E lde r L aw fo r the Parale g al, Part I I PRE SE NT E D - PowerPoint PPT Presentation

Sta tuto ry L iving Will  I n 1985, Misso uri a do pte d the L ife Suppo rt De c la ra tio n Ac t  VAMS §§459.010 e t se q  Applie s o nly to “de a th pro lo ng ing ” pro c e dure s  Whe n te rmina l  Whic h a rtific ia lly pro lo ng the pro c e ss • Do e s no t a pply to the pe rsiste nt ve g e ta tive sta te • Do e s no t a pply to withho lding o r withdra wing fo o d o r nutritio n

L iving Will  De c la ra tio n/ sta te me nt tha t a pe rso n ma ke s re g a rding :  Whe the r o r no t the y wa nt c e rta in me dic a l tre a tme nts to b e withhe ld o r withdra wn unde r c e rta in c irc umsta nc e s  Give n e ffe c t o nly if the pe rso n is te rmina l a nd no t a b le to ma ke tre a tme nt de c isio ns §459.025  Ca n b e g e ne ra l o r spe c ific  Sta tute sug g e sts a b a sic fo rm

Adva nc e d Dire c tive s  Pe rso na lize d to me e t a c lie nt’ s wishe s  Antic ipa te a nd purpo se fully ma ke the do c ume nt dyna mic  Sub stitute d judg me nt  Be st inte re st  Pro vide fo r a ntic ipa te d de c isio ns  Auto psy c o nse nt  Ana to mic a l g ifts  Rig ht o f se pulc he r

Gua rdia nship  A pro c e ss whe re a pe rso n who ha s b e e n a ppo inte d b y a c o urt to ha ve the c a re a nd c usto dy o f a mino r o r a n a dult pe rso n who ha s b e e n le g a lly de te rmine d to b e inc a pa c ita te d

Co nse rva to rship  Pro c e ss whe re a pe rso n is a ppo inte d b y the c o urt to ma na g e the pro pe rty o f a mino r o r o f a n a dult pe rso n who ha s b e e n le g a lly de te rmine d to b e disa b le d.

Gua rdia nship – T he L a w  Gua rdia nship la w is sta tuto ry  Go ve rne d b y Cha pte r 475 o f Misso uri L a w  Gua rdia nships a re file d in the c o unty whe re the pe rso n is do mic ile d o r if no do mic ile , the c o unty whe re the pe rso n ma y b e fo und  Do mic ile =whe re a pe rso n inte nds to re side

I mpo rta nt T e rms  Disa b le d  pe rso n who is una b le b y re a so n o f a ny physic a l o r me nta l c o nditio n to re c e ive a nd e va lua te info rma tio n; o r  to c o mmunic a te de c isio ns to suc h a n e xte nt tha t the pe rso n la c ks the a b ility to ma na g e his fina nc ia l re so urc e s.  L a yma n te rms • ha s a me nta l o r physic a l c o nditio n • c a nno t ma na g e the ir fina nc ia l re so urc e s • like ly tha t se rio us ha rm will o c c ur

I mpo rta nt T e rms  I nc a pa c ita te d  a pe rso n who is una b le b y re a so n o f a ny physic a l o r me nta l c o nditio n to re c e ive a nd e va lua te info rma tio n o r  to c o mmunic a te d de c isio ns to suc h a n e xte nt tha t he la c ks the c a pa c ity to me e t e sse ntia l re q uire me nts fo r fo o d, she lte r, sa fe ty o r o the r c a re suc h tha t se rio us physic a l injury o r ha rm is like ly to o c c ur  L a yma n T e rms  ha s a me nta l a nd/ o r physic a l c o nditio n  c a nno t me e t the ir b a sic ne e d fo r fo o d, she lte r sa fe ty a nd o the r c a re  like ly tha t se rio us injury o r ha rm will o c c ur

I mpo rta nt T e rms  L e a st Re stric tive E nviro nme nt  Only impo se o n the pe rso n suc h re stra int tha t is ne c e ssa ry to pre ve nt him fro m injuring himse lf o r o the rs  Pro vide him with the c a re a nd tre a tme nt a ppro pria te fo r him c o nside ring his physic a l, me nta l c o nditio n a nd fina nc ia l me a ns

I mpo rta nt T e rms  Alle g e d inc a pa c ita te d pe rso n  Re spo nde nt  Pro te c te e  Wa rd  Atto rne y  Co urt a ppo inte d a tto rne y  Gua rdia n a d lite m Ad L ite m-fo r the purpo se s o f the la wsuit •  Priva te c o unse l

T he Pe titio ne r  Pro c e ss b e g ins with the filing o f a Pe titio n fo r Appo intme nt o f a Gua rdia n a nd/ o r Co nse rva to r  Any pe rso n c a n file a pe titio n  Do e s no t ne e d to b e a re la tive o r e ve n a n inte re ste d pa rty  Ca n b e file d in a n e me rg e nc y  T he De pa rtme nt o f He a lth a nd Se nio r Se rvic e s c a n file a pe titio n fo r g ua rdia nship

No tic e  No tic e is re q uire d b y la w  Must no tify pe rso ns se rving a s g ua rdia n o r c o nse rva to r, a nyo ne with fiduc ia ry po we r, (se rving a s po we r o f a tto rne y) a ny pe rso n ha ving the c a re a nd c usto dy o f the pe rso n  Clo se st re la tive s

Se rvic e  Misso uri L a w re q uire s the pro po se d wa rd o r the a lle g e d inc a pa c ita te d pe rso n re c e ive pe rso na l no tic e  Also re fe rre d to a s the Re spo nde nt  Ha nd de live re d to the a lle g e d inc a pa c ita te d pe rso n  T his is pure ly sta tuto ry a nd must b e fo llo we d fo r the c o urt to ha ve the po we r to e xe rc ise its jurisdic tio n  All o the r inte re ste d pa rtie s ma y re c e ive no tic e b y ma il

Re spo nde nt’ s Rig hts  Rig ht to ha ve a jury tria l  Jury wo uld de c ide the issue o f disa b ility a nd inc a pa c ity o nly b ut the c o urt de te rmine s who is to se rve a s the g ua rdia n a nd/ o r c o nse rva to r  Rig ht to re ma in sile nt  Re spo nde nt c a nno t b e ma de to te stify  Rig ht to ha ve the he a ring o pe n o r c lo se d  Rig ht to b e pre se nt a t the he a ring

Re spo nde nt’ s Rig hts  Rig ht to le g a l re pre se nta tio n  A c o urt a ppo inte d a tto rne y a nd rig ht to e mplo y a priva te a tto rne y  Appo inte d a tto rne y must me e t with the Re spo nde nt b e fo re the he a ring  Rig ht to pre se nt e vide nc e o n his b e ha lf  Rig ht to c ro ss-e xa mine witne sse s who te stify a g a inst him

Pro o f o f I nc a pa c ity  L e ve ls o f inc a pa c ity e xist  Pa rtia l inc a pa c ity  Pa rtia l disa b ility  Burde n o f pro ving inc a pa c ity is o n the Pe titio ne r  Must pro ve b y c le a r a nd c o nvinc ing e vide nc e  Cle a rly c o nvinc e s the fa c t finde r  E vide nc e tha t ‘ tilts the sc a le s’ in the a ffirma tive whe n we ig he d a g a inst the o ppo sitio n  F a c t finde r’ s mind is le ft with the a b iding c o nvic tio n tha t the e vide nc e is true  E xa mina tio n b y physic ia n, inte rro g a to rie s  E xtre me ly diffic ult to pro ve witho ut me dic a l te stimo ny

Wa ive r o f Rig hts  Due to the se rio usne ss o f the pro c e e ding , a ny wa ive r o f rig hts must b e a ffirma tive ly wa ive d b y the Re spo nde nt o n the re c o rd  Gua rdia nship a nd Co nse rva to rship is a re stric tio n o f a pe rso n’ s c ivil lib e rtie s  Sho uld no t b e ta ke n lig htly b y a ny o f the pa rtie s  Priva te c o unse l-he a ring re q uire d fo r the c o urt to de te rmine tha t the Re spo nde nt ha s the c a pa c ity to ma ke the c ho ic e to hire the ir o wn a tto rne y b e fo re the c o urt a ppo inte d a tto rne y ma y withdra w

Who Ma y Be Appo inte d  So le disc re tio n o f the tria l c o urt  Se c tio n 475.050 g o ve rns a nd is hie ra rc ha l  Co urt c o nside rs the suita b ility o f a ppo inting the fo llo wing pe rso ns:  Co urt c o nside rs the pe rso n no mina te d b y the Re spo nde nt if the pe rso n is a b le to ma ke a nd c o mmunic a te a re a so na b le c ho ic e a t the time  Pe rso n no mina te d in a DPOA, within 5 ye a rs o f the he a ring if the pe rso n c o uld ma ke a nd c o mmunic a te a c ho ic e  Spo use , pa re nts, c hildre n, sib ling s o r o the r c lo se re la tive s

Who Ma y Be Appo inte d  Any o the r pe rso n no mina te d in a will o r POA within 5 ye a rs  Do e s no t ha ve to b e the pe rso n who file d the pe titio n  E xc e pt fo r g o o d c a use sho wn, the c o urt sha ll fo llo w the re spo nde nt’ s mo st re c e nt va lid no mina tio n o f a n e lig ib le pe rso n  I f the va lid no mina tio n wa s within 5 ye a rs b e fo re the he a ring , the c o urt is no t re q uire d to fo llo w b ut ma y c o nside r

T he Co urt’ s F inding s  Co urt ma ke s a finding a s to whe the r inc a pa c ity o r disa b ility e xists  I f so , the e xte nt o f inc a pa c ity o r disa b ility  Whe the r a supe rvise d living situa tio n is ne e de d  Hig h de g re e o f supe rvisio n re q uire d b y the c o urts  Whe the r supe rvisio n o f fina nc e s is ne e de d a nd to wha t e xte nt

Gua rdia n’ s Autho rity  Gua rdia n-must a lwa ys a c t in the b e st inte re sts o f the pro te c te e  “Gua rds the pe rso n”  Must a c t a nd ma ke de c isio ns a b o ut the pro te c te e ’ s c a re  Ho using  T re a tme nt  E duc a tio n  Autho rity o ve r a ll pe rso na l de c isio ns

Co nse rva to r’ s Autho rity  Re spo nsib le fo r the pro te c tio n a nd ma na g e me nt o f the pro te c te e ’ s mo ne y  “Co nse rve s the mo ne y”  Supe rvise d b y the c o urt, ma na g e s the fina nc ia l e sta te  Re q uire s stric t a c c o unting  Co urt o rde r ne c e ssa ry to a utho rize a ll e xpe nditure s  Co nse rva to r must wo rk with a n a tto rne y no ma tte r ho w la rg e o r sma ll the e sta te

E me rg e nc ie s  I f the re is a sub sta ntia l risk o f se rio us physic a l ha rm to Re spo nde nt’ s pe rso n o r  I f irre pa ra b le da ma g e will o c c ur to pro pe rty, a pplic a tio n fo r a ppo intme nt o f a g ua rdia n a d lite m o r c o nse rva to r a d lite m ma y b e ma de  Usua lly a re 30 da y a ppo intme nts  I f the g ua rdia n is no t pe rfo rming e ffe c tive ly, the c o urt ma y re mo ve the m  I f the re is a life thre a te ning me dic a l e me rg e nc y a nd the pe rso n’ s c o nse nt c a nno t b e o b ta ine d, the c o urt a fte r a he a ring ma y a utho rize c o nse nt  Co urt a ppo ints a n a tto rne y to a c t a s g ua rdia n

He lping the Clie nt: Be yo nd Dra fting  Wha t is the he a lth o f the se nio r, a nd is the re e no ug h time to b e o f a ssista nc e ?  Wha t re so urc e s a re a va ila b le to the se nio r?  Whe n de a ling with multiple pa rtie s, wha t e thic a l issue s a rise ?  I s the re suffic ie nt time to de te rmine the ke y issue s?

He lping the Clie nt: Be yo nd Dra fting E lde r la w a tto rne ys re ly o n:  So c ia l wo rke rs, g e ria tric physic ia ns a nd o the r spe c ia lists to a ssist the c lie nt  F ina nc ia l a dviso rs a nd b a nks to no tify a nd/ o r re po rt suspic io us a c tivitie s o r b e ha vio rs

L o ng T e rm Ca re - Co nside ra tio ns  I s L o ng T e rm Ca re I nsura nc e in pla c e ?  Do e s L o ng T e rm Ca re I nsura nc e pro vide g o o d c o ve ra g e ?  I s L o ng T e rm Ca re I nsura nc e still po ssib le ?  Wha t is the use o f I mme dia te Ca re Annuitie s?  Ho w c a n a F ina nc ia l Pla nne r he lp?

L o ng T e rm Ca re - Optio ns  T he thre e mo st c o mmo n c a re o ptio ns a re : ho me he a lth c a re a ssiste d living a nd nursing ho me c a re  Pa ying fo r lo ng -te rm c a re c o me s fro m thre e so urc e s: se lf-pa y lo ng -te rm c a re insura nc e g o ve rnme nt b e ne fits

L o ng T e rm Ca re - Co st  Re se a rc h sho ws tha t a t le a st 70 pe rc e nt o f pe o ple o ve r 65 will ne e d lo ng te rm c a re se rvic e s a nd suppo rt a t so me po int in the irlife time .  I n St. L o uis, a g o o d nursing ho me c ha rg e s b e twe e n $6000 to $7500 a mo nth fo r skille d nursing c a re .  Rura l a re a nursing ho me s c o st le ss  Ca re c o nc e rns d o no t e va po ra te just b e c a use nursing ho me c ha rg e s mo re  No t a ll St. L o uis nursing ho me s a c c e pt Me dic a id a nd mo st re q uire a wa iting pe rio d.  F a c ilitie s tha t a re 100% Me dic a id re a d y a re usua lly no t o n the sa me le ve l a s tho se tha t o ffe r b o th priva te a nd Me d ic a id b e d s  Use o f so c ia l wo rke r o r g e ria tric c a se ma na g e r to so rt o ut ne e ds o f c lie nt

Me dic a id  I n Misso uri, re fe rre d to a s “MO He a lthNe t.”  Diffe re nt tha n Me dic a re (a no n-me a ns te ste d b e ne fit). Me dic a re do e s no t pa y lo ng -te rm c a re c o sts.  Me dic a id te sts re so urc e s a nd to a c e rta in e xte nt, inc o me .  Re so urc e limit fo r a lmo st a ll Me dic a id is $999.99.  Co mmunity Sp o use rule s a llo w spo use tha t re ma ins in the ho me up to $119,220 in 2016. T he Minimum Co mmunity Spo use Re so urc e Allo wa nc e fo r 2016 is $23,844  Divisio n o f Asse ts de te rmine s the re so urc e s tha t the c o mmunity spo use c a n ke e p a nd the a mo unt o f a ny “spe nd do wn” re q uire d to me e t Me dic a id e lig ib ility.  Divisio n is o nly do ne with ma rrie d pe o ple —no t use d in sing le Me dic a id a pplic a tio ns.

Me dic a id I nc o me  I nc o me a nd re so urc e s a re two se pa ra te issue s. Do no t g e t the m c o nfuse d!  F o r Ve ndo r Me dic a id (o r Nursing Ho me Me dic a id) a n a pplic a nt’ s inc o me c a nno t e xc e e d the a c tua l c o st o f the mo nthly nursing ho me b ill; o the rwise the re is no thing fo r Me dic a id to c o ntrib ute .  T he inc o me c o nside re d b y Me dic a id is So c ia l Se c urity a nd pe nsio n; divide nds a nd inte re st a re no t inc o me . Re nt c a n b e inc o me .  Surplus inc o me is pa id to the nursing ho me with Me dic a id ma king up the diffe re nc e .  Co mmunity spo use s a re e ntitle d to a Minimum Mo nthly Ma inte na nc e Ne e ds Allo wa nc e = $1991.25 fo r 2016  T he Ma ximum Mo nthly Ma inte na nc e Ne e ds Allo wa nc e is $2,981 fo r 2016

No n Co unta b le Re so urc e s  E xe mpt re so urc e s inc lude  Ho use  Ve hic le  Pe rso na l pro pe rty (no n-c o lle c tio ns)  L ife insura nc e with a $1500 o r le ss c a sh va lue o r a pre -ne e d, irre vo c a b le b uria l c o ntra c t

T ra nsfe r Pe na ltie s  Pe na lty diviso r is $4889 fo r 2016  T ra nsa c tio ns fo r the five ye a r pro c e e ding a pplic a tio n a re sub je c t to “lo o k b a c k” a nd impo sitio n o f pe na ltie s  Pe na lty will b e impo se d fo r tra nsfe rs ma de fo r le ss tha n fa ir ma rke t va lue

Me dic a id Myths  Myth : “Iha ve to g ive a wa y e ve rything Io wn to g e t Me dic a id.”  T ruth : A pe rso n is pe rmitte d to o wn so me pro pe rty, a nd still b e e lig ib le fo r he T Me dic a id. So me thing s, like the ho me yo u live in o r a pre -pa id b uria l pla n, do no t c o unt a g a inst Me d ic a id e lig ib ility. F o r a ma rrie d c o uple whe n o ne spo use is e nte ring a nursing ho me , the o the r spo use will b e a b le to ke e p so me o f the ma rita l a sse ts.  Myth : “I f I put my pro pe rty into my spo use ’ s na me , I will b e e lig ib le fo r Me dic a id.”  T ruth : Asse ts a re c o unte d, re g a rdle ss o f whic h spo use ’ s na me is o n the title . I t he T ma y b e po ssib le , ho we ve r, fo r a n a sse t to b e re -title d into the na me o f the he a lthy spo use , a fte r Me dic a id b e ne fits ha ve b e e n a ppro ve d fo r the spo use ne e ding nursing ho me c a re .

Me dic a id Myths  Myth : “Me dic a re will c o ve r my nursing ho me b ill.”  T ruth : Me dic a re o nly c o ve rs a sma ll a mo unt o f the nursing ho me c a re he T pro vide d in the US. T his is a surprise to ma ny pe o ple . I n g e ne ra l, Me dic a re will pa y fo r 20 da ys o f nursing ho me c a re if the pe rso n wa s in the ho spita l fo r a t le a st 3 da ys prio r to e nte ring the nursing ho me a nd the pe rso n re q uire d skille d c a re (suc h a s physic a l the ra py). Me dic a re will pa y pa rt o f the c o sts fo r a n a dditio na l 80 da ys, b ut o nly if the re side nt c o ntinue s to ne e d skille d c a re .  Myth : “I f I e nte r a nursing ho me a s a priva te pa y re side nt, I must use up a ll my a sse ts b e fo re Ic a n g e t Me dic a id.”  T ruth : So me nursing ho me s ma y te ll yo u tha t yo ur o nly o ptio n is to spe nd a ll o f he T yo ur a sse ts to priva te ly pa y fo r nursing ho me c o sts, b ut this is b e c a use the y g e t pa id le ss unde r the Me dic a id pro g ra m. Yo u ma y wa nt to se e k the a dvic e o f a n a tto rne y who und e rsta nds the Me dic a id rule s to le a rn wha t o the r o p tio ns yo u ma y ha ve .

Me dic a id Myths  Myth : “Ic a n o nly g ive a wa y $10,000 a ye a r unde r Me dic a id rule s.”  T ruth: T he $10,000 pe r ye a r rule is a fe de ra l g ift ta x rule (a nd the a mo unt ha s he T b e e n inc re a se d a nd a pplie s o nly to pe o ple with a ve ry la rg e e sta te .) Unde r the Me dic a id rule s, a g ift tha t c re a te s ine lig ib ility c a use s the pe rso n to b e ine lig ib le fo r a numb e r o f mo nths d e te rmine d b y the va lue o f the g ift divide d b y the Me dic a id diviso r. Se e # 3.  Myth : “My inc o me ma y ha ve to b e use d to pa y my spo use ’ s nursing ho me b ill.”  T ruth : T he he a lthy spo use g e ts to ke e p his o r he r o wn inc o me . I n fa c t, the he T he a lthy spo use is g ua ra nte e d a minimum mo nthly inc o me a nd, if ne c e ssa ry, so me o f the nursing ho me re side nt spo use ’ s inc o me will b e a ttrib ute d to the he a lth spo use .

Me dic a id Myths  Myth : “Ic a n hide my a sse ts a nd g e t Me dic a id.”  T ruth : I nte ntio na l misre pre se nta tio n in a Me dic a id he T a pplic a tio n is a c rime with sig nific a nt pe na ltie s.  Myth : “I c a n de pe nd o n the Me dic a id rule s no t c ha ng ing fo r ma ny ye a rs.”  T ruth : Me dic a id rule s c ha ng e , so do no t de pe nd o n wha t a he T frie nd o r ne ig hb o r ha s to ld yo u. I t is b e st to c o nsult with a n a tto rne y who unde rsta nds Me dic a id la w a nd kno ws wha t the c urre nt rule s a re .

Me dic a id I n o rde r to q ua lify fo r Me dic a id, the a pplic a nt must:  Be a Unite d Sta te s c itize n  A re side nt o f Misso uri  Me e t the a g e limita tio ns  Be pe rma ne ntly a nd to ta lly disa b le d  Me e t the fina nc ia l e lig ib ility c rite ria whic h pe rta ins to the inc o me a nd a sse ts o f the a pplic a nt

Ve te ra n’ s Be ne fits  Aid a nd Atte nda nc e ; No n-Se rvic e Co nne c te d Ve te ra n  Re so urc e a nd I nc o me L imita tio ns  Milita ry Se rvic e  Pe nding in Co ng re ss is a b ill tha t ma nda te s a 3-ye a r pe na lty fo r tra nsfe rs  T he pe na lty ma y b e a sse sse d whe n a pplic a tio n o c c ur

Ve te ra n’ s Be ne fits Ba sic s: I ndividua ls who a re ve te ra ns ma y b e e lig ib le fo r c e rta in b e ne fits te rme d “a id a nd a tte nda nc e .”  Ve te ra n must ha ve se rve d a t le a st nine ty da ys o n a c tive duty; o ne da y o f whic h ha d to ha ve b e e n during a wa r time pe rio d  Ve te ra n must ha ve ha d a n o the r tha n disho no ra b le disc ha rg e  Cla ima nt’ s physic ia n must de c la re him/ he r a s ho use b o und a nd/ o r in ne e d o f a ssista nc e fro m a no the r individua l, whic h ma y inc lude se rvic e s o ffe re d b y ho me he a lth c a re , a ssiste d living o r nursing ho me c a re  Cla ima nt, if ma rrie d, must ha ve le ss tha n $50,000 in a sse ts, e xc luding ho me , c a r a nd pe rso na l b e lo ng ing s  Cla ima nt, if sing le , must ha ve le ss tha n $30,000 in a sse ts, e xc luding ho me , c a r a nd pe rso na l b e lo ng ing s  Me e t inc o me re q uire me nts  Wido we d spo use must ha ve b e e n ma rrie d to the ve te ra n a t the time o f the ve te ra n’ s de a th o r ha ve ha d c hildre n b y the ve te ra n a nd ne ve r re ma rrie d

2016 Se rvic e Pe nsio n ra te s

2016 Survivo rs Pe nsio n ra te s

ME DI CARE SE T ASI DE S AND PE RSONAL I NJURY

I ntro duc tio n  K no w yo ur c lie nt  K no w a nd unde rsta nd the b e ne fits tha t the c lie nt re c e ive s:  Me dic a re  SSDI  SSI  F o o d Sta mps  Me dic a id  Se c tio n 8

Who is E ntitle d to Me dic a re  A pe rso n 65 ye a rs o f a g e o r o lde r;  A disa b le d pe rso n;  A pe rso n (o r c hild) with e nd sta g e re na l dise a se .  I ndividua l must b e insure d; must ha ve suffic ie nt q ua rte rs o f c o ve ra g e  I ndividua l who is a pplying o n b a sis o f a g e who is no t insure d ma y pa y into the syste m  I ndividua l who a pplie s fo r SSDI is e lig ib le fo r Me dic a re within 24 mo nths o f e lig ib ility  Co mpa ssio na te Dise a se s

Me dic a re Se c o nda ry Pa ye r Ac t (the MSP)  Me dic a re wa s c re a te d in 1965  Me dic a re Se c o nda ry Pa ye r Ac t wa s c re a te d in 1980

T he L a w  42 U.S.C. §1395y  42 C.F .R. §§ 411.20 e t.se q .  Me dic a re is a se c o nda ry pa ye r

Se c tio n 1862(b )(2)(A)(ii) 42 U.S.C. §1395y  Pre c lude s Me dic a re pa yme nt fo r se rvic e s to the e xte nt tha t pa yme nt ha s b e e n ma de o r c a n re a so na b ly b e e xpe c te d to b e ma de pro mptly unde r lia b ility insura nc e (a s de fine d in 42 CF R 411.50)

T hre e Co mplia nc e Pa rts; T he Pre se nt, the Pa st a nd the F uture  I n e ve ry lia b ility se ttle me nt invo lving a Me d ic a re b e ne fic ia ry, the pa rtie s, inc luding a ny g ro up he a lth pla n o r lia b ility insure r, no w ha s thre e distinc t o b lig a tio ns:  1) re po rt the se ttle me nt to CMS (the pre se nt);  2) re so lve a ny c o nditio na l pa yme nts (the pa st)a nd  3) pro vide fo r pa yme nt o f future me dic a l e xpe nse s a s a te rm o f the se ttle me nt, ta king into c o nside ra tio n Me dic a re ’ s inte re sts (the future ).  E a c h o b lig a tio n c a rrie s its o wn pe na lty fo r fa ilure to fulfill it.

Me dic a re , Me dic a id a nd SCHI P E xte nsio n Ac t o f 2007 (MMSE A)  E nfo rc e s Me dic a re ’ s b a sic rig ht o f re c o ve ry a nd to e nsure tha t Me dic a re se rve s a s a se c o nda ry pa ye r, whe ne ve r po ssib le .  Se c tio n 111: re po rting re q uire me nts

Wha t T rig g e rs Re po rting  T he RRE must re po rt a T POC) whic h ota l Pa yme nt Oblig a tion to the Cla ima nt (T g e ne ra lly re pre se nt a ‘ o ne -time ’ o r ‘ lump sum’ pa yme nt o f a se ttle me nt, judg me nt, a wa rd, o r o the r pa yme nt inte nde d to re so lve o r pa rtia lly re so lve a c la im. T he RRE must a lso re po rt no -fa ult/ Me d Pa y/ PI P a nd wo rke rs’ c o mpe nsa tio n c la ims.  Ma nda tory re porting is re quire d whe n the T POC da te a nd se ttle me nt a mount a re a s follows:  Ove r $100,000 – On o r a fte r Oc to b e r 1, 2011  Ove r $50,000 – On o r a fte r April 1, 2012  Ove r $25,000 – On o r a fte r July 1, 2012  Ove r $5,000 – On o r a fte r Oc to b e r 1, 2012  Ove r $2,000 – On o r a fte r Oc to b e r 1, 2013  Ove r $300 – On o r a fte r Oc to b e r 1, 2014

Se c tio n 111 a nd Disc o ve ry  Se c tio n 111 re q uire d e xte nsive info rma tio n disc lo sure , inc luding a c lie nt’ s SSN fo r the de fe nda nt to re po rt the c la im  CMS ha s no t b e e n willing to a c c e pt le ss tha n c o mple te info rma tio n  I nfo rma tio n so ug ht is g e ne ra lly no t the type e xc ha ng e d, e spe c ia lly in simple se ttle me nts  Co urt c o mpe lle d disc lo sure o f SSN re a so na b le in lig ht o f de fe nda nt’ s re po rting re q uire me nts:  Se ge r C , Do c ke t No .: 8:08CV75, US Dist. L E XI S v. T ank Conne c tion, L L 49013, D.Ne b . (Apr. 22, 2010)  Hac kle y v. Gar ofano, 2010 Co nn. Supe r. L E XI S 1669 (Sup.Ct. July 1, 2010)

Co nditio na l Pa yme nts  Me dic a re ha s the rig ht to re c o ve r a ny c o nditio na l pa yme nt ma de a g a inst the se ttle me nt pro c e e ds o f a Wo rke r’ s Co mpe nsa tio n o r third-pa rty lia b ility c a se .  So me time s re fe rre d to a s a “supe r lie n” b e c a use o f the b ro a d po we r CMS ha s  F ro m the da te o f inc ide nt to the da te o f se ttle me nt

Pro c ure me nt Co sts  Me dic a re re duc e s its re c o ve ry a uto ma tic a lly to ta ke into a c c o unt the c o st o f pro c uring the judg me nt o r se ttle me nt.  T he c o sts inc lude a tto rne y’ s fe e s, e xpe rt witne ss fe e s a nd c o urt c o sts. I n o rde r to pro pe rly c a lc ula te this re duc tio n, the c la ima nt’ s a tto rne y must pro vide a c o py o f the fe e a g re e me nt a lo ng with do c ume nta tio n o f c o sts inc urre d during litig a tio n. 42 C.F .R. 411.37.

SMART Ac t Purpo se  T he SMART Ac t wa s pa sse d a s pa rt o f H.R. 1845 a nd a tta c he d o nto a Me dic a re I VI G Ac c e ss Bill;  I t re fo rms se ve ra l a spe c ts o f the c o nditio na l pa yme nt a nd MMSE A Se c tio n 111 pro c e sse s  Ame nds Se c tio n 1862(b )(2)(B) o f the So c ia l Se c urity Ac t (42 U.S.C. 1395y(b )(2)(B))

Curre nt Sta te o f the SMART Ac t  T he fina l rule will b e pub lishe d in 2014  I nte rim fina l rule e xte nds the time pe rio d fo r CMS to a ppro ve a se ttle me nt to a s lo ng a s 245 da ys.  I F R “ig no re s the 120-da y sta tuto ry time -fra me ” o n CMS re spo nding to a re q ue st fo r a ppro va l o f a se ttle me nt.

Stra te g ie s  E lde r la w a tto rne ys who ha ve Me dic a id a nd VA pla nning a s pa rt o f the ir pra c tic e try to pre se rve so me o r a ll o f the a sse ts fo r the c lie nt o r the c lie nt’ s fa mily.  Go a l: T he c o mb ine d b e ne fits c a n pe rmit a c lie nt to re ma in in the ir ho me with ho me c a re a nd if skille d c a re is re q uire d ha ve Me dic a id e lig ib ility in pla c e whe n ne e de d.  Clie nts try te c hniq ue s o n the ir o wn tha t c a n le a d to c a ta stro phic re sults.

Stra te g ie s to Pla n fo r a Co ntinuum o f Ca re  Me d ic a id o r VA Asse t Pro te c tio n T rusts  I rre vo c a b le T rust  F o r VA pla nning purpo se s, the se ttlo r must no t re ta in a ny po ssibility o f re c e iving inc o me o r princ ipa l  F o r Me dic a id, the se ttlo r must no t re ta in a ny po ssibility o f re c e iving princ ipa l, b ut inc o me is pe rmissib le .  F ive ye a r lo o k b a c k fo rMe dic a id  No pe na lty fo r VA  Pre se rve s ste p-up b a sis a nd the 121 E xc lusio n o n the sa le o f the fa mily ho me  A re ta ine d limite d po we r o f a ppo intme nt is utilize d to c a use e sta te inc lusio n a nd the re sulting ste p-up o f b a sis a nd a n to re a llo c a te who will g e t wha t sha re s o f the trust a sse ts upo n the se ttlo r’ s de a th.  I nc o me c a n b e sprinkle d a mo ng multiple b e ne fic ia rie s in o rde r to o b ta in the b e st re sult b o th fo r inc o me ta x minimiza tio n a nd a sse t pro te c tio n (b y no t distrib uting to a n inc o me b e ne fic ia ry with c re dito rpro b le ms).

I mme dia te Stra te g ie s  Use o f a Spe c ia l Ne e ds T rust fo r disa b le d c hildre n  Use o f c a re ta ke r e xc e ptio n to tra nsfe r pe na lty rule s  Ha lf-a -lo a f pla nning  Me dic a id a nnuitie s

Pla nning F rustra tio ns  I mpro pe rly dra fte d F ina nc ia l Dura b le Po we r o f Atto rne y o r Re vo c a b le T rust;  Gifting pro visio ns a nd limita tio ns  Olde r do c ume nts  Do c ume nts tha t do no t pe rmit a me ndme nts to e xisting trusts  Gre e dy o r sho rt-sig hte d c hildre n;  T a x c o nc e rns;  He a lth o f the se nio r a nd so phistic a tio n o f the c hildre n.

T HE ME DI CARE SE CONDARY PAYE R ST AT UT E

Me dic a re Se t-Aside (MSA) Arra ng e me nts  Se c tio n 1862(b )(2)(A)(ii) o f the So c ia l Se c urity, Ac t [42 USC 1395 y(b )(2)], pre c lude s Me dic a re pa yme nt fo r se rvic e s to the e xte nt tha t pa yme nt ha s b e e n ma de o r c a n re a so na b ly b e e xpe c te d to b e ma de pro mptly unde r lia b ility insura nc e .  Me dic a re ha s the rig ht to sc rutinize a ny se ttle me nt o f wo rke r’ s c o mpe nsa tio n c a se o r third-pa rty lia b ility c a se to de te rmine if its rig ht must b e pro te c te d a g a inst a shift to Me dic a re o f a ny third pa rtie s’ lia b ility a s it re la te s to future me dic a l c a re .  Unle ss funds a re se t a side tha t will me e t the pa rtic ipa nt’ s future me dic a l b ills, Me dic a re will no t a ssume lia b ility fo r future me dic a l tre a tme nt whe n a third pa rty is re spo nsib le .

Sa lly Sta lc up Me mo – 5/ 25/ 11  Sta lc up is the MSP Re g io na l Co o rdina to r-Da lla s, T e xa s (pe rta ins to AR, OK , T X, NM, L A).  “T he L a w re q uire s tha t the Me dic a re T rust F unds b e pro te c te d fro m pa yme nt fo r future se rvic e s whe the r it’ s a Wo rke r’ s Co mpe nsa tio n o r lia b ility c a se . T he re is no distinc tio n in the la w.”  T he re is no fo rma l pro c e ss fo r re vie w o f lia b ility c a se s.  Atto rne ys must de c ide b a se d upo n the fa c ts o f the ir c a se whe the r the T rust F und must b e pro te c te d.

Sa lly Sta lc up Me mo – 5/ 25/ 11  “T he fa c t tha t a se ttle me nt/ judg me nt/ a wa rd do e s no t spe c ify pa yme nt fo r future me dic a l se rvic e s do e s no t me a n tha t the y a re no t funde d.”  “T he fa c t tha t the a g re e me nt de sig na te s the e ntire a mo unt fo r pa in a nd suffe ring do e s no t me a n tha t future me dic a ls a re no t funde d.”  “Se t-a side is o ur me tho d o f c ho ic e a nd the a g e nc y fe e ls it pro vide s the b e st pro te c tio n fo r the pro g ra m a nd Me dic a re b e ne fic ia ry.”

Cha rlo tte Be nso n Guida nc e Me mo – 9/ 30/ 11  Be nso n is the Ac ting Dire c to r o f the F ina nc ia l Se rvic e s Gro up o f the Offic e o f F ina nc ia l Ma na g e me nt in Ba ltimo re , Ma ryla nd  Whe re the b e ne fic ia ry’ s tre a ting physic ia n c e rtifie s in writing tha t tre a tme nt fo r the a lle g e d injury re la te d to the lia b ility “se ttle me nt” ha s b e e n c o mple te d a s o f the da te o f the “se ttle me nt,” a nd future me dic a l se rvic e s fo r injury will no t b e re q uire d, Me dic a re c o nside rs its inte re st, with re spe c t to future me dic a ls fo r tha t pa rtic ula r “se ttle me nt” sa tisfie d.  Whe n the re is suc h a c e rtific a tio n, the re is no ne e d fo r the b e ne fic ia ry to sub mit the c e rtific a tio n o r a pro po se d L MSA fo r re vie w. CMS will no t pro vide the se ttling pa rtie s with c o nfirma tio n tha t Me dic a re ’ s inte re st with re spe c t to future me dic a ls fo r tha t “se ttle me nt” ha s b e e n sa tisfie d.  T he b e ne fic ia ry a nd/ o r the ir re pre se nta tive a re e nc o ura g e d to ma inta in the physic ia n’ s c e rtific a tio n.

T ype s o f Arra ng e me nts  Se lf-Administe re d  Custo dia l Ac c o unts  Spe c ia l Ne e ds T rust  Po o le d T rust

Othe r Be ne fits tha t Must b e Co nside re d  SSI  Me dic a id  T he se “me a ns-te ste d” b e ne fits c o uld b e je o pa rdize d b y the re c e ipt o f a se ttle me nt.  Ma ny re c ipie nts o f Me dic a id ha ve no o the r fo rm o f he a lth insura nc e . T he lo ss o f Me dic a id c o uld b e de va sta ting

Pro te c ting Othe r Me a ns T e ste d Be ne fits  An MSA do e s no t pro te c t o the r “me a ns te ste d b e ne fits” a nd will impa c t o ng o ing e lig ib ility.  An MSA sho uld b e a sub -trust in a Spe c ia l Ne e ds T rust.  Summa ry  T wo issue s; ma inta ining “me a ns te ste d b e ne fits” De a ling with – RSMo . 208.215 - Me dic a id L ie n; • Ma inta ining “me a ns te ste d b e ne fits” •  Spe c ia l Ne e ds T rusts  Othe r o ptio ns

Spe c ia l Ne e ds T rusts  T hird Pa rty (“T idro w”) Spe c ia l Ne e ds T rust  Se lf-Se ttle d o r Pa y Ba c k Spe c ia l Ne e ds T rust  42 U.S.C.1396(d )(4)(A)  Po o le d Spe c ia l Ne e ds T rust  42 U.S.C. Se c tio n1396p(d)(4)(C)

Se lf-Se ttle d o r Pa y Ba c k- Spe c ia l Ne e ds T rusts 42 U.S.C. 1396(d)(4)(A)  T he individua l must b e unde r a g e 65 a t the time the trust is c re a te d a nd funde d  T he trust ma y b e e sta b lishe d b y a pa re nt, g ra ndpa re nt, le g a l g ua rdia n, o r a c o urt  Se e RSMo . §475.092 a nd RSMo . §511.030  T he individua l must b e disa b le d (sa me de finitio n fo r disa b ility a s use d fo r SSDI o r SSI)  T he T rust must c o nta in pa y-b a c k pro visio ns  Misso uri ha s spe c ia l re q uire me nts Se e RSMo . §475.092 •  T he trust must b e irre vo c a b le

Co urt Cre a te d SNT  Misso uri’ s sta tuto ry a utho rity fo r c o urt a ppro va l o f a pa y-b a c k trust is fo und a t Se c tio n 475.092.2 RsMo .  T ria l divisio n ha s sa me a utho rity, witho ut a ppo inting a c o nse rva to r, a s pro b a te divisio n unde r Se c tio n 511.030 RsMo .

Ark. De p't o f He a lth & Hum. Se rvs. v. Ahlb o rn, 126 S. Ct. 1752 (2006)  T he US Supre me Co urt rule d una nimo usly to limit sta te Me dic a id a g e nc ie s' c la ims fo r re imb urse me nt to the po rtio n o f a ny to rt se ttle me nt a ttrib uta b le to pa st me dic a l e xpe nse s.  T he a g e nc ie s ma y no t c la im a ny pa rt o f a pla intiff's re c o ve ry fo r lo st wa g e s, pa in a nd suffe ring , o r o the r no nme dic a l da ma g e s.

WOS v. E MA, U.S. Supre me Co urt, No . 12-98  No rth Ca ro lina c la ime d o ve r $900,000 o f a le g a l me dic a l ma lpra c tic e se ttle me nt wo n b y the pa re nts o f a 13-ye a r-o ld g irl b o rn with se rio us injurie s tha t le ft he r una b le to live o r wo rk inde pe nde ntly.  Anti-lie n pro visio n in fe de ra l Me dic a id sta tute pre e mpte d No rth Ca ro lina 's irre b utta b le sta tuto ry pre sumptio n tha t o ne -third o f to rt re c o ve ry wa s a ttrib uta b le to me dic a l e xpe nse s  T he c o urt sta te d tha t whe n “the re ha s b e e n a judic ia l finding o r a ppro va l o f a n a llo c a tio n b e twe e n me dic a l a nd no nme dic a l da ma g e s—in the fo rm o f e ithe r a jury ve rdic t, c o urt de c re e , o r stipula tio n b inding o n a ll pa rtie s—tha t is the e nd o f the ma tte r.” “With a stipula tio n o r judg me nt unde r this pro c e dure , the a nti- lie n pro visio n pro te c ts fro m sta te de ma nd the po rtio n o f a b e ne fic ia ry’ s to rt re c o ve ry tha t the stipula tio n o r judg me nt do e s no t a ttrib ute to me dic a l e xpe nse s.”

Se c tio n 202 o f the Bipa rtisa n Budg e t Ac t o f 2013  Co ng re ss ha s de la ye d b y two ye a rs a pro visio n in la st De c e mb e r's b udg e t b ill tha t g ive s sta te s the a b ility to re c o ve r Me dic a id c o sts fro m a b e ne fic ia ry's full pe rso na l injury se ttle me nt o r a wa rd.  T he la w, whic h a me nds the So c ia l Se c urity Ac t to ne g a te the U.S. Supre me Co urt's de c isio ns in Arkansas De partme nt o f He alth and Human Se rvic e s v. Ahlb o rn a nd Wo s v. E .M.A. , wa s se t to ta ke e ffe c t Oc to b e r 1, 2014.

Misso uri Me dic a id L ie n  RSMo . §208.215 – Me dic a id is e ntitle d to b e re pa id fro m the pro c e e ds o f the to rt re c o ve ry.  T he lie n ma y b e re duc e d b y the tria l c o urt.  E v., WD72706 (Mo . Ct. App. state of Wr ight v. Mo. De p’t of Soc . Se r April 19, 2011); c o urt ho lds tha t the Sta te ’ s e vide nc e re g a rding its c la im wa s insuffic ie nt; Sta te must de mo nstra te c la im a nd tha t pa yme nt wa s in fa c t ma de .  T he lie n ma y b e de fe rre d if a Spe c ia l Ne e ds T rust is pro pe rly dra fte d, a ppro ve d a nd funde d.

I s Se c tio n 208.215 Unc o nstitutio na l  Wilho ite is a n unre po rte d We ste rn Distric t F e de ra l Co urt c a se , 2012 WL 3723304 whic h ho lds tha t Se c tio n 208.215 vio la te s the Ahlb o rn c a se b e c a use it do e s no t sta te tha t re c o ve ry is limite d to the me dic a l pa id, a nd the re fo re , vio la te s fe de ra l la w, b ut tha t the lie n re duc tio n pa rt o f 208.215 pro te c ts the due pro c e ss rig hts o f the pla intiff.