Monday, November 23, 2015

Mass. Appellate Court Reinstates Legal Malpractice Verdict Following Flawed Medicaid-Planning Advice

In October 2015, the Massachusetts Court of Appeals addressed the question of whether there were damages flowing from a lawyer's Medicaid advice to an older couple. The lawyer had counseled that, for Medicaid planning reasons, the couple should not retain a life estate in a house purchased with their money but held in the name of their adult children. The court found the surviving mother suffered real damages, even if eviction from the house by her children was unlikely.  Key allegations included:

Thirteen years later, in July of 2007, the Brissettes [the parents] and two of their four children, Paul Brissette and Cynthia Parenteau, met at [Attorney] Ryan's office to discuss the Brissettes' desires to sell the South Hadley home and to buy property located in Springfield. They discussed the prospect of putting the Springfield property in the names of Paul and Cynthia. Ryan told the Brissettes that if they reserved life estates in the Springfield property, they could be ineligible for Medicaid if they applied any time within five years of getting the life estates. He also told them that if they took life estates in the Springfield property, there could be a Medicaid lien against that property when they died. There was evidence that the Brissettes asked about “protection,” but Ryan told them that he did not feel that the Brissettes needed protection because they could trust their children to do what they wanted them to do. In reliance on Ryan's advice, the Brissettes decided that the Springfield property would be bought with their money  but put in Paul's and Cynthia's names, and that the Brissettes would not have life estates in the Springfield house.

After her husband's death. Mrs. Brissette concluded she wished to own "her" home in her own name, but the children declined to re-convey the property to her. 

During the malpractice trial, Lawyer Ryan conceded his advice about the effect of a life estate on Medicaid and/or a Medicaid lien was wrong, and expert witnesses also testified that the incorrect Medicaid advice was "below the standard of care applicable to the average qualified attorney advising clients for Medicaid planning."

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November 23, 2015 in Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, November 18, 2015

Health Affairs Publishes Report on New Models for Long-Term Services and Supports

Coinciding with the presentation yesterday at the National Press Club in Washington, D.C., the journal Health Affairs released a report  by Melissa Favreault, Howard Gleckman, and Richard W. Johnson, titled "Financing Long-Term Services And Supports: Options Reflect Trade-Offs For Older Americans And Federal Spending."  Noting the history of weak buy-in for existing long-term care insurance products, the authors' study, funded by the SCAN Foundation, AARP and LeadingAge, looks to future alternatives.  From the abstract:

To show how policy changes could expand insurance’s role in financing these needs, we modeled several new insurance options. Specifically, we looked at a front-end-only benefit that provides coverage relatively early in the period of disability but caps benefits, a back-end benefit with no lifetime limit, and a combined comprehensive benefit. We modeled mandatory and voluntary versions of each option, and subsidized and unsubsidized versions of each voluntary option. We identified important differences among the alternatives, highlighting relevant trade-offs that policy makers can consider in evaluating proposals. If the primary goal is to significantly increase insurance coverage, the mandatory options would be more successful than the voluntary versions. If the major aim is to reduce Medicaid costs, the comprehensive and back-end mandatory options would be most beneficial.

The full article is linked here. Several related pieces are also on the Health Affairs website.  Much to read and evaluate here and helpful for those planning spring Elder Law courses. 

November 18, 2015 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (1)

Tuesday, November 10, 2015

New York Court Addresses "Medicaid Transfer" Issue in Context of Continuing Care Community (CCRC)

On November 6, 2015 the appellate division of New York's Supreme Court addressed an issue long brewing in some states, whether Continuing Care Retirement Communities (CCRCs) can insist on "private pay" for skilled nursing care despite a resident's "eligibility" for Medicaid under state and federal laws.  In Good Shepherd Village at Endwell, Inc. v. Yezzi, the unanimous panel affirmed summary judgment in favor of the CCRC on the payment question.

The decision highlights Congressional DRA action in 2005/6 that amended federal Medicaid law to expressly permit CCRCs to offer contracts that require residents to "spend on their care resources declared for the purposes of admission before applying for medical assistance."  The DRA amendment was a response to the industry's lobbying efforts, following a 2004 decision by a Maryland appellate court in Oak Crest Village, Inc. v. Murphy that held such a contractual provision violated the federal Nursing Home Residents' Bill of Rights, viewed as prohibiting nursing homes from conditioning admission on guarantees of private pay.

In the New York case history, the couple apparently signed two separate documents, beginning with a "contract" at the time of their entrance into the CCRC that required them to pay both an entrance fee ($143,850) and "basic monthly fees" of approximately  $2,550 to cover the cost of independent living.  Any need for skilled nursing care would be assessed "an additional charge."  That contract provided that residents could "not transfer assets represented as available" for less than fair market value.  When the wife needed skilled care, the couple signed a second document, referred to in the case as an "admission agreement," for treatment in the CCRC's skilled nursing unit. The "admission agreement" reportedly required the Yezzis to "pay for, or arrange to have paid for by Medicaid" all services provided by the CCRC.

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November 10, 2015 in Consumer Information, Estates and Trusts, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, State Statutes/Regulations | Permalink | Comments (0)

Friday, October 9, 2015

Filial Friday: Freakonomics Asks "Should Kids Pay Back Parents for Raising Them?"

In a convergence of my teaching, research and public outreach work, this week I've found myself in several overlapping conversations about whether adult children have obligations -- moral or legal -- to care for or financially support their parents.  

This week, following my Elder Law Prof Blog post recommending Hendrik Hartog's fascinating book, Someday All This Will Be Yours, which I also recommended to my Trust & Estate students, I had a nice series of virtual conversations with Dirk about his book. What a thoughtful historian he is.  We were talking about his research-based observation in the book about adult children and needy parents:

Adult children were not legally bound to remain and to work for their parents.  Nor were they obligated to care for the old.  Adult children were, paradigmatically and legally, free individuals, "emancipated," to use the technical term. . . . Furthermore, there was little -- perhaps nothing-- to keep an uncaring or careless adult child from allowing a parent to go over the hill to the poorhouse.

I asked, "what about filial support laws?"  Turns out that was a timely question because Professor Hartog  had just been interviewed for a Freakonomics Radio episode, "Should Kids Pay Back Their Parent for Raising Them?" The program became publically available, via podcast or written transcript, on October 8, 2015.  In the interview Professor Hartog was asked to comment on filial support laws.  He said in part:

Filial responsibility statutes are very weak efforts to ensure that the young will support the old if they are needy.... They rarely are enforced.  Very, very, very, very rarely.  So, you know, in a sense, every time they are enforced they become a New York Times article or they become an article in the local newspapers. 

Professor Hartog was speaking in large measure from the perspective of his important historical research, including review of a body of case reports from New Jersey spanning some 100 years from the mid 1880s to the mid 1900s.  And based on my own historical research, I would also say that in the U.S., filial support laws have been rarely enforced, although I would characterize the enforcement as often "episodic" in nature, especially after the growth of Social Security and Medicaid benefits.  But...

I think the modern story is quite different in at least one state -- Pennsylvania.  Part of this difference is tied to the fact that Pennsylvania's filial support law permits enforcement by commercial third-parties, including nursing homes, as I discussed in my 2013 article on Filial Support Laws in the Modern Era.  Other U.S. jurisdictions with "modern" enforcement cases are South Dakota and Puerto Rico.

Indeed, I'm speaking on October 9, 2015 at the invitation of a Bench and Bar Conference in Gettysburg, PA about "The Festering Hot Topic" of Filial Support Laws in Pennsylvania. In the presentation, I report on controversies arising from recent, aggressive collection efforts by law firms representing nursing homes, as well the latest examples of successful enforcement suits by nursing homes and family members. I also analyze a disturbing additional claim, where Germany is seeking to enforce its filial support law to compel a U.S. resident to pay toward the costs of care for an ailing father in Germany. 

Ultimately, I think that Professor Hartog and I agree more than we disagree about the lack of behavioral impact flowing from filial support laws. As demonstrated by Professor Hartog in his book, much care and support is provided by children, but flowing from complicated moral or personal inclinations, rather than statute-based lawsuits.

This seems a more realistic paradigm, although  not without opportunities for misunderstanding and disappointment. But, as I often observe, the very last person I would want involved in my care would be someone who is doing it "only" because a statute -- much less a court -- is telling them they must care for me.

October 9, 2015 in Books, Current Affairs, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Housing, International, Medicaid, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Monday, October 5, 2015

Webinar on October 6: The "A to Zahner" on Medicaid Annuities

Sorry for the short notice, but on Tuesday, October 6, 2015 from noon to 1 p.m. (Eastern time), the Pennsylvania Bar Institute is hosting a very timely (and cleverly titled) webinar, focusing on the impact of the Third Circuit's recent decision in Zahner on Medicaid planning generally and specifically on the sue of annuities. 

Here is a link to PBI's details on "The A to Zahner on Medicaid Annuities," including how to register.

October 5, 2015 in Current Affairs, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Medicaid, Property Management, Webinars | Permalink

Sunday, September 27, 2015

Keeping Track of Preventive Services

Trying to keep straight all of the preventive services available to individuals is daunting, but the Kaiser Family Foundation (KFF) has made it easy with their new tool, Preventive Services Tracker.   There are separate trackers for each condition including cancer chronic conditions, immunizations, sexual health, health promotions and preganancy-based.  Organized into easy-to-use charts,, each chart provides information on the required service, the target population, the recommendation, coverage clarifications and effective dates.  The charts also provide links for each required service to explain more details.

You might also want to check out their article on Preventive Services Covered by Private Health Plans Under the Affordable Care Act and the accompanying fact sheet.


September 27, 2015 in Cognitive Impairment, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Thursday, September 24, 2015

Family Caregivers Show Support for Pennsylvania State Assistance at State Capitol

If you have worked in Elder Law long enough, you have probably received a panicked call from a family caregiver who is unprepared for a loved one to be discharged on short notice from hospital care.

2015-capitol-caregiving-event-tamesha-keelOn September 22, the Pennsylvania Capitol in Harrisburg was crowded with individuals wearing coordinated colors, showing their support for Pennsylvania Caregivers, including family members who are often struggling with financial and practical challenges in caring for frail elders. Here's a link to a CBS-21-TV news report, with eloquent remarks from Tamesha Keel (also pictured left), who has first-hand experience as a stay-at-home caregiver for her own aging mother.  Tamesha recently joined our law school as Director of Career Services.

AARP helped to rally support for House Bill 1329, the Pennsylvania CARE Act.  The acronym, coined as part of a national campaign by AARP to assist family caregivers, stands for Caregiver Advise, Record and Enable Act.  HB 1329  passed the Pennsylvania House in July 2015 and is now pending in the Pennsylvania Senate.

We have written on this Blog before about pending CARE legislation in other states.  A central AARP-supported goal is to achieve better coordination of aftercare, starting with identification of patient-chosen caregivers who should receive notice in advance of any discharge of the patient from the hospital.  Pennsylvania's version of the CARE Act would require hospitals to give both notice and training, either in person or by video, to such caregivers about how to provide appropriate post-discharge care in the home. 

I'd actually like to see a bit more in Pennsylvania. It is unfortunate that the Pennsylvania CARE Act, at least in its current iteration (Printer's Number 1883), does not go further by requiring written notice, delivered at least a minimum number of hours in advance of the actual discharge. AARP's own model act suggests a minimum of 4 hours, consistent with Medicare rules.

Under Federal Law, Medicare-participating hospitals must deliver advance written notice of a discharge plan, and such notice must explain the patient's rights to appeal an inadequate plan or premature discharge. A timely appeal puts a temporary hold on the discharge. See the Center for Medicare Advocacy's (CMA) summary of key provisions of Medicare law on hospital discharges, applicable even if a patient at the Medicare-certified hospital isn't a Medicare-patient. CMA's outline also suggests some weaknesses of the Medicare notice requirement.

AARP's original CARE Act proposals are important and evidence-based, seeking to improve the patient's prospects for post-hospitalization care through better advance planning. At the same time, there's some irony for me in reading the Pennsylvania legislature's required "fiscal impact" report on HR 1329, as it reports a "0" dollar impact.  That may be true from the Pennsylvania government's cost perspective, but for the hospitals, to do it right, whether in person or by video, training is unlikely to be revenue neutral.  I think we need to talk openly about the costs of providing effective education or training to home caregivers.

If passed by the Senate, Pennsylvania's CARE Act would be not become effective for another 12 months.  The bill further provides for evaluation of the effectiveness of the rules on patient outcomes.   

As is so often true, states are constantly juggling the need for reforms to solve identified problems, with the costs of such reforms.  Perhaps the current version of the Pennsylvania bill reflects some compromises among stakeholders. According to this press statement, the Hospital and Health System Association of Pennsylvania supports the current version of AARP's Pennsylvania CARE Act.

September 24, 2015 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations | Permalink | Comments (0)

Friday, September 18, 2015

Medicare Criminal Investigation? FBI Raids Home of CEO of Nursing Home Company

As we have frequently reported on this Blog (see e.g., here and here and here), the Obama Administration has been aggressive in pursuit of Medicare and Medicaid claims tied to unlawful reimbursement or kickback claims for companies involved in long-term care.  But even given that history, often tied to whistleblowing by current or former employees, it is unusual to see criminal investigations. Thus recent media reports about the FBI raiding the CEO of American Senior Communities was eye-catching, including this report from the Indianapolis Star:  

A cadre of federal agents raided the Carmel home of an executive of a chain of nursing homes Tuesday morning. But the most important question remains unanswered: Why?

The home is owned by James G. Burkhart, the CEO of American Senior Communities, according to Hamilton County property records. FBI investigators also were at the Southside headquarters of American Senior Communities, at 6900 Gray Road, according to reports.

American Senior Communities manages nearly 100 senior care facilities and is one of the largest nursing home management companies in Indiana. Among those are 60 sites, including skilled nursing facilities and assisted living facilities throughout the state, that the company manages under a contract with Marion County’s public health agency.

According to media reports, American Senior Communities (ASC) issued the following press statement following the raid:

"American Senior Communities’ most important priority is to continue to provide excellent care to our patients and residents. ASC has been contacted by the federal government in connection with an investigation into certain individuals or practices. ASC is fully cooperating with the government and is conducting its own review to ascertain the relevant facts. ASC is in compliance with all federal, state and local laws and regulations and will continue to conduct its business in accordance with the highest standards of integrity." 

Stay tuned...(but don't hold your breath).

September 18, 2015 in Ethical Issues, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Monday, September 14, 2015

Commenting on Proposed Medicaid Regs? Comment Period Expanded to October 14

As we have reported earlier on this Blog, CMS is seeking comments on proposed Medicaid rules affecting nursing facilities, including proposals that could affect the use of pre-dispute "arbitration" agreements. Justice in Aging provided the helpful update that the comment period has been extended to October 14, 2015.  In addition, Justice in Aging has provided a link to model or sample comments to use clarify consumer concerns.  

Here is a link to the CMS extension notice.  Here is a link to important information about commenting on key aspects of the proposals, prepared by The National Consumer Voice for Quality Long-Term Care.    

September 14, 2015 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Tuesday, September 8, 2015

Deadline 9/14/2015: Comments Due to CMS re "Binding Arbitration" in Nursing Home Admission Agreements

Erica Wood, a director for the ABA Commission on Law and Aging,  writing for the August 2015 issue of the ABA's Bifocal Journal, reminds us that the Centers for Medicare and Medicaid Services (CMS) is seeking comments on proposed changes to rules affecting Long-Term Care Facilities that participate in Medicare and Medicaid programs, including the issue of whether CMS should prohibit "binding" pre-dispute arbitration provisions in nursing home contracts.  The deadline for public comments is 5 p.m., on Monday, September 14, 2015.  Electronic comments, using the file code CMS-2360-P, can be submitted through this portal:

How do you feel about pre-dispute "agreements" binding consumers, including consumers of long-term care, to arbitration? Your comments to CMS can make a difference! 

I remember my first encounter with "binding" pre-dispute arbitration provisions in care facilities. In the early years of my law school's Elder Protection Clinic, a resident of a nursing home had purportedly "given away" possessions to an aide at nursing home, who promptly sold them on EBay.  The resident was lonely and the "friendship" included the aide taking her out the front door of the facility, via a wheel chair, on little outings, including trips where the resident could visit her beloved house, still full of a life-time of antiques and jewelry.  (The resident might have recovered enough to go home -- although eventually a second stroke intervened.)

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September 8, 2015 in Cognitive Impairment, Consumer Information, Current Affairs, Estates and Trusts, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Property Management | Permalink | Comments (0)

Thursday, September 3, 2015

Third Circuit Rules Medicaid Applicants' Short-Term Annuities Are Not "Resources" Preventing Eligibility

In a long awaited decision on two consolidated cases analyzing coverage for nursing home care, the Third Circuit ruled that "short-term annuities" purchased by the applicants cannot be treated by the state as "available resources" that would delay or prevent Medicaid eligibility.  The 2 to 1 decision by the court in Zahner v. Secretary Pennsylvania Department of Human Services was published September 2, 2015, reversing the decision (linked here) of the Western District of Pennsylvania in January 2014.

The opinion arises out of (1) an almost $85k annuity payable in equal monthly installments of $6,100 for 14 months, that would be used to pay Donna Claypoole's nursing home care "during the period of Medicaid ineligibility that resulted from her large gifts to family members"; and (2) a $53k annuity purchased by Connie Sanner, that would pay $4,499 per month for 12 months, again to cover an ineligibility period created by a large gift to her children. 

The Pennsylvania Department of Human Services (DHS) argued that the transactions were "shams" intended "only to shield resources from the calculation of Medicaid eligibility."  However, the majority of the Third Circuit analyzed the transactions under federal law's "four-part test for determining whether an annuity is included within the safe harbor and thus not counted as a resource," concluding:

Clearly, if Congress intended to limit the safe harbor to annuities lasing two or more years, it would have been the height of simplicity to say so.  We will not judicially amend Transmittal 64 by adding that requirement to the requirements Congress established for safe harbor treatment.  Therefore, Claypoole's and Sanner's 14-and 12-month contracts with ELCO are for a term of years as is required by Transmittal 64.

Further, on the issue of "actuarial soundness," the court ruled:

 [W]e conclude that any attempt to fashion a rule that would create some minimum ratio between duration of annuity and life expectancy would constitute an improper judicial amendment of the applicable statutes and regulations.  It would be an additional requirement to those that Congress has already prescribed and result in very practical difficulties that can best be addressed by policy choices made by elected representatives and their appointees.

The her short dissent, Judge Marjorie Rendell explained she would have affirmed the lower court's ruling in favor of DHS on the "grounds that the annuities ... were not purchased for an investment purpose, but, rather, were purchased in order to qualify for benefits."  In addition, she accepted DHS' argument the annuities were not actuarially sound.

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September 3, 2015 in Current Affairs, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, September 2, 2015

Seniors Who Cannot Make Ends Meet -- UCLA Documents "The Hidden Poor"

UCLA's Center for Health Policy Research has issued its August 2015 report on "The Hidden Poor," using county-by-county data to demonstrate that "federal" definitions of poverty are not a sufficient measure of true poverty for seniors.  What are the "hidden poor?"  The UCLA report explains:  "The Hidden Poor are defined as those who have incomes above 100 percent of the Federal Poverty Level (FPL), but who do not have enough income to make ends meet as calculated by the Elder Index."

A recent article in the Sacramento Bee highlights key components of the analysis: 

More than 300,000 elderly Californians are officially poor, as measured by the federal government, but their numbers triple to more than 1 million when the “hidden poor” are counted, according to a new study from UCLA’s Center for Health Policy Research.


National poverty guidelines say that for a single elderly adult living alone, the poverty line is $10,890 a year, but UCLA’s “elder index” puts it at $23,364 in California.


Those “hidden poor” Californians over 65 tend to be Latino or black. Their greatest concentrations are found in rural counties with overall low income levels, topped by Imperial County, where more than 40 percent of the elderly are the hidden poor....


The study said population groups with especially large proportions of the hidden poor include grandparents raising grandchildren, elderly with adult children living at home, and single elders.

Accurate measurements of poverty are core to planning of resources for any age group, including seniors.  How does your state account for needy seniors? 

Read more here:

September 2, 2015 in Consumer Information, Current Affairs, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Housing, Medicaid, Statistics | Permalink | Comments (0)

Friday, August 28, 2015

Medicaid Eligibility: Ohio Supreme Court Addresses Effect of Post-Admission, Pre-Eligibility Transfer of Home

One year and six days after hearing oral argument in Estate of Atkinson v. Ohio Department of Job & Family Services, a divided Ohio Supreme Court ruled in favor of the State in a Medicaid eligibility case involving transfer of the community home.  The majority, in a 4-3 vote, ruled that "federal and state Medicaid law do not permit unlimited transfers of assets from an institutional spouse to a community spouse after the CSRA (Community Spouse Resource Allowance) has been set." However, the court also remanded the case to the lower court for recalculation of the penalty period under narrow, specific provisions of state and federal law.

Attorneys representing families in "Medicaid planning" scenarios will be disappointed in the ruling, because it rejected "exempt asset" and "timing" arguments that would have permitted some greater sheltering of assets after the ill spouse's admission to the nursing home. 

At the same time, the complex reasoning and specific facts (involving transfer of the family home out of the married couple's "revocable trust" to the community spouse), will likely create additional business for elder law specialists, especially as the majority distinguished the 2013 federal appellate court ruling in Hughes v. McCarthy, that permitted use of spousal transfers using "annuities."   

The dissent was strongly worded:

It is clear that the law treats the marital home very carefully to prevent spousal impoverishment at the end of life. And that is the public policy we should be embracing. Based on the plain language of the federal statutes and the Ohio Administrative Code, as well as the holding of the United States Court of Appeals for the Sixth Circuit in Hughes v. McCarthy, 734 F.3d 473, I would hold that the transfer of the home between spouses prior to Medicaid eligibility being established is not an improper transfer and is not subject to the CSRA cap.

To view the oral argument of the case before the Ohio Supreme Court, see here. 

August 28, 2015 in Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Who "Owns" Funds in Joint Accounts -- and Why Might It Matter for Medicaid Purposes?

Sometimes "small" cases reveal larger problems. A recent appellate case in Pennsylvania is a reminder of how practical solutions, such as establishing a joint bank account to facilitate management of money or to permit sharing of resources during early stages of elder care, may have unforeseen legal implications later. In Toney v. Dept. of Human Services, decided August 25, 2015, the Commonwealth Court of Pennsylvania ruled that "half" of funds held in a joint savings account under the names of the father and his son, were available resources for the 93-year-old father.  Thus the father, who moved into a nursing home in May 2014, was not immediately eligible for Medicaid funding. 

The son argued, however, that most of the money in the account was the son's money, proceeds of the sale of his own home when he moved out of state almost ten years earlier:

"The son alleged that his father used the bulk of that money to maintain himself, with the understanding that any money remaining from that CD after his father's death would revert to him. The ALJ, however, rejected the son's testimony as self-serving and not credible...."

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August 28, 2015 in Estates and Trusts, Health Care/Long Term Care, Medicaid, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, August 20, 2015

Reading the "Alphabet Soup of Medicare & Medicaid Contractors"

Attorneys Don Romano and Jennifer Colagiovanni have a useful article in the August issue of The Health Lawyer, published by the ABA.  In The Alphabet Soup of Medicare and Medicaid Contractors, the authors spell out the many players involved in claims processing, payment and oversight for federal/state health care payments:

Healthcare providers, suppliers, and their staff, as well as attorneys representing healthcare entities are faced regularly with a barrage of private contractors tasked with a variety of responsibilities for administering the Medicare program, including claims processing, reimbursement, enrollment and auditing activities.  Given the number of different contractors (and different acronyms, for that matter), it can be difficult to identify the role of the particular contractor one is dealing with, the focus of goal of the program the contractor is involved in , and the responsibilities it is tasked with managing, as well as the statutory and regulatory scope of its authority.  This article seeks to identify the various Medicare and Medicaid contractors and outline their authority, focus and responsibilities.

If you ever had any question about why Medicare and Medicaid are expensive programs, this article suggests that payment for services is not the "only" significant cost factor. 

August 20, 2015 in Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Sunday, August 16, 2015

2015 National Aging & Law Conference

The National Aging & Law Conference is scheduled for October 29-30, 2015 at the Hilton Arlington, Arlington, VA. A number of ABA commissions and divisions are sponsors of this conference including the Commission on Legal Problems of the Elderly, the Coordinating Committee on Veterans Benefits & Services, the Senior Lawyers Division and the Real Property, Trust & Estate Law Section.  The website describes the conference

The 2015 National Aging and Law Conference (NALC) will bring together substantive law, policy, and legal service development and delivery practitioners from across the country.  The program will include sessions on Medicare, Medicaid, guardianship, elder abuse, legal ethics, legal service program development and delivery, consumer law, income security, and other issues.

The 2015 National Aging and Law Conference marks the second year that this conference has been hosted by the American Bar Association. This year’s agenda will include 24 workshops and 4 plenary sessions on key topics in health care, income security, elder abuse, alternatives to guardianship, consumer law, and  legal service development and delivery.  The focus of the agenda is on issues impacting law to moderate income Americans age 60 and over and the front line advocates that serve them. 

The agenda is available here. To register, click here.  Early bird registration ends August 28, 2015.


August 16, 2015 in Advance Directives/End-of-Life, Cognitive Impairment, Dementia/Alzheimer’s, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, Programs/CLEs, Social Security, Veterans | Permalink | Comments (0)

Monday, August 10, 2015

Will "Single Seniors" Change the Face of Long-Term Living and Supports?

The Public Policy Institute (PPI) of California recently profiled demographic changes likely to affect that state in coming decades, including the impact of a projected increase, to 20%, of the proportion of the population aged 65+.  One especially interesting component is the impact of seniors who are likely to be "single," especially those without the assistance of  children, spouses, or other close family members, a trend that seems likely to be true nationwide. From PPI's report (minus charts and footnotes):

Family structures in this age group will also change considerably—in particular, marital status will look quite different among seniors in 2030 than it does today.... The fastest projected rates of growth are among the divorced/separated and never married groups. Between 2012 and 2030, the number of married people over age 65 will increase by 75 percent—but the number who are divorced or separated will increase by 115 percent, and the number who are never married will increase by 210 percent....


Another significant change will be in the number of seniors who have children. Those who have never been married are much less likely to have children than those who have been married at some point. As a result, seniors in the future will be more likely to be childless than those today.... In 2012, just 12 percent of 75-year-old women had no children. We project that by 2030, nearly 20 percent will be childless. Since we know that adult children often provide care for their senior parents, these projections suggest that alternative non-family sources of care will become more common in the future.

Thus, just as we're making noise about supporting seniors' preference to "age at home," we may be over-assuming that family members will be available to provide key care without direct cost to the states.  Hmmm.  That's problematic, right?

More from the California PPI report, including some conclusions: 

California's senior population will grow rapidly over the next two decades, increasing by an estimated 87 percent, or four million people.  This population will be more diverse and less likely to be married or have children than senior are today.  The policy implications of an aging population are wide-ranging.  We estimate that about one million seniors will have some difficulties with self-care, and that more than 100,000 will require nursing home care. To ensure nursing home populations do not increase beyond this number, the state will need to pursue policies that provide resources to allow more people to age in their own homes....


The [California In-Home Service & Supports] IHSS program provides resources for seniors to hire workers, including family members, to provide support with personal care, household work, and errands. One benefit of hiring family members is that they may provide more culturally competent care. Medi-Cal is already the primary payer for nursing home residents, and the state could potentially save money by providing more home- and community-based services that support people as they age, helping to keep them out of institutions. Finally, the projected growth in nursing home residents and in seniors with self-care limitations will require a larger health care workforce. California’s community college system will be a critical resource in training qualified workers focused on the senior population.

The San Diego Union-Tribune follows up on this theme in California Will Have More Seniors Living Alone, by Joshua Stewart.

August 10, 2015 in Consumer Information, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Retirement, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Thursday, July 16, 2015

Highlights from Upcoming Pennsylvania Elder Law Institute on July 23 & 24

Probably the best bang for your CLE buck in Pennsylvania comes from the two-day Elder Law Institute hosted each summer by the Pennsylvania Bar Institute. This year the 18th annual event is on July 23 & 24 in Harrisburg. 

Highlights include:

  • "The Year in Review" with attorneys Marielle Hazen and Robert Clofine sharing duties to report on key legislative, regulatory and judicial developments from the last 12 months;
  • How to "maximize" eligibility for home and community based services (Steve Feldman and Pam Walz);
  • Cross disciplinary discussions of end-of-life care with medical professionals and hospice providers;
  • LTC "provider" perspectives (Kimber Latsha and Jacqueline Shafer);
  • Latest on proposals to change Veterans' Pension Benefits (Dennis Pappas);
  • Implementation of the Pa Supreme Court's Elder Law Task Force Recommendations (Judges Lois Murphy, Paula Ott, Sheila Woods-Skipper & Christin Hamel);
  • A closing session opportunity, "Let's Ask the Department of Human Services Counsel" (with Addie Abelson, Mike Newell & Lesley Oakes)

There is still time to registration (you can attend one or both days; lunches are included and there is a reception the first evening).  

I think this is the first year I have missed this key opportunity for networking and updates; but I'm sending my research assistant!    

July 16, 2015 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Federal Cases, Health Care/Long Term Care, Legal Practice/Practice Management, Medicaid, Medicare, Programs/CLEs, Property Management, Social Security, State Cases, State Statutes/Regulations, Veterans | Permalink | Comments (0)

Friday, July 10, 2015

Louisiana Governor Signs Amended "Lifetime Necessities" Law Obligating "Ascendants & Descendants"

Louisiana Governor Bobby Jindal, one of (now many) candidates for the Republican nomination for President,  has been making a fair amount of press of late, for his positions on so-called medical marijuana, Common Core education standards, and how his state will handle same-sex marriage. Lower on the radar screen, however, was his signing of Act 260, an interesting package of legal changes affecting obligations between various family members.

One of these changes was to adopt a new provision affecting the obligations of "ascendants and descendants" to provide "basic necessities of life" for family members "in need."  In other words, filial support. 

Louisiana already had a provision, Section 229, providing that "children are bound to maintain their father and mother and other ascendants who are in need."  The new provision continues this statutory obligation, but makes enforcement "personal" only.  The substitute provision was signed into law on June 29 and becomes effective on January 1, 2016.  New Article 237 of Act 260 provides:

Descendants are bound to provide the basic necessities of life to their ascendants who are in need, upon proof of inability to obtain these necessities by other means or from other sources, and ascendants are likewise bound to provide for their needy descendants, this obligation being reciprocal.


This obligation is strictly personal and is limited to the basic necessities of food, clothing, shelter, and health care.


This obligation is owed by descendants and ascendants in the order of their degree of relationship to the obligee and is joint and divisible among obligors. Nevertheless, if the obligee is married, the obligation of support owed by his descendants and ascendants is secondary to the obligation owed by his spouse.

Official comments explaining the revisions emphasize that the necessities obligation kicks in only when the needy family member is unable to obtain necessities "by other means" or from "other sources," thus signaling any filial support obligation is secondary to the individual's eligibility for public assistance or other welfare benefits. Further "for the first time" Louisiana law "provides a ranking of those descendants and ascendants who owe this reciprocal, lifetime obligation."

The commentary explains that the revision makes the obligation "strictly personal," and there it precludes enforcement by "a third person."  Thus, it would appear that unlike in Pennsylvania (or Germany?) nursing homes and the state may not use these statutes in order to sue family members to collect necessities for indigent elders.

According to the comments, the obligation is also not "heritable."  This appears to reflect a Louisiana Court of Appeals decision from 2010, In re Succession of Elie,denying a mother's claims for funds from a deceased son's estate brought under former Section 229.     

July 10, 2015 in Current Affairs, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, July 3, 2015

Pennsylvania AG Files Consumer Protection Suit Against Golden Living Nursing Homes

On July 1, 2015, Pennsylvania's Attorney General filed a complaint in the Commonwealth Court against Golden Gate National Senior Care LLC (GGNSC) which manages and operates Golden Living Centers nationally.  The AG's suit focuses on 14 facilities in Pennsylvania. From the AG's press statement:

The legal action asserts Golden Living violated the Unfair Trade Practices and Consumer Protection Law by deceiving consumers through its marketing practices.


The company advertised it would keep its residents clean and comfortable while providing food and water at any time. But its facilities were understaffed, leaving residents thirsty, hungry, dirty, unkempt and sometimes unable to summon anyone to help meet their most basic needs, such as going to the bathroom, the legal action asserts.   

According to the AG's office, evidence comes from residents' family members and former employees of Golden Living, including certified nursing assistants.  The allegations focus on an alleged "widespread pattern of understaffing and omitted care."

Further, the AG makes the following specific allegations:  

  • Continent residents left in diapers because they were unable to obtain assistance going to the bathroom.    
  • Incontinent residents left in soiled diapers, in their own feces or urine, for extended periods of time.    
  • Residents at risk for bedsores from not being turned every two hours as required.   
  • Residents not receiving range of motion exercises.    
  • Residents not receiving showers or other hygiene services as required.     
  • Residents being woken at 5 a.m. or earlier to be washed and dressed for the day.    
  • Residents not being timely dressed in order to attend their meals.    
  • Residents not being escorted to the dining hall and sometimes missing meals entirely.   
  • Long waits for responses to call bells or no responses at all.   
  • Staff, under the direction of management or fear of management, falsifying records to indicate residents received services when in fact they did not.  
  • Improved staffing when state inspections occurred, leading to deceit about the true conditions at the facility.     
  • The investigation also included a review of staffing levels self-reported by Golden Living facilities and deficiencies cited in surveys conducted by the state Department of Health. 

According to one news source, Golden Living responded to the suit with a statement expressing the company's confidence that the "claims made by the Attorney General are baseless and wholly without merit," and further alleging the suit is the "unfortunate result of Kathleen Kane's inappropriate and questionable relationship with a Washington D.C.-based plaintiff's firm that preys on legitimate businesses and is paid by contingency fees."  (For those of you not privy to the local news on Pennsylvania politics generally and AG Kathleen Kane specifically, I think it is fair to say that the press frequently refers to her as the "embattled AG."  She first took office in January 2013).

The Pennsylvania AG's suit comes on the heels of a broader report released in June by Community Legal Services of Philadelphia, asserting that from 2012 through 2014 the Pennsylvania Department of Health under former Governor Corbett's administration, failed significantly to conduct proper investigation of complaints about a large number of nursing homes (not limited to Golden Living) and failed to enforce existing regulations designed to protect residents. 

For Golden Living, allegations are not limited to Pennsylvania. For example, in June 2015, claims about chronic understaffing of 12 Golden Living Center nursing homes in Arkansas were certified to be litigated as a class action. 

Hat tip to Douglas Roeder, Esq., for bringing the latest Pennsylvania AG's suit to my attention. Last month I reported on the A.G.'s suit for unfair trade practices filed against a law firm that was alleged to be improperly using Pennsylvania's filial support law as a basis for collection demands against family members of the debtor. 

July 3, 2015 in Cognitive Impairment, Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, Medicare, State Cases, State Statutes/Regulations | Permalink | Comments (0)