCD  4.129
    • F.  Form: Sample Letter to Nursing Home Administrator About AHCD  4.130
    • G.  Form: Sample Letter to RCFE Administrator From Attorney About Client’s AHCD  4.131
    • H.  Form: Agreement to Serve as Agent  4.132
    • I.  Form: Sample Questions for Agent to Ask Doctor About Specific Health Care Treatment or Procedure  4.133
    • J.  Form: Sample Questionnaire for Client to Fill Out About Final Wishes  4.134
    • K.  Form: Sample Memo of Instructions From Client About Things to Do After Death  4.135
    • L.  Form: Price Comparison of Costs for Funeral Homes  4.136
    • M.  Form: Death Certificate Information  4.137
    • N.  Form: Obituary Information  4.138
    • O.  Form: Nomination of Conservator  4.139
    • P.  Form: Sample Questions for Health Care Provider About Client’s Pain  4.140
    • Q.  Form: Sample Questions When Choosing Institution to Receive Body Donation  4.141
    • R.  Form: Cemetery and Funeral Bureau Complaint Form  4.142
    • S.  Form: Information Necessary for Veteran’s Burial  4.143
    • T.  Form: Disclosure of Preneed Funeral Agreement  4.144

5

Public Benefits and Resources for the Elderly

Terry M. Magady

Bettie Baker Marshall

  • I.  INTRODUCTION  5.1
  • II.  WHERE TO BEGIN
    • A.  Prepare to Refer Clients for Appropriate Public Benefits
      • 1.  Identify Resources in Area  5.2
        • a.  California Department of Aging (CDA)  5.3
        • b.  Area Agencies on Aging (AAA)  5.4
        • c.  Legal Services and Related Programs  5.5
        • d.  Population-Specific Programs  5.6
      • 2.  Major Government Programs  5.7
    • B.  Determine Client’s Needs and Appropriate Public Benefits  5.8
  • III.  INCOME ASSISTANCE
    • A.  Social Security Retirement, Disability, and Survivor Benefits  5.9
      • 1.  Retirement Benefits  5.10
      • 2.  Disability Benefits  5.11
      • 3.  Benefits for Family Members of Worker  5.12
      • 4.  Inquiries and Application  5.13
    • B.  Supplemental Security Income  5.14
      • 1.  Income Limits  5.15
      • 2.  Reductions and Increases in Amount of Benefits  5.16
      • 3.  Resource Limits  5.17
        • a.  Resources: Exempt Assets and Exclusions  5.18
        • b.  Trust Generally Not Exempt Resource  5.18A
      • 4.  Noncitizen Eligibility  5.19
      • 5.  Cash Assistance Program for Immigrants  5.20
    • C.  Veterans’ Benefits  5.21
    • D.  General Assistance  5.22
  • IV.  MEDICAL COVERAGE AND HEALTH CARE PROGRAMS
    • A.  Medicare  5.23
    • B.  Medi-Cal  5.24
      • 1.  Eligibility Requirements  5.25
      • 2.  Covered Benefits  5.26
      • 3.  Providers  5.27
    • C.  Veterans’ Medical Benefits  5.28
      • 1.  Eligibility Requirements  5.29
      • 2.  Benefits  5.30
      • 3.  Where and How to Apply  5.31
    • D.  Options for Individuals Ineligible for Medi-Cal  5.32
    • E.  Health Insurance Counseling and Advocacy Program (HICAP)  5.33
    • F.  County (General) Hospitals  5.34
    • G.  County or Regional Health Departments  5.35
    • H.  Mental Health Services  5.36
    • I.  Charitable and Religious Groups  5.37
    • J.  Uncompensated Care Under Hill-Burton Act  5.38
  • V.  STAYING AT HOME  5.39
    • A.  Impact of Federal Health Care Reform of 2010  5.39A
    • B.  Long-Term Care at Home: PACE  5.39B
    • C.  Community Social Services  5.40
      • 1.  In-Home Supportive Services (IHSS)  5.41
      • 2.  Nutrition and Brown Bag Programs  5.42
        • a.  Home-Delivered Meal Services  5.43
        • b.  Brown Bag Network Program  5.44
        • c.  Congregate Nutrition Services  5.45
      • 3.  Transportation Services  5.46
      • 4.  Energy Assistance Programs  5.47
      • 5.  Senior Community Services Employment Program  5.48
      • 6.  Senior Companion Program  5.49
      • 7.  Senior Centers  5.50
      • 8.  Subsidized Housing
        • a.  Variety of Programs; Sources of Information  5.51
        • b.  Eligibility Requirements  5.52
      • 9.  Habitat for Humanity  5.53
    • D.  Case Management
      • 1.  Multipurpose Senior Services Program (MSSP)  5.54
      • 2.  Linkages  5.55
      • 3.  Veterans Administration Case Management Services  5.55A
      • 4.  Mental Health Case Management Services  5.56
      • 5.  Aging Life Care Association  5.57
    • E.  Day Care Services
      • 1.  Community-Based Adult Services (CBAS)/Adult Day Health Care Centers (ADHCs)
        • a.  Services Provided  5.58
        • b.  Funding  5.59
      • 2.  Alzheimer’s Day Care Resource Centers (ADCRCs)  5.60
    • F.  Respite Care and Caregivers Resource Centers
      • 1.  Respite Care  5.61
      • 2.  Resource Centers for Caregivers of Cognitively Impaired Adults  5.62
    • G.  Locating Residential Living Facilities  5.63
  • VI.  TAX RELIEF
    • A.  Property Tax
      • 1.  Homeowners’ Property Tax Assistance  5.64
      • 2.  Property Tax Postponement  5.65
      • 3.  Retention of Proposition 13 Tax Basis  5.66
      • 4.  Parent-Child/Grandparent-Grandchild Transfer Exclusion  5.67
    • B.  Renters’ Property Tax Assistance  5.68
    • C.  Income Tax Deductions  5.69
  • VII.  PROTECTION AND ADVOCACY
    • A.  Adult Protective Services  5.70
    • B.  Long-Term Care Ombudsman  5.71
    • C.  Fiduciary Services  5.72
    • D.  Public Defender and Other Court-Appointed Attorneys
      • 1.  Conservatorship  5.73
      • 2.  Involuntary Mental Health Treatment  5.74
      • 3.  Criminal Matters  5.75
    • E.  Consumer Protection  5.76
  • VIII.  DEVELOPMENTALLY DISABLED AND SERIOUSLY MENTALLY ILL INDIVIDUALS
    • A.  Elderly Disabled Individuals
      • 1.  Regional Center Services for Developmentally Disabled Elders  5.77
      • 2.  Mental Health Department Services for Mentally Ill Elders  5.78
    • B.  Adult Children of Elders  5.79
  • IX.  RESOURCE DIRECTORIES
    • A.  Chart: Area Agencies on Aging [Deleted]  5.80
    • B.  Departments in California Department of Aging  5.81
    • C.  Resource Centers for Caregivers of Cognitively Impaired Adults [Deleted]  5.82
    • D.  Public Benefit Needs Assessment Checklist  5.83
    • E.  Public Benefit Eligibility Status Worksheet  5.84

6

Planning to Stay at Home

Terry M. Magady

  • I.  INTRODUCTION  6.1
    • A.  The Desire to Remain at Home  6.1A
    • B.  Role of Counsel  6.2
  • II.  DECISION-MAKING AUTHORITY  6.3
    • A.  Elder With Capacity to Decide  6.4
    • B.  Powers of Attorney  6.5
      • 1.  Issues to Consider  6.6
      • 2.  Form: Personal Care Provisions—Home Care Directive  6.7
      • 3.  Financial Powers  6.8
    • C.  Court-Ordered Conservatorship
      • 1.  Power of Conservator to Place Conservatee  6.9
      • 2.  Restrictions on Conservator’s Power of Placement
        • a.  General Requirements
          • (1)  Court Approval to Establish Out-of-State Residence  6.9A
          • (2)  Notice Requirements if Removal From Personal Residence Proposed  6.10
        • b.  Power to Purchase or Sell Real Property Home  6.10A
        • c.  Least Restrictive Residence and Appropriate Level of Care  6.10B
      • 3.  Placement by Temporary Conservator of the Person  6.11
      • 4.  Counsel for Conservatee or Proposed Conservatee
        • a.  Appointment  6.12
        • b.  Role of Counsel  6.13
  • III.  GOVERNMENT BENEFITS  6.14
    • A.  In-Home Supportive Services (IHSS)
      • 1.  Overview  6.15
      • 2.  Funding Source and Administration  6.16
      • 3.  IHSS Plus Waiver [Deleted]  6.16A
      • 4.  IHSS Plus Option (IPO)  6.16B
      • 5.  Sources of Law  6.17
      • 6.  Certification Requirement  6.17A
      • 7.  Eligibility  6.18
      • 8.  Functional Index (FI): Quantification of a Recipient’s Functioning  6.19
      • 9.  Share of Cost
        • a.  Who Must Pay Share of Cost  6.19A
        • b.  Calculating Share of Cost  6.19B
      • 10.  Limitation on Eligibility: Consideration of Alternative Resources  6.20
      • 11.  Services Provided  6.21
      • 12.  Who Can Be a Service Provider?  6.22
        • a.  Criminal Background Check  6.22A
      • 13.  Fraud Prevention Requirements  6.22B
      • 14.  Application Procedure  6.23
      • 15.  Appeal Procedure  6.24
      • 16.  Planning Limitations  6.25
        • a.  Residual Program Gifting Penalties  6.26
        • b.  Exceptions From Residual Program Gifting Penalties  6.27
        • c.  No Gifting Penalties for IHSS Plus Option or Personal Care Services Programs  6.27A
      • 17.  Planning Opportunities
        • a.  Maximize Hours Allotted
          • (1)  Prepare Presentation for Case Worker  6.28
          • (2)  Establish Need for Protective Supervision  6.29
        • b.  Medi-Cal 250 Percent Working Disabled Program  6.30
        • c.  Medical Insurance Coverage for Provider  6.31
        • d.  Planning Opportunities for Couples Under MSSP Waiver  6.31A
        • e.  Divorce  6.32
        • f.  Expanded Medi-Cal Program  6.32A
    • B.  Waiver Programs
      • 1.  General Principles  6.33
      • 2.  California Participation  6.34
      • 3.  Sources of Law  6.35
      • 4.  In-Home Operations (IHO) Waiver  6.36
      • 5.  Nursing Facility/Acute Hospital (NF/AH) Waiver  6.37
      • 6.  Application Procedures  6.38
      • 7.  Appeal Procedures  6.39
    • C.  Community-Based Adult Services (CBAS)/Adult Day Health Care Centers (ADHCs)
      • 1.  Role of ADHCs  6.40
      • 2.  Legislation Curtailing ADHC Services; Litigation in Response  6.40A
      • 3.  Funding Source and Administration  6.41
      • 4.  Eligibility  6.42
      • 5.  Services Provided  6.43
      • 6.  Application Procedure; Appeals  6.44
      • 7.  Planning Opportunities
        • a.  Assessing How ADHC Might Be Helpful  6.45
        • b.  Assets and Income  6.46
      • 8.  Community-Based Adult Services (CBAS) as Successor to ADHCs  6.46A
    • D.  Other Government Programs and Services
      • 1.  PACE  6.47
      • 2.  Regional Centers  6.48
      • 3.  Veterans’ Aid and Attendance or Housebound Benefits  6.48A
        • a.  Income Limitations  6.48B
        • b.  Asset Limitations  6.48C
        • c.  Gifts  6.48D
      • 4.  Other Programs and Services  6.49
    • E.  Medicare Home Health Care Services  6.50
    • F.  Medi-Cal Home Health Care Services
      • 1.  Overview  6.51
      • 2.  Funding Source, Administration, and Sources of Law  6.52
      • 3.  Eligibility  6.53
      • 4.  Cost Factors  6.54
      • 5.  Services Provided  6.55
      • 6.  Limitations on Service  6.56
      • 7.  Service Providers  6.57
      • 8.  Application Procedure  6.58
      • 9.  Appeal Procedure  6.59
  • IV.  OTHER SOURCES FOR PAYMENT  6.60
    • A.  Private Funding  6.61
    • B.  Long-Term Care Insurance  6.62
      • 1.  California Requirements  6.63
      • 2.  Eligibility: Inability to Perform Activities of Daily Living [Deleted]  6.64
      • 3.  Federal Tax Advantages [Deleted]  6.65
    • C.  The Home
      • 1.  Home Equity Loan  6.66
      • 2.  Amortized Loan  6.67
      • 3.  Reverse Mortgage  6.68
      • 4.  Shared Appreciation Mortgages  6.69
      • 5.  Leasebacks and Multiple Units  6.70
    • D.  Life Insurance
      • 1.  Viatical and Senior Life Insurance Settlements  6.71
      • 2.  Changes in Secondary Market for Purchase of Senior Life Insurance Policies  6.71A
      • 3.  California Regulations  6.71B
        • a.  Statutory Definition of Life Settlement Contract  6.71C
        • b.  Prohibitions, Restrictions, and Requirements  6.71D
      • 4.  Role of Counsel in Sale of Policy  6.71E
    • E.  Income Tax Deductions and Property Tax Relief  6.72
    • F.  Family Members  6.73
      • 1.  Income Taxes Related to Families  6.74
      • 2.  Effect of Family Support on Government Benefits
        • a.  Medi-Cal  6.75
        • b.  IHSS  6.76
      • 3.  Liability of Family Members  6.77
      • 4.  Employer Issues  6.78
        • a.  Injury or Loss Involving Caregiver  6.79
        • b.  Minimum Wage, Overtime, and Withholding Requirements  6.80
      • 5.  Meeting Withholding Requirements Can Be Time-Consuming for Someone Not Set Up to Handle Them  6.81

7

Introduction to Medicare

Carol Small Jimenez

David A. Lipschutz

Stephanie K. Lee

  • I.  PURPOSE AND SCOPE OF CHAPTER
    • A.  Overview  7.1
    • B.  Keeping Current With Medicare Law  7.2
    • C.  Health Care Reform 2010; Impact on Medicare  7.2A
    • D.  Legal Challenges to Health Care Reform 2010  7.2B
  • II.  REGULATORY AGENCIES  7.3
  • III.  ELIGIBILITY AND ENROLLMENT
    • A.  Eligibility  7.4
      • 1.  Automatic Medicare Eligibility
        • a.  Title II Retirement-Based Eligibility  7.5
        • b.  Civil Service and Railroad Retirement Eligibility  7.6
        • c.  Social Security and Railroad Retirement Disability Recipients  7.7
        • d.  Qualified Disabled and Working Individuals  7.8
        • e.  End-Stage Renal Disease (ESRD)  7.9
        • f.  Amyotrophic Lateral Sclerosis (ALS)  7.10
      • 2.  Voluntary Medicare Eligibility  7.11
      • 3.  Premiums  7.12
    • B.  Enrollment  7.13
      • 1.  Initial Enrollment Period (IEP)  7.14
      • 2.  Employer Group Health Plan  7.15
      • 3.  General Enrollment Period  7.16
      • 4.  Late Enrollment Penalties  7.17
      • 5.  Waiver of Premium Penalty  7.18
      • 6.  Chart: Interaction of Parts A, B, and D Enrollment Periods  7.19
  • IV.  BENEFITS
    • A.  Summary of the Medicare Program  7.20
    • B.  Limitations of Coverage  7.21
    • C.  Part A Benefits
      • 1.  Inpatient Hospital Services  7.22
        • a.  “Spell of Illness” Defined  7.23
        • b.  Notice of Hospital Patient Rights and Appeals  7.24
        • c.  Beneficiary’s Copayment [Deleted]  7.25
        • d.  Hospital Discharges; Patient Protections  7.26
        • e.  Challenging Inappropriate Transfer  7.27
      • 2.  Limited Coverage for Skilled Nursing Facility Services
        • a.  Requirements for Coverage  7.28
        • b.  Qualifying Skilled Nursing Services  7.29
        • c.  Qualified Skilled Rehabilitation Services  7.30
        • d.  Prospective Payment System [Deleted]  7.31
        • e.  Prepayment Demands Prohibited  7.32
        • f.  Beneficiary’s Liability for Cost Sharing  7.33
        • g.  Notice of Noncoverage  7.34
      • 3.  Home Health Care
        • a.  Criteria for Coverage  7.35
          • (1)  Homebound Requirement  7.36
          • (2)  Skilled Services  7.37
          • (3)  Additional Part A Criteria for Beneficiaries Who Also Have Part B  7.38
        • b.  Covered Services  7.39
        • c.  Amount of Coverage  7.40
        • d.  Prospective Payment System [Deleted]  7.41
        • e.  Advance Beneficiary Notices  7.42
      • 4.  Hospice Care  7.43
      • 5.  Chart: 2019 Medicare Cost Sharing, Part A  7.44
    • D.  Part B Benefits
      • 1.  Covered Services  7.45
      • 2.  Exclusions From Coverage  7.46
      • 3.  Durable Medical Equipment (DME)  7.47
        • a.  Criteria for Coverage of DME  7.48
          • (1)  Covered Items  7.49
          • (2)  Medical Necessity  7.50
          • (3)  Use in the Home  7.51
        • b.  Rental or Purchase of DME  7.52
        • c.  Repair, Replacement, and Supplies  7.53
      • 4.  Medicare Coverage of Ambulance Services  7.53A
      • 5.  Covered Preventive Services  7.54
      • 6.  Cost to Beneficiaries
        • a.  Deductible and Copayments  7.55
        • b.  Chart: 2019 Medicare Cost Sharing, Part B  7.56
        • c.  Income-Related Premium  7.57
        • d.  Assignment and Limiting Charge  7.58
        • e.  Cost for Specific Services
          • (1)  Nonemergency Surgery  7.59
          • (2)  Clinical Laboratory Services  7.60
          • (3)  Physical and Occupational Therapy Services  7.61
          • (4)  Outpatient Psychiatric Services  7.62
          • (5)  Hospital Outpatient and Ambulance Services  7.63
        • f.  Private Contracts; Opting Out  7.64
  • V.  MEDICARE ADVANTAGE (PART C BENEFITS)
    • A.  Medicare Advantage Organizations  7.65
      • 1.  Summary of Changes Under 2010 Health Care Reform  7.65A
      • 2.  Availability and Enrollment  7.66
      • 3.  Applicable Federal Standards  7.67
    • B.  Advantages and Disadvantages of Medicare Managed Care  7.68
    • C.  Medicare Advantage and Part D  7.69
    • D.  Options Under Medicare Advantage (MA)
      • 1.  HMOs, PPOs, and PSOs (Coordinated Care Plans)  7.70
        • a.  Special Needs Plans  7.71
        • b.  Regional PPOs  7.72
      • 2.  Private Fee-for-Service (PFFS) Plans  7.73
        • a.  PFFS Plan Provider Contracting  7.74
        • b.  Marketing Misconduct  7.75
      • 3.  Medical Savings Accounts  7.76
    • E.  Eligibility
      • 1.  General Requirements  7.77
      • 2.  End-Stage Renal Disease  7.78
    • F.  Enrollment
      • 1.  Lock-In Rules  7.79
      • 2.  Enrollment Periods  7.80
        • a.  Initial Coverage Election Period (ICEP)  7.81
        • b.  Annual Coordinated Election Period (AEP)  7.82
        • c.  Medicare Advantage Disenrollment Period (MADP)  7.83
        • d.  Special Enrollment Periods (SEPs)  7.84
    • G.  Involuntary Disenrollment
      • 1.  Basis for Disenrollment  7.85
      • 2.  Optional Disenrollment  7.86
      • 3.  Required Disenrollment  7.87
    • H.  Out-of-Plan Services
      • 1.  Beneficiaries Must Use In-Network Facilities and Physicians  7.88
      • 2.  Reasons for Claims for Out-of-Network Services  7.89
        • a.  Need to Obtain Out-of-Network Services  7.90
        • b.  Problems With Enrollment and Disenrollment  7.91
      • 3.  MA Liability for Out-of-Network Claims  7.92
      • 4.  Emergency and Urgently Needed Services  7.93
      • 5.  Retroactive Disenrollment  7.94
    • I.  Restrictions on Retroactive Disenrollment  7.95
    • J.  Procedure for Retroactive Disenrollment  7.96
    • K.  Pursuing MA Plan Liability and Retroactive Disenrollment Concurrently  7.97
  • VI.  PRESCRIPTION DRUG BENEFIT (PART D)
    • A.  Overview of Part D  7.98
    • B.  Eligibility and Enrollment
      • 1.  Eligibility  7.99
      • 2.  Enrollment  7.100
        • a.  Initial Enrollment Period (IEP)  7.101
        • b.  Annual Coordinated Election Period (AEP)  7.102
        • c.  Special Enrollment Periods (SEPs)  7.103
      • 3.  Involuntary Disenrollment by PDP  7.104
        • a.  Optional Disenrollment by PDP  7.105
        • b.  Required Disenrollment by PDP  7.106
    • C.  Premiums, Penalties, and Creditable Coverage  7.107
      • 1.  Premiums for Part D Plans  7.108
      • 2.  Late Enrollment Penalty for Individuals Who Fail to Maintain Creditable Coverage  7.109
      • 3.  Creditable Coverage Requirements
        • a.  Definition of “Creditable Coverage”  7.110
        • b.  Disclosure of Coverage to Beneficiaries  7.111
    • D.  Benefits Under Part D  7.112
      • 1.  Benefit Structures Under Part D  7.113
        • a.  Standard (or Basic) Prescription Drug Coverage  7.114
        • b.  Closing the “Doughnut Hole”  7.114A
        • c.  Chart: Standard Part D Drug Benefit for 2019  7.115
        • d.  Alternative Prescription Drug Coverage  7.116
        • e.  Supplemental (or Enhanced Alternative) Prescription Drug Coverage  7.117
      • 2.  Incurred Costs (Expenses Countable Toward “TrOOP”)  7.118
        • a.  Cost Not Included in Incurred Costs [Deleted]  7.119
        • b.  Payments Counted as Incurred Costs [Deleted]  7.120
      • 3.  Covered Drugs  7.121
        • a.  Part D Drugs  7.122
        • b.  Formularies  7.123
          • (1)  Notice of Change in Formulary  7.124
          • (2)  Removal of Covered Drug From Formulary  7.125
          • (3)  Drugs Included in Formulary  7.126
          • (4)  Obtaining Coverage for Drugs Not Included in Formulary  7.127
        • c.  Access to Negotiated Prices  7.128
      • 4.  Waiver of Cost Sharing by Pharmacies  7.129
    • E.  Low-Income Subsidy (LIS)  7.130
      • 1.  Eligibility and Benefits  7.131
        • a.  Enrolled in Medicaid (Medi-Cal)  7.132
        • b.  Not Enrolled in Medicaid  7.133
        • c.  Chart: Part D Low-Income Subsidy (LIS)  7.134
      • 2.  Enrollment and Redetermination  7.135
      • 3.  Facilitated Enrollment in Part D Plans for LIS Enrollees  7.136
    • F.  Relation to California’s Prescription Drug Discount Program (“SB 393”)  7.137
  • VII.  MEDICARE AND OTHER HEALTH INSURANCE  7.138
    • A.  Employer-Based Insurance
      • 1.  Working Aged and Disabled  7.139
      • 2.  End-Stage Renal Disease Beneficiaries  7.140
      • 3.  Chart: Coordination of Medicare and Group Health Coverage  7.141
    • B.  Retiree Health Insurance
      • 1.  Overview of Retiree Health Insurance  7.142
      • 2.  Retiree Health Insurance Coverage and Part D
        • a.  Part D Coverage Options  7.143
          • (1)  Options for Employers Who Continue to Offer Retiree Coverage  7.144
          • (2)  Options for Retirees of Employers Who Continue to Offer Retiree Coverage  7.145
        • b.  Retiree Drug Plan Subsidies  7.146
    • C.  COBRA and Cal-COBRA  7.147
      • 1.  Eligibility and Duration  7.148
      • 2.  Chart: Maximum Length of COBRA Continuation Coverage  7.149
      • 3.  Effect of Medicare on Right to COBRA Coverage  7.150
      • 4.  End-Stage Renal Disease, Medicare, and COBRA  7.151
      • 5.  Senior Cal-COBRA (Before 2005) [Deleted]  7.152
      • 6.  Chart: Maximum Charge for Continuation Coverage [Deleted]  7.153
    • D.  Individual Policies  7.154
    • E.  Health Savings Accounts  7.155
  • VIII.  MEDICARE/MEDICAID DUAL ELIGIBLE ISSUES
    • A.  Overview and Definition of “Dual Eligible”  7.156
    • B.  Eligibility and Enrollment Issues
      • 1.  Medi-Cal  7.157
        • a.  SSI-Linked Eligibility  7.158
        • b.  Aged and Disabled Federal Poverty Level Program  7.159
        • c.  Coverage With Share of Cost for Medically Needy  7.160
        • d.  Chart: Eligibility for Medi-Cal for Aged and Disabled  7.161
      • 2.  Medicare Savings or Buy-in Programs  7.162
        • a.  Qualified Medicare Beneficiary (QMB)  7.163
        • b.  Specified Low-Income Medicare Beneficiary (SLMB)  7.164
        • c.  Qualifying Individuals (QI)  7.165
        • d.  Qualified Disabled and Working Individuals (QDWI)  7.166
        • e.  Chart: Summary of Medicare Savings Programs/Buy-in Programs  7.167
      • 3.  SSI Rules: Exclusions From Income and Resources  7.168
        • a.  Exclusions From Income  7.169
        • b.  Exclusions From Resources  7.170
    • C.  Dual Eligibles and Part D  7.171
      • 1.  Automatic Enrollment System  7.172
      • 2.  Limited Income Newly Eligible Transition (LI NET) Back-Up Enrollment Program  7.173
      • 3.  Ongoing Special Enrollment Program  7.174
      • 4.  Low-Income Subsidy (LIS) for Part D Premiums  7.175
      • 5.  Ongoing Problems  7.176
        • a.  CMS Data Lags  7.177
        • b.  Limited Choice of Drug Benefit Plans  7.177A
        • c.  Special Problems for Long-Term Care Beneficiaries  7.178
    • D.  Other Coordination of Benefits Issues  7.179
      • 1.  Balance Billing Protections  7.179A
      • 2.  Medi-Cal and Medicare Fee-for-Service  7.180
      • 3.  Medi-Cal and Medicare Managed Care  7.181
      • 4.  Medi-Cal Managed Care and Medicare Fee-for-Service  7.181A
      • 5.  California’s Coordinated Care Initiative: Medi-Cal Managed Care and Medicare Managed Care  7.181B
        • a.  Cal MediConnect Program Design  7.181C
        • b.  Eligibility and Enrollment for Cal MediConnect  7.181D
        • c.  Cal MediConnect Issues and Its Future  7.181E
  • IX.  MEDICARE SUPPLEMENTAL INSURANCE
    • A.  Overview of Medicare Supplemental Policies  7.182
      • 1.  Plan Changes Effective June 1, 2010  7.182A
      • 2.  Chart: Medicare Supplemental Insurance Policies (Medigaps) Created Before June 2010  7.183
      • 3.  Chart: Additional Medicare Supplemental Insurance Policies (Medigaps) Created in 2006  7.184
      • 4.  Chart: Medicare Supplement Plans With Effective Dates On or After June 1, 2010  7.184A
    • B.  Guaranteed Issue Provisions  7.185
    • C.  MMA Changes to Existing Plans for 2006 [Deleted]  7.186
      • 1.  Medigap Drug Coverage Prohibited for Part D Enrollees [Deleted]  7.187
      • 2.  Creditable Coverage by Medigap Plans [Deleted]  7.188
  • X.  OTHER COVERAGE ISSUES
    • A.  Waiver of Beneficiary’s Liability
      • 1.  Situations When Waiver May Apply  7.189
      • 2.  Criteria for Waiver  7.190
      • 3.  Challenging a Denial of Claim  7.191
      • 4.  Provider Avoidance of Waiver by Giving Beneficiary Advance Notice of Likely Denial [Deleted]  7.192
    • B.  Obstacles to Medicare Coverage
      • 1.  Utilization Screens
        • a.  Definition of “Utilization Screen”  7.193
        • b.  Challenging Coverage Denials Based on Utilization Screens  7.194
      • 2.  National Coverage Determinations (NCDs)
        • a.  Definition and Effect of NCDs  7.195
        • b.  Legal Review and Challenges to NCDs [Deleted]  7.196
      • 3.  Local Coverage Determinations (LCDs)  7.197
  • XI.  RESOURCES
    • A.  Official Medicare Program Contacts  7.198
    • B.  Consumer Assistance Contacts
      • 1.  Direct Service Providers  7.199
      • 2.  Support Centers  7.200
    • C.  Published Resources  7.201
  • XII.  GLOSSARY OF ABBREVIATIONS  7.202

8

Medicare Appeals

Lenore Ellen Gerard

Stephanie K. Lee

David A. Lipschutz

Julie R. Schoen

Deepti S. Sethi

  • I.  INTRODUCTION TO MEDICARE APPEALS  8.1
    • A.  Medical Care Providers as Advocates  8.2
    • B.  Who May Appeal
      • 1.  Parties  8.3
      • 2.  Appointed Representative  8.4
        • a.  Ascertain Whether Beneficiary Is Capable of Appeal  8.5
        • b.  Assignment of Appeal Rights  8.6
      • 3.  Service Providers as Parties  8.7
    • C.  When Exhaustion of Administrative Remedies Is Required  8.8
    • D.  Evaluating Merits of Case  8.9
      • 1.  Review General Legal Guidelines  8.10
      • 2.  Ascertain Basis of Denial  8.11
      • 3.  Ascertain Whether Advance Beneficiary Notice Met Criteria  8.11A
      • 4.  Evaluate if Requirement of Medical Necessity Is Met  8.12
      • 5.  Obtain Records  8.13
    • E.  Attorney Fees  8.14
    • F.  Medicare as Secondary Payer (MSP)  8.15
  • II.  MEDICARE APPEALS UNDER BIPA (PARTS A AND B)  8.16
    • A.  Single Appeals System  8.17
    • B.  Appeals Filed Under Former Appeal Procedures [Deleted]  8.18
    • C.  Initial Determination
      • 1.  Processing Claims; Subjects of Initial Determination  8.19
      • 2.  Time Limits; Notice  8.20
    • D.  Redetermination
      • 1.  Request for Redetermination  8.21
      • 2.  Time Limits; Notice  8.22
      • 3.  Denial on Redetermination  8.23
      • 4.  Favorable Decision on Redetermination  8.24
    • E.  Reconsideration  8.25
      • 1.  Time Limits  8.26
      • 2.  Submission of Evidence  8.27
      • 3.  Basis of Qualified Independent Contractor’s (QIC’s) Decision  8.28
      • 4.  Decision and Notice of Decision  8.29
    • F.  Hearing Before Administrative Law Judge (ALJ)
      • 1.  If No Timely QIC Decision on Reconsideration  8.30
      • 2.  If Dissatisfied With QIC’s Reconsideration Decision  8.31
      • 3.  Amount in Controversy  8.32
      • 4.  Conduct of ALJ Hearing  8.33
      • 5.  Basis of ALJ or Attorney Adjudicator Decision  8.34
      • 6.  Timeframe for ALJ or Attorney Adjudicator Decision  8.35
      • 7.  Notice of Decision  8.36
      • 8.  Effect of ALJ or Attorney Adjudicator Decision  8.37
    • G.  Review by Medicare Appeals Council
      • 1.  Who May Initiate Review  8.38
      • 2.  Council Decision  8.39
    • H.  Judicial Review  8.40
    • I.  Reopening  8.41
    • J.  Expedited Proceedings
      • 1.  Hospital Discharges  8.41A
        • a.  Notice Requirements  8.41B
        • b.  Request for Expedited Determination  8.42
        • c.  Beneficiary’s Financial Responsibility  8.43
        • d.  Notice of Expedited Determination  8.44
        • e.  Reconsideration  8.45
        • f.  Posthospitalization Extended Care Services  8.46
      • 2.  Expedited Determination on Termination of Services or Discharge From SNF, HHA, Hospice, or CORF
        • a.  Request for Expedited Determination  8.47
        • b.  Definitions  8.48
        • c.  Decision on Request for Expedited Determination  8.49
        • d.  Expedited Reconsideration  8.50
      • 3.  Expedited Access to Judicial Review
        • a.  Requirements  8.51
        • b.  Certification  8.52
    • K.  Direct Appeals of National and Local Coverage Determinations (NCDs and LCDs)  8.53
      • 1.  NCD Appeals  8.54
      • 2.  LCD Appeals  8.55
  • III.  MEDICARE ADVANTAGE APPEALS (PART C)  8.56
    • A.  Emergency and Urgent Services  8.57
    • B.  Two Procedures for Resolving MA Disputes  8.58
    • C.  Appeal Process
      • 1.  Hospital Discharge Procedures  8.59
        • a.  Notice Requirements  8.60
        • b.  Request for Expedited Review After Service of Written Notice  8.61
        • c.  Posthospitalization Extended Care Services  8.62
      • 2.  Appeal of Organization Determination
        • a.  Definition of Organization Determination  8.63
        • b.  Standard Organization Determination  8.64
        • c.  Expedited Organization Determination  8.65
          • (1)  If Organization Agrees to Expedite Determination  8.66
          • (2)  If Organization Denies Request to Expedite Determination  8.67
          • (3)  Practical Considerations  8.68
      • 3.  Reconsideration  8.69
        • a.  Standard Reconsideration  8.70
        • b.  Expedited Reconsideration  8.71
        • c.  Independent Review if Negative Reconsideration Determination  8.72
        • d.  Finality of Reconsideration Determination; Reopening  8.73
      • 4.  Further Proceedings: ALJ, Council, and Federal Court  8.74
      • 5.  Fast-Track Review of Termination of Services in SNF, HHA, or CORF  8.75
        • a.  Notice  8.76
        • b.  Fast-Track Appeal  8.77
    • D.  Grievance Procedure  8.78
  • IV.  MEDICARE PART D APPEALS
    • A.  Overview  8.79
    • B.  Where to Obtain Information About Medicare Part D Appeals  8.80
    • C.  Appeal of Coverage Determination
      • 1.  Definition of Coverage Determination  8.81
      • 2.  Starting the Process  8.82
      • 3.  Exceptions Requests  8.83
      • 4.  Standard Coverage Determination  8.84
      • 5.  Expedited Coverage Determination  8.85
      • 6.  Redetermination by Plan  8.86
      • 7.  Reconsideration by Independent Review Entity  8.87
      • 8.  Further Stages of Appeal: ALJ, Council, and Federal Court  8.88
    • D.  Grievances  8.89
  • V.  MEDICARE APPEALS CHARTS AND FORMS
    • A.  Federal Government Agencies  8.90
    • B.  Medicare Contractors for California  8.91
  • VI.  GLOSSARY OF ABBREVIATIONS  8.92

9

Introduction to Medi-Cal

Susanne B. Cohen

  • I.  INTRODUCTION TO MEDI-CAL
    • A.  Organization of Material  9.1
    • B.  Medi-Cal and Medicare Distinguished  9.2
  • II.  LEGAL AUTHORITY
    • A.  Federal Law  9.3
    • B.  State Law  9.4
  • III.  TYPES OF MEDI-CAL BENEFICIARIES  9.5
    • A.  The Affordable Care Act (ACA)  9.5A
    • B.  SSI-Linked Medi-Cal  9.5B
    • C.  Pickle Amendment  9.5C
    • D.  Aged and Disabled Federal Poverty Level Medi-Cal (A&D FPL)  9.5D
    • E.  Aged, Blind, and Disabled—Medically Needy Medi-Cal  9.5E
    • F.  California Working Disabled (CWD) Program  9.5F
    • G.  CalWORKs/TANF-Linked Medi-Cal  9.5G
    • H.  Medi-Cal/HIPP Program  9.5H
  • IV.  MEDI-CAL PROCEDURES
    • A.  Application and Medi-Cal Determination  9.6
    • B.  Fair Hearings; Appeals  9.6A
    • C.  Procedure for Obtaining 3 Months’ Retroactive Coverage  9.6B
  • V.  MEDI-CAL PROVIDERS  9.7
  • VI.  MEDI-CAL COVERAGE  9.8
    • A.  Combined Medicare and Medi-Cal Coverage  9.9
    • B.  Home Health Care Services  9.10
    • C.  Residential Care Facilities  9.11
    • D.  Nursing Homes  9.12
  • VII.  MEDI-CAL ELIGIBILITY  9.13
    • A.  Assets
      • 1.  Property Reserve  9.14
      • 2.  Property Distinguished From Income  9.15
      • 3.  Exempt Assets  9.16
        • a.  Principal Residence
          • (1)  When Exemption Applies  9.17
          • (2)  Limitations on Value of Principal Residence  9.17A
          • (3)  When Home Equity Limit Does Not Apply  9.17B
          • (4)  Out-of-State Residence; Absence From State  9.18
          • (5)  Property Included in Principal Residence  9.19
          • (6)  Prior Residence Requirement  9.20
        • b.  Vehicle  9.21
        • c.  Burial Plots or Burial Contracts  9.22
        • d.  Income-Producing Property and Property Used for Self-Support
          • (1)  Property Used in Trade or Business  9.23
          • (2)  Rental Property and Other Nonbusiness Income-Producing Property  9.24
          • (3)  Nonbusiness Property Necessary for Self-Support  9.25
        • e.  Other Exempt Assets  9.26
      • 4.  Unavailable and Nonexempt Assets  9.27
        • a.  “Other Real Property”  9.28
        • b.  IRAs and Pensions  9.29
        • c.  Annuities  9.30
          • (1)  Types of Annuities
            • (a)  Immediate Annuities  9.30A
            • (b)  Deferred Annuities  9.30B
            • (c)  Private Annuities  9.30C
          • (2)  Annuities Purchased Before August 11, 1993  9.31
          • (3)  Annuities Purchased After August 11, 1993  9.32
        • d.  Cash and Bank Accounts  9.33
        • e.  Life Care and Continuing Care Contract Fees  9.33A
      • 5.  Valuation of Nonexempt Assets  9.34
        • a.  Real Property  9.35
        • b.  Promissory Notes  9.36
        • c.  Debts Owed by Applicant or Beneficiary  9.37
        • d.  Nonexempt Vehicles  9.38
    • B.  Income
      • 1.  Share of Cost  9.39
      • 2.  Income Counted  9.40
        • a.  Lump Sums  9.41
        • b.  Periodic Receipts  9.42
        • c.  Deductions From Income That Are Permitted  9.43
          • (1)  Expenses for Rental Real Property  9.44
          • (2)  Medical and Personal Care Expenses  9.45
    • C.  Transfers
      • 1.  Restrictions on Transfers Generally Apply Only to Long-Term Care Benefits  9.46
      • 2.  OBRA 1993, MCCA, and DRA Transfer Rules: Overview  9.47
    • D.  Basic Medi-Cal Issues Raised by Trusts  9.48
      • 1.  Nonexempt Trusts
        • a.  Revocable Trust Corpus Is Resource  9.49
        • b.  Revocable Trust Distributions to Medi-Cal Beneficiary or Spouse Are Income  9.50
        • c.  Placing Assets In or Making Distributions From Revocable Trust Is Transfer  9.51
        • d.  Irrevocable Trusts
          • (1)  Trust That Could Benefit Applicant  9.52
          • (2)  Trust That Could Not Benefit Applicant  9.53
      • 2.  Exempt Trusts  9.54
        • a.  Testamentary Trusts  9.55
        • b.  Special Exempt Trusts for Persons With Disabilities  9.56
          • (1)  Trusts for Beneficiaries With Disabilities Under Age 65  9.57
            • (a)  Establishment by Court Order  9.58
            • (b)  “For the Benefit of” SNT Beneficiary  9.59
          • (2)  Pooled Trusts for Disabled Beneficiaries of Any Age  9.60
          • (3)  Reimbursement to State  9.61
      • 3.  Transfer Penalty for Transferring Assets to and From Trusts
        • a.  Legal Authority
          • (1)  Federal Law  9.62
          • (2)  State Law  9.63
        • b.  Definition of Trust  9.64
          • (1)  Similar Legal Device (SLD)  9.64A
          • (2)  Transfers for “Sole Benefit” of Applicant’s Spouse Treated as SLD  9.64B
        • c.  Trusts Subject to Trust Rules
          • (1)  Trust Must Be “Established” by Applicant
            • (a)  Requirements  9.64C
            • (b)  Potential Trap: Agent Acting for Applicant  9.64D
          • (2)  Exception to Transfer Rules for Transfer of Home to Trust  9.64E
        • d.  Irrevocable Income-Only Trusts  9.64F
        • e.  Hardship Waivers  9.65
    • E.  Citizen and Noncitizen Eligibility for Medi-Cal
      • 1.  U.S. Citizens and U.S. Nationals Must Prove Citizenship  9.65A
        • a.  When Additional Documentation of Citizenship Required  9.65B
        • b.  Acceptable Documents; Consequences of Failure to Provide Documentation  9.65C
      • 2.  Noncitizen Eligibility for Medi-Cal  9.66
  • VIII.  DECIDING WHETHER TO QUALIFY FOR MEDI-CAL  9.67

10

Medi-Cal Eligibility for Nursing Home Care Benefits

Gregory Wilcox

  • I.  INTRODUCTION  10.1
    • A.  Organization of Material  10.1A
    • B.  Problem of Keeping Current With Medi-Cal Law  10.2
    • C.  Components of Medi-Cal Law
      • 1.  MCCA, OBRA 1993, and DRA  10.3
      • 2.  Effective Date of DRA  10.4
    • D.  Rising Demand and Cost of Nursing Home Care  10.5
  • II.  ALTERNATIVES TO MEDI-CAL FOR PAYMENT OF NURSING HOME CARE
    • A.  Medicare  10.6
    • B.  Medigap and Medicare HMO Health Insurance Policies  10.7
    • C.  Insurance for Care in a Nursing Home, Residential Care Facility for the Elderly, and Home and Community Care  10.8
    • D.  Personal Savings  10.9
  • III.  REASONS FOR RELUCTANCE TO TRY TO QUALIFY FOR MEDI-CAL  10.10
    • A.  Fewer Possible Placements  10.11
    • B.  Fear of Discrimination and Substandard Care
      • 1.  Difference in Payment Rates  10.12
      • 2.  Difference in Quality of Care  10.13
      • 3.  Difference Between Private and Semi-Private Rooms  10.14
    • C.  Other Considerations  10.15
  • IV.  MEDI-CAL ELIGIBILITY REQUIREMENTS  10.16
    • A.  Long-Term Care Covered  10.17
    • B.  Asset Limitations  10.18
    • C.  Asset Exemption: The Home  10.19
      • 1.  Excess Home Equity Disqualifying Under DRA  10.20
      • 2.  California Has Increased DRA Home Equity Cap
        • a.  Procedural Provisions  10.20A
        • b.  Determining Equity Interest Subject to Cap  10.20B
        • c.  Other Provisions and Exemptions Favorable to Applicant  10.20C
      • 3.  Intent to Return Home  10.21
    • D.  Income Requirements
      • 1.  Share of Cost  10.22
      • 2.  Operation of “Share of Cost” Rule  10.23
      • 3.  Income Counted  10.24
    • E.  Transfer of Assets Restrictions  10.25
      • 1.  Governing Rules  10.26
        • a.  MCCA Rules  10.27
          • (1)  30-Month Look-Back  10.28
          • (2)  Transfers by Spouses  10.29
          • (3)  Transfers of Resources  10.30
            • (a)  Gifts  10.31
            • (b)  Disclaimers  10.32
            • (c)  Exempt Property  10.33
          • (4)  Calculation of Disqualification Period: 30 Months Maximum  10.34
          • (5)  Services Affected  10.35
          • (6)  Multiple Transfers  10.36
        • b.  OBRA 1993 Rules  10.37
          • (1)  Transfers by Spouses  10.38
          • (2)  Transfers of Resources and Income; Disclaimers  10.39
          • (3)  Gifts  10.40
          • (4)  Calculation of Disqualification Period: Unlimited  10.41
          • (5)  Services Affected  10.42
          • (6)  Multiple Transfers  10.43
          • (7)  Joint Tenancy Transfers  10.44
        • c.  DRA Rules  10.45
          • (1)  60-Month Look-Back  10.46
          • (2)  Change in Penalty’s Beginning Date  10.47
          • (3)  No Rounding Down of Ineligibility Periods  10.48
          • (4)  Multiple Transfers  10.49
          • (5)  Purchase of Notes and Loans as Transfer of Assets  10.50
            • (a)  Exceptions to Treatment as Transfer of Assets  10.51
            • (b)  Valuation  10.52
          • (6)  Transfers to Purchase Life Estates  10.53
        • d.  California’s Implementation of DRA Transfer Rules  10.53A
      • 2.  Exceptions to Transfer Rules  10.54
        • a.  California’s Implied Exemption for Transfer of All Exempt Assets, Including the Home  10.55
        • b.  Express Statutory Exemptions for Transfer of Home to Specified Individuals  10.56
        • c.  Transfers to (or for Benefit of) Spouse or Disabled Child, and to Trusts for Disabled Persons Under 65  10.57
          • (1)  MCCA
            • (a)  Transfers That Are Not Disqualifying  10.58
            • (b)  Transfers That Are Disqualifying  10.59
          • (2)  OBRA 1993  10.60
            • (a)  Exempt Transfers for “Sole Benefit” of Spouse  10.61
            • (b)  Exempt Transfers to Trusts for Applicant’s Blind or Disabled Child, and to Trusts for Disabled Persons Under Age 65  10.62
        • d.  Innocent and Partially Returned Transfers  10.63
        • e.  Undue Hardship
          • (1)  MCCA Rule  10.64
          • (2)  OBRA 1993 Rule  10.65
          • (3)  DRA Rule  10.66
            • (a)  Similarity of DRA’s and CMS’s Language  10.67
            • (b)  State Flexibility Under CMS Guidelines  10.68
            • (c)  California Statutory Implementation of DRA Hardship Rules
              • (i)  Circumstances of Undue Hardship  10.68A
              • (ii)  Procedural Hardship Protections  10.68B
            • (d)  Protection of Nursing Homes  10.69
      • 3.  Criminal Exposure for Transfer of Assets  10.70
  • V.  SPECIAL MEDI-CAL ELIGIBILITY RULES TO PREVENT SPOUSAL IMPOVERISHMENT
    • A.  Applicable Rules
      • 1.  MCCA Spousal Impoverishment Provisions  10.71
      • 2.  California Regulations  10.72
      • 3.  Treatment of Same-Sex Marriages  10.72A
      • 4.  Treatment of Other Same-Sex Couples  10.72B
    • B.  Content of Spousal Impoverishment Rules  10.73
      • 1.  Income Protection for Spouse and Other Dependents
        • a.  Minimum Monthly Maintenance Needs Allowance (MMMNA)  10.74
          • (1)  Supplementation From Income Allocation  10.75
          • (2)  Supplementation From Additional Assets  10.76
          • (3)  DRA’s “Income-First” Rule  10.77
          • (4)  No Limits on Community Spouse’s Income  10.78
          • (5)  Evidence of Transfer of Income to Community Spouse  10.79
        • b.  Attribution of Income: “Name on the Check” Rule  10.80
        • c.  Support Allowance for Other Dependents  10.81
      • 2.  Community Spouse Resource Allowance (CSRA)  10.82
        • a.  Amount of CSRA  10.83
        • b.  Separate Treatment of Community Spouse’s Resources Acquired After Eligibility Established  10.84
        • c.  Transfer of CSRA Resources to Community Spouse  10.85
        • d.  Exceptions to CSRA Restrictions  10.86

11

Medi-Cal Planning Strategies for Nursing Home Care Benefits

Gregory Wilcox

  • I.  INTRODUCTION
    • A.  Planning Purposes  11.1
    • B.  Planning to Accelerate Eligibility  11.2
    • C.  Impact of Deficit Reduction Act (DRA)
      • 1.  DRA Will Require New Planning Strategies  11.3
      • 2.  Summary of DRA Impact  11.4
    • D.  Does Client Need Medi-Cal Planning?  11.5
      • 1.  Need for Long-Term Institutional Care?  11.6
      • 2.  Private-Pay Alternatives  11.7
      • 3.  Consequences of No Planning  11.8
    • E.  Counseling on Medi-Cal Planning Drawbacks  11.9
      • 1.  Tax Impacts  11.10
      • 2.  Estate Planning  11.11
      • 3.  Personal Desires and Abilities  11.12
    • F.  Liability and Ethical Issues for Attorneys  11.13
      • 1.  Professional Responsibility  11.14
      • 2.  Malpractice  11.15
      • 3.  Elder Abuse and Undue Influence Issues
        • a.  Medi-Cal Planning Perceived as Elder Abuse and Undue Influence  11.16
        • b.  Increased Risk if Plan Involves Gifts  11.17
        • c.  Ways to Protect Against False Allegations  11.18
      • 4.  Public Policy and Morality  11.19
  • II.  ELIGIBILITY STRATEGIES INVOLVING UNAVAILABILITY  11.20
    • A.  “Unavailability” Defined  11.21
    • B.  Demonstrating Unavailability
      • 1.  Inability to Liquidate  11.22
      • 2.  Unconscious, Comatose, or Incompetent Applicant  11.23
  • III.  ELIGIBILITY STRATEGIES INVOLVING SPENDING  11.24
    • A.  Spend Down on Nursing Home Care  11.25
    • B.  Retroactive Spend Down of Excess Assets on Medical Expenses  11.26
    • C.  Spending to Purchase Exempt Assets and Services  11.27
      • 1.  Home  11.28
      • 2.  Advisability of Paying Off Medical Bills  11.29
      • 3.  Prepayment of Obligations  11.30
      • 4.  Other Exempt Assets  11.31
      • 5.  Annuities
        • a.  Introduction to Annuities  11.32
        • b.  When Annuity Will Be Considered Unavailable, Noncountable Asset  11.33
          • (1)  Under Current Law  11.34
          • (2)  Requirements Under DRA Annuity Rules  11.35
            • (a)  Transfer of Assets Exceptions  11.35A
              • (i)  State Must Be Remainder Beneficiary  11.36
              • (ii)  Consequences if Remainderman Requirements Not Met  11.36A
            • (b)  Procedural Requirements for Disclosure and Notice  11.37
          • (3)  California’s Implementation of DRA Annuity Rules  11.37A
            • (a)  When State Shall Not Be Remainder Beneficiary  11.37B
              • (i)  State as Remainder Beneficiary by Operation of Law  11.37C
            • (b)  Procedural Requirements for Disclosure and Notice  11.37D
        • c.  Planning Considerations
          • (1)  Financial Disadvantages of Annuities  11.38
          • (2)  Annuities for Spouses of Medi-Cal Beneficiaries  11.39
            • (a)  Short-Term Annuities for Spouses  11.40
            • (b)  Spousal Protection Alternatives  11.41
          • (3)  Annuities for Medi-Cal Beneficiaries Under DRA  11.42
      • 6.  Personal Service Contracts
        • a.  Basics  11.43
        • b.  Drawbacks
          • (1)  Risks of Default  11.44
          • (2)  Tax Issues  11.45
        • c.  Drafting Issues
          • (1)  Services to Be Provided  11.46
          • (2)  Calculation of Value of Promise  11.47
        • d.  California’s Response  11.48
  • IV.  ELIGIBILITY STRATEGIES INVOLVING TRANSFERS
    • A.  Preliminary Considerations  11.49
      • 1.  Adverse Economic and Psychological Impact of Transfers  11.50
      • 2.  Client’s Lack of Capacity to Make Transfers  11.51
        • a.  Durable Power of Attorney for Financial Management: Express Authorization Required to Make Gifts  11.52
        • b.  DPOA Agent as Beneficiary; Tax Consequences  11.53
      • 3.  Client’s Estate Planning Goals  11.54
      • 4.  Tax Factors
        • a.  Gift and Capital Gains Taxes  11.55
        • b.  Planning Strategies Under Carryover Basis Rules in 2010 [Deleted]  11.56
    • B.  Curing Improvident Transfers  11.57
    • C.  General Transfer Strategies
      • 1.  Transferring Countable Assets
        • a.  Disqualification Period
          • (1)  Under MCCA  11.58
          • (2)  Under DRA  11.59
        • b.  Fragmenting and Bunching Gifts
          • (1)  MCCA Rules  11.60
          • (2)  Pending DRA and OBRA 1993 Rules  11.61
        • c.  Reducing Size of Gifts  11.62
          • (1)  Under MCCA
            • (a)  Monthly Gifts Below APPR  11.63
            • (b)  Half-a-Loaf Gifts  11.64
          • (2)  Under DRA  11.65
      • 2.  Transferring Noncountable Assets
        • a.  Transferring Income  11.66
          • (1)  Life Insurance and Inheritance  11.67
          • (2)  Personal Injury Awards  11.68
        • b.  Transferring Unavailable Assets  11.69
        • c.  Transferring Exempt Assets Other Than Home  11.70
        • d.  Transferring Home Under Current Law  11.71
          • (1)  Outright Transfer With “Right to Return Home” Safe Harbor  11.72
          • (2)  Form: Declaration of Right to Return Home  11.73
          • (3)  Life Estates  11.74
          • (4)  Retained Personal Right of Occupancy  11.75
            • (a)  Retained Right of Occupancy in Deed  11.76
            • (b)  Separate Occupancy Agreement  11.77
            • (c)  Specific Provisions  11.78
              • (i)  Advantages of Occupancy Agreement  11.79
              • (ii)  Form: Occupancy Agreement  11.80
            • (d)  Irrevocable Grantor Trust  11.81
        • e.  Transferring Home Under DRA  11.82
      • 3.  Transfer Strategies Unique to Married Clients
        • a.  Transfers to Spouse  11.83
        • b.  Retransfers by Spouse
          • (1)  The Rules  11.84
          • (2)  Using the Rules  11.85
        • c.  Transfer of Applicant Spouse’s Home
          • (1)  Avoiding Disqualification on Sale  11.86
          • (2)  Avoiding Later Medi-Cal Estate Claim  11.87
          • (3)  Court Proceedings to Effect Transfer  11.88
          • (4)  Planning Without Transfer  11.89
        • d.  Divorce  11.90
          • (1)  Substantial Community Property  11.91
          • (2)  Substantial Separate Property  11.92
          • (3)  Advising Divorce as Planning Strategy  11.93
          • (4)  Issues to Consider in Divorce Proceedings  11.94
    • D.  Transfer Strategies Under DRA  11.95
  • V.  INCOME PLANNING STRATEGIES  11.96
    • A.  Changing Name on the Check  11.97
    • B.  Increasing Community Spouse’s Income to the Minimum Monthly Maintenance Needs Allowance (MMMNA) Level
      • 1.  Possible Procedures  11.98
      • 2.  Enlarging Community Spouse Resource Allowance (CSRA)  11.98A
      • 3.  Optimizing Allocation From Institutionalized Spouse’s Income  11.98B
    • C.  Paying With Share of Cost  11.99
    • D.  Paying for Upkeep of a Home  11.100
  • VI.  TRUST PLANNING STRATEGIES  11.101
    • A.  Trusts Safe by Statutory Exemption
      • 1.  Testamentary Trusts  11.102
      • 2.  Disability Trusts  11.103
    • B.  Trusts That May Be Safe to Use
      • 1.  Donee Trusts  11.104
      • 2.  Irrevocable Income-Only Trusts  11.105
      • 3.  Irrevocable Grantor Trusts  11.106
        • a.  Sale or Borrowing  11.106A
        • b.  Earlier Death of Donees and Contingent Beneficiaries  11.106B
        • c.  Reducing the Tax Impact of Reorganizing Distributions Among Beneficiaries  11.106C
        • d.  Arguments Against Using Irrevocable Grantor Trusts  11.106D
        • e.  How to Obtain Grantor Trust Status  11.106E
  • VII.  STRATEGIES TO ENLARGE CSRA AND MMMNA AND TO MAKE TRANSFERS
    • A.  Administrative Appeals and Court Proceedings  11.107
    • B.  Warning to Client  11.108
    • C.  Initial Strategic Considerations
      • 1.  Procedures  11.109
      • 2.  Practical Considerations  11.110
      • 3.  Other Desired Goals  11.111
    • D.  Administrative Appeals
      • 1.  Administrative Appeal to Enlarge CSRA
        • a.  Under MCCA  11.112
        • b.  “Income-First” Rule Under DRA  11.113
        • c.  Initiating Appeal  11.114
        • d.  Authorized Representative  11.115
        • e.  Setting Hearing Date  11.116
        • f.  Preparation for Hearing  11.117
        • g.  Administrative Law Judges’ Guidelines on Rate of Return on CSRA  11.118
        • h.  Hearing  11.119
        • i.  Posthearing Matters  11.120
      • 2.  Administrative Appeal to Increase Allowance Above MMMNA  11.121
    • E.  Court Petitions
      • 1.  Court’s Role in Medi-Cal Eligibility Planning  11.122
        • a.  Judicial Order to Enlarge Applicant’s CSRA and MMMNA
          • (1)  CSRA
            • (a)  “Income-First” Rule Not Expected to Be Applicable  11.123
            • (b)  Substantive Issues  11.124
          • (2)  MMMNA  11.125
            • (a)  Substantive Issues  11.126
            • (b)  Formulating Request in Petition for “Enlarging MMMNA”  11.127
          • (3)  Possible Proceedings  11.128
        • b.  Judicial Order to Transfer Assets
          • (1)  Transfers to Fulfill Spouse’s CSRA and Maintain Eligibility  11.129
          • (2)  Transfers by Single Person to Accelerate Eligibility or Avoid Claims  11.130
      • 2.  Court Concerns
        • a.  Judges’ Limited Experience with Medi-Cal; Lack of Substantive Standards  11.131
        • b.  Need to Protect Interests of Incapacitated Person  11.132
        • c.  Specific Procedural Protections That Court May Order  11.133
        • d.  Propriety of Planning to Accelerate Eligibility or Increase Medi-Cal Benefits  11.134
          • (1)  Congressional Intent  11.135
          • (2)  Parallels to Tax Planning Techniques  11.136
          • (3)  Court’s Responsibility in Protective Proceedings  11.137
      • 3.  Specific Court Proceedings
        • a.  Proceeding for Particular Transaction (Prob C §§3100–3154)  11.138
          • (1)  Statutory Requirements
            • (a)  Allegation of Incapacity
              • (i)  Application of DPCDA  11.139
              • (ii)  Effect of HIPAA and CMIA  11.140
            • (b)  Authorization Is for Permissible Purpose  11.141
            • (c)  Procedural Requirements  11.142
            • (d)  Notice Requirements  11.143
              • (i)  Protections for Incapacitated Spouse  11.144
          • (2)  Transfers to Fulfill CSRA
            • (a)  Petition for Transfer and Transmutation of Assets  11.145
            • (b)  Transmutation of Trust Assets  11.146
          • (3)  Transfers to Enlarge CSRA  11.147
            • (a)  Arguments Based on Practical Considerations  11.148
            • (b)  Factors Proving Necessity for Support of Community Spouse  11.149
            • (c)  Petition for Order Authorizing Particular Transaction and Enlarging CSRA  11.150
            • (d)  Form: Sample Petition for Order Authorizing Particular Transaction  11.151
          • (4)  Transfers to Increase Income Allowance Above MMMNA  11.152
        • b.  Conservatorship Proceedings
          • (1)  Married Applicants  11.153
            • (a)  Petition for Substituted Judgment
            • (b)  Substantive Law  11.154
              • (i)  Arguments in Support of Petition  11.155
            • (c)  Support of Conservatee’s Dependents  11.156
            • (d)  Order “Against Institutionalized Spouse” Required Under MCCA  11.157
          • (2)  Single Applicants
            • (a)  When Conservatorship Proceeding May Be Needed  11.158
            • (b)  Substituted Judgment Petition  11.159
        • c.  Proceedings When Both Spouses Have Capacity  11.160
          • (1)  Civil Liability for Support  11.161
          • (2)  Community Property Accountings  11.162
          • (3)  Voluntary Conservatorships  11.163

12

Medi-Cal Estate Recovery

Gregory Wilcox

  • I.  INTRODUCTION TO MEDI-CAL ESTATE RECOVERY
    • A.  Recent Changes in the Law  12.1
    • B.  Basic Rules  12.2
    • C.  Legal Authority  12.3
    • D.  Informational Materials  12.4
  • II.  LIENS
    • A.  Federal Law
      • 1.  When Lien May Be Imposed  12.5
      • 2.  Limitations on Imposing Liens  12.6
      • 3.  When Recovery May Be Made on Lien  12.7
    • B.  State Law  12.8
      • 1.  Liens if No Intent to Return Home  12.9
      • 2.  Listing Lien  12.10
      • 3.  “Voluntary Postdeath Lien”  12.11
        • a.  Procedure for Payment by Successor  12.12
        • b.  If Successor Conveys Property  12.13
        • c.  Enforcement  12.14
  • III.  CLAIMS AGAINST DECEASED BENEFICIARY’S ESTATE
    • A.  Federal Law
      • 1.  When Recovery Is Mandatory  12.15
      • 2.  When Recovery Is Barred  12.16
      • 3.  Definition of “Estate” for Purposes of Medi-Cal Recovery  12.17
      • 4.  Hardship Waiver  12.18
    • B.  State Law  12.19
      • 1.  Mandatory Claims  12.20
      • 2.  Amount of Claim
        • a.  Lesser of Payments Made or Value of Decedent’s Property  12.21
        • b.  Claims for Reimbursement of “Health Care Services”  12.22
        • c.  Recovery in Counties Using Managed Care  12.22A
      • 3.  Property Subject to Recovery
        • a.  Property Subject to Recovery for Beneficiaries Dying On or After January 1, 2017  12.22B
        • b.  Property Subject to Recovery for Beneficiaries Dying Before January 1, 2017  12.23
        • c.  Regulations (Applicable to Decedents Dying Before January 1, 2017)  12.24
        • d.  Probate Estates (Applicable to Decedents Dying Before January 1, 2017)  12.25
        • e.  Joint Tenancies (Applicable to Decedents Dying Before January 1, 2017)  12.25A
        • f.  Revocable Trusts (Applicable to Decedents Dying Before January 1, 2017)  12.25B
        • g.  Irrevocable Trusts (Applicable to Decedents Dying Before January 1, 2017)  12.25C
        • h.  Life Estates (Applicable to Decedents Dying Before January 1, 2017)  12.26
          • (1)  When DHCS Cannot Recover  12.27
          • (2)  When DHCS Will Recover  12.28
        • i.  Annuities (Applicable to Decedents Dying Before January 1, 2017)  12.29
          • (1)  DHCS Regulations  12.30
          • (2)  DRA Annuity Rules  12.31
        • j.  Life Insurance and Retirement Accounts (Applicable to Decedents Dying Before January 1, 2017)  12.32
        • k.  Tangible Personal Property and “Other Arrangements” (Applicable to Decedents Dying Before January 1, 2017)  12.33
        • l.  Revocable Transfer on Death Deed (Applicable to Decedents Dying Before January 1, 2017)  12.33A
      • 4.  Recovery Barred
        • a.  Unless Beneficiary Was 55 or Permanently Institutionalized  12.34
        • b.  When There Is a Surviving Spouse  12.35
          • (1)  State Recovery Statute (Applicable to Decedents Dying Before January 1, 2017)  12.36
          • (2)  DHCS Regulations (Applicable to Decedents Dying Before January 1, 2017)  12.37
          • (3)  State Recovery Statute (Applicable to Decedents Dying On or After January 1, 2017)  12.37A
        • c.  When There Are Minor, Blind, or Disabled Surviving Children  12.38
          • (1)  Date for Determining Age or Disability  12.39
          • (2)  No Recovery Allowed for Proportionate Share  12.40
        • d.  Procedure for Claiming Exemption From Recovery Based on Age or Disability
          • (1)  Documenting the Exemption Claim for Age or Disability  12.41
          • (2)  Effect of Disability Determination Request  12.42
          • (3)  Earned Income Limits  12.43
          • (4)  Decision From DSS  12.44
      • 5.  Bar to Liens Not Applicable to Recovery Claims  12.45
    • C.  Claims Procedures
      • 1.  Notice to DHCS of Death of Recipient or Recipient’s Surviving Spouse
        • a.  Under Prob C §215 and 22 Cal Code Regs §50962(a)  12.46
        • b.  Under Prob C §9202 if Formal Probate Administration  12.47
        • c.  Under Prob C §19202 if Claims Procedure Is Used in Trust Administration (Applicable to Decedents Dying Before January 1, 2017)  12.48
        • d.  Enforcement of Prob C §215  12.49
      • 2.  DHCS Notice of Claim, Basis for Exemption, and Right to Seek Waiver  12.50
      • 3.  Time Limits on DHCS Claims
        • a.  Time Limit to File Estate Claim  12.51
        • b.  Statute of Limitations and When It Begins to Run  12.52
      • 4.  Hardship Waiver
        • a.  Federal and State Rules  12.53
        • b.  “Factors” Under California Regulations  12.54
          • (1)  Care Provided  12.55
            • (a)  Requirements  12.56
            • (b)  Practical Considerations  12.57
          • (2)  Inability to Repay  12.58
          • (3)  Applicant’s Need to Use Home Equity  12.59
          • (4)  Other Factors  12.60
        • c.  Waiver Procedures
          • (1)  Regulations
            • (a)  Application; Initial Decision  12.61
            • (b)  Hearing After Denial  12.62
            • (c)  Final Decision; Judicial Review  12.63
          • (2)  DHCS Practices  12.64
      • 5.  Amount of Claim  12.65
      • 6.  Interest Charges
        • a.  Authority  12.66
        • b.  When Interest Begins to Accrue  12.67
    • D.  Planning Strategies to Minimize or Avoid Estate Claims
      • 1.  Introduction  12.68
      • 2.  Divestiture  12.69
      • 3.  Other Ways to Reduce Estate Claims
        • a.  Increasing Income and Share of Cost  12.70
        • b.  In-Home Care  12.71

13

Long-Term Care Insurance

Timothy Patrick Millar, CFP®

  • I.  INTRODUCTION TO LONG-TERM CARE INSURANCE (LTCI)  13.1
  • II.  EVALUATING LONG-TERM CARE (LTC) ALTERNATIVES  13.2
    • A.  Self-Insurance
      • 1.  Difficulty of Analysis  13.3
      • 2.  Factors Affecting Analysis  13.4
      • 3.  Need to Set Aside Funds  13.5
      • 4.  Risks of Self-Insurance  13.6
    • B.  Public Benefits  13.7
    • C.  Life Insurance  13.8
    • D.  Life Insurance With LTCI Provisions
      • 1.  Basic Concepts  13.8A
      • 2.  Effect of LTC Withdrawals  13.8B
    • E.  Annuity With LTC Benefit  13.8C
    • F.  Pension Protection Act of 2006
      • 1.  Relevant Provisions of PPA  13.8D
      • 2.  Examples of Application of PPA  13.8E
      • 3.  Additional LTCI Reform  13.8F
  • III.  PRIVATE LTCI
    • A.  Original Purpose: Filling Gap in Medicare Coverage  13.9
    • B.  Regulation of LTCI
      • 1.  California Law  13.10
      • 2.  Federal Law  13.10A
    • C.  Ineffective as Solution  13.11
    • D.  High Rates Likely to Continue to Increase  13.12
    • E.  Impact of Economic and Political Factors: Difficulty of LTC Planning  13.12A
    • F.  Impediments to Sales of LTCI; Industry Response  13.12B
  • IV.  EVALUATING LTCI INSURERS AND POLICIES  13.13
    • A.  Reasons to Consider Purchasing LTCI  13.14
    • B.  Deciding Whether LTCI Is Best Option: Cost-Benefit Analysis  13.15
      • 1.  Coverage Limits  13.16
      • 2.  Premium Increases  13.17
      • 3.  Financial Analysis of LTCI  13.17A
        • a.  Analysis of Short-Term Efficiency  13.17B
        • b.  Analysis of Long-Term Efficiency  13.17C
          • (1)  Adjustment for “Present Value”  13.17D
          • (2)  Adjustment for Premium Increase  13.17E
          • (3)  Adjustment for Duration of Use of LTCI  13.17F
        • c.  Individual Considerations  13.17G
    • C.  Assessing Carrier’s Strength  13.18
    • D.  Selecting Policy  13.19
      • 1.  Basic Policy Provisions  13.20
        • a.  Benefits and Benefit Amounts  13.21
        • b.  Benefit Period  13.22
        • c.  Pool of Benefits  13.23
        • d.  When Benefits Become Payable
          • (1)  Benefit Triggers
            • (a)  Physical Inability to Perform ADLs  13.24
            • (b)  Mental Inability to Perform ADLs  13.25
          • (2)  Elimination Period  13.26
      • 2.  Tax Issues  13.27
        • a.  Non-Tax-Qualified Policies  13.28
        • b.  Tax-Qualified (TQ) Policies
          • (1)  Tax Qualification and Benefit Triggers  13.29
          • (2)  Tax Treatment
            • (a)  Deductibility of Premiums  13.30
              • (i)  Deductibility Threshold  13.31
              • (ii)  Limitation on Deductions  13.32
            • (b)  Taxability of Benefits  13.33
      • 3.  Required Provisions  13.34
        • a.  Required Provisions for Different Levels of Coverage  13.35
          • (1)  Policies for Home Care and Community-Based Services  13.36
            • (a)  Services Provided in the Home  13.37
            • (b)  Services Provided Outside the Home  13.38
          • (2)  Nursing Facility Coverage  13.39
          • (3)  Comprehensive Policies  13.40
        • b.  Free-Look Provision  13.41
        • c.  Preexisting Conditions  13.42
        • d.  Prohibition on Post-Underwriting  13.43
        • e.  Protections Based on Long-Term Nature of Insurance  13.44
          • (1)  Guaranteed Renewable or Noncancelable  13.45
          • (2)  Nonforfeiture  13.46
          • (3)  Right to Reduce Coverage  13.47
          • (4)  Protection Against Unintended Lapse  13.48
            • (a)  Election of Designee and Notice of Potential Lapse  13.49
            • (b)  Reinstatement  13.50
          • (5)  Right to Increase Coverage  13.51
          • (6)  Option to Upgrade Policy  13.52
          • (7)  Premium Increases  13.53
          • (8)  Premium Review  13.54
          • (9)  Partnership Policies  13.55
        • f.  Consumer Protections in Sale of Policies
          • (1)  Required Disclosures  13.56
          • (2)  Prohibited Practices  13.57
      • 4.  Optional Provisions  13.58
        • a.  Inflation Protection  13.59
          • (1)  Example: Problem if No Inflation Protection  13.60
          • (2)  Strategies to Adjust for Inflation  13.61
        • b.  Waiver of Premium  13.62
        • c.  Alternate Plan of Care  13.63
        • d.  Bed Reservation  13.64
        • e.  Restoration of Benefits  13.65
        • f.  Care Facilitation: Home Modification, Devices, Caregiver Training  13.66
        • g.  Limited Pay  13.67
        • h.  Return of Premium  13.68
  • V.  COORDINATION WITH PUBLIC BENEFIT PLANNING  13.69
    • A.  Medi-Cal
      • 1.  Eligibility  13.70
      • 2.  Share of Cost  13.71
        • a.  Characterization of Payments  13.71A
          • (1)  When Characterization May Have No Impact  13.71B
          • (2)  When Characterization May Be Significant  13.71C
        • b.  Identifying the Income Owner  13.71D
      • 3.  Estate Recovery  13.72
    • B.  California Partnership for Long-Term Care  13.73
      • 1.  Dollar-for-Dollar Plan Affects Eligibility and Estate Recovery  13.74
      • 2.  Cost of Premiums  13.75
      • 3.  Inflation Protection  13.76
      • 4.  Coordination with Medi-Cal  13.77
      • 5.  Assessing Usefulness of a Partnership Policy  13.78
      • 6.  Impact of Deficit Reduction Act of 2005  13.79
  • VI.  CONCLUSION  13.80

14

Reverse Mortgages

Timothy Patrick Millar, CFP®

  • I.  INTRODUCTION TO REVERSE MORTGAGES  14.1
  • II.  EVALUATING ALTERNATIVES
    • A.  Sale of Home  14.2
      • 1.  Mover’s Regret  14.3
      • 2.  Intra-Family Home Sales  14.4
    • B.  Rental of Home
      • 1.  General Advantages and Disadvantages  14.5
      • 2.  Interaction With Medi-Cal Rules  14.6
    • C.  Traditional Mortgage  14.7
    • D.  Diagram: Decreasing Equity With Line of Credit  14.8
    • E.  A Reverse Mortgage That Is Not a Reverse Mortgage  14.9
  • III.  REVERSE MORTGAGES  14.10
    • A.  Types of Reverse Mortgages
      • 1.  Home Equity Conversion Mortgages (HECMs)
        • a.  Authorizing Legislation  14.11
        • b.  Subsequent Legislation  14.11A
        • c.  HECM Saver  14.11B
      • 2.  Other Reverse Mortgage Options  14.12
    • B.  Elements of a Reverse Mortgage
      • 1.  Eligibility Requirements  14.13
      • 2.  Payment Options  14.14
      • 3.  Amount Borrowed; Only Primary Loans Allowed  14.15
      • 4.  Costs  14.16
        • a.  Interest  14.17
        • b.  Insurance and Origination Fees  14.18
      • 5.  Payoff Triggering Events  14.19
      • 6.  Warning to Heirs and Beneficiaries About Repayment  14.19A
      • 7.  Special Note on Foreclosure  14.19B
      • 8.  Loan Amount Increases and Equity Interest Decreases Over Time  14.20
      • 9.  FMA 2007 [Deleted]  14.21
    • C.  Chart: Comparison of Traditional and Reverse Mortgages  14.22
    • D.  Possible Uses of Reverse Mortgage  14.23
      • 1.  To Provide Retirement Income  14.24
      • 2.  For Debt Consolidation or Refinancing Existing Mortgage  14.25
      • 3.  As Source of Funds for Investment  14.26
      • 4.  To Purchase Home While Retaining Income  14.26A
      • 5.  To Fund Long-Term Home Care  14.27
        • a.  Reverse Mortgages and LTC Medi-Cal
          • (1)  Not Useful to Reduce Assets to Create Eligibility  14.28
          • (2)  May Be Useful to Provide Additional Cash Flow for Well Spouse of Institutionalized Medi-Cal Beneficiary  14.29
        • b.  Risks of RAM Loans and Using Reverse Mortgages to Fund Certain Annuities  14.30
    • E.  Consumer Protections
      • 1.  Mandatory Counseling  14.31
      • 2.  Three-Day Right of Rescission  14.32
      • 3.  California Statutory Protections  14.33

CALIFORNIA ELDER LAW RESOURCES, BENEFITS, AND PLANNING

(1st Edition)

August 2019

TABLE OF CONTENTS

 

File Name

Book Section

Title

CH01A

Chapter 1A

Introduction to LGBT Elder Law

01A-008A

§1A.8A

Change of Gender Affidavit

01A-009

§1A.9

Doctor’s Affidavit of Gender Transition

01A-014

§1A.14

Transgender-Inclusive Language for Power of Attorney for Health Care/Advance Health Care Directive (AHCD)

01A-015

§1A.15

Disposition of Remains Worksheet

01A-023

§1A.23

Hospital Visitation Authorization

CH02

Chapter 2

Ethical Considerations in Elder Law Practice

02-036

§2.36

Sample Paragraphs in Engagement Letter Confirming Family Member’s Role

02-049

§2.49

Potential Conflicts Disclosure and Waiver

CH04

Chapter 4

Health Care and Personal Decision Making

04-125

§4.125

Sample Questions for Client to Consider Before Meeting With Attorney

04-126

§4.126

Sample Physician Statement Regarding Capacity

04-127

§4.127

Issues for Client to Discuss With Physician

04-128

§4.128

Sample Letter to Physician About AHCD

04-129

§4.129

Sample Letter to Clergy About AHCD

04-130

§4.130

Sample Letter to Nursing Home Administrator About AHCD

04-131

§4.131

Sample Letter to RCFE Administrator From Attorney About Client’s AHCD

04-132

§4.132

Agreement to Serve as Agent

04-133

§4.133

Sample Questions for Agent to Ask Doctor About Specific Health Care Treatment or Procedure

04-134

§4.134

Sample Questionnaire for Client to Fill Out About Final Wishes

04-135

§4.135

Sample Memo of Instructions From Client About Things to Do After Death

04-136

§4.136

Price Comparison of Costs for Funeral Homes

04-137

§4.137

Death Certificate Information

04-138

§4.138

Obituary Information

04-139

§4.139

Nomination of Conservator

04-140

§4.140

Sample Questions for Health Care Provider About Client’s Pain

04-141

§4.141

Sample Questions When Choosing Institution to Receive Body Donation

04-143

§4.143

Information Necessary for Veteran’s Burial

CH06

Chapter 6

Planning to Stay at Home

06-007

§6.7

Personal Care Provisions—Home Care Directive

CH11

Chapter 11

Medi-Cal Planning Strategies for Nursing Home Care Benefits

11-073

§11.73

Declaration of Right to Return Home

11-080

§11.80

Occupancy Agreement

11-151

§11.151

Sample Petition for Order Authorizing Particular Transaction

 

Selected Developments

August 2019 Update

To obtain a legal gender change, an individual previously had to obtain an affidavit from a doctor stating that they received “clinically appropriate treatment for the purposes of gender transition.” Now, when petitioning the superior court, an individual must only complete an affidavit stating that, “I, (petitioner’s full name), hereby attest under penalty of perjury that the request for a change in gender to (female, male, or nonbinary) is to conform my legal gender to my gender identity and is not for any fraudulent purpose.” Health & S C §103430(a). See §§1A.8–1A.8A.

In 2018, the California Supreme Court extensively revised and renumbered the California Rules of Professional Conduct. Chapter 2 has been thoroughly revised to explain how the new Rules affect the elder law practitioner.

There was a 2.8 percent cost-of-living adjustment (COLA) for SSI beneficiaries and Social Security beneficiaries for benefit year 2019. In 2019, the standard Medicare Part B monthly premium (without an income-related adjustment) is $135.50. Because there was a 2.8 percent COLA for Social Security benefits in 2019, some Medicare beneficiaries, who were “held harmless” against Part B premium increases in prior years, will see an increase in their 2019 monthly Part B premium. ACWD Letter No. 19–11 (Mar. 28, 2019). See §7.12.

The charts in §§7.44, 7.56, and 7.115 have been updated to reflect 2019 cost-sharing amounts for Medicare Parts A, B, and D, respectively. All other amounts have also been updated throughout the chapter, including those for the Part D low-income subsidy (see §§7.131–7.134) and Medicare savings programs (see §7.167).

It appears that California may not implement the transfer rules of the Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) and the Deficit Reduction Act of 2005 (DRA) until mid-2020 or later. See, e.g., §§9.4, 10.4, 11.3, 11.49, 11.59.

For 2019, the Medi-Cal Minimum Monthly Maintenance Needs Allowance (MMMNA) is $3161. ACWD Letter No. 18–28 (Jan. 14, 2019). See §§9.34, 10.74, 10.83, 11.85, 11.91, 11.107, 11.112, 13.71C–13.71D.

A person with a disability who is under age 65 may now establish his or her own special needs trust without the need to have a relative, guardian, or court establish it. 42 USC §1396p(d)(4)(A). See §9.57.

For 2019, the average private-pay rate (APPR) set by the California Department of Health Care Services (DHCS) for nursing home care is $9337. For 2018, the figure was $8841, and for 2017, it was $8515. ACWD Letter No. 19–07 (Feb. 15, 2019). Calculations that include the APPR have been updated with the 2019 amount. See chaps 10–11.

For 2018, the lifetime exemption amount is $11.4 million. Like the lifetime exemption, the annual gift tax exclusion is adjusted for cost-of-living increases. For 2019, it remains at $15,000. Rev Proc 2018–57, 2018–49 Int Rev Bull 827. See §11.55.

The community spouse resource allowance (CSRA) is $126,420 for 2019. ACWD Letter No. 18–28 (Jan. 14, 2019). See §§9.34, 11.85, 11.107.

The cost of long-term care continues to rise. For example, in 2018, the median annual cost for a semiprivate room in a California skilled nursing facility (SNF) was $100,375 (an increase from $97,367 in 2017); a private room costs $117,804 per year (an increase from $116,435 in 2018). Additional expenses, such as supplies and pharmaceuticals, can add thousands of dollars annually to this base cost. See https://www.genworth.com/aging-and-you/finances/cost-of-care.html. See §13.1.

The Tax Cuts and Jobs Act increased the threshold for the deduction of medical expenses to 10 percent of a taxpayer’s adjusted gross income (AGI) from the previous “floor” of 7.5 percent of AGI for taxable years 2017 and 2018. IRC §213(f). Even if a taxpayer itemizes deductions and has medical expenses exceeding 10 percent of AGI, the Internal Revenue Service limits the amount that can be deducted from income for long-term care insurance (LTCI) on the basis of an individual’s age. The amount is adjusted annually to reflect changes in the cost of living. IRC §213(d)(10). See §§13.31–13.32.

The financial analysis of the fiscal benefits and efficiency of LTCI contained in §§13.17A–13.17F is updated to reflect the current costs of LTCI.

The Department of Housing and Urban Development (HUD) published the Single Family Policy Handbook (HUD Handbook 4000.1), which supersedes previous Mortgagee Letters. However, the handbook’s section on home equity conversion mortgages (HECMs) is reserved for future use and notes that FHA-approved reverse mortgages (HECMs) must continue to comply with all existing handbooks, mortgagee letters, notices, and “outstanding guidance.” HUD Handbook 4000.1 §III(B). The handbook and mortgagee letters are combined in the FHA Single Family Housing Policy Library. See §14.11.

In 2019, the national Federal Housing Administration (FHA) loan limit for a home equity conversion mortgage (HECM) is $726,525 (150 percent of the national conforming limit of $484,350). The loan limit is effective for all HECMs assigned an FHA case number on or after January 1, 2019, through December 31, 2019. See HUD Mortgagee Letter 2018–12 (Dec. 14, 2018). See §§14.11A, 14.12, 14.15.

About the Authors

MARILYN D. ANTICOUNI has her own practice in Santa Barbara limited to conservatorship, elder law, estate planning, and probate. Ms. Anticouni received her B.A. degree from California State University at Northridge and her J.D. degree from Ventura College of Law in 1980. A frequent lecturer on estate planning and probate issues for legal and civic organizations, Ms. Anticouni has served as Judge Pro Tem in the Santa Barbara County Superior Court, court-appointed counsel for proposed conservatees, and chair of the Santa Barbara County Bar’s Elder Law Section. She is chair of the Santa Barbara County Assessment Appeals Board and a past president of the Santa Barbara County Bar Association.

FAY BLIX has her own practice in Laguna Hills at the Elder Law Center, specializing in elder law, estate planning, probate, and conservatorships. She received her B.A. degree in 1971 from Walla Walla College, her M.A. degree in 1972 from the University of Washington, and her J.D. degree from Western State University College of Law in 1983. She was among the first group of attorneys to be certified by the National Elder Law Foundation as a Certified Elder Law Attorney (CELA) in 1995. She was founding chair of the Elder Law Section of the Orange County Bar Association and has served as president of the Southern California Chapter of the National Academy of Elder Law Attorneys. She currently serves on the executive committee of the California Council of the Alzheimer’s Association. She speaks extensively on many long-term care issues to both community groups as well as attorneys. She also is a contributing author to CEB’s California Durable Powers of Attorney.

PRISCILLA CAMP is an Oakland attorney whose practice is limited to elder law. Ms. Camp received her B.S. and M.S. degrees in education from the University of Kansas in 1963 and 1966 and a J.D. degree from Golden Gate University School of Law in 1977. She has been Director of Legal Assistance for Seniors, President of Women Lawyers of Alameda County, and Secretary of California Women Lawyers, and is a founding member of the National Academy of Elder Law Attorneys. A frequent speaker to community and professional groups about elder law concerns, Ms. Camp is past chair of the Elder Law Committee of the Alameda County Bar Association’s Estate Planning, Trust, and Probate Law Section, vice-chair of the Section’s Conservatorship and Guardianship Committee, and chair of the State Bar’s Legal Services Trust Fund Commission’s Eligibility Review Committee. She is a contributing author to CEB’s Action Guide, Capacity and Undue Influence: Assessing, Challenging, and Defending.

SUSANNE B. COHEN is an attorney in private practice in Berkeley specializing in conservatorships and trust administration, elder financial abuse litigation, long-term care and estate planning, and probate litigation. She received her B.A. degree from Vassar College and her J.D. from Loyola Law School of Los Angeles. A former legal services attorney specializing in aging and disability issues, she has served as a staff attorney at Legal Assistance for Seniors in Oakland, California Rural Legal Assistance in Modesto, and The Arizona Center for Disability Law.

MONICA DELL’OSSO is a partner in the Oakland law firm of Burnham & Brown, practicing in the fields of estate planning, trust, and probate law. She earned her B.A. degree in 1971 from Saint Mary-of-the-Woods College, her J.D. degree in 1981 from the University of California, Berkeley, School of Law, and a Ph.D. in history in 1989 from the University of Virginia. A certified specialist in Probate, Estate Planning and Trust Law, Ms. Dell’Osso is a past Chair of the Estate Planning, Trust and Probate Law Section of the Alameda County Bar Association and a former member of the Executive Committee of the State Bar’s Estate Planning, Trust and Probate Law Section. Ms. Dell’Osso is a Fellow of the American College of Trust and Estate Counsel.

LENORE ELLEN GERARD is a San Francisco attorney practicing in the fields of health care and elder law. She earned her B.A. degree in 1973 from the University of California, Berkeley, and her J.D. degree in 1987 from Golden Gate University School of Law. Ms. Gerard has served as policy scholar at the Institute for Health & Aging (UCSF) and has written and lectured on the federal role in health care. Ms. Gerard has litigated several important class actions to ensure government accountability, quality of care, and fair treatment, most notably as co-counsel in Grijalva v Shalala (D Ariz 1996) 946 F Supp 747, aff’d (9th Cir 1998) 152 F3d 1115, aff’d, reh’g en banc, vacated and remanded (1999) 526 US 1096; 12/4/00 Settlement Order, Civ 93–711 TUC ACM (D Ariz), involving Medicare managed care, and as co-counsel in Zinman v Shalala (ND Cal 1993) 835 F Supp 1163, aff’d (9th Cir 1995) 67 F3d 841, involving Medicare Secondary Payor.

BRIDGET K. HOMER is a staff attorney with the Center for Health Care Rights, a nonprofit health care consumer advocacy organization that provides education, technical assistance, and direct services to Medicare beneficiaries and community-based organizations in Los Angeles County. Ms. Homer received her B.A. degree cum laude from the University of Massachusetts, Amherst, and her J.D. degree from Thomas Jefferson School of Law, San Diego. She has been a recipient of a Wiley W. Manuel certificate award for pro bono legal services.

CAROL SMALL JIMENEZ is in private practice in Los Alamitos and specializes in health care law. She also serves as Legal Counsel for California Health Advocates (the California HICAP Association), which comprises California’s 24 Health Insurance Counseling and Advocacy Programs, consumer advocacy groups that provide education, counseling, and assistance to more than 100,000 individual Californians each year on Medicare, managed care, and related health insurance issues. She earned her B.A. degree from the University of Rochester in 1978 and her J.D. degree from Georgetown University Law Center in 1981. Ms. Jimenez has successfully brought numerous law-making cases in the areas of Medicare and managed care and has testified before Congress and spoken nationwide on Medicare and related issues.

STEPHANIE K. LEE is a staff attorney with the Center for Health Care Rights (CHCR), a nonprofit health care consumer advocacy organization that provides education, technical assistance, and direct services to Medicare beneficiaries and community-based organizations in Los Angeles County. Before joining CHCR, she worked at the Service Employees International Union conducting research on labor and health policy issues. Ms. Lee earned her B.A. degree from Duke University in 2000 and her J.D. degree from the University of California, Los Angeles, School of Law in 2004.

DAVID A. LIPSCHUTZ is a staff attorney in the Los Angeles office of California Health Advocates (CHA), a Sacramento-based nonprofit organization that provides advocacy and education for California beneficiaries and promotes the work of the state-administered Health Insurance Counseling and Advocacy Program (HICAP). Mr. Lipschutz has been active in policy work surrounding the implementation of the Medicare Part D prescription drug benefit in California, focusing, in particular, on its impact on individuals dually eligible for Medicare and Medi-Cal. In this respect, he has testified before Congress and the state legislature; he is a frequent lecturer and trainer on Medicare issues. Before joining CHA, he worked as a staff attorney at the Center for Health Care Rights, a nonprofit agency that provides direct services to Medicare beneficiaries in Los Angeles County. Mr. Lipschutz earned his B.A. degree from the University of California, Santa Cruz, in 1993 and his J.D. degree from the University of California, Davis, School of Law in 1999.

TERRY M. MAGADY is in private practice in Los Angeles and specializes in Medi-Cal and other government benefits planning, conservatorships, and estate planning for people with disabilities. He received his B.A. from Occidental College in 1978, his M.A. in Public Affairs from Princeton University’s Woodrow Wilson School of Public & International Affairs in 1981, and his J.D. from the University of Southern California in 1986. Mr. Magady is certified as an Elder Law Attorney by the National Elder Law Foundation. He is Chairman of the Elder Law Committee of the Beverly Hills Bar Association’s Trust & Estates Section and is a member of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys. Mr. Magady formerly served on Los Angeles County’s Adult Day Health Care Planning Council and now serves on Los Angeles County’s public authority for the In-Home Supportive Services Program. Mr. Magady has published articles for legal periodicals on both Medi-Cal planning and special needs trusts. He lectures frequently to attorneys and other professionals regarding elder law matters.

BETTIE BAKER MARSHALL has her own practice in Campbell (Santa Clara County) limited to conservatorship, elder law, estate planning, and probate. Ms. Marshall received her B.A. degree from the University of San Francisco in 1985 and her J.D. degree, cum laude, from the Santa Clara University School of Law in 1991. She has lectured and written on elder law and conservatorships for fiduciary, legal, and civic organizations, is certified as a Specialist by the California Board of Legal Specialization in Estate Planning, Trust and Probate Law, and has been named as a top elder law attorney by San Jose Magazine for 6 years, and as a Northern California Super Lawyer in Elder Law, by Law & Politics Magazine, publishers of San Francisco Magazine, for 3 years. She is a court-appointed counsel for proposed conservatees, is a member of the executive committee of, and Newsletter Editor of, the Silicon Valley Bar Association, Trusts & Estates Section, and is AV rated by Martindale-Hubbel.

TIMOTHY PATRICK MILLAR is a Certified Financial Planner® and Registered Investment Advisor in Fremont, specializing in managing and preserving assets for retirees with an emphasis on families facing long-term and catastrophic illness. Tim received his B.A. from the University of California, Berkeley, and his M.B.A. in personal financial planning from Golden Gate University in San Francisco. He is a frequent continuing education trainer for California Advocates for Nursing Home Reform (CANHR), San Francisco, and is a board member of its Lawyer Referral Service. He is past president of the Greater San Francisco Bay Area Alzheimer’s Association and member of the National Board of the Alzheimer’s Association in Chicago.

DANIEL R. REDMAN is counsel at Shartsis Friese LLP and is the author of chapter 1A. Mr. Redman’s practice focuses on estate planning and administration. He received his B.A. from Johns Hopkins University and his J.D. from the University of California, Berkeley, School of Law. Mr. Redman has worked as an estate planning and elder law attorney for many years, including practice with the Elder Law Project of the National Center for Lesbian Rights. Mr. Redman has spoken on elder issues across the country, including at Harvard Law School, Temple University, and Rutgers University. He has written for a variety of academic journals, as well as The Nation, Slate, the New Republic, and the American Prospect. In 2012, Mr. Redman was appointed by the San Francisco Board of Supervisors to the City’s LGBT Aging Policy Task Force. As chair of the legal committee, Mr. Redman led the effort to draft and pass the “LGBT Long-Term Care Residents’ Bill of Rights,” a first-in-the-nation ordinance to protect LGBT seniors in care facilities.

JULIE R. SCHOEN received her B.S. from the University of Wisconsin, Madison, and her J.D. from Western State University College of Law. She is a well-known speaker and advocate throughout Southern California on behalf of the needs of the Medicare population. Ms. Schoen is the past director of the Orange County Health Insurance Counseling Advocacy Program (HICAP) and is the current legal counsel for the same program. She serves as the Special Projects Director for the California HICAP Association and is currently heavily involved in federal government efforts to curtail fraud and abuse in the Medicare system. Ms. Schoen also teaches a course on issues in elder law as an adjunct professor at California State University (Fullerton). She is a member of the California and Orange County Bar Associations.

DEEPTI S. SETHI is the staff attorney for the Center for Health Care Rights in Los Angeles, a nonprofit health care consumer advocacy organization that provides education, technical advice, and direct services to Medicare beneficiaries in Los Angeles County. She worked to support nonprofit advocacy efforts through a fellowship with the Alliance for Justice in Washington, D.C., prior to joining the Center. Ms. Sethi received her B.A. from Hampshire College and her J.D. from the University of California, Hastings College of the Law, with a concentration in public interest law.

GREGORY WILCOX has his own practice in Berkeley, specializing in public benefits planning and related estate planning. He received his B.A. degree in 1968 from Haverford College, his Master of Public Affairs degree in 1971 from Princeton University, and a J.D. degree in 1976 from the University of California, Berkeley, School of Law. Mr. Wilcox is past Chair of the Northern California Chapter of the National Academy of Elder Law Attorneys (NAELA) and currently chairs the Amicus Committee of the national organization. He is a frequent continuing education trainer for California Advocates for Nursing Home Reform (CANHR), San Francisco, and is a board member of its Lawyer Referral Service. He is a member of the Medi-Cal Estate Recovery Stakeholders Advisory Group of the California Department of Health Services and former Chair of the Elder Law Committee of the Alameda County Bar Association’s Trust and Estates Section. A frequent lecturer to attorneys on elder law issues, Mr. Wilcox has also published numerous articles on Medi-Cal planning for long-term care.

About the 2019 Update Authors

SUSANNE B. COHEN is the update author of chapters 1 and 9. See biography in About the Authors section.

DAVID KANE is a Staff Attorney at the Health Consumer Center, a project of Neighborhood Legal Services of Los Angeles County, and is an update author of chapter 7. He assists low-income consumers with public and private health coverage, with a particular focus on dual eligible consumers under Cal MediConnect and Medi-Cal managed care plans. Previously, he worked as a research attorney for the California Court of Appeal, an intern at the ACLU of Northern California and Public Advocates, and interim executive director of a community-based nonprofit in East Palo Alto. He also served as a Bill Emerson National Hunger Fellow, working as a food stamp advocate at Boston Medical Center, and an anti-poverty research assistant at a progressive think tank. Mr. Kane received his B.S. from Northwestern University and his J.D. with a specialization in public interest law and policy from the University of California, Los Angeles, School of Law. He is licensed to practice in California.

TERRY M. MAGADY is the update author of chapters 5 and 6. See biography in About the Authors section.

DANIEL MULLIGAN is a founding partner with Jenkins Mulligan & Gabriel LLP and the update author of chapter 14. Mr. Mulligan received his B.A. in Economics in 1975 and his M.A. in Economics in 1982 from the University of California, Berkeley, and his J.D. in 1982 from the University of California, Berkeley, School of Law. He has specialized in consumer matters, including class litigation, since 1992. He has been lead or co-counsel on many of the nation’s leading consumer rights cases involving lending and servicing of residential mortgage loans. Mr. Mulligan also continues a strong practice in the antitrust field; most recently, he has served as co-counsel in the natural gas price-fixing cases in San Diego Superior Court, which resulted in settlements in excess of $140 million, and in the LCD price-fixing cases, which resulted in over $1 billion in settlements. He is recognized as a leading member of the plaintiffs’ bar on consumer issues, particularly consumer lending. He regularly speaks at meetings of the California State Bar Association, the Practicing Law Institute, the American Conference Institute, the National Consumer Law Center, and the National Association of Consumer Advocates. Mr. Mulligan also helped found and is a former member of the Board of Directors of the Center for California Homeowner Law, a nonprofit entity dedicated to education and advocacy on behalf of homeowners in common interest developments. Mr. Mulligan is located in the firm’s San Diego office.

CLIFFORD ROTH is manager of Medicare operations at Local Initiative Health Authority of Los Angeles County and is an update author of chapter 7. Mr. Roth is also a part-time lecturer at California State University, Fullerton. Mr. Roth received his undergraduate degree in Psychology from Ithaca College and his J.D. from Thomas Cooley Law School. He served as the Medicare regulatory manager at Orange County Health Authority. He is a former vice-chair of the In-Home Supportive Services Advisory Committee in Orange County. Mr. Roth also served as an associate manager and legal advisor with the Health Insurance Counseling and Advocacy Program (HICAP) in Santa Ana.

DENNIS M. SANDOVAL is the update author of chapter 13 and is the principal at Dennis M. Sandoval, A Professional Law Corporation. He specializes in estate planning, elder law, tax planning, and tax controversy. He received his B.A. in Business Administration from California State University, Fullerton; his J.D., cum laude, from Western State University College of Law; and his LL.M. in Taxation Law, cum laude, from Golden Gate University College of Law. Mr. Sandoval serves as the Director of Education for the American Academy of Estate Planning Attorneys. He is a member of the Academy of Special Needs Planners, American Academy of Estate Planning Attorneys, and the National Academy of Elder Law Attorneys. Mr. Sandoval is a certified Estate Planning, Trust & Probate Law Specialist and a certified Taxation Law Specialist by the California State Bar Board of Legal Specialization. He is a certified Elder Law Attorney by the National Elder Law Foundation.

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