By Lynn Davis

(I would like to dedicate this article to my mother-in-law, Mary Carapella, who recently passed away at the age of 79.)

It usually comes as a surprise. My wife and I were called to the hospital one day last May. My mother-in-law was taken there by ambulance. When we arrived at the hospital we were met by a social worker that attempted to "prepare us for the worst." After discussing her religious preferences, we were asked such questions as: "Does your mother have a health care proxy? Does your mother have a living will? Does your mother have a power of attorney? Does she have Medicare? Does she have the supplement?"

Fortunately my mother-in-law lived through 3 operations over a two-day period. Her health, not great to start with, was severely compromised. After coming to the realization that she was going to survive came more questions from the doctors: "Where would we like to send her for rehabilitation?" and eventually, " It appears to us that after rehab she may need to live in either an assisted living or a skilled nursing care facility. Do you have any preferences where she is sent?"

Toward the end of this process we were informed, "The skilled nursing facility your mom is staying at costs $216 per day, or around $6,500 per month plus medications ($78,000 per year). Because Medicare does not cover the costs associated with nursing homes, who is going to be responsible for these bills? Would you be willing to help pay if she is unable to make the payments?"

In this article I will give you some elder care insights we learned the hard way -- under the pressure of having a loved one put into that situation. Hopefully it will give you a starting point from which you can begin to handle all the decisions you may be faced with.

The first thing you need to know are the basic differences between Medicare and Medicaid. "Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government." (http://questions.cms.hhs.gov/). For more information regarding Medicare and its components, please go to: http://www.medicare.gov

There is also a Medicare supplemental insurance that gives you more comprehensive coverage than just Medicare -- you have to pay for it from a private insurance provider (like Blue Cross / Blue Shield). For information on this insurance go to http://hiicap.state.ny.us/mgap/index.htm. It is usually highly recommended that elderly people on Medicare purchase the additional insurance protection of the supplemental coverage.

"Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines. A person on Medicaid can have no more than $3,800 in assets and $50 per month in spending money." For more information on Medicaid, please visit: http://www.cms.hhs.gov/home/medicaid.asp

Prior to being eligible for Medicare / Medicaid a person should have had their own health insurance coverage. Private health insurance may or may not pay nursing home or rehab costs. You should consult your personal plan to find out if you have this coverage -- and how much it will pay if you need to use it. At age 65 people switch from their private health insurance to Medicare.

Some people confuse Medicare / Medicaid with Social Security. Assuming you have paid into Social Security, it provides benefits when you retire, benefits if you become disabled (prior to age 65), and support for your family when you die. The retirement benefits start at age 62 for a reduced payment, then increase up to age 70 -- depending on what age you elect to receive retirement benefits.

In summary, "Medicare, a separate program run by the Health Care Financing Administration, helps pay for inpatient hospital care, nursing care, doctors' fees and other medical services and supplies to people over 65 or to people who have received Social Security disability benefits for two years." (Your Social Security Statement, Social Security Administration). You must pay a quarterly premium to receive Medicare coverage. For additional Social Security information visit their web site at: http://www.ssa.gov. People should also purchase the additional Medicare Supplement for complete health insurance coverage.

Medicaid pays for people that have used up practically all their financial assets. Most single individuals will ONLY be allowed to have $3,800 and $50.00 per month from their Social Security payment before Medicaid "kicks in." Married couples are treated differently. There is an extensive application process prior to the start of Medicaid benefits. Your parent, you or your attorney must apply for these benefits.

There are many types of nursing care available. One of the most comprehensive is called "skilled nursing care." A skilled nursing facility has nurses on duty 24 hours per day, 7 days per week and each patient is carefully monitored. As my mother-in-law qualified for skilled nursing care, this is the type that I am most familiar with. This type of care costs between $6,000 - $8,000 per month (St. Camillus is $216 per day plus medications). Medicare does not cover these costs. Patients are self-pay until the person runs out of resources -- then Medicaid kicks in to pay the bills.

My mother-in-law continues to receive her monthly Social Security check. At the present time that check is being used to pay part of the $6,000 plus monthly St. Camillus bill. Once her assets are reduced to $3,800, Medicaid will begin to pay all her expenses. Besides being left with the $3,800, she will receive an additional $50.00 per month from Social Security (the rest of her monthly Social Security payment going to St. Camillus). We must apply for Medicaid -- the program doesn't "start" on it's own.

Another level of elder care is "extended care facilities" where medical help is available but patients are not monitored 24/7. Patients have to be able to pretty much take care of themselves. I don't know a lot about these facilities -- the cost is around $3,000+ per month. They are also "self-pay" until the person has no financial resources left -- then Medicaid pays.

In addition there are retirement homes for the elderly. These range in price, there are usually no medical resources on site, and they are not covered by Medicare or Medicaid. Many are like townhouses or apartments, some have common meeting areas, some serve meals, some have on-site services like a hair dresser, grocery store, etc.

There are also "rehab" facilities -- where people are sent to build up their bodies after surgery, etc. Medicare covers a while, as long as the facility deems you "need" rehab. (Rehab is also covered by some private health insurance policies.) Medicare will pay up to 30 days in rehab -- if a person has the Medicare supplement it will pay up to 100 days. In rehab people are evaluated every week to see if they are still making progress. Once they stop making progress -- they are out of rehab.

Once a person is done with rehab they are either sent home or into an elder care facility -- depending on the recommendation of the medical people assigned to their case. My mother-in-law was in rehab (at St. Camillus) for approximately 60 days (paid for by Medicare and her supplement). It was then determined that she qualified for skilled nursing care and was put in a nursing home room also located at St. Camillus. (St. Camillus is both a rehab facility and a skilled nursing care facility.)

St. Camillus continued to work with my mother-in-law trying to make her self-sufficient enough to move into an assisted living facility. Unfortunately she will never be moved out of skilled nursing care. She is currently on self-pay until she runs out of money -- then she will be placed on Medicaid which will pay all her room, board and medical bills.

People can also receive "in home" care -- where medical help comes to their house. This can be very expensive, the costs depending on the level of care needed. I don't know much at all about in-home care. It is my understanding that Medicare does NOT cover these costs.

There are other levels of care for the elderly. For a comprehensive summary please visit the following web site (NY Association of Housing and Services for the Aged) and click on the "Consumer Guide." You must have a PDF reader program attached to your browser. The web site is:
http://www.nyahsa.org/index.CFM?down_page_ID=167&group_id=1

There are 14 skilled care nursing homes in Central New York. I sent out E-mails to 100 teachers in our union E-mail Directory, I sent out 50 E-mails to golfers in my league. I also talked with a funeral home director who has visited most of them, I talked with the elder care lawyer, my doctor (who specializes in geriatrics), neighbors (one of whom who works in a nursing home), and friends. I probably talked with over 250 people all together -- not all of them had experiences with nursing homes -- some with only one nursing home -- and some with many. Here's what I found.

Based on my survey, the top rated places in CNY are Syracuse Home in Baldwinsville, Birchwood in Liverpool, Van Duyn (county home in Syracuse), St. Camillus (Syracuse), Nottingham in Jamesville (expensive) and Iroquois in Jamesville. Iroquois only takes patients from 3 local hospitals (it was money from those hospitals that built the facility -- Crouse Hospital, Community Hospital St. Joe's).

Getting "so-so" results were Hallmark in Minoa and Loretto in Syracuse (Loretto is huge and the quality of care in the skilled nursing part depends on the floor you are on -- the third floor is great, the first floor is not, that's all I was told).

Rated "NO" by my family doctor and several others was James Square (Syracuse) and Rosewood Heights (Syracuse). Rosewood is also affiliated with certain hospitals in CNY. Also rated no (but by only one person) were the Vivian Teal Howard Home in Syracuse and Sunnyside in East Syracuse. I received no results about the Jewish Home in Syracuse and Stonehedge in Chittenango.

Loretto for rehab is said to be very good (it's in a different wing than the nursing home), as is rehab at St. Camillus. Also reported good for rehab is Birchwood. I don't know any more about rehab, as that was all that I had time to research before my mother-in-law was accepted into St. Camillus.

Everyone should realize that no nursing home is perfect. They all face a shortage of nurses, aides, financing, etc. HOWEVER, some are much better at providing care and protection than others. Part of one federal government web site devoted to comparing nursing homes can be found at http://www.medicare.gov/NHCompare/Home.asp

I highly suggest that everyone reading this look into long-term care insurance for themselves and their spouse. One place to look is a policy endorsed and offered through the NYSUT web site (http://www.nysut.org). In addition there are many other plans available from insurance agents. Length of coverage, amount of coverage, how a person is declared eligible for the insurance benefits, and what type of different coverage's you are eligible for are a few of the questions you should be asking. The younger you are when you start your coverage, the less the cost of the insurance.

In addition, NYSUT Social Services offers a wealth of information -- it is a free phone call and a free service offered by NYSUT and staffed by trained professionals. They were very helpful to both my wife and I and are happy to answer questions about family members. I highly recommend the help they can offer. Their phone number is 1-800-342--9810 ext. 640. E-mail can also reach them at socsvcs@nysutmail.org.

The elderly have many legal concerns that should be addressed while they are still of "sound mind and body." One concern of course would be a will, a statement of how the person's property is to be divided up after their death.

In addition, however, the elderly should also think about a living will, a written indication as to health treatments that the person would like to receive if they become unable to make that decision for themselves. This is different from a health care proxy (another legal document they should have), which is a document that designates a person to make health care decisions in the event that the elderly person becomes incapable of making such decisions.

Another important legal concern is a power of attorney. This document gives another family person the ability to make legal decisions for the elderly person. This is especially important if the elderly person experiences any form of memory loss or dementia.

Still another important legal concern for the elderly is an irrevocable living trust. An irrevocable living trust, set up properly within a certain time frame (the trust has to be in effect for at least 39 months prior to applying for Medicaid, I believe), can protect an elderly person from losing all their money and assets in payments to a nursing home. This document removes an elderly person's assets from consideration when calculating benefits for Medicaid. The "downside" to an irrevocable living trust is that the elderly gives away all their assets -- hopefully to someone (like a family member) that watches over the elderly person and provides financial support back to them.

If a person without a living trust becomes ill and has to go into a nursing home, there is still a way to protect some of that person's assets through a process called "gifting." The amount of the gifts and the timing of the gifts are important, you must consult an attorney for specifics. The earlier you start the "gifting" process, the more assets you can protect.

Unless you are independently wealthy I would not suggest volunteering to take on the bills that your parent might incur in a nursing home. At $78,000 per year a family can go through a lot of cash in a very short period of time. You probably also don't want to give all your parents money to the nursing home. If your family has set up a living trust you can protect almost all of your parent's assets. In lieu of a living trust, "gifting" can protest around 40-50% of your parent's assets. Timing of both types of protection is critical -- and requires an elder care lawyer.

While the nursing homes are pleasant enough to work with, they do insist on being paid. If your parent ends up in a nursing home with NO legal financial protection, the nursing home will eventually put a lien on your parent's home and other assets and -- assuming your parent lives long enough -- the nursing home will eventually own everything.

To do all the legal work a person probably needs an attorney. I would strongly suggest finding one that specializes in "elder care." Elder care attorneys specialize in this type of legal work and are more up-to-date on the current laws regarding the elderly. Elder care attorneys can be found in the yellow pages of the phone book, recommendations from friends and relatives that have used their services, or recommended from a legal service that one can purchase from NYSUT.

The NYSUT Legal Plan ($65 per year) has an elder care rider which does the following: "Elder Law Rider ­ For $35 more per year, you can have access to Elder Law attorneys who have agreed to reduce their legal fees by 20% for Plan members. These attorneys specialize in the financial and health care needs of the elderly. This rider provides one free Legal Security Package that includes a simple will, health care proxy, living will and durable power of attorney. Elder Law rider benefits are extended to spouse/domestic partner, parents, parents-in-law, grandparents and grandparents-in-law." (NYSUT's web site) http://www.nysut.org/cps/rde/xchg/nysut/hs.xsl/3455_3013.htm

I joined the NYSUT plan and was put in touch with the Syracuse law firm of Sargent and Gilmore. They would do the above work for me, and help me set up my mother-in-law's Medicaid application. The cost was $80.00 per hour (20% off) for their services and they estimated it would cost over (I believe) $2,500, depending on all the circumstances.

I also talked with a local (Camillus) elder care attorney that had done work for some of the staff at Camillus Middle School. This person charged $5,500 but agreed to do ALL the work, including the Medicare application and representing us at the Medicare hearing(s). As we have been told that the Medicare application process is a tremendous amount of work, we decided to go with the more comprehensive legal plan.

Even working with this attorney has required us to do a huge amount of work. We have had to find all of my mother-in-laws legal and financial papers -- which included the deed and abstract for her house, bank records for the last 5 years, financial statements for her CD and pension, social security card, marriage certificate, death certificate of her former spouse, private health insurance card, Medicare card, deed to cemetery plot, etc. In addition we had to turn all her assets into cash (so we could pay her St. Camillus bills and "gift" her money). We had to sell her house, sell the contents of her house, and sell a Certificate of Deposit that she had owned for the past 20 years.

In addition to all of this, we still monitor her care and well being at St. Camillus. We make sure she gets to her outside health care check-ups. We ensure that she has the things she needs at St. Camillus (hair styling, signing her up for little trips, purchasing personal items she needs, etc.), and try to work with her so she is more accepting of the situation that she now finds herself. We also try to get her out of St. Camillus at least once or twice a week.

I once remarked to a co-worker that I couldn't wait until all the "work was over." She gave what has turned out to be the best advice I have yet to receive. She told me, "It never ends -- so prepare yourself." I hope this information helps you and others if you find yourself in the same situation.

Please be advised that every attempt was made at bringing you accurate information. HOWEVER, I am NOT an expert in health care, Medicare and Medicaid, a lawyer or a nursing home professional. In addition, conditions at nursing homes are subject to change as are the state and federal laws concerning elder care. For information regarding your own personal circumstances please contact your own elder care professionals or The Health Insurance Information Counseling and Assistance Program from the NYS Department for the Aging at http://hiicap.state.ny.us/