Master's Level Elder Law CLE November 18, 2016 | 6.75 Law and Legal CLE Credits
WSBA Activity ID #1022190
Agenda 8-8:30 a.m. Registration and Continental Breakfast
8:30-9:30 a.m. Session 1 - The Social Security Administration Office of SSI and Program Integrity Policy
Presenter: Ken Brown, SSA's Office of SSI and Program Integrity Policy
A speaker not to miss. Mr. Brown sets policy on SSI interpretation of exempt SNT's. He is the person who sets policy and reconciles differences between Regions and reviews your appeals. He will discuss current status within SSA and how you get to decision makers directly. If you want to speak to the source of the rules, this is that person.
9:30-10:30 a.m. Session 2 - Funding Intervivos and Testementary Special Needs Accumulation Trust with Qualified Funds
Presenter: Robert Fleming, Fleming and Curti PLC
Robert will present on funding and management of testamentary and intervivos SNT's with qualified funds. Robert hails from Arizona, and is a well known and entertaining speaker with concentrated information and language you can use. Another do not miss presentation.
10:30-10:45 a.m. Break
10:45 a.m.-12:00 noon Session 3 - Working with Trauma Engaged Clients
Presenter: Mark Sideman, Trauma Therapist, Director, Continuing Legal Education, Seattle University School of Law
Provide a framework for understanding and engaging Trauma impacted clients. The session will discuss ranges of impact for trauma engaged clients and on those who work with them; the difference between traumatic and traumatized; the trauma continuum; and strategies for engagement.
12:00-1:00 p.m. Lunch (included in program)
1:00-2:30 p.m. Session 4 - Long Term Care
Presenter: Lori Rolley, DSHS Long Term Care, Home and Community Services; William Reeves, DSHS, HCP
Lori and Will are the ‘drivers' of new DSHS programs and policies. DSHS will be rolling out a new (yes, another new) program for health care, which will be discussed. They have promised to break out all the programs and discuss entry points and qualification differences.
2:30-2:45 p.m. Break
2:45-4:00 p.m. Session 5 - "End of Life on One's Own Terms": An In-depth Panel Discussion
Moderator: Carla Calogero, Reed Longyear Malnati & Ahrens, PLLC
Panelists: Trudy James, MRE, Inter-Faith Chaplain; Elizabeth K. Vig, M.D., M.P.H., Associate Professor U.W. Medicine, Division of Gerontology; Lisa J. Stewart, MSW, Evergreen Hospice.
This panel discussion will include: How Palliative care and hospice are distinct and complementary; Dementia and end-of-life decision making along with treatment options and advance care planning; death with dignity.
4:00-4:45 p.m.
Session 6 - ABLE accounts and how they will change your practice
Presenter: Robert Fleming, Fleming and Curti PLC
The tax code allows for tax "breaks" for 529 plans and 529A (ABLE) plans. This session will explain the Tax Code provisions for both plans, how the plans are administered and how the IRS treats deposits into and distributions from these plans.
4:45 p.m. Evaluations and Adjourn
Faculty Biographies
Program Chairs Richard L. Sayre Richard L. Sayre is a principal in the law firm of Sayre Sayre & Fossum, P.S., Spokane, Washington. Mr. Sayre received his undergraduate degree from the University of Washington in 1976, and his JD (Juris Doctorate) from Gonzaga University School of Law in 1979. He serves on the Spokane County Superior Court Guardianship Committee, is a member of the Executive Committee of the Washington State Bar Association Elder Law Section, and is a member of the Washington State Bar Association, the Spokane County Bar Association, the National Academy of Elder Law Attorneys, where he served as 1995-1996 Washington State Chapter President, the Special Needs Alliance, an invitation only association of experienced special needs trust counsel who focus on special needs issues and trusts, and the Spokane Estate Planning Council. He is a former member of the Washington State Medical Associations' POLST Task Force. He previously served as Chair and later as Co-Chair of the Washington State Bar Association's Continuing Legal Education Committee, and served from 1998 through September of 2004 on the Washington State Professional Guardian Certification Board, a position appointed by the Supreme Court of Washington. He is also an Adjunct Professor of Law at Gonzaga University School of Law in Spokane, Washington, and has participated in the Gonzaga in Florence program, teaching International Comparative Elder Law. His practice emphasizes estate and disability planning and estate tax issues, governmental benefits law for disabled individuals, special needs trusts and Elder Law. He has been certified as an Elder Law Attorney by the National Elder Law Foundation, and has been designated a "Super Lawyer" by the publication Washington Law and Politics from 2000 through 2016, based upon a peer rating survey which selected less than five percent of Washington lawyers for this distinction, and was selected 2005 Member of the Year by the Washington Chapter of the National Academy of Elder Law Attorneys. He has been repeatedly named as one of the Best Lawyers in Spokane by Spokane Magazine. He is a frequent speaker on Elder Law and estate planning and taxation issues throughout the State of Washington. Mr. Sayre is a recipient of the Distinguished Alumni Merit Award given by Gonzaga University, Spokane, Washington, in October, 2012 Richard Sayre is a Certified Elder Law Attorney, a certification given by the National Elder Law Foundation, an ABA approved certification program. The Supreme Court of Washington does not recognize specialties, and certification is not required to practice law in Washington Carla Calogero Carla Calogero is an attorney at Reed, Longyear, Malnati & Ahrens, PLLC in Seattle. Ms. Calogero's practice is limited to the representation of persons involved in guardianships, vulnerable adult protective actions, probates, and trusts, and to advance care, end of life, and estate planning. In addition, Ms. Calogero is regularly appointed by the King County Superior Court as Guardian ad Litem or Special Representative for incapacitated persons in guardianship, trust, probate and litigation matters. She the immediate past Chair of the Elder Law Section of the Washington State Bar Association and a past Chair of the King County Bar Association Guardianship and Elder Law Section. Ms. Calogero received her J.D. from Seattle University School of Law, as well as an M.A. in Bioethics from the University of Washington, and an M.A. in Education from Western Washington University.
Presenters Kenneth Brown Kenneth Brown is a Team Leader with the Social Security Administration, Office of Intergovernmental and External Affairs. Robert Fleming Robert Fleming in an attorney with the firm of Fleming & Curti, P.L.C., a firm devoted solely to the practice of elder law, including guardianship and conservatorship, long-term care planning, estate planning, and probate. Fleming has been certified as a Specialist in Estate and Trust Law and he is a Certified Elder Law Attorney by the National Elder Law Foundation. Additionally, Fleming was one of the litigants in the Arizona Supreme Court case of Rasmussen v. Fleming, which established the right of incompetent patients (through their guardians) to refuse life-sustaining treatment when there is little prospect of recovery. Fleming authored The Elder Law Answer Book. Additionally, Fleming is a member of the Special Needs Alliance and the Elder Law Alliance. He is also a fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. Trudy James Trudy James is a seminary graduate and retired interfaith hospital chaplain. She learned hands-on lessons about death, dying and grief in the early days of the AIDS epidemic in the South, and her ground-breaking work with AIDS was honored at the Clinton White House. Later, she created an AIDS Care Team program in Seattle and served as a chaplain at the Seattle Cancer Care Alliance. After retiring, she spent four years pioneering community-based end of life planning workshops and two years producing a 30 minute film called Speaking of Dying that reflects the heart of those groups. The film is useful for individuals, groups and families who want to become more comfortable discussing good endings. She has also trained ten Heartwork facilitators who conduct end-of-life planning workshops throughout the Puget Sound area. Learn more at www.speakingofdying.com. William Reeves Will Reeves is a Financial Policy Analyst for the Washington State Department of Social and Health Services (DSHS), Aging and Long-Term Support Administration (ALTSA). Will is charged primarily with financial eligibility and policy training for the state’s workers who determine eligibility for services through Medicaid or state-funded programs, but also tackles a range of policy issues regarding Medicaid financial eligibility. Will grew up in Seattle and began his training career serving eight years in the Navy’s submarine service. After the military, Will completed his masters and law degree at Seattle University. He then soon joined Home & Community Services (HCS) division within ALTSA at the Seattle office in 2012. With HCS, Will has been a financial eligibility worker and financial lead worker, and has been at ALTSA headquarters since 2014. Will enjoys listening to all kinds of music through an ever-expanding collection of headphones, running, bicycling, and winetasting across Washington State. Lori Rolley Lori Rolley is the Financial Policy Analyst for the Washington State Department of Social and Health
Services (DSHS), Aging and Long Term Support Administration (ALTSA). She grew up in Port Angeles and
was inspired to work with the elderly and disabled by her mother, an RN who was the Director for
Volunteer Hospice of Clallam County. She started working for DSHS in Spokane as a college intern in
1977. In 1980 Lori started working primarily with the Institutional and SSI related programs at Medical
Assistance Administration (now called Health Care Authority) and Home and Community Services in
Olympia. She is the program lead for Chapter 182-513 WAC (Institutional), Chapter 182-515 WAC
(Home and Community Based Waiver), Chapter 182-516 WAC (Trusts, Annuities and Life Estates).
Mark Sideman Mark Sideman has a long history of working within the field of trauma intervention. Most recently he completed the 3 year training program initiated by Peter Levine and his Somatic Experience Institute on therapeutic interventions for trauma. Mark has received training from Kathy Kain on the impact of early childhood trauma and its effects later in life. He spent 15 years with the Division of Children and Family services working extensively with families and then training the professionals who worked with the Department's clients. Mark has worked with street youth and runaways as well as being a therapist in an intensive day treatment for sexually and emotionally abused pre-school children. Mark's background also includes being an autism special education teacher. Recently Mark has performed Trauma workshops for the Federal Office On Civil Rights; Dispute Resolution Center of King County; and the Washington Home Care Association's statewide conference. Diversity is an important area of engagement for Mark. He has served for a number of years as a member of the Seattle Race Conference Planning Committee; serves currently as part of the team for the Young Men and Women of Color Youth Summits with Highline Community College; and recently served on the Diversity Committee for the Snohomish Council on Aging. Mark has been certified as a Counselor in Washington since 1989. Mark is an expert in adult education and currently serves as the Director of Continuing Legal Education for the Seattle University School of Law. Lisa Stewart Lisa Stewart is a Hospice and Palliative Care Manager at EvergreenHealth, serving King and Snohomish counties. She is a licensed social worker with over 25 years of experience working in human services and health care management with a focus on the areas of trauma, forgiveness and resilience. She currently leads the NHPCO We Honor Veterans initiative at EvergreenHealth working to best serve and honor veterans receiving hospice care at end of life. Elizabeth Vig Elizabeth (Lisa) Vig is an Associate Professor of Medicine in the Division of Gerontology and Geriatric Medicine at the UW. She is board certified in geriatric medicine and in palliative medicine, and does clinical work at the VA Puget Sound Health Care System. She also is the Chair of the VA hospital's ethics committee. In addition, she does research in end of life decision-making.
Master's Level Elder Law CLE
NOVEMBER 18, 2016
Session 2 - Funding Intervivos and Testementary Special
Needs Accumulation Trust with Qualified Funds
Presented by: Robert Fleming, Fleming and Curti PLC
Fleming – SNTs and Qualified Plans, Page 1
Funding a SNT With Qualified Funds Washington Master’s Level Elder Law CLE November 18, 2016 Robert B. Fleming Fleming & Curti, PLC www.FlemingAndCurti.com 330 N. Granada Ave. Tucson, AZ 85701 520-622-0400
Qualified Fund Principles Upon death of an IRA1 participant, there are several questions that need to get addressed. Each will result in different options and payout rules. They include:
Required Beginning Date
Has it passed yet? Normally the participant will have to begin withdrawing RMDs (required minimum distributions) on April 1 of the year after the year in which she turns 70½. That is the RBD. If death occurred before that date, then it might be that the beneficiary has to withdraw all of the IRA funds within five years of the date of death. If the death occurred after the RBD, then the five-year rule never applies.
Spouse as beneficiary
If the beneficiary of the IRA is the participant’s spouse, he will have the option of “rolling over” the IRA into his own, owned IRA. Only spouses have this option. If it applies, then it is almost always beneficial to implement it – but that does mean that the carefully-crafted alternate beneficiary designation signed by the deceased participant becomes irrelevant. Unless, of course, the spouse re-adopts it.
Death after RBD with no spouse as beneficiary
Is this the scenario? If so, the beneficiary may continue to use the deceased participant’s life expectancy to determine RMD. If (but only if) the beneficiary is a Designated Beneficiary (an individual, multiple individuals, or a see-through trust [about which more later]), then the DB’s life expectancy can be used instead. This is of course a simplification – the life expectancy of multiple
1 We will quickly tire of writing – and you of reading – “IRA or qualified retirement plan.” Accordingly, we are just going to generalize and use IRA as if it included non-IRA retirement plans. We know it doesn’t. But for our purposes, the rules will not vary – and the writing and reading will both be much easier.
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Special Needs Accumulation Trust with Qualified Funds
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Fleming – SNTs and Qualified Plans, Page 2
beneficiaries requires further explication. But for now, let’s leave this at this level of sophistication.
Death before RBD with non-spouse Designated Beneficiary
In this scenario, the RMD will be calculated on the life expectancy of the DB.
Death before RBD with no Designated Beneficiary
Remember that “Designated Beneficiary” is a defined term – and defined as something other than the plain language. An estate is not a DB, even if it is actually designated as beneficiary (but why would anyone do that?). A trust is not a DB, unless it can qualify as a see-through trust for IRS purposes. But back to the scenario: if the participant died before her RBD leaving no DB, then the five-year rule applies. That means that all of the IRA must be withdrawn – and the resultant income tax liability paid – within five years of the participant’s death. Not 20% each year, nor any other sliding-scale figure – it just must all be withdrawn within five years.
Applying RMD Rules Generally speaking, the goal is to withdraw IRA funds as slowly as possible, so that they can continue to grow income-tax-free (well, actually, “deferred”) as long as possible. But stop a moment and consider: is that really important? What if the beneficiary will have huge income tax deductions? What if the beneficiary has immediate and substantial needs? What if the IRA is small, and the cost of mucking about with all of this is large?
On the other side of the coin, look at (and think about) the generalizations above about “life expectancy” as actually applied to the actuarial tables. No really – go look at the actuarial tables. Here’s a link to IRS Form 590-b's tables https://www.irs.gov/pub/irs-pdf/p590b.pdf; you want Appendix C, Tables III (uniform lifetime), I (single life expectancy), and II (joint life and last survivor expectancy). We’ve included them as an Appendix to this outline – but we’ve “improved” them by adding the conversion from life expectancy to percentage withdrawal. Note that we’ve only given you the percentages to two decimal places, and so using those numbers would sometimes result in a small undercalculation of the RMD.
Note that we listed them in a peculiar order: III, I, II. That’s because III is the table for the IRA owner herself/himself, and Table II is almost insignificant. II only gets used when the IRA participant names her spouse as the sole beneficiary, and her spouse is more than ten years younger than her. Yes, it does come up – but not often, and pretty much never in SNT country.
Look at Tables I and III for, say, a 71-year-old participant (Mary) with a 45-year-old beneficiary (Fred). If Mary lives to her RBD, she will have to take out about 3.77% (1/26.5) of her IRA. If she dies before that, leaving Fred as the sole
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Special Needs Accumulation Trust with Qualified Funds
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Fleming – SNTs and Qualified Plans, Page 3
beneficiary (with no trust, just to save us having to sort that out for now), he will have to take out about 2.58% (1/38.8) of his now-inherited IRA. If the IRA is worth $100,000, the difference is between $3,774 for Mary and $2,578 for Fred (rounding up for both of them). If the five-year rule applies, Fred will have to take out $100,000 over the next five years (plus accruing income) or an average of a little more than $20,000/year. If Mary lives one more year, and then dies, the largest amount Fred would have to withdraw even if he were not a DB would be $3,907. Of course, all of those numbers increase each year (or, more accurately, the divisors decrease), but that should help keep the relationships in perspective.
Introduction to trusts in IRA planning So now let’s assume that Mary would like to give Fred the maximum stretch-out (or, even, compel him to implement the maximum stretch-out) but not leave her IRA to him directly. Can she leave it to a trust? Yes, so long as the trust is a see-through trust. What does that mean? The trust must meet four tests:2
1. It must be valid under state law. 2. It must be irrevocable or become irrevocable upon the death of the
participant. 3. Beneficiaries must be identifiable from the trust instrument. 4. Documentation must be provided to the plan administrator (though there
is no specific requirement of timing). That’s all that is required. Of course, as Natalie Choate points out in her excellent “Life and Death Planning for Retirement Benefits”3 getting a see-through trust to see non-DB beneficiaries at the end is not much benefit – so she adds a fifth requirement:
All the trust’s beneficiaries must qualify to be DBs. Note, however, that “all” in this usage is not precisely what it looks like. Instead, we should qualify her instruction: All the trust’s beneficiaries who will be treated as a beneficiary by IRS rules must qualify as DBs.
Why the limitation? Because the IRS says that any successor beneficiary is a “mere potential successor” if the trust requires distribution of the RMD amounts received each year to one beneficiary who is a DB. That gives rise to the concept of a “conduit” trust.
2 These requirements are imposed by Reg. §1.401(a)(9)-4, A-5(b).
3 7th Ed. 2011. See, particularly, §6.2.03.
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Special Needs Accumulation Trust with Qualified Funds
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Fleming – SNTs and Qualified Plans, Page 4
Inter vivos versus testamentary trusts
Does it matter whether Mary’s trust is testamentary or inter vivos? Not really – with one notable exception. Mary’s beneficiary designation needs to be to the trust itself, and not to her estate. If the trust is to be created by her will, the four (or five) standards described above are still easy to satisfy. But if the beneficiary designation is to Mary’s estate, and her estate in turn passes through to a testamentary trust, the stretch-out possibilities are lost at the point at which the IRA passes to her estate.
Note that the “Beneficiary Finalization Date” of September 30 (see below) might give some comfort here. If the estate’s distribution of the IRA to the testamentary can be accomplished quickly, it might be overlooked by the IRS. There are two reasons that this solution is unsatisfactory, however: (1) that’s not actually what the regulations say, and (2) the IRA custodian is likely to insist on issuing a 1099 showing distribution of the entire IRA balance, even if there is an arguable position. Planners should not allow the possibilities to go awry in this fashion.
Beneficiary designations can either be to the inter vivos trust directly, or to “the trust established by my Will dated November 19, 2014, for the benefit of Fred.” But what if the will is updated, or a codicil written, or … the possibilities seem endless. An unfunded trust established just for the purpose of receiving IRA or qualified plan funds seems much more appropriate and considerably safer.
Conduit trusts
One popular kind of see-through trust is the so-called “conduit” trust. “So-called” because there is no IRS regulation or statute defining the term, though it is in common use. A conduit trust is one which names a single income beneficiary and compels distribution of at least all RMD amounts coming into the trust to that beneficiary. Such a trust can use the single beneficiary’s life expectancy and apply Table I from Publication 590 – incidentally (though not relevant to our discussion), even after the single beneficiary’s later death. But our SNT cannot be a conduit trust because it would require distributions to the beneficiary with public benefits issues, and that would be a bad result. So instead we have to drop this sub-type, attractive though it might be, and make our see-through trust an “accumulation” trust.
Accumulation trusts
There is no particular reason that the trust-as-IRA-beneficiary cannot be an accumulation trust. It is, admittedly, easier to think through the effects if we can use a conduit trust – and they are very popular in other, non-SNT, settings. But it’s not that hard to handle the basic requirements of see-through trusts in a SNT. We just have to deal with two realities:
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Special Needs Accumulation Trust with Qualified Funds
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Fleming – SNTs and Qualified Plans, Page 5
No beneficiary of the trust can be a non-DB, or we’ll be stuck with non-DB treatment (and possibly defeat the whole purpose of creating a trust to be beneficiary), and
The RMDs will be pegged to the oldest beneficiary – including possible beneficiaries we haven’t considered clearly. So, for instance, if we refer to the “heirs at law” of any beneficiary, that will introduce the possibility of older beneficiaries. Problem solved: limit the remainder beneficiaries to only those who meet the terms of the description but are younger than the primary beneficiary, or some other closely-aged beneficiary. Perhaps have the remainder go to the beneficiaries’ siblings, or, in the event that any one of them has died before the distribution, to those of his heirs at law, if any, who are younger than the income beneficiary was at the time of his death.
So how does this work in actual application? Consider some possibilities. In each of the following scenarios, Fred is a special needs beneficiary with two living children at the time of Mary’s death. Mary’s trust gives the trustee discretionary ability to use both income and principal for the benefit of Fred, and upon Fred’s death distributes:
1. To Fred’s children outright. If any child has predeceased Fred, his or her share will go to his or her children outright. If Fred’s child has died with no issue, his or her share goes to Fred’s other child.
2. To Fred’s children outright. If any child has predeceased Fred, his or her share will go to a designated charity.
3. In continued trust for the benefit of Fred’s children, with mandatory income distributions (but no conduit language) and discretionary access to principal. Upon the death of each child of Fred’s, his or her share will go to his or her children outright.
Note that the calculation of DB status is made as of Mary’s date of death, and remains unchanged regardless of how events play out after that date. Also note that the RMD calculation is made as of Mary’s death, and does not change as Fred and his children later die.
Additional important rules Because people who love taxes also thrive on complexity, there are a number of other rules that often get invoked. None of them changes the outcome of the basic rules described above, but they are good to know about and to apply properly. They include:
September 30
By September 30 of the year following the calendar year of the participant’s death, the beneficiary designation must have been finalized. Natalie Choate (but
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Special Needs Accumulation Trust with Qualified Funds
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Fleming – SNTs and Qualified Plans, Page 6
not the IRS) refers to this as the Beneficiary Finalization Date.4 This gives the trustee/personal representative/executor a chance to fix many, perhaps most, flaws in beneficiary designations. It’s odd that people who die in October give their beneficiaries almost two years to get this done, while people who die in September leave only a little more than twelve months. But that’s what makes tax rules so much fun.
Separate accounts rule. If multiple beneficiaries’ shares can be separated by the end of the calendar year of the participant’s death (not by September 30 of the next year), then they will not be stuck with using the oldest beneficiary’s life expectancy for RMD calculations.
Ownership of an inherited IRA in a self-settled SNT
Much has been written about this question, but the one authority we have is actually simple and straightforward: where an IRA beneficiary was a public benefits recipient, in one case his mother was allowed to (a) create a “self-settled” SNT and (b) transfer his inherited IRA to the SNT (without incurring a tax liability as would be involved if the transfer were to be treated as a distribution).5
Charitable beneficiaries of SNTs
People who set up SNTs often have very strong positive feelings about charitable organizations. If they really, really want to leave an IRA to a charitable organization upon the death of the primary beneficiary, there are ways to think about doing this – but they are all ultimately unsatisfying. The best of the bad lot: create a CRT, name it as beneficiary of the IRA and have the lifetime distributions go not to the intended beneficiary but to a SNT for his benefit. But that results in a loss of significant flexibility (the SNT will receive only the annual income distribution, whether annuity-based or unitrust) and probably requires substantial non-IRA assets to comfortably fund the SNT. For the person with significant assets, a large IRA and no potential individual remainder beneficiaries, the problem may simply be insoluble.
4 Choate’s “Life and Death Planning for Retirement Benefits” is actually a good read, and lord knows it will teach you about IRAs and qualified retirement plans – but sometimes one does get the notion that she gets paid by the Capital Letter.
5 PLR 200620025. Note that PLRs reflect current thinking of the IRS, but cannot be used as precedent. Reading this PLR will make you scratch your head regarding the IRS’s collective understanding of grantor trusts and the possibility of owning even a non-inherited IRA in a grantor trust, but that might mean you’re reading too much into it.
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Special Needs Accumulation Trust with Qualified Funds
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Appendix B. Life Expectancy Tables
Age Percentage Age Percentage
0 1.22 28 1.81
1 1.23 29 1.85
2 1.25 30 1.88
3 1.26 31 1.91
4 1.28 32 1.95
5 1.29 33 1.99
6 1.31 34 2.03
7 1.32 35 2.07
8 1.34 36 2.11
9 1.36 37 2.16
10 1.38 38 2.20
11 1.40 39 2.25
12 1.42 40 2.30
13 1.44 41 2.35
14 1.46 42 2.40
15 1.48 43 2.46
16 1.50 44 2.52
17 1.52 45 2.58
18 1.54 46 2.64
19 1.57 47 2.71
20 1.59 48 2.78
21 1.62 49 2.85
22 1.64 50 2.93
23 1.67 51 3.01
24 1.70 52 3.10
25 1.72 53 3.19
26 1.75 54 3.28
27 1.78 55 3.3829.6
41.7
40.7
30.5
39.8
38.8
37.9
37
36
35.1
34.2
33.3
32.3
31.4
51.4
50.4
49.4
48.5
47.5
46.5
45.6
44.6
43.6
42.7
56.2
61.1
69.9
68.9
67.9
66.9
60.1
59.1
58.2
57.2
66
65
64
63
62.1
78.7
77.7
76.7
75.8
74.8
73.8
72.8
71.8
70.8
Life Expectancy
82.4
81.6
Table I
(Single Life Expectancy)
(For Use by Beneficiaries)
80.6
79.7
Life Expectancy
55.3
54.3
53.3
52.4
(Percentages are rounded up to two decimal places)
(Modified From) IRS Publication 590-B (2015)
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Special Needs Accumulation Trust with Qualified Funds
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Age Percentage Age Percentage
56 3.49 84 12.35
57 3.59 85 13.16
58 3.71 86 14.09
59 3.84 87 14.93
60 3.97 88 15.88
61 4.10 89 16.95
62 4.26 90 18.19
63 4.41 91 19.24
64 4.59 92 20.41
65 4.77 93 21.74
66 4.96 94 23.26
67 5.16 95 24.40
68 5.38 96 26.32
69 5.62 97 27.78
70 5.89 98 29.42
71 6.14 99 32.26
72 6.46 100 34.49
73 6.76 101 37.04
74 7.10 102 40.00
75 7.47 103 43.48
76 7.88 104 47.62
77 8.27 105 52.64
78 8.78 106 58.83
79 9.26 107 66.67
80 9.81 108 71.43
81 10.31 109 83.34
82 10.99 110 90.91
83 11.63 100
1.1
111 and over 1.0.
Appendix B. ( Continued)
1.9
1.7
1.5
1.4
1.2
2.9
2.7
2.5
2.3
2.1
4.1
3.8
3.6
3.4
6.3
5.9
5.5
5.2
4.9
4.6
4.3
3.1
8.6
11.4
17.8
17
16.3
15.5
10.8
10.2
9.7
9.1
14.8
14.1
13.4
12.7
12.1
25.2
24.4
23.5
22.7
21.8
21
20.2
19.4
18.6
Life Expectancy
28.7
27.9
Table I
(Single Life Expectancy)
(For Use by Beneficiaries)
27
26.1
Life Expectancy
8.1
7.6
7.1
6.7
(Percentages are rounded up to two decimal places)
(Modified From) IRS Publication 590-B (2015)
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Special Needs Accumulation Trust with Qualified Funds
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Appendix B. Uniform Lifetime Table
Age Life Expectancy Percentage Age Life Expectancy Percentage
70 27.4 3.65 93 9.6 10.42
71 26.5 3.78 94 9.1 10.99
72 25.6 3.91 95 8.6 11.63
73 24.7 4.05 96 8.1 12.35
74 23.8 4.21 97 7.6 13.16
75 22.9 4.37 98 7.1 14.08
76 22 4.55 99 6.7 14.93
77 21.2 4.72 100 6.3 15.87
78 20.3 4.93 101 5.9 16.95
79 19.5 5.13 102 5.5 18.18
80 18.7 5.35 103 5.2 19.23
81 17.9 5.59 104 4.9 20.41
82 17.1 5.85 105 4.5 22.22
83 16.3 6.14 106 4.2 23.81
84 15.5 6.46 107 3.9 25.64
85 14.8 6.76 108 3.7 27.03
86 14.1 7.10 109 3.4 29.41
87 13.4 7.47 110 3.1 32.26
88 12.7 7.88 111 2.9 34.49
89 12 8.34 112 2.6 38.46
90 11.4 8.78 113 2.4 41.67
91 10.8 9.26 114 2.1 47.62
92 10.2 9.81 52.63
•Married Owners Whose Spouses Are Not the Sole Beneficiaries of Their IRAs)
115 and over 1.9
•Unmarried Owners,
•Married Owners Whose Spouses Are Not More Than 10 Years Younger, and
•Married Owners Whose Spouses Are Not the Sole Beneficiaries of Their IRAs)
(Note that the percentage numbers are rounded up to two decimal places)
Table III
(Uniform Lifetime)
(For Use by:
(Modified From) IRS Publication 590-B (2015)
Master's Level Elder Law CLE - 11/18/2016Session 2 - Funding Intervivos and Testementary
Special Needs Accumulation Trust with Qualified Funds
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Master's Level Elder Law CLE
NOVEMBER 18, 2016
Working with Trauma Engaged Clients Presented by: Mark Sideman
RESOURCES FOR WORKING WITH TRAUMA ENGAGED CLIENTS
Overcoming Trauma Through Yoga: Reclaiming your Body By
David Emerson, Elizabeth Hopper
Waking the Tiger: Trauma and Healing By Peter Levine with Ann
Frederick
Trauma and Recovery; The Aftermath of Violence‐‐‐From
Domestic Abuse to Political Terror By Judith Herman, M.D.
How we became a country where bad hair days and campaign
signs cause "Trauma" (google this title)
Preparing Your Client for Court. Excerpted From ‐ Representing
Domestic Violence Survivors Who Are Experiencing Trauma and
Other Mental Health Challenges: A Handbook for Attorneys
created by:
The Forensic Experiential Trauma Interview (FETI) By Russell W.
Strand United States Army Military Police School
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk M.D
The Haunted Self: Structural Dissociation and the Treatment of
Chronic Traumatization by Onno van der Hart, Ellert R.S.
Nijenhuis, Kathy Steele
The Polyvagal Theory; Neurophysiological Foundations of
Emotions Attachment Communication Self‐Regulation by Stephen
W. Porges
Master's Level Elder Law CLE - 11/18/2016 Session 3 - Working with Trauma Engaged Clients
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Trauma Continuum
Modified from “The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization”
spectrum of Trauma Related Disorders as identified in the DSM‐lV
Acute Stress Disorder: Experienced or witnessed a traumatizing event. Lasts from two days to four weeks.
Begins no longer than 4 weeks after the traumatizing event. When these parameters are exceeded the diagnosis
becomes PTSD. Some criteria of ASD—persistent experiences; marked avoidance of trauma related stimuli; and
marked hyperarousal or anxiety.
PTSD is acute when the duration of symptoms is less than three months; PTSD becomes chronic when symptoms
last three months or longer—has a delayed onset when at least six months have passed between the
traumatizing event and the onset of symptoms. Criteria may include: persistent re‐experiences; persistent
avoidance; persistent hyperarousal (or hypoarousal—note by MS).
Complex PTSD: mostly caused by chronic interpersonal traumatization; high risk of victimization; alterations in
regulation of affect and impulses; alterations in self‐perception; alterations in systems of meaning.
Dissociative Disorders ‐‐‐‐ (purposely left out)
Master's Level Elder Law CLE - 11/18/2016 Session 3 - Working with Trauma Engaged Clients
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Excerpted from: Representing Domestic Violence Survivors Who Are Experiencing Trauma and Other Mental Health Challenges: A Handbook for Attorneys
Preparing Your Client for Court Oncethesurvivordecidestopursuetrial,youthenneedtoprepareherforwhattoexpect.Whenasurvivorhasmentalhealthconcerns,youmaywanttodiscusstheimpactthecourtproceedingsmayhaveonhermentalhealth.Introduce the Court Process Walkthesurvivorthrougheachstepofthecourtproceedingandhelphertothinkaboutherpossiblereactions.Iffeasible,meetatthecourtwherethecasewillbeheld.Witheachstep,besuretoexplain
thethingsthatcouldhappen.Thereisabalancehereofgivingherenoughinformationtohelpherknowwhattoexpectandgivinghertoomuchinformation,whichcouldpossiblyoverwhelmher.Letherguideyou.Checkinasyoudiscusseachstageoftheprocessandaskhowcertain
thingsmakeherfeel,whethershehasconcernsabouttheprocess,andwhethertherearestrategiesthatyoumightemploytomitigateherconcerns.
Askthesurvivorifshewouldliketohaveoneortwosupportivepeopleatthecourtproceedingthatcanhelp,shouldshehaveahardtimewiththeprocess.AttorneyTipSomepeoplewhohaveexperiencedtraumaneedtoknowwhattoexpectwhenproceedingwithatotallynewexperience.Ithelpsreduceanxietyanditbuildstrust.Itisaveryimportantstepinpreparingasurvivorforcourt. Discuss Strategies for Mental Health Symptoms in the Courtroom Ifyouhaven’talready,youshouldgentlydiscusswiththesurvivoranysymptomsthatyouhavenoticedduringthecourseofyourworktogetherthusfar.Makesuresheunderstandsthatyouareonlysharingyourobservationstohelpthetwoofyoustrategizeaboutthecourtproceedings–itisnotduetoalackofconfidenceinher,oralackofbeliefinhercase.Youareworkingwithhertomakesurethetwoofyouarepreparedforthecourtcase.Forexample:Ifyounoticethat,whensherecountsviolentincidentsthatoccurred,shehasaflattoneanda
deep,blankstareoranabsentlook,askheraboutthis.Often,thisisaresultofanoverwhelminglytraumaticexperienceandthesurvivorhasdissociatedinordertocopewithit.Herreportingoftheexperiencewillbefromthatsafedistanceandwilllacktheterrorandphysicalpain.RepresentingDomesticViolenceSurvivorsWhoAreExperiencingTraumaandOtherMentalHealthChallenges42
Master's Level Elder Law CLE - 11/18/2016 Session 3 - Working with Trauma Engaged Clients
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� Ifshehasnoticedtalkabouthowcounselfortheopposingpartymayusethisagainstherandsaythatsheislying,talkabouthowyoumightcounterthatclaim.Ifthesurvivorisawareofheraffect,youcanaskaboutitduringtheproceedingsothatshemayexplainherlackofemotiontothecourt.Ifnot,youmaywanttodiscussusinganexperttocountertheopposingside’sallegations(seeSectionSix:DeterminingWhetherYouShouldHaveanExpertWitness).Develop Strategies to Address Your Client’s Fears About the Court Process Inadditiontothesymptomsyouhavenoticed,youalsowillwanttodiscussandplanforfearsthatthesurvivormayexpressaboutthecourtcase.Youshouldaskifthesurvivorhashadpanicattacksorifshefeelsintensefearwhentheopposingpartyisinthesameroomwithher.Askherifshehasanystrategiesfordealingwiththose.Ifshehasaclinicianshesees,askhertodiscusswithhertherapiststrategiestogetherthroughthecourtproceedingandhowyoumightbeabletohelp.Whethershehasamentalprofessionalhelpingherornot,suggestionsyoucanofferincludethefollowing:Usingyourbodytoblocktheviewtotheopposingpartyasmuchaspossiblewhilesheisin
thecourtroom,includingwhiletestifying.Whenyouarenotabletoblockhisviewsheshouldlookawayfromtheotherside,eitherfocusingonyouorasupportivepersonoradvocateatthecourt.Askingthecourtforarecesswhenthesurvivorfeelssheneedsoneorwhenyounoticesome
ofthesymptomsoftraumacomingup(e.g.,ifsheisdissociatingandherresponsestoquestionsareslowandincomplete).Thisisusuallyasignofadeeperlevelofdissociationusuallybroughtonbyintensefearorrelivingofaparticularattackorexperience.Discusswhethersheknowsifthishappenstoherandhowyoucanhelp.Oncethecourtisadjourned,inacalmvoice,askhertotakesomedeepbreathsandaskherif
sheknowswheresheisandwhatdayitis.Thisisusefulforhelpingasurvivortogroundherselfinthepresentandbringingthemoutofthepast.Youmayneedtoremindthesurvivorthatsheisinthecourtroom,herabusercan’thurther,theopposingattorneyaskedheraquestionintendedtoscareher,shegotscared,she“wentaway,”andnothingbadhappened.Asimilarresponsecanalsohelpiftheoppositereactionoccursandthesurvivoristriggeredandsheiscryinguncontrollablyorscreamsattheopposingparty.Acalmvoiceremindingthesurvivorwheresheisandwhatjusthappenedshouldhelphertofeelmorecalmandrestoreasenseofbalance.Discussthisstrategywiththesurvivorbeforetrial.Youmaynotbethebestpersontohelpher.Askherifthiswouldbehelpfulandifsowhoshewouldwanttotakeherthroughthisprocess.Itmaybebetterlefttooneofhersupportpersons.Ifsheasksyoutoconductthisexercisewithhermakesureyoufeelcomfortabledoingso.Ifyoudonot,itisimportanttoletherknowandtellherwhy.Forexample,ifyouareafraidyouwillnotdoitrightandmaycauseherharmthenitisimportanttotellherthis.Thiskindoftransparencybuildstrust.Ifshethinksyouarethebestpersontodoitortheonlypersonshehas,youmaywanttopracticewithheraheadoftime.
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Youwanttohaveextensivediscussionswiththesurvivorpriortothecourtproceedingstohelpbothofyouanticipatepossiblereactions.Sheistheexpertonherowncircumstances,sopartnershipiscriticalhere.Askhertoguideyouthroughanyreactionshecanthinkofthatmayhappen.
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The Forensic Experiential Trauma Interview (FETI) By Russell W. Strand
United States Army Military Police School
Traumatized individuals often undergo a process many professionals and victims do not commonly understand. Many professionals inside and outside law enforcement have been trained to believe when an individual experiences an event, to include a trauma event, the cognitive (prefrontal cortex) brain usually records the vast majority of the event including the who, what, where, why, when, and how, and peripheral vs. central information. This approach often ignores the role of bottom-up attention of the more primitive portion of the brain during a highly stressful or traumatic event. Therefore, when the criminal justice system responds to the report of a crime most professionals are trained to obtain this type of peripheral and higher-level thinking and processing of information. This may lead to discounting the enhancement of memory traces – for what was attended, via bottom-up mechanisms and norepinephine and glucocorticoid effects on the amygdala and hippocampus. Sadly, collecting information about the event in this manner while overlooking the manner in which trauma shapes the memory may actually inhibit traumatic or highly stressful or fear-producing memory recall and the accuracy of the details provided. Trauma victims/witnesses do not generally experience trauma in the in the same way most of us experience a non-traumatic event. The body and brain react to and record trauma in a different way then we have traditionally been led to believe. When trauma occurs, the prefrontal cortex will frequently shut down leaving the less advanced portions of the brain to experience and record the event. The more primitive areas of the brain do a great job recording experiential and sensory information, but do not do very well recording the information many professionals have been trained to obtain. Most interview techniques have been developed to interview the more advance portion of the brain (prefrontal cortex) and obtain specific detail/peripheral information such as the color of shirt, description of the suspect, time frame, and other important information. Some victims are in fact capable of providing this information in a limited fashion. Most trauma victims however are not only unable to accurately provide this type of information, but when asked to do so often inadvertenly provide inaccurate information and details which frequently causes the fact-finder to become suspicious of the information provided. Stress and trauma routinely interrupt the memory process thereby changing the memory in ways most people do not accurately appreciate. One of the mantras within the criminal justice system is “inconsistent
When trauma occurs, the prefrontal cortex will frequently shut down
leaving the less advanced portions of the brain to experience and
record the event.
1
When trauma occurs, the prefrontal cortex will frequently shut down
leaving the less advanced portions of the brain to
experience and record the event.
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statements equal a lie”. Nothing could be further from the truth when stress and trauma impact memory, research shows.
In fact, good solid neurobiological science routinely demonstrates that, when a person is stressed or traumatized, inconsistent statements are not only the norm, but sometimes strong evidence that the memory was encoded in the context of severe stress and trauma. In addition, what many in the criminal justice field have been educated to believe people do when they lie (e.g., changes in body language, affect, ah-filled pauses, lack of eye contact, etc.) actually occur naturally when human beings are highly stressed or traumatized. Science of memory and psychological trauma must be applied to interview approaches and techniques.
Since the vast majority of traditional training and experience has caused many to focus on the higher functioning portons of the brain and research clearly shows these portions of the brain are not generally involved in experiencing, reacting to, or recording the experience, the FETI process was developed and implemented as proven methods to properly interview the more primitive portions of the brain. This technique not only reduces the innacuarcy of the information provided, but will greatly enhance understanding of the the experience, thereby increasing the likelyhood of a better understanding of the totality of the event. FETI is a highly effective technique for victim, witness, and some suspect/subject interviews. FETI entails the adaptation of the principles used in critical incident stress debriefing and defusing (impact of the event including emotional and physical responses) as well as principles and techniques developed for forensic child interviews (open-ended, non-leading questions, soft interview room, and empathy) as well as neurobiology of memory and psychological trauma (initially tapping into the lower-functioning portion of the brain to understand the experience as well as the meaning of the experience in a non-threatening, non-suggestive manner). This concept and approach of this technique can be described as a forensic psychophysiological investigation – an opportunity for the victim to describe the experience of the sexual assault or other traumatic and/or fear-producing event, physically and emotionally. This method has resulted in reports of better victim interviews by those who have used it. More importantly, the FETI interview process obtains significantly more information about the experience, enhances a trauma victim’s ability to recall, reduces the potential for false information, and allows the interviewee to recount the experience in the manner in which the trauma was experienced. The FETI interview enhances the investigative process by taking a one-dimensional traditional investigation and turning it into a three-dimensional, offense-centric investigation, including subjective experiences indicative of trauma-based brain states. Traumatic memories are often encoded and retrieved differently than non-traumatic memories, so they have that dimension of the experience, and then presenting the fullness – and limitations – of the victim’s memories, including the fragmented sensations and emotions, lack of narrative and sequencing, etc., which are then critical facts of their own.
This technique significantly enhances the quality and quantity of testimonial and psychophysiological evidence obtained. This method has also been shown to drastically reduce victim recantations, increase victim cooperation and participation and significantly improves chances for successful investigations and prosecutions.
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The forensic experiential trauma interview includes using interview techniques described below:
a. Acknowledge the victim’s trauma and/or pain. This will assist you, the listener, to
demonstrate genuine concern and empathy towards the interviewee in an attempt to provide a sense of
psychological and physical safety during the interview process. It may be difficult to establish trust with
someone whose trust may have been horribly violated by another human being they may have trusted.
Every effort should be made by you to demonstrate genuine empathy, patience, and understanding
towards the person with whom you are facilitating a disclosure of their experience. You may need to
spend additional time establishing sincere empathy and caring concern to be invited into their traumatic
and/or painful experience, which we call the trauma bubble. One of the greatest needs of anyone who
has experienced or is experiencing high stress and/or trauma is the need to be safe; trust is central to that
need. The interviewer must take responsibility to build trust in the most effective and appropriate way.
Once trust is established, the interviewer may be invited into what can be termed as “the trauma
bubble”. The trauma bubble is where much of the most important psychophysiological evidence may
reside. It is vitally important for the interviewer to demonstrate patience, understanding, and empathy in
a non-judgmental manner throughout the interview process.
b. Ask the victim/witness what they are able to remember about their experience.
Two key words in this question are “able” and “experience”. Not all victims are able to recall all
significant information about something that happened to them initially or even after a period of time.
Using the word “able” has been proven to relieve some pressures on the trauma victim thereby
increasing the information they are able to provide. Using the term “experience” encourages the victim
to describe their actual experience relieving the pressure on the interviewee to try to figure out what is
important to the interviewee in the context of a criminal investigation. As the victim/witness describes
3
One of the greatest needs of anyone who has experienced or is
experiencing high stress and/or trauma is the need to be safe; trust is central
to that need.
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their experience, the interviewer can better understand what happened as they are provided a recounting of the events that are generally extremely rich in details. Following the initial open-ended prompt, employ active listening techniques allowing the interviewee to free-flow their description of what they remember about their experience. The interviewer will enhance this description by adding additional open-ended prompts such as “tell me more about that” or “tell me more about ____”. This technique will allow the interviewee to provide even more significant information about their experience by prompting their memory in a more natural way. Open-ended prompts should include the interviewee’s emotional and physical experiences, before, during, and after the reported incident. Do not tell the interviewee to start at the beginning. This technique often inhibits trauma memory recall. Providing an opportunity for the victim to communicate his/her experience in the manner in which he/she recalls what happened is much more effective than initially requiring the victim to provide a chronological narrative. A sequential narrative may come to the victim later.
c. Ask the victim/witness about their thought process at particular points duringtheir experience. What was he/she thinking and how was he/she processing his/her experiences. This will assist the interviewer to better understand the actions/inactions and behaviors of the victim before, during, and after the assault. This will also reduce or even eliminate the need for the interviewer to ask the victim/witness why they did or did not do something such as fight back, kick, scream, run, etc. “Why” questions of this nature have been proven to re-victimize victims, close them down, increase false information, and destroy or damage fragile trauma memories. By asking what their thought process was not only provides additional understanding of the victim/witness reaction and behaviors, but also increases their ability to recall additional psychophysiological evidence. For example, if the victim was sexually assaulted and during the sexual assault they may have “frozen” due to tonic immobility, asking them what they were thinking at the time they were being assaulted will often prompt will often solicit responses such as “I thought he was going to kill me”, “I couldn’t move or scream”, “I couldn’t understand what was happening at that moment”. This type of information not only assists the interviewer in determining a better understanding of why the victim/witness did or did not do something, but also identifies significant forensic physiological evidence that will assist in proving or disproving and/or corroborating the reported offense.
d. Ask about tactile memories such as sounds, sights, smells, and feelings before,during, and after the incident. This is one of the most important aspects of the FETI process and a central theme. Because the primitive portion of the brain is optimized to collect, store, and recount this information far more efficiently than peripheral information or details, this is crucial evidence to collect as well. It is also believed that tactile and sensory details may block some memories and negatively impact on the victim’s ability to disclose additional information. Asking about sensory information has been shown to increase the victim’s ability to relate to the experience in a way that produces significantly more information. Sensory information also assists fact-finders and juries to better relate to the experience of the victim as well. Asking about sights, sounds, smells, feelings (physical and emotional), body sensations, and tastes throughout the interview about specific memories related by the interview is extremely beneficial for the interviewer. This will assist you to better
4
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understand the experience and assist the interviewee in remembering and relating essential memories including central details (those details most important to the interviewee) and peripheral details (those details judged not important to the interviewee). For example, during the interview of an experienced police officer who witnessed a woman shooting herself in the head (specifically – “blew her brains out” as related by the officer) following an attempt to talk her out of shooting herself, this officer provided details of the events surrounding this experience. Following open-ended questions about this officer’s experience, the officer concluded he recounted all the details he could recall. This officer was then asked what, if anything he was able to remember about what it smelled like after the woman “blew her brains out”. This officer appeared to reel back in his chair, his nose started to twitch and he appeared to become emotional following this question. The officer then recounted in a very animated manner that he smelled “honeysuckle”. Following his disclosure about the honeysuckle, this officer became even more animated and disclosed, and demonstrated, that this woman’s hand was shaking and she was breathing deeply after she shot herself. This officer then added that her blood flowed from her open head “like motor oil”. This officer had not remembered these specific details during previous traditional interviews and was surprised by the amount of detail he was able to recall following the sensory cue provided by the FETI interviewer. This is but one example of many in which victims and witnesses of trauma can be assisted to recall specific sensory memories, which often assist them in remembering not only explicit memories, but implicit memories as well. Sensory information is often at the core of central details for most individuals. Therefore, asking specific questions about the various senses throughout the FETI process greatly enhances the likelihood of obtaining accurate experiential information increasing the ability of the interviewee to recall essential central details of the experience. Some individuals will recall certain senses better than others, so it is important to ask about all senses separately while obtaining specific memories during specific aspects of the experience before, during, and after the traumatic event.
e. Ask the interviewee how this experience affected them physically and emotionally.This is extremely important to understand because the effects of the assault will increase the interviewer’s understanding the context of the experience, as well as provide evidence and insights about the trauma in ways that will further an in-depth conception of the impact of the assault on the victim. How the victim felt before, during, and after the event under investigation is fundamentally important for the interviewer to understand and collect. During fear-producing and traumatic events the sympathetic and parasympathetic systems of the human body react to the fear stimulus in significant ways. The victim/witness may experience the emotional feelings of fear, shock, anger, rage, sadness, etc. The victim/witness may also experience physiological reactions to the trauma including the emotional feelings combined with the physical manifestations of stress, crisis, and trauma such as shortness of breath, increased heart rate, dilated pupils, muscle rigidity and/or pain, light-headedness and/or headache, tonic immobility, dissociation, etc. Identifying and properly documenting these reactions to their experience are essential pieces of information that can greatly assist the interviewer in understanding the context of the experience and provide significant forensic psychophysiological evidence.
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f. Ask the victim/witness what the most difficult part of the experience was for them.Trauma victims/witnesses will often intentionally or unintentionally repress extremely difficult to handle information about their experiences. A sensitive inquiry about the most difficult part of their experience may provide significant evidence of the trauma experience and/or crime and will in many cases increase understanding of the totality of circumstances in reference to the victim/witness experience. Additionally, the most difficult part of the interviewee’s experience is more often than not the “key” central detail that may have not only framed the manner in which the trauma was experienced and remembered, but may also be a fundamentally important aspect for investigators to better understand the context of that experience and subsequent reactions/behaviors of the interviewee following that experience.
g. The interviewer should inquire what, if anything, the interviewee cannot forget about their experience. This question may assist the interviewer and interviewee to better understand another critical “central detail” and a better understanding of the interviewee’s perception and response to the trauma. This question also may obtain additional psychophysiological evidence. For example, a victim of a robbery in which the victim was brutally beaten by two assailants with hammers, was initially interviewed by a responding police officer utilizing traditional “who, what, where, why, when, and how” police questions in an attempt to obtain a chronological narrative immediately following the event. This particular victim became increasingly frustrated during the interview because he could not remember and did not know the answers to the majority of the questions the police officer was asking the robbery victim. Questions such as “what time did the incident occur”, “how many times did they hit you”, “how long did they hit you”, “what did they look like”, “how tall were they”, “what were they wearing”, “why didn’t you let them take your watch” (the victim continued to hold his arm on which he was wearing the watch during the attack – possible tonic immobility). As these questions, and many others, were being asked, the victim continued to become more frustrated and agitated because he felt he should know the answers simply because the police officer was asking them. This line of questioning was potentially increasing the victim’s stress level, increasing stress hormones, decreasing the ability of the victim to answer the questions, and potentially increasing the possibility that the victim, with a desire to assist the officer, would provide inaccurate information. During a subsequent FETI interview of this same victim, the victim was initially unable to provide any additional experiential information. This victim was then asked, “What, if anything, can’t you forget about your experience?” Following this question, the interviewee began to hit his head stating, “The hammers hitting my skull, the hammers hitting my skull, I can’t get that sound out of my mind, I can’t sleep well, I can’t concentrate, the hammers hitting my skull.” After this disclosure, this victim was able to remember significant details about the robbery including other sensory information, what happened before, during, and after the robbery, and other significant information about this experience.
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h. The interviewer should clarify other information and details (e.g., who, what,where, when, and how) after facilitation and collection of the forensic psychophysiological experiential evidence. Although the primitive portions of the brain collect, store, and recall information pertaining to the experience, the cognitive brain may have collected or is able to retrieve from other portions of the brain information pertaining to the who, what, where, when, and how types of information. Interviewers should be careful about asking specific questions pertaining to length of time and elements of distance due to the fact that fear and trauma often distorts time and distance. The interviewer should explore the additional central/peripheral information and who, what, where, when, and how type of information in a sensitive and empathetic manner taking great care not to inhibit or change already fragile testimonial trauma evidence.
The FETI interview techniques are specifically designed to provide an opportunity for the interviewer to obtain significantly more psychophysiological evidence than traditional interview techniques. Psychophysiological evidence is defined as “evidence which tends to prove or disprove the matter under investigation based on psychological and physical reactions to the criminal conduct the person experienced or witnessed. Examples would include, but are not limited to: nausea, flashbacks, muscle rigidity, trembling, terror, memory gaps, etc.” In addition, these techniques provide the victim a better avenue for disclosure, reducing the potential for defensive feelings and uncooperative behavior, which can limit the information/evidence provided to an interviewer.
Memory encoding during a traumatic event is diminished and sometimes inaccurate. Due to bottom-up attention processes focused only on central details perceived as essential to survival and self-defense, many aspects of the event, including those deemed by investigators as essential facts of the crime, may not be encoded strongly or at all. But the assault’s psychophysiological impact is registered with much greater accuracy and strength in the brain’s circuitries of fear and stress, and remembered with far more precision. The impact of the psychophysiological experience also continues to produce potential psychophysiological evidence long after the event. Indeed, psychophysiological evidence is often the only evidence available to distinguish between consent/non-consent and levels of incapacitation. It is also extremely beneficial in demonstrating the ‘three dimensional’ assault experience and subsequent victim reactions and behaviors.
7
Memory encoding during a traumatic event is diminished
and sometimes inaccurate. Due to
bottom-up attention processes
focused only on central details perceived as
essential to survival and self-defense,
many aspects of the event, including those deemed by investigators as essential facts of
the crime, may not be encoded
strongly or at all.
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Master's Level Elder Law CLE
NOVEMBER 18, 2016
Long Term Care
Presented by: Lori Rolley, DSHS Long Term Care, Home
and Community Services; William Reeves, DSHS, HCP
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
1
Medicaid Transformation Waiver New options for Long‐term Services
and Supports
November 18th, 2016
• Initiative 2 Long‐Term Services and Supports– Medicaid Alternative Care (MAC)
– Tailored Supports for Older Adults (TSOA)
• Financial Eligibility
• Benefit Design
• Initiative 3 – Supportive Housing
– Supported Employment
• Questions and answers
Today’s topics
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
2
Initiative 2Initiative 1 Initiative 3Enable Older Adults to Stay at Home; Delay or Avoid the Need for More Intensive Care
Transformation through Accountable Communities of Health
Targeted Foundational Community Supports
Benefit: Tailored Supports for Older Adults (TSOA)
Benefit: Medicaid Alternative Care (MAC)
Benefit: Supported Employment
Benefit: Supportive Housing
• For individuals “at risk” of future Medicaid LTSS not currently meeting Medicaid financial eligibility criteria
• Primarily services to support unpaid family caregivers
• Community based option for Medicaid clients and their families
• Services to support unpaid family caregivers
• Services such as individualized job coaching and training, employer relations, and assistance with job placement.
• Individualized, critical services and supports that will assist Medicaid clients to obtain and maintain housing. The housing‐related services do not include Medicaid payment for room and board.
Medicaid Benefits/ServicesTransformation Projects
Delivery System Reform
• Each region, through its Accountable Community of Health, will be able to pursue projects that will transform the Medicaid delivery system to serve the whole person and use resources more wisely.
Waiver Initiatives
• Goal: Principled agreement reached in October
• Goal: Final agreement by the end of the year
– Including Special Terms and Conditions (STCs)
Medicaid Transformation Waiver:Negotiations with CMS
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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5
Initiative 2Long‐Term Services and Supports
6
Washington Seeks to address the age wave through innovative service delivery
Source: Washington State Department of Social and Health Services, Research and Data Analysis Division
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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ALTSA Client Demographics ‐2015
7
Age: Most clients are “seniors”, but over one third are working age
Age Clients %
18‐64 23,800 37%
65‐84 28,000 43%
85+ 13,000 20%
Gender Clients %
Female 43,300 67%
Male 21,900 34%
Race Clients %
American Indian or Alaska Native 1,500 2%
Asian 7,300 11%
Black or African American 4,200 6%
Native Hawaiian or Pacific Islander 800 1%
White 46,300 71%
Unknown/Unreported 4,800 7%
Ethnicity* Clients %
Hispanic 3,500 7%
Non‐Hispanic 48,000 90%
Unknown 1,900 4%
Totals of each subsection may not be equivalent due to rounding.
*Ethnicity is shown only for home and community clients;
327 nursing home clients indicated Hispanic for "race",
nursing home race and ethnicity not identified separately.
Source: CARE and MDS data, October 2015.
8
The 1115 Waiver will allow us to Sustain and Continue LTSS Innovation
The LTSS System of the Future Must:• Provide effective services for individuals before they spend down
to Medicaid • Provide effective supports to unpaid family caregivers• Promote the right service at the right time and place• Have the capacity to meet the needs of the population• Strategically target LTSS Medicaid investments to slow the growth
rate of public expenditures
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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• Medicaid Alternative Care (MAC)
– A new choice designed to support unpaid caregivers in continuing to provide quality care
• Tailored Supports for Older Adults (TSOA)
– A new eligibility group to support individuals who need LTSS and are at risk of spending down to impoverishment
What is Initiative 2:
Why focus on Family Caregivers?
• Approximately 80% of the care is provided by family members and other unpaid caregivers.
• Caregiving has an economic and health impact on families.
• We need to strengthen the supports available to caregivers so they can continue their role while maintaining their mental and physical health.
• If 1/5th of unpaid caregivers stopped providing care, it would double the cost of long‐term services and supports in Washington.
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Building on what works
• State Family Caregiver Support Program
– Successful 10 year old program
– Documented success with the model
– Existing infrastructure & provider network
• Trained and certified staff
• TCARE and GetCare systems
• Network of locally contracted providers
Financial Eligibility for MAC and TSOA
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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• Extensive work being done to make application simple and accessible.
• Ways an individual can apply:– on-line through WA Connections -adding new
information about the new programs – Paper application (TSOA) HCA Form 18-008– contacting a local Area Agency on
Aging(AAA)– contacting DSHS
Application for MAC & TSOA
14
Final Proposal
Age limit 55+
Estate Recovery Waived for services provided under the MAC benefit.
Cost sharing No
Resources No specific asset level. Must meet Medicaid program requirements.Spousal impoverishment protections will apply to this population so potentially higher resource limits for married couples.
Income Medicaid Eligible
No specific income level. Applicant must be eligible for CN (categorically needy) or ABP (alternate benefit plan).
Medicaid Alternative Care (MAC)
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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15
Final Proposal
Age limit 55+
Income 300% Federal Benefit Rate($2,199 based on 2016 standards)will use community income rule for married applicants.
Post‐eligibility cost sharing No cost sharing or ‘participation’ for TSOA recipients.
Estate recovery Waived for services provided under the MAC benefit.
Resources Asset limit of:‐ $53,100 for a single individual‐ $53,100 plus $54,726 for a spouse
not receiving services
Note: Spousal impoverishment protections apply to this program.
Tailored Services for Older Adults (TSOA)
• Working to simplify processes & create least burden to client.
– TSOA: will have continuous 12 month eligibility, regardless if a service is received every month.
– Financial eligibility will be reviewed every 12 months, as will functional eligibility for services.
– Must meet Nursing Facility Level of Care for both programs.
Eligibility: MAC & TSOA
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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• Presumptive eligibility allows us to authorize services prior to a full financial and functional eligibility determination, for a period of 90 days.
– Allows us to have a ‘no wrong door’ approach to service.
– Provides service quickly to meet a need.
• Exploring ways to expand our successful wellness education program to MAC & TSOA recipients.
Presumptive Eligibility for Services
Benefit Design for MAC and TSOA
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Benefits
• Based on client eligibility and choice of service model
• Services based on immediate needs and some on assessment of caregiver burden
• Grouped into categories of service
• Services align with those offered in existing program and outcomes identified by assessment
Caregiver Assistance Services
• take the place of those typically performed by the unpaid caregiver
• Services to decrease the burden of the unpaid caregiver and/or provide the caregiver with short‐term relief in providing care to the participant.
• Includes:– Household tasks, respite, essential shopping, home
delivered meals, home safety evaluations.
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Caregiver Assistance ServicesProvider types
• Include:
– Individual providers
– Home Care Agency
– Adult Day services
– Transportation providers
– Food service vendor
Training, Education & Consultation
• Services for the participant or caregiver to promote the participant’s ability to live and participate in the community;
• Services for the unpaid family caregiver to learn or enhance caregiving, safety and coping skills
• Includes:
– training on health issues, supported decision‐making, skill development, support groups…
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Training, Education & ConsultationProvider types
• Licensed Health Professionals
• Mental Health Professionals
• Evidence based intervention consultant/trainer
• Dementia behavior consultants
• Colleges/University/Professional and Community Organizations/Associations
Specialized Equipment and Supplies
• Specialized equipment and supplies are items needed for participant and/or caregiver health and safety.
• Includes:
– devices to assist with mobility, assistive technology, adaptive equipment
– Personal Emergency Response Systems (PERS)
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Specialized Equipment and SuppliesProvider Types
• Specialized equipment supply company
• Assistive technology company
• PERS monitoring agency
Health Maintenance & Therapy Supports
• Services that assist the participant to remain in their home or the caregiver to remain in their caregiving role and provide high quality care.
• Services to prevent further deterioration, improve or maintaining current level of functioning of the participant and reducing the stress and level of burden experienced by the caregiver
• Includes: – Evidence based health and exercise programs, massage,
individual and family counseling, wellness education
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Health Maintenance & Therapy SupportsProvider Types
• Wellness instructor
• Fitness center
• Evidence‐based Program practitioners
• Mental health professional
• Massage therapist
Personal Assistance Services (only in TSOA)
• To be used instead of Caregiver Assistance when the participant is not supporting an unpaid caregiver.
• Supports involving the labor of another person to help waiver participants carry out everyday activities they are unable to perform independently.
• Services may be provided in the person's home or to access community resources.
• Includes: – personal care services
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Personal Assistance ServicesProvider Types
• Individual provider
• Home Care Agency
• Home Health Agency
• Food Service Vendor
• Adult day Health
• Adult day care
• Registered Nurse
• Continue work with stakeholders to keep fidelity of existing program and align with Medicaid requirements:
– System design work
– WAC
– Developing benefit scope
– Hand‐off protocols – case management and options counseling
– Staff training
– Outreach to and engagement of existing state family caregiver program clients
Operationalizing a new Medicaid service
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Initiative 3: Supportive housing and supported employment
31
• Housing transition services that provide direct support to help individuals obtain housing, including:
– Housing assessment and development of a plan toaddress barriers.
– Assistance with applications, community resources, andoutreach to landlords.
• Housing tenancy sustaining services that help individuals maintain their housing, including:
– Education, training, coaching, resolving disputes, and advocacy.
• Activities that help providers identify and secure housing resources.
Supportive housing services do not include funds for room and board or the development of housing.
32
Initiative 3: Supportive Housing—Eligible Services
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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• Chronically Homeless (HUD Definition)
• Frequent/Lengthy Institutional Contact
• Frequent/Lengthy Adult Residential Care Stays
• Frequent turnover of in‐home caregivers (LTSS)
• PRISM Score 1.5+
33
Supportive Housing Target Population
• An evidence‐based approach to supported employment for individuals with significant barriers to employment– 23 randomized controlled trials (Dartmouth, 2015)
• Principles of Supported Employment:‒ Open to anyone who wants to work‒ Focus on competitive employment– Rapid job search– Systematic job development– Client preferences guide decisions– Individualized long‐term supports– Integrated with treatment– Benefits counseling included
34
Initiative 3: Supported EmploymentIndividual Placement and Support (IPS) Model
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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• Aged, Blind, Disabled (ABD)/Housing and Essential Needs (HEN)
• Individuals with severe and persistent mental illness, individuals with multiple episodes of inpatient substance use treatment and/or co‐occurring
• Working age youth with behavioral health conditions
• Individuals eligible for long‐term care services who have a traumatic brain injury
Supported Employment Target Population
Medicaid
HCA
MCOs
SH/SE –Physical Health
Conditions
BHA
BHOs
SH/SE –Behavioral
Health Conditions
ALTSA
HCS/AAAs
SH/SE ‐ LTSS
Tribes
SH/SE –Tribal
Members
Initiative 3: Medicaid Funds Flow
Purchaser
Payer
Provider
36
Data
Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve
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Q & A
* New # L32 will trickle to L95/L99 if income >SIL in an institution (no L99 PACE) @ Includes Group A through Group D & Ignore this 08/06/2015
CFC Cheat Sheet
Eligibility Groups | New L-Track Coverage Groups | New HCBS Indicators
Group Income Resources Notes
CFC Eligibility Only (L52*)
Group A
< 2-person CNIL (married + deemed income)
< 1-person CNIL (all other)
< $3000 (married living together)
< $2000 (all other)
Regular S02 rules
Group B < 1-person CNIL <$2000 &
<state CSRA With SIPC spouse
Group C < SIL and < state rate + $38.84
< $2000 Not income eligible in Group A, lives in
contracted ALF
Group D < SIL and
< state rate + $38.84 <$2000 &
<state CSRA With SIPC spouse,
not Group C
HCB Waiver + CFC or HCB Waiver Eligibility (L22 /L32* / L42*)
Group 1 Otherwise eligible using Group A
<$2000 (single) & <state CSRA (with
CS) HCS & DDA
Group 2 Not Group A, but < SIL <$2000 (single) & <state CSRA (with
CS) HCS & DDA
Group 3 Not Group 2, but < Effective MNIL
<$2000 (single) & <state CSRA (with
CS)
HCS Only (no hospice only)
Coverage Group Description HCBS Code Description
L01 Institutional SSI C COPES / RSW
L02/L95/L99 Institutional SSI-Related P DDA Waiver
L21 HCB Waiver SSI M MPC
L22 HCB Waiver SSI-Related H Hospice
L31* PACE / Hospice SSI W 45-slot
L32*# PACE / Hospice SSI-Related A* PACE
L41* RCL SSI K* CFC
L42* RCL SSI-Related N* New Freedom
L51* CFC SSI R* RCL
L52*@ CFC SSI-Related I 1915(i)&
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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* New # L32 will trickle to L95/L99 if income >SIL in an institution (no L99 PACE) @ Includes Group A through Group D & Ignore this 08/06/2015
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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ALTSA and DDA Service Comparison Chart 1915(c) Waivers vs. State Plan Programs
Effective August 1, 2016
Revised August 2016
DDA 1915c Waivers ALTSA (HCS) Waivers State Plan Programs Grant State Funds
BASIC PLUS CORE CP CIIBS IFS COPES
RESIDENTIAL SUPPORT
WVR
1915k option CFC
(DDA & HCS)
MPC (DDA
& HCS)
Roads to Community Living (RCL)
HCS Washington
Roads HCS DDA
Adult Day Care
X X
Adult Day Health
X X X
Adult Family Home Specialized Behavior Support Service
X
Assistive Technology
X X
X X X X
Behavior Support & Consultation X X X X X
X X X
Behavioral Health Crisis Diversion Bed Services X X X X
X
Behavioral Health Stabilization Services X X X X X
X X X
Caregiver Management Training* X X X X X X X
Client Support Training
X
Client Support Training/Wellness Education X X
Community Access X X X
Community Engagement X
Community Guide X X
X
(CCG) X X (CCG)
Community Transition
X
X X X X
Emergency Assistance X
X (RENT ONLY)
Enhanced Residential Services X
Environmental Modifications X X X X X X X X X
Expanded Community Services X
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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ALTSA and DDA Service Comparison Chart 1915(c) Waivers vs. State Plan Programs
Effective August 1, 2016
Revised August 2016
DDA 1915c Waivers ALTSA (HCS) Waivers State Plan Programs Grant State Funds
BASIC PLUS CORE CP CIIBS IFS COPES
RESIDENTIAL SUPPORT
WVR
1915k option CFC
(DDA & HCS)
MPC (DDA
& HCS)
Roads to Community Living (RCL)
HCS Washington
Roads HCS DDA
Home Delivered Meals
X
X
Home Health Aide Service
X X
Individual Technical Assistance X X X X X X
Nurse Delegation X X X X X
X X X*** X X
Occupational Therapy X X X X X
X X X
Peer Mentoring X
Person-Centered Planning Facilitation X X
Personal Care In-home X X X X
Personal Care licensed Adult Family Home X X X
Personal Care licensed Assisted Living Facilities X X** X
Personal Emergency Response System
X X X
Physical Therapy X X X X X
X X X
Prevocational Services X X X X X
Relief Care X X
Residential Habilitation
X X
X
Respite Care X X
X X
X X
Sexual Deviancy Evaluation X X X X X
X
Skills Acquisition Training X X
Skilled Nursing X X X X X X X X
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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ALTSA and DDA Service Comparison Chart 1915(c) Waivers vs. State Plan Programs
Effective August 1, 2016
Revised August 2016
Note: “X” means the service is available on the waiver *Administrative activity available to all clients **ARC only ***Residential settings only
DDA 1915c Waivers ALTSA (HCS) Waivers State Plan Programs Grant State Funds
BASIC PLUS CORE CP CIIBS IFS COPES
RESIDENTIAL SUPPORT
WVR
1915k option CFC
(DDA & HCS)
MPC (DDA
& HCS)
Roads to Community Living (RCL)
HCS Washington
Roads HCS DDA
Specialized Medical Equip. & Supplies X X X X X X
X
X X X
Specialized Nutrition & Clothing
X X
X X
Specialized Psychiatric Services X X X X X
X
Speech, Hearing & Language Services X X X X X X X X
Staff/Family Consultation & Training X X X X X
X X X
Substance Abuse Services X X
Supported Employment X X X
X
Supportive Parenting Services X X
Therapeutic Equipment & Supplies
X X
Transportation (non-Medicaid Broker) X X X X X X X X
Vehicle Modifications
X X
X X
Wellness Education X X
HCS Self-Directed waiver: New Freedom Waiver (King and Pierce Counties only)
● Personal Assistance Services Training and Educational Supports
● Environmental and Vehicle Modifications Treatment and Health Maintenance
● Individual Directed Goods, Services and Supports
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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CrossAgencyDeskAidReferralCommunicationsCommittee LastUpdated10/24/2016
Department of Social and Health Services Health Benefit Exchange Health Care Authority
Community Services Division Customer Service Contact Center
Development Disabilities Administration (DDA)
Long-Term Care Specialty Unit
Aging and Long-Term Support Administration (Long-Term Care)
Washington Healthplanfinder Customer Support Center
Lead Organizations Navigators
Medical Assistance Customer Service Center (MACSC)
Medical Eligibility Determination Services
(MEDS) Home & Community
Services (HCS)
Residential Care Services (RCS)
1-877-501-2233
1-877-980-9220 (Answer Phone)
Apply here: www.washingtonconnection.org
1-888-338-7410 (FAX)
1-855-873-0642
Apply for Specialty Unit programs:
www.washingtonconnection.org
1-855-635-8305 (FAX)
Find your local HCS office: http://adsaweb.dshs.wa.gov/hcs/
maps.htm
Apply for HCS programs: www.washingtonconnection.org
1-855-635-8305 (FAX)
Report abuse or neglect in a licensed/certified setting:
1-800-562-6078
RCS is responsible for the licensing/certification and oversight of the following: • Nursing facilities • Adult family homes • Assisted living facilities • Intermediate care for
individuals with intellectual disabilities
• Enhanced services facilities
• Certified community residential services & supports
To search for a licensed home in your area, visit https://www.dshs.wa.gov/altsa/residential-care-services/residential-care-services, select the setting and then the locator link. To find an RCS office near you, visit https://www.dshs.wa.gov/altsa/residential-care-services/residential-care-services-offices
1-855-923-4633
http://www.wahealthplanfinder.org// customersupport@wahbexchange.
org 1-360-841-7620 (FAX)
Lead Organization Contact Information available at:
http://www.wahbexchange.org/wp-content/uploads/2013/05/HBE_NAV_151124_Navigator_Organizations.pdf
1-800-562-3022
https://fortress.wa.gov/hca/p1contactus/
1-800-562-3022
https://fortress.wa.gov/hca/magicontactus/ContactUs.aspx
• Apply for, report changes or renew Food, Cash, and Child Care programs (SNAP, EBT, ABD/ HEN Referral, TANF/WorkFirst, Refugee Assistance)
• Apply for Classic Medicaid programs, SSI, 65+, and disabled
• Request an appeal of Classic Medicaid, Food, Cash and Child Care programs
• WASHCAP (Food for households whose only income is SSI or combination of SSI/SSA) 1-877-380-5784
• For additional application assistance refer to the Public Access Directory for community partners: https://www.washingtonconnection.org/home/publicaccessdirectory.go
• Constituent Relations 1-800-865-7801
The Specialty Unit processes the following Medicaid programs: • DDA Waiver service
programs • Hospice medical • Healthcare for Workers
with Disabilities (HWD) program (S08)
1-800-871-9275 • Children’s institutional
(K01) • Residential mental
health
HCS processes the following Medicaid programs: • Nursing facility
services • LTC services for
community settings: o In-home care o assisted living o adult family home
• HCS Waiver services: o Community First
Choice (CFC) o Medicaid Personal
Care (MPC) o COPES o PACE o Roads to Community
Living (RCL) • Associated cash and
food benefits for HCS clients (except for TANF/Food)
• Request an appeal for HCS programs
• Apply for or renew health care coverage (families, children, pregnant women and single adults)
• Health Insurance Premium Tax Credit (HIPTC) questions
• Qualified Health and Dental Plans (QHP/QDP) questions
• Healthplanfinder Business questions
• Locate an HBE Navigator or Broker http://wahbexchange.org/how-enroll/customer-support-network/
• Request an appeal for denial of HIPTC/QHP, Special Enrollment: www.wahbexchange.org/appeals or call for information: 1-855-859-2512
For planned maintenance and outages, visit Healthplanfinder Status Center: http://wahbexchange.org/customer-resources/outages-and-maintenance/ Email [email protected] • For questions about
becoming a Navigator • To request outreach
materials and presentations
• HPF password reset or lockout: 1-855-256-9598
• ProviderOne Client Services Card
• Provider billing and claims questions
• Apple Health Managed Care enrollment and questions
• ProviderOne benefit coverage questions
• Foster Care inquiries • In Clark and Skamania
Counties only: Mental Health, Substance Use Disorder and Crisis Services o Additional Supports for
SW WA: 24/hr Crisis Line:
1-800-626-8137 http://wa.beaconhealt
hoptions.com
• Apple Health Modified Adjusted Gross Income (MAGI) Medicaid eligibility questions (families, children, pregnant women and single adults)
• Post-Eligibility Case Review questions or report changes
• Apple Health for Kids premium payment questions (CHIP)
• Request an appeal for Apple Health Programs
Hours of operation: 8:00 am – 5:00 pm, Monday – Friday (except state holidays).
Suggested script: “Please have your Client ID or Social Security Number available.”
Hours of operation: 8:00 am – 5:00 pm, Monday – Friday (except state holidays). closed from Noon – 1pm Suggested script: “Please have your Client ID or Social Security Number available.”
Hours of operation: 8:00 am – 8:00 pm, Monday – Friday (except state holidays). For weekend hours, visit: Contact Us | Washington Health Benefit Exchange - Washington Health Benefit Exchange Suggested script: “Please have your HPF application ID or Social Security Number available.”
Hours of operation are generally 8:00 am – 5:00 pm, Monday – Friday (except holidays). Suggested script: “For application issues, please have the HPF application ID available.”
Hours of operation: 7:00 am – 5:00 pm, Monday - Friday (except state holidays). Suggested script: “Please have your Client ID or ProviderOne ID available.”
Hours of operation: 7:00 am – 5:00 pm Monday - Friday (except state holidays).
Suggested script: “Please have your Application ID, Client ID or Social Security Number available.”
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
26
Office of Insurance Commissioner (OIC) Department of Social and Health Services Additional Supports
Consumer Advocacy Statewide Health Insurance Benefits Advisors (SHIBA) Division of Child Support (DCS) Behavioral Health Administration
Fidelity Information System (FIS) 1-888-328-9271 (24hrs) http://www.ebtedge.com
• EBT Card Replacement and Balance
Information • Change PIN number • Client will need their EBT card
number and Social Security
Office of Financial Recovery 1-800-562-6114
• DSHS Overpayments • Premium Payments • Estate Recovery
2-1-1 1-877-211-9274
7-1-1 (relay service) www.211.org
• Provide information and referral for community resources and volunteer opportunities.
• Support community-based organizations network.
Answer Phone 1-877-980-9220
Automated system where clients can check their DSHS benefits
• Obtain case status and payment information
• Hear information about your child care benefits
• Check voice messages left by your worker
Department of Commerce Locate Homeless Prevention and Assistance/Statewide Coordinated Entry Points for Housing
Tribal Resources
• HBE- Tribal Liaison – Deborah Sosa
[email protected] • HCA- Tribal Affairs Administrator –
Jessie Dean 360-725-1649 or [email protected]
• DSHS Indian Policy: https://www.dshs.wa.gov/sesa/indian-policy
Long-Term Care Ombudsman Program
1-800-562-6028 TTY: 1-800-737-7931
www.waombudsman.org
• Protect, promote and advocate for residents in nursing homes, adult family homes, and assisted living facilities. Report mistreatment of residents in facilities.
How to report Medicaid fraud You can help prevent misuse by reporting suspected Medicaid fraud for the following:
Recipients of Apple Health (Medicaid) coverage If you suspect someone is fraudulently reporting their circumstances to receive Washington Apple Health (Medicaid) coverage, please notify [email protected]
Medicaid Providers Suspected Medicaid Provider fraud may be reported by calling 1-800-562-6906 or emailing [email protected]
1-800-562-6900 http://www.insurance.wa.gov/
1-800-562-6900 http://www.insurance.wa.gov/shiba/
1-800-442-5437 (KIDS) http://www.dshs.wa.gov/dcs/
1-800-446-0259 https://www.dshs.wa.gov/bha
• Complaints against insurances companies, claim denials, poor service, coverage, cancellations, etc.
• Insurance options • Legal rights: insurance laws &
regulations • Health insurance appeals • Complaints against insurance
agents/brokers/producers • Insurance fraud
• Understand your Medicare coverage options and rights: Original Medicare, Medicare Advantage, prescriptions and Medigap plans
• Evaluate and compare Medicare plans • Medicare coordination with Medicaid
(dual), state & federal government retirees, veterans, private plans and HBE
• Medicare Savings Program & low-income subsidies
• Medicare complaints, questions and fraud prevention
• Establish Paternity and Child Support Orders
• Collect / Distribute Child Support • Employer Support • Negotiate Payment Plans • Payment/EFT options
1-800-468-7422 • Hearings and Conference Boards • Outreach to Community Partners and
Stakeholders • Community Relations Unit
1-800-457-6202 • Modify Orders • Employer New Hire Reporting • “Alternative Solutions Program”
A Compassionate Portal To Child Support Barrier Removal
360-664-5028 [email protected] http://tiny.cc/DCSAlternativeSolutions
Need a job? Contact the Employment Pipeline*: [email protected]
*All DSHS clients are eligible
• Medicaid Enrollees are covered for mental health and substance use disorder treatment (also known as behavioral health).
Mental Health Crisis Services: • Anyone who needs mental health crisis
services can receive them, including those who don’t have insurance
• For a life-threatening emergency, call 911 • For other help in a crisis, call the
Washington Recovery HelpLine: 1-866-789-1511
How to Get Services: • Find the Behavioral Health Organization in
your area, and get other information, in this guide: https://www.dshs.wa.gov/sites/default/files/BHSIA/dbh/BHO/BH_Info_Clients.pdf
• If you live in Clark or Skamania County, contact your Apple Health plan directly. If you don’t know how to contact your plan, call Apple Health: 1-800-562-3022
• If you are an American Indian or Alaska Native and need substance use treatment services only, and you don’t live in Clark or Skamania County, you may contact agencies directly on this list: https://www.dshs.wa.gov/sites/default/files/BHSIA/dbh/Providers/SUD_Fee-for-Service_Providers.pdf
• For free, confidential referrals to services and 24/7 crisis support, call: Washington Recovery Helpline 1-866-789-1511
Hours of operation: 8:00 am – 5:00 pm, Monday - Friday (except state holidays).
Hours of operation: 8:00 am – 5:00 pm Monday - Friday (except state holidays).
Hours of operation: 8:00 am – 5:00 pm, Monday - Friday (except state holidays). Suggested script: “Please have your Case Number, or Social Security Number available.”
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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Washington State Apple Health for Workers with Disabilities (HWD)
The Apple Health for Workers with Disabilities (HWD) program recognizes the employment potential of people with disabilities, and represents Washington State’s response to the landmark “Ticket to Work” legislation passed by Congress in 1999. The Ticket to Work and Work Incentives Improvement Act (TWWIIA) enables people with disabilities to no longer have to choose between taking a job and having health care. View online information about TWWIIA at: http://choosework.net/. Under HWD, people with disabilities can earn more money and purchase healthcare coverage for an amount based on a sliding income scale. HWD benefits include:
Medicaid benefit package Greater personal and financial independence Members can earn and save more without the risk of losing their healthcare
coverage Who qualifies for HWD? Washington residents who
Are age 16 through 64 Meet federal disability requirements Are employed (including self-employment) full or part time Have monthly net income at or below 220% of the federal poverty level - $2,178 for
one person or $2,937 for a married couple (effective 4/1/2016). (See examples on back page for determining net income)
What does it cost? Your monthly premium is based on a sliding scale. It cannot be more than 7.5% of your total income - but it can be less! How to apply: Call 1 (800) 871-9275 to leave a message with designated staff that complete HWD applications. They will contact you directly and check their direct message line daily. Apply online at www.washingtonconnection.org. For online information about HWD, see http://www.hca.wa.gov/medicaid/eligibility/Pages/hwd.aspx for basic information about the program and HWD Frequently Asked Questions at http://www.hca.wa.gov/medicaid/eligibility/pages/hwd_faq.aspx for more details.
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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Examples for determining net income Example 1. An individual receives an SSDI cash benefit of $820, which is unearned income. The individual receives a salary of $2,065, which is earned income. Deduct $20 from $820 (820 - 20) for a net amount of $800. Deduct $65 from $2,065, then one-half of the remainder [(2,065 - 65) - 1,000] for a net amount of $1,000. Add amounts together (800 + 1,000) to calculate a total net income of $1,800. This individual may enroll in HWD. Example 2. An individual no longer receives SSDI because of earnings at or above the "substantial gainful activity" (SGA) level of $1,130 (or $1,820 if statutorily blind) after completing the Trial Work Period*. The individual receives a salary of $3,785, which is earned income. Deduct $20 and $65, then one-half the remainder from $3,785 [(3,785 - 85) - 1,850] for a total net income of $1,850. Note: Since this person is no longer receiving SSDI (unearned income) from which only $20 would be deducted, his net income of $1,850 is equal to a "gross" income (before deductions) of $3,785. Since his net income is not more than $2,178, he may enroll in HWD, if he meets other program requirements. ______________________________________________________________________ *Trial Work Period - A period of nine months (not necessarily consecutive) during which the earnings of a Social Security beneficiary with disabilities will not affect his benefit. The nine months of work ($810 or more) are counted within a 60-month period.
If you receive county services as an individual with intellectual or developmental disabilities, ask your Case Resource Manager (CRM) about Benefits Planning services that may be available for you.
If you receive services from the state Division of Vocational Rehabilitation (DVR), DVR provides Benefits Planning services for DVR customers ONLY.
Visit the Washington Pathways to Employment (P2E) Web Portal for more information. www.pathwaystoemployment.wa.gov/
Master's Level Elder Law CLE - 11/18/2016 Session 4 - Long Term Care
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Level of Care 1915(c ) Waiver
State Plan Nursing
facility
Application Needed?
New non-medicaid
application required
Financial application needed Financial application needed,
unless MAGI eligible
Nursing Facility Level of Care
Age: 55+
Participation: No
Estate Recovery: No
Age: 55+
Participation: No
Estate Recovery: No
Age: 18+
Participation: No
Estate Recovery: Yes
Age: 18+
Participation: Yes
Estate Recovery: Yes
Age: No age restriction
Participation: Yes
Estate Recovery: Yes
MPC Level of Care
Income: 300% FBR
using Name on Check
or 1/2 community
income rules
Age: 18+
Participation: Yes
Estate Recovery: Yes
Income: No specific
limit. Must be CN or
ABP eligible
Income: No specific limit.
Must be CN or ABP
eligible
Income: 300 % FBR or <
average state monthly NF rate
Income: < state NF rate or
spenddown
T'Care screen
Age: 18+
Participation: Copay
for respite
Estate Recovery: No
Coverage: No
medical coverage
Resources: 180 days
private NF rate
($53,100)
$107,826 couple
Coverage: No
medical coverage
Income/Resources: No
specific limit.
Coverage: CN or ABP
Resources: No specific
limit.
Coverage: CN or ABP
Resources: No specific
limit.
Coverage: CN or ABP
Resources:
$2000 single
$56,726 couple
Coverage: CN only
Resources:
$2000 single
$56,726 couple
Coverage: CN, MN or ABP
State-funded
Family Caregiver
Support
Tailored Support
for Older Adults
(TSOA)
Medicaid Personal
Care (MPC)
Medicaid
Alternative Care
(MAC)
Community First
Choice (CFC)
Home & Community
Based Waivers (HCB) Nursing Home
Array of Home & Community Services Program Options 2017
Pre-Medicaid Services State Plan ServicesAvailable to clients
not eligible for TSOA,
due to age, income or
resources.
Clients can transition between these programs without a financial
application.
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10/2016 ALTSA L Rolley –field staff handout
Healthcare for Workers with Disabilities (HWD) Medical Coverage Group S08 in ACES
Chapter 182-511 WAC
HWD may be beneficial for HCB Waiver clients who have earnings
Provides CN scope of care
No asset test.
Age 16 through 64
Employed full or part time (including self‐employment)
Higher income test based on net income at or below 220% of FPL.
Can receive either CFC, MPC or HCB Waiver.
No participation toward personal care. HWD premium is usually far less than HCB Waiver participation.
HWD clients pay the HWD premium and room and board if living in a residential setting.
DDA clients in the community under age 65 with income including earnings over the SIL, must be considered for HWD.
Premium is based on income but not more than 7.5%. 2 calculations, initial eligibility and premium determination.
HWD must be closed if client is in a medical institution 30 days. Can be used to authorize a short stay letter with ‐0‐ participation if admission is less than 30 days.
Unpaid HWD premiums cannot be used to reduce spenddown (in a future base period)‐‐not an unpaid bill for medical services.
Spousal impoverishment rules do not apply to HWD on MPC services. Spousal income follows SSI related rule for initial HWD eligibility, but is not used in determining the premium.
Spousal impoverishment rules do apply to HWD on HCB Waiver or CFC services. Use name on check rule for initial eligibility of HWD by indicating the community spouse as a NM on the assistance unit.
HWD premiums are waived for American Indians and Alaska natives
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10/2016 ALTSA L Rolley –field staff handout
Changes in ACES on a S08 case should only be done by an HWD specialist.
How is HWD similar to other SSI-related medical (CN)?
• Same application form- HCA 18-005 • SSI related rules when determining eligibility. NGMA is needed if no current disability determination. • Provides Medicaid Personal Care, Community First Choice or HCB Waiver
How is HWD different from other SSI-related medical (CN)?
• No asset test • Higher income standard - clients pay monthly premiums instead of participation. • Substantial gainful activity (SGA) test is waived for HWD. For all other SSI related Medicaid programs, including HCB Waivers, earnings cannot exceed the SGA, unless the client continues to receive a Title 2 cash benefit, such as SSDI or DAC.
Policy – 1619(b) – Medicaid for SSI recipients While Working. An individual receiving SSI based
on disability or blindness may qualify for continued SSI recipient status and Medicaid under
1619(b) when their earnings (alone or in combination with other income) make them ineligible
for either regular 1611 or 1619(a) cash payments. By retaining SSI recipient status, an individual
retains his or her rights to Medicaid eligibility and payment reinstatement. Clients that have
1619(b) status determined by Social Security remain on SSI Medicaid until SSA sends an SDX
interface for the State to re‐determine Medicaid. If a client wishes to end their 1619(b) status,
refer to a benefit planner so the client can go over their options. Social Security makes the
decision on 1619(b) status, not the Medicaid agency.
For more information: Healthcare for Workers with Disabilities – Apple Health Manual http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/apple-health-workers-disabilities Working clients on Long Term Care – Apple Health Manual http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/working-clients-long-term-care-programs-waiver Pathways to Employment https://fortress.wa.gov/dshs/pathways/(S(lnmn2zn0nutfoyaonssmc4qh))/p2emain.aspx
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WASHINGTON APPLE HEALTH INCOME AND RESOURCE STANDARDS *October 1, 2016 Changes
Modified Adjusted Gross Income (MAGI) and Classic Medicaid PROGRAM
STANDARDS 1 2 3 4 5 6 7 8 9 10 11+
FAMILY (N01) 511 658 820 972 1127 1284 1471 1631 1792 1951 N/A
133% FPL NEW ADULT
(N05) 1317 1776 2235 2694 3153 3611 4071 4532 4994 5455 462
193% FPL PREGNANCY
(N03/N23) 1911 2577 3243 3909 4575 5240 5908 6577 7246 7915 670
210% FPL CHILDREN (N11/N31)
2079 2804 3528 4253 4977 5702 6428 7156 7884 8612 728
220% FPL HWD (S08) (SSI-related)
2178 2937 NA NA NA NA NA NA NA NA NA
260% FPL TAKE CHARGE 2574 3471 4368 5265 6162 7059 7959 8860 9761 10663 902
260% FPL CHIP T1 (N13/N33)
$20 mo/premium 2574 3471 4368 5265 6162 7059 7959 8860 9761 10663 902
312% FPL CHIP T2 (N13/N33)
$30 mo/premium 3089 4166 5242 6318 7395 8471 9550 10632 11713 12795 1082
MN INCOME 733 733 733 742 858 975 1125 1242 1358 1483 1483
MN RESOURCES 2000 3000 3050 3100 3150 3200 3250 3300 3350 3400 50
SSI / CNIL STANDARDS 1/1/2016
Single Eligible Eligible Couple
CNIL INCOME 733 1,100
FBR (SSI Standard) 733 1,100
1/2 FBR 366.50
SHARED LIVING FBR 489 733
SSI RESOURCES 2000 3000
MEDICARE SAVINGS PROGRAMS Income 4/1/2016
People
1 2 QMB (S03) 100% FPL 990 1,335
SLMB (S05) 120% FPL 1,188 1,602
QI-1 (ESLMB) (S06) 135% FPL 1,337 1,803 QDWI (S04) 200% FPL
Must be employed for eligibility 1,980 2,670
QMB, SLMB, QI-1 Resources QDWI Resources
7,280 4,000
10,930 6,000
MEDICARE STANDARDS 1/1/2016
PART A PREMIUM: 40+ wk qtrs = Free Part A; if >29 wk qtrs, but < 40 = $226; if < 30 wk qtrs = $411
PART B PREMIUM
$121.80 Part A Deductible:
Inpatient Hospital = $1,288/ benefit period Part B
Deductible $166
Part A coinsurance for Inpatient hospital $322/day for 61st - 90th day; $644/day for over 90 days
Part A coinsurance for NF $161/day for 21st - 90th day
INSTITUTIONAL STANDARDS
Date of last change AMT
Medicaid Special Income Level (SIL) 1/1/2015 $2,199
DDA PNA at home 1/1/2015 $2,199
Cash PNA ALF $38.84
Cash PNA Medical Institution $41.62
PNA State Veterans Home Maximum $160 All other PNA Medical Institution 7/1/2009 $57.28
HCS, DDA HCB Waivers, CFC & MPC PNA in ALF 1/1/2010 $62.79 HCS, DDA HCB Waivers, CFC & MPC R&B in ALF 1/1/2015 $670.21
HCS HCB Waivers at home PNA with CS 1/1/2015 $733 HCS HCB Waivers at home PNA
without CS, or both spouses on HCB Waiver 4/1/2016 $990
Housing Maintenance Allowance Maximum 4/1/2016 $990
CS Maintenance Needs Allowance Maximum 1/1/2015 $2,981
CS & Dependent Allowance Standard 7/1/2016 $2,003
Standard Utility Allowance 10/1/2016* $411
CS Excess Shelter 7/1/2016 $601 Home Equity Limit 1/1/2015 $552,000
State Spousal Resource Standard 7/1/2015 $54,726
Federal Spousal Resource Maximum 1/1/2015 $119,220
Daily Private NF Rate 10/1/2016* $297
Monthly Private NF Rate 10/1/2016* $9,038
Monthly State NF Rate 10/1/2016* $6,086
An unborn child is included in H/H size for family medical and pregnancy AUs.
Substantial Gainful Activity (SGA) 1/1/2016
Non-Blind Blind $1,130 $1,820
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08/2016
Program Category ACES Description Scope HCB
Waiver CFC MPC
NF short stay b (if not managed care)
Institutional b 30 days or more
SSI and SSI‐related (non‐institutional)
ABD category
Disability is determined by
SSA, or by NGMA referral to DDDS
S01 SSI Recipients Categorically Needy (CN) CN a x x
S02 SSI‐related CN a x x
S03 QMB Medicare Savings Program (MSP).
Medicare premiums, copayments, coinsurance, deductibles. MSP
Pays Medicare co‐insurance days as a claim if QMB only. No application
required for NF if co‐insurance days only & no other service is needed.
Instructions in NF billing guide.
S04 Qualified disabled working individual (QDWI).
Medicare Part A premiums. MSP
S05 Specific low‐income Medicare beneficiary (SLMB).
Medicare Part B premiums. MSP
S06 Qualified individual (QI‐1). Medicare Part B premiums.
MSP
S07 SSI‐related Alien Emergency Medical (AEM).
Emergency Related Service Only (ERSO). ERSO
Hospital, cancer, or end
stage renal
S95 SSI‐related Medically Needy (MN) no spenddown. MN x
S99 SSI‐related with spenddown. MN If SD met
SSI‐related (non‐institutional)
Living in an alternate living
facility (ALF) ‐ AFH, AL or DDA group
home.
G03 Income under the SIL & under state rate x 31 days + $38.84.
Only used for MPC and RSN placements. CN a x
G95 ALF private pay no spenddown.
Income under the SIL, and under the private rate. MN x
G99 ALF private pay with spenddown.
Income under the SIL, but over the private rate. MN If SD met
SSI‐related (non‐institutional)
Healthcare for Workers with
Disabilities (HWD)
S08 Premium based program. Substantial Gainful Activity (SGA)
not a factor in disability determination. CN x x x x
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Program Category ACES Description Scope HCB
Waiver CFC MPC
NF short stay b (if not managed care)
Institutional b 30 days or more
HCB Waiver (institutional)
SSI or SSI‐related 1915(c) waivers
authorized by HCS or DDA
L21 SSI recipients CN x x x
L22 SSI‐related.
DDA – income at or below special income level (SIL). HCS – income < effective MNIL after deducting state NF rate.
CN x x x
L24
Undocumented Alien / Non‐Citizen LTC. Must be preapproved by HCS (Sandy Spiegelberg).
State‐funded CN (SFCN) scope. Community component of SFCN program.
SFCN
State‐funded personal care based on NFLOC criteria. Financial Eligibility based on HCB Waiver rules. If in NF 30 days or more,
change to L04 program. In home or state funded services in an ALF WAC 182‐507‐0125.
SSI and SSI‐related (non‐institutional) PACE, or Hospice
L31 SSI recipient on PACE; or
SSI recipient in institution on hospice (do not change S01 to L31 for hospice outside of an institution).
CN NF services included in PACE. Hospice services provided in
institutions.
L32
SSI‐related PACE or hospice as a program. PACE is managed care (no CFC or HCB waiver with PACE).
CFC or HCB waiver with hospice only. Hospice + HCB waiver will trickle to L22 as priority program.
CN x x NF services included in PACE Hospice services provided in
institutions.
SSI and SSI‐related Roads to
Community Living (RCL)
L41 SSI recipient on RCL. CN x
L42 SSI‐related RCL.
365 day medical upon approval by social services. Must be receiving Medicaid on day of institutional discharge.
CN x
SSI and SSI‐related Community First Choice (CFC)
L51 SSI recipient on CFC. CN x x
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Program Category ACES Description Scope HCB
Waiver CFC MPC
NF short stay b (if not managed care)
Institutional b 30 days or more
L52 Effective 10/01/2015.
SSI‐related CFC. L52 includes S02 and G03 eligibility rules with and without spousal impoverishment.
CN x x
SSI and SSI‐related (institutional) In a medical
institution for 30 days or more
L01 SSI recipient CN x
L02 SSI‐related.
Income under the SIL. CN x
L04
Undocumented Alien / Non‐Citizen LTC. Must be preapproved by HCS (Sandy Spiegelberg).
State‐funded CN (SFCN) scope. Institutional component of SFCN program.
SFCN x
L95 SSI‐related no spenddown
Income over the SIL, but less than the state rate. MN x
L99 SSI‐related with spenddown
Income over the state rate, but under the private rate. Client participation locked to state rate.
MN
Eligible for services, but client pays all cost of care
MAGI (institutional) Only used for
individuals not eligible under non‐institutional MAGI
K01 Categorically Needy Family in Medical Institution CN x
K03 AEM Family in Medical Institution. ERSO Hospital, cancer
or end stage renal.
K95 Family LTC Medically Needy no Spenddown in Medical
Institution MN x
K99 Family LTC Medically Needy with Spenddown in Medical
Institution MN If SD met
Pregnancy/Family Planning
P02 Pregnant 185 FPL & Postpartum Extension CN
P04 Undocumented Alien Pregnant Woman CN
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Program Category ACES Description Scope HCB
Waiver CFC MPC
NF short stay b (if not managed care)
Institutional b 30 days or more
P05 Family Planning (FP) Service FP
P06 Take Charge FP
P99 Pregnant Women & Postpartum Extension MN If SD met
Refugee R03 Refugee Categorically Needy CN x x x
Foster Care/JRA
D01 SSI Recipient FC/AS/JRA Categorically Needy CN x x x x
D02 FC/AS/JRA Categorically Needy CN x* x x x
D26 Title IV‐E federal foster care – under 26 CN x* x x x
MAGI
N01 Parent / caretaker CN x x
Pays as a claim (no award letter). Instructions in NF billing guide.
N02 12 month transitional parent / caretaker CN x x
N03 Pregnancy CN x x
N05 Adult alternative benefits plan (ABP) (age 19‐64) ABP x x
N10 Newborn medical birth to one year CN x x
N11 Children's (age under 19) CN x x
N13 Children's Health Insurance Program (CHIP) (age under 19) CN c c
N21 AEM parent / caretaker ERSO Hospital, cancer
or end stage renal
N23 Pregnancy; not lawfully present CN x Pays as a claim (no award letter)
N25 AEM (age 19‐64) ERSO Hospital, cancer
or end stage renal
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Program Category ACES Description Scope HCB
Waiver CFC MPC
NF short stay b (if not managed care)
Institutional b 30 days or more
N31 Non‐citizen children's (age under 19) SFCN x** x**
Pays as a claim (no award letter)
N33 Non‐citizen CHIP (age under 19) SFCN x** x**
Medical Care Services (MCS)
Medical eligibility through eligibility
for HEN or ABD Cash
A01 ABD legally admitted persons in their 5‐year bar or
otherwise ineligible due to their immigration status. LTSS include state‐funded residential and NF.
MCS x** x x
A05 Incapacitated legally admitted persons in their 5‐year bar or
otherwise ineligible due to their immigration status. LTSS include state‐funded residential and NF.
MCS x** x x
Breast and Cervical Cancer
program S30 Breast and Cervical Cancer (Health Department approval) CN x x
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Acronym Definition
ABP Alternative Benefits Plan
Classic Medicaid programs that are not determined by the Health Benefit Exchange. These programs did not change with the Affordable Care Act (ACA). Classic programs are those who are age 65 or older and those under age 65 who are disabled or blind and not on Medicare. It also includes foster care medical, institutional, Home and Community Based (HCB) Waivers.
CN Categorically Needy
ERSO Emergency Related Services Only for Alien Emergency Medical (AEM)
FP Family planning service
MAGI Modified Adjusted Gross Income
MCS Medical Care Services (state‐funded medical assistance)
MN Medically Needy
MPC Medicaid Personal Care
MSP Medicare Savings Program
NF Nursing Facility
SD Spenddown
SF State‐funded
SFCN State‐funded with state funded CN scope of care
WAH Washington Apple Health. This general term is used for all medical coverage including MAGI,Classic Medicaid, MCS, Institutional and HCB Waiver medical.
This is a desk tool used by Aging and Long Term Supports Administration (ALTSA) field staff that has all the medical coverage groups/programs in Washington and what Home and Community Service can be authorized under that medical program if functionally eligible.
x – Service is covered under the medical coverage group a – This is provided under L51 for SSI recipients or L52 for SSI‐related recipients. S01 and S02 clients are financially eligible for CFC and once financial is notified services have opened under CFC, the FSS will change the case to a L51 or L52. Also, G03 rules are built into L52. b – All NF admissions for skilled or rehabilitation are the responsibility of the managed care entity if enrolled and must be pre‐approved by the managed care plan c – CHIP is Title XXI, and not eligible for Title XIX CFC/MPC. There is a CFC/MPC “look‐alike” service for Title XXI eligible individuals * Must have disability, resource, and income determination for HCB Waiver services. (HCB Waiver services can be used for individuals on cash assistance or foster care as long as a disability determination has been established and the financial worker must keep the assistance unit (AU) as a foster care AU. Until cash assistance is de‐linked from the medical assistance, the cash AU must be used in ACES. ** State funded
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What is Hospice? Hospice is a 24‐hour intermi ent program coordinated by a hospice interdisciplinary team for people with
a terminal illness and a prognosis of six months or less to live. The hospice program allows the terminally ill
person to choose physical; pastoral, spiritual, and psychosocial comfort; and pallia ve care rather than
cure. Hospitaliza on is used only for acute symptom management.
Hospice care is ini ated by the choice of the person, family, or physician. The person’s physician must
cer fy them as appropriate for hospice care. Hospice can be ended at any me by the person or family
(revoca on) by the hospice agency (discharge) or by death.
Hospice care may be in a person’s home, in a medical ins tu on (including a hospice care center), nursing
facility, or in an alternate living facility (ALF).
Func onal eligibility for hospice is discussed in Chapter 182‐551 WAC. The following informa on is
regarding financial eligibility for hospice.
WHO IS FINANCIALLY ELIGIBLE FOR HOSPICE? If a person is eligible for federally funded Medicaid – either categorically needy (CN), medically needy (MN),
alterna ve benefits plan (ABP) – that person is financially eligible for hospice. However, how a person
accesses Medicaid is determined by their financial situa on.
If someone is not otherwise eligible for federal Medicaid (i.e., they are instead eligible for state‐funded
medical), hospice must be pre‐approved by the Healthcare Authority (HCA).
Hospice as a Service
For persons otherwise eligible under non‐ins tu onal CN, MN, or ABP coverage groups: hospice care is a
service covered by their medical service card.
For Supplemental Security Income (SSI) recipients or SSI‐related persons in the community, this means the
following coverage groups are eligible for hospice as a service:
S01 – SSI CN
S02 – SSI‐related CN
S95 – SSI‐related MN, no spenddown
S99 – SSI‐related MN, with spenddown and spenddown is met
G03 – SSI‐related CN in an ALF
G95 – SSI‐related MN in an ALF, no spenddown
G99 – SSI‐related MN in an ALF, with spenddown and spenddown is met
S08 – SSI‐related Healthcare for Workers with Disabili es (HWD)
L51 – SSI CFC
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L52 – SSI‐related CFC
D01 – SSI foster care
D02 – SSI‐related foster care
Hospice as a Program
If not otherwise eligible for hospice as a service, a person can be eligible for hospice as a program by using
Home and Community‐Based (HCB) waiver rules to access CN eligibility. However, when accessing hospice
while in a medical ins tu on, ins tu onal rules are used for eligibility. A person accessing hospice as a
program using ins tu onal rules is not subject to transfer of asset penal es.
When using HCB waiver rules to access hospice, or when in a medical ins tu on, hospice is the priority
program, and par cipa on (if any) is paid to the hospice provider.
For Supplemental Security Income (SSI) recipients or SSI‐related persons, the following coverage groups are
considered hospice as a program:
L31 – SSI in a medical ins tu on
L32 – SSI‐related CN in a medical ins tu on, or at home
L95 – SSI‐related MN in a medical ins tu on, no spenddown
L99 – SSI‐related MN in a medical ins tu on, with spenddown
NOTE: A person cannot receive L32 hospice as a program in an ALF. This is because while
on hospice as a program, hospice is the priority program, and any par cipa on would be
paid towards hospice. In this scenario, Medicaid would not pay for the person’s cost of
care at the ALF. Therefore, if in an ALF, the person must be eligible for a Medicaid
program that pays for ALF services and en tles them to hospice as a service.
When Is Hospice Not the Priority Program?
If a person is not eligible for hospice as a service under a non‐ins tu onal program, but is on an
ins tu onal CN program, a person is s ll eligible for hospice as a service.
FOR EXAMPLE, AN HCB WAIVER CLIENT IN THE COMMUNITY IS ON INSTITUTIONAL CN
MEDICAID. THIS PERSON IS ELIGIBLE FOR HOSPICE AS A SERVICE. THE HCB WAIVER
CONTINUES TO BE THE PRIORITY PROGRAM, MEANING PARTICIPATION – IF ANY – IS PAID
TO THE HCB WAIVER PROVIDER, NOT THE HOSPICE PROVIDER.
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For Supplemental Security Income (SSI) recipients or SSI‐related persons, the following ins tu onal
coverage groups are eligible for hospice as a service (and hospice is not the priority program):
L21 – SSI recipient HCB waiver
L22 – SSI‐related HCB waiver
L41 – SSI recipient Roads to Community Living (RCL)
L42 – SSI‐related RCL
NOTE: The L31 & L32 coverage groups are used for both hospice as a program and PACE.
This is because both hospice as a program and PACE both use the same HCB waiver rules
for eligibility. ACES determines which program (hospice or PACE) a client is on based on
the service indicator and facility coded. However, a PACE recipient cannot receive hospice
as a service, because they receive ALL care through the PACE provider.
DO PERSONS PAY FOR HOSPICE SERVICES? A person may be required to pay towards their costs of hospice services, but it depends on how the person
accessed hospice services.
Hospice as a Service
Persons receiving hospice as a service do not pay towards their hospice services.
When Hospice is Not the Priority Program
Just like when receiving hospice as a service, if hospice is not the priority program, a person does not pay
towards their hospice services. However, a person is s ll required to pay towards the priority program, if
that program independently requires payment (e.g., HCB waiver, or G03 – SSI‐related CN in an ALF).
Hospice as a Program
Persons receiving hospice as a program are required to pay towards their hospice care. If at home, they
par cipate using HCS HCB waiver rule (WAC 182‐515‐1509). If in a medical ins tu on, they par cipate
using ins tu onal rule (WAC 182‐513‐1380).
SPECIAL NOTE ABOUT HOSPICE AS A PROGRAM AND CFC Because hospice as a program is CN Medicaid in the community, persons can access CFC through this
“doorway.” Though it generally may not be required, be sure to keep this in mind. We predict the more
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frequent route for persons who are not CFC‐only eligible is to access an HCB waiver service (Wellness
Educa on) rather than elect hospice for CN Medicaid.
CHANGES IN ACES All ini al and post‐eligibility for hospice as a program is the same. The only real change in ACES is the
medical coverage group for hospice as a program:
When elec ng hospice in a nursing facility, the it will trickle from L01/L02 to L31/L32, instead of
L01/L02 to L21/L22
When approving hospice at home, an L32 will open instead of an L22
If MN in a medical ins tu on, hospice will con nue to be either L95 or L99
NOTE: there is no L31 hospice outside of a medical ins tu on. This person would receive
hospice as a service under S01.
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WHAT IS MEDICAID PERSONAL CARE (MPC)? MPC is a Medicaid service, allowed under Washington State’s Medicaid State Plan, which provides
assistance with activities of daily living (ADLs) to individuals.
A person can receive MPC in their own home, and adult family home (AFH), or in an assisted living
(AL) facility contracted for MPC.
The functional criteria for MPC is discussed in Chapter 388-106 WAC. There is one important change
that was effective 07/01/2015:
If a person meets nursing facility level of care (NFLOC) or intermediate care facility
for the intellectually disabled (ICF/ID) level of care, that person is not functionally
eligible for MPC, as Community First Choice (CFC) is now the priority program.
The following information is regarding financial eligibility for MPC.
WHO IS FINANCIALLY ELIGIBLE FOR MPC? If a person is eligible for non-institutional categorically needy (CN), or alterative benefits plan (ABP),
scope of care under the state plan, that person is financially eligible for MPC.
For Supplemental Security Income (SSI) recipients or SSI-related persons, this means the following
coverage groups are eligible for MPC:
NOTE: although both CFC and MPC are state plan entitlements, and their eligibility
under the state plan looks similar, CFC applies spousal impoverishment
protections while MPC does not. A married person who is financially eligible for
MPC IS financially eligible for CFC (if home equity limits are met); however, a
married person who is financially eligible for CFC IS NOT necessarily financially
eligible for MPC.
DO PERSONS PAY FOR MPC SERVICES? A person may be required contribute towards their MPC services, but there is a technical distinction
among the three “types” of payments a person may make
Participation
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An MPC recipient will never “participate” towards their cost of care. Participation is also called post-
eligibility treatment of income (PETI). PETI is only for institutional programs, or services using
institutional rules.
Room & Board
If an MPC recipient lives in an ALF, they are required to pay their Room & Board (food, shelter, and
heat) to their provider. Room & Board is not participation. The Room & Board standard is the
current federal benefits rate (FBR), less the personal needs allowance (PNA) for HCS CN waivers in
an ALF.
As of 01/01/2015, this is $733.00 FBR - $62.79 PNA = $670.21 Room & Board
Further, a person will only pay “up to” the Room & Board standard. Meaning, someone with less
than $733.00 in income will pay their gross income, less $62.79; and someone with income more
than $733.00 will pay $670.21 at most.
Lastly, payment towards Room & Board is a post-eligibility calculation. As such, any income
deducted, disregarded, or otherwise excluded in eligibility is not excluded for the purposes of Room
& Board.
EXAMPLE: A protected disabled adult child (DAC) has their DAC income completely
excluded for the purposes of Medicaid eligibility and PETI. However, this income is
still used to pay Room & Board.
Total Client Responsibility
If a person is eligible under the G03 medical coverage group, the person pays all their remaining
income (after their PNA) to their provider. This payment is not participation. This is generally
referred to as “Total Client Responsibility.” There are no allowed deductions as typically seen in
institutional programs (like medical expenses and an allocation to a spouse or dependent).
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WHAT IS ROADS TO COMMUNITY LIVING (RCL)? RCL is a statewide demonstra on project funded by a “Money Follows the Person” grant. The grant
was received by Washington State from the federal Centers for Medicare and Medicaid Services
(CMS). The purpose of the RCL demonstra on project is to inves gate what services and supports
will successfully help people with complex, long‐term care needs transi on from an ins tu on to a
community se ng.
Services and supports from the RCL demonstra on project that have proven successful are being
used to help shape recommended changes to Washington State’s long‐term care system. This will
result in more people with complex long‐term care needs being able to remain independent or
transi on from ins tu onal into community se ngs in Washington State.
The func onal criteria for RCL are discussed in Chapter 388‐106 WAC. In general, a person must
have a qualifying ins tu onal stay of at least 90 days, and be func onally eligible for state plan or
home and community‐based (HCB) waiver services.
The following informa on is regarding financial eligibility for RCL.
WHO IS FINANCIALLY ELIGIBLE FOR RCL? If a person is eligible for and receiving categorically needy (CN), medically needy (MN), or
alterna ve benefits plan (ABP) Medicaid on the day of discharge from a medical facility (following a
qualifying stay), this person is eligible for RCL.
Upon RCL approval by social services, a recipient is guaranteed to 365 days of CN Medicaid. Because
of this guarantee, a person would not be terminated from Medicaid due to such things like too
many resources, too much income, or asset transfer penal es. However, there are a few mes
when Medicaid will be terminated:
Ci zenship;
Washington state residency;
Incarcera on (30 days or more);
Death; or
It was later determined a person was not actually eligible for Medicaid on the
day of discharge (for example – unreported resources or transfers)
DOES A PERSON PAY FOR RCL SERVICES? A person pays for their RCL services using the rules for either Home and Community Services (HCS)
or Developmental Disabili es Administra on (DDA) HCB waiver post‐eligibility rules. Meaning, there
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are some who will pay, and some who will not. RCL is not an HCB waiver; it only uses the post‐
eligibility rules to calculate how much a person should contribute towards their cost of care!
HCS|DDA HCB Waiver Group 1 – Otherwise Eligible for CN
Group 1 persons do not par cipate towards their RCL services. If an RCL recipient lives in an
alternate living facility (ALF), they are required to pay their Room & Board (food, shelter, and heat)
to their provider. Room & Board is not par cipa on. The Room & Board standard is the current
federal benefits rate (FBR), less the personal needs allowance (PNA) for HCS CN waivers in an ALF.
As of 01/01/2015, this is $733.00 FBR ‐ $62.79 PNA = $670.21 Room & Board
Further, a person will only pay “up to” the Room & Board standard. Meaning, someone with less
than $733.00 in income will pay their gross income, less $62.79; and someone with income more
than $733.00 will pay $670.21 at most.
Lastly, payment towards Room & Board is a post‐eligibility calcula on. As such, any income
deducted, disregarded, or otherwise excluded in ini al eligibility is not excluded for the purposes of
Room & Board.
EXAMPLE: A protected disabled adult child (DAC) has their DAC income completely
excluded for the purposes of Medicaid eligibility and PETI. However, this income is
s ll used to pay Room & Board.
HCS|DDA HCB Waiver Group 2 – Eligible Using HCB Waiver Rules
Group 2 persons par cipate towards their RCL services using the par cipa on rule based on the
authorizing administra on. For HCS clients – WAC 182‐515‐1509. For DDA clients – WAC 182‐515‐
1514.
If living in an ALF, a person is required to pay towards their Room & Board prior to par cipa on (see
discussion of Room & Board under Group 1).
HCS HCB Waiver Group 3 – Eligible Using HCS HCB Waiver Rules
Some mes referred to as “Mega‐COPES,” Group 3 persons are eligible because their net income
does not exceed the effec ve one‐person medically needy income level (MNIL). These persons
par cipate towards their RCL services and Room & Board just like Group 2 persons.
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NOTE: for Group 2 DDA and Group 3 HCS persons, an increase in income will not
cause RCL to terminate. If a person’s income increases and exceeds the standard,
their par cipa on will just increase using the post‐eligibility rules.
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Master's Level Elder Law CLE
NOVEMBER 18, 2016
"End of Life on One's Own Terms": An In-depth Panel
Discussion
Moderator: Carla Calogero, Reed Longyear Malnati &
Ahrens, PLLC
Panelists: Trudy James, MRE, Inter-Faith Chaplain;
Elizabeth K. Vig, M.D., M.P.H., Associate Professor U.W.
Medicine, Division of Gerontology; Lisa J. Stewart, MSW,
Evergreen Hospice.
Speaking of Dying Book Selections
Books focused on the journey to a peaceful, meaningful ending.
Two poignant, informative memoirs about aging parents in today’s health care system:
A Bittersweet Season: Caring for Our Aging Parents—And Ourselves, Jane Gross
(2012) – Gross, a health journalist, weaves the story of her mother’s final years and days into a
moving account of the toll caregiving takes on her life and the life of her brother. Includes practical,
hard-to-access, vitally useful information. An emotionally touching story and indispensable handbook
for anyone facing the prospect of caring for an aged and/or dying parent.
Knocking on Heaven's Door: The Path to a Better Way of Death, Katy Butler (2014) – A thoroughly researched and compelling mix of personal narrative and hard-nosed reporting.
Sharing her journey with her parents, Butler conveys the strain on caregivers, feelings of guilt and
grief, and the confusion between saving a life and prolonging a death. Hard to put down, the book captures how flawed end-of-life care has become.
Physicians exploring end-of-life options and choices:
Being Mortal: Medicine and What Matters in the End, Atul Gawande (2014) – Gawande, a practicing surgeon, addresses his profession’s ultimate limitation, arguing that quality of
life is the desired goal for patients and families. He offers examples of freer, more socially fulfilling models for assisting the infirm and dependent elderly, and explores the varieties of hospice care to
demonstrate that a person's last weeks or months can be rich and dignified.
When Breath Becomes Air, Paul Kalanithi, forward by Abraham Verghese (2016) A compelling,
inspiring memoir by a successful, idealistic young neurosurgeon facing his own terminal illness. He finds hope and beauty in the face of insurmountable odds, attempting to answer the question What makes a life worth living in the face of death?
The Conversation: A Revolutionary Plan for End-of-Life Care, Angelo Volandes
(2015) – Volandes argues for a radical re-envisioning of the patient-doctor relationship and offers
ways for patients and their families to talk about this difficult issue, to ensure that patients will be at the center and in charge of their medical care.
Patient-Directed Dying: A Call for Legalized Aid in Dying for the Terminally Ill, Tom
Preston (2007) – Preston advocates for improvements in palliative care for the seriously ill and
increased choice for those who are dying. Helpful stories and real-life examples.
A hospital chaplain gives clear examples of challenging medical choices:
Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care, and the
Patient with a Life-Threatening Illness, Hank Dunn (2009) – A short guide to help
patients and families with end-of-life decisions, written by a nursing home/hospice/hospital chaplain. Shares patient and family stories, cites journal articles, and gives common sense, practical advice.
www.speakingofdying.com
Master's Level Elder Law CLE - 11/18/2016 Session 5 - End of Life on One's Own Terms Panel - James
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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Lisa Stewart, MSW, LICSWAManager
EvergreenHealth Hospice and Palliative Care
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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WHAT IS HOSPICE?Hospice is a philosophy of care around
providing comfort at end of life. Hospice strives to meet people where they are and
creatively and compassionately walk alongside them through their end of life journey, helping
to provide comfort and care while accepting the unique approach each individual and family
takes in planning for, facing and coping with end of life.
HOSPICE IS NOT: Custodial care
Active treatment
The entity that ultimately decides on the individual’s plan of care
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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How do we hold these two separate concepts and experiences at the same time?
How does one live as fully as possible AND take action on things that are important while simultaneously coming to the end of life?
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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How does this impact identity?
How does this affect decision making for the person planning for or coming to end of life and/or decision making for their surrogate(s)?
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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In hospice, what are the areas of decision making we most often see individuals and their loved
ones/surrogates struggle with?:1. POC - Active Treatment vs Comfort Care2. POLST/DNR3. DPOA4. Finances/Estate5. Caregiving6. Living Situation 7. Funeral Home/Disposition
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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BACKGROUND*Courtesy of Cynthia Tomik, EvergreenHealth, Manager Palliative Care
Honoring Choices is a state-wide, 6-year initiative sponsored by Washington State Hospital Association and Washington State Medical Association.
It is modeled after Respecting Choices, a 20-year old program developed in La Croix, WI that has demonstrated success in raising the percentage of Advance Care Planning conversations and Advance Directive documents in the electronic medical record (EMR).
Honoring Choices has created an Advance Directive document that captures patient wishes.
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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Five Promises We will initiate the conversation We will provide assistance with ACP We will make sure plans are clear We will maintain and retrieve plans We will appropriately follow plans
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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WHAT ARE THE GOALS?:The overarching goal is for the Honoring Choices Advanced
Directive document to be standardized across Washington state. To that end, EvergreenHealth is taking part in the first year of this
initiative. Our organization started with a small pilot program in our Pulmonary services area with the larger goal of spreading the
initiative throughout all EvergreenHealth services to make system-wide changes:
To ensure that patients have advance care planning conversations (working to push advance care planning upstream toward healthy adults).
To ensure these conversations are recorded, modifiable and easily retrievable in the electronic medical record (EMR).
To ensure that these expressed wishes are followed.
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
Life ‐ Stewart
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WHAT ARE SURROGATES FACED WITH IN DECISION MAKING WHEN THEIR LOVED ONE IS NO LONGER
ABLE?
Surrogates may be faced with making “treatment decisions based on the person’s comfort at one
end of the spectrum and extending life or maintaining abilities for a little longer at the
other.”
*Courtesy of Illinois Cognitive Resources Network
“Ideally, the person with dementia has putin place advance directives that specify his or her
wishes. Without such directives, orif certain issues have not been addressed,families must make choices based on what
they believe the person would want. Allend-of-life decisions should respect the
person’s values and wishes while maintaininghis or her comfort and dignity.”
-Alzheimer’s Association, 2016
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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WHAT CAN HELP GUIDE A SURROGATE’S DECISION-MAKING?“Stay true to the person’s values and beliefs. Consider all factors that would influence the person’s decisions about treatments, and definitions of quality of life and death, including:
Cultural background. Spirituality. Religious beliefs. Family values.
Be aware of the differences between your values and beliefs, and those of the person with Alzheimer’s. Make sure that his or her values and beliefs are guiding your decision.”
-Alzheimer’s Association, 2016
WHAT QUESTIONS CAN BE HELPFUL FOR THE SURROGATE TO ASK THE HEALTH CARE TEAM?
How will the approach the doctor is suggesting affect the person’s quality of life?
Will it make a difference in comfort and well-being?
If considering home hospice for the person with dementia, what will be needed to care for him or her? Does the facility have special experience with people with dementia?
What can I expect as the disease gets worse?
*Courtesy of Illinois Cognitive Resources Network
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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*Courtesy of Dr. Hope Wechkin, Medical Director, EvergreenHealthHospice and Palliative Care
Initial Eligibility: If a patient is not otherwise eligible for hospice, s/he should go two to three days without eating or drinking before s/he is considered medically eligible for hospice.
Continuing Eligibility: If a patient initiates the process of VSED, and then starts eating/drinking again (i.e. “Actually, I think that, after all, I’d like to go out to dinner tonight!”) s/he should only be considered to maintain hospice eligibility after a total of two to three attempts.
Family/Friend Support: For patients to be successful with this, it often requires vigilant support from family and friends, usually two to three people to be with the patient. Importantly, hospice staff – whether outpatient or especially inpatient – should not be relied on to decline nutrition/hydration if asked, and they should not be relied on to refrain from offering, or at least making available, nutrition or hydration. Hospice staff should be expected to provide pharmaceutical symptom management in response to emerging symptoms of agitation, delirium, etc.
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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Decisional capacity at end of life
Physical capacity to self-administer medications
Financial burden related to cost of medication
Moral distress for hospice clincians
Resources: End of Life Washington
Master's Level Elder Law CLE ‐ 11/18/2016 Session 5 ‐ End of Life on One's Own Terms Panel ‐ Navigating Difficult Decisions at End of
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Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
1
Palliative care, Hospice, and Surrogate Decision-Making at the End of Life
Lisa Vig, MD MPHAssociate Professor of Medicine, UW Chair, Ethics Consultation Service, VAPSHCS
Disclosures
I have no financial conflicts of interest to disclose.
The views expressed in this presentation don’t represent those of the Veterans Administration or the UW.
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
2
Objectives
1. Define palliative care and explain how it is similar and different from hospice care
2. Identify 2 things that can ease surrogate decision-making and 2 things that can make it harder
Overview
Palliative care Hospice care Common goals of care Surrogate decision-making
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
3
Palliative Care Definition“Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a team of palliative care doctors, nurses, social workers and others who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”
Center to Advance Palliative Care, www.capc.org
Palliative Care vs. Hospice Care
Palliative Care Serious illness
+ curative care
Identify goals
Treat symptoms
Interdisciplinary team
Hospice Care Terminal illness (6 mos)
Forgo curative care
Comfort goals
Treat symptoms
Interdisciplinary team
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
4
Palliative care vs. Hospice care
Hospic
e
Adapted from ijccm.org
Common Goals of Care
1. Be cured
2. Live longer
3. Improve or maintain functional status/quality of life/independence
4. Be comfortable
5. Achieve life goals
6. Provide support for others
Kaldjian, Am J Hosp Pall Care, 2009
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
5
Hospice isn’t right for everyone
Some people want to “go out fighting”◦ Health and Retirement Study – 2% wanted “all care
possible” (Silveira, NEJM, 2010)
◦ Oregon POLST registry – 1/3 want CPR (Fromme, JAMA, 2012)
Health care professionals homogenous end of life preferences
◦ death
Surrogate Decision-Making
Picasso 1881
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
6
Surrogate decision-making topics
How accurate are surrogates at predicting their loved ones’ preferences?
How do surrogates make decisions?◦ Substituted judgment vs. best interests standards
◦ What really happens? Is this okay?
What are the effects of decision-making on the surrogate?
What can help and hamper surrogate decision-making?
How accurate are surrogates? Studies comparing patient-surrogate judgments
in hypothetical scenarios Systemic review of 16 studies,
2,595 patient/surrogate pairs, 19, 526 paired responses
How often did surrogates correctly estimate patient preferences? 89% 76% 68% 55% Less than 50%
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
7
Surrogates aren’t perfect Studies comparing patient-surrogate judgments
in hypothetical scenarios Systemic review of 16 studies,
2,595 patient/surrogate pairs, 19, 526 paired responses
Surrogates correctly predicted patient’s preferences 68% of the time
Shalowitz, Arch Int Med, 2006
How do surrogates make decisions?
◦ Substituted judgment vs. best interests standards
◦What really happens?
◦ Is this okay?
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
8
1. Conversations with loved one about preferences
or thresholds for “living versus existing” (66%)
2. Rely on written documents (10%)
3. Shared values/life experience with the patient (16%)
4. Surrogate’s own beliefs, values, preferences (28%)
5. Defer decision-making to qualified others (18%)
Surrogate Bases for Future Decision-making *
Vig, J Am Geriatr Soc, 2006
* >100% - 18 used >1 basis
“He wanted me to pull the plug a little too
soon. I didn’t like that. I said, you’re going
to be incapacitated anyway, so I’ll make the
decision. I don’t want him to suffer, though,
of course.”
Example - Surrogate’s own values
- Wife of an older veteran
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
9
Is this okay?
Granddaughter to Grandfather, “…You just told me that you wouldn’t want a breathing machine or shocks, but it sounds like Grandma would tell the doctors to do those things. Is that right, Grandma?”
Grandmother, “ Yes, darling.”
Granddaughter, “Grandpa, is that OK with you?”
Sudore, JAMA, 2009
Is this okay?
Grandfather, “Yes it is. I am ready to go, but if it helps your grandmother to feel that she did everything possible for me, even if it is because she doesn’t want me to go, that is okay. She is the one who has to go on living with her decision. If this is what she wants, then this is what I want because I love her.”
Sudore, JAMA, 2009
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
10
Capturing Leeway inVA Advance Directive
Section D – How strictly do you want your preferences followed?
1. “I want my preferences expressed in this Living Will to serve as a general guide….”
2. “I want my preferences expressed in this Living Will to be followed strictly…”
Surrogate perspectives on decision-making
What are the effects of decision-making on the surrogate?
What can help and hamper surrogate decision-making?
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
11
Hazards of Surrogate Decision-Making
Study of surrogates who had made decisions for a loved one in an ICU in France – 6 months later◦ PTSD symptoms in 1/3 of surrogates ◦ PTSD symptoms in ~82% who had made end-
of-life decisions
Families of ICU pts in US – 6 months later◦ 35% had PTSD ◦ 46% of bereaved had complicated grief
Azoulay, Am J Respir Crit Care Med, 2005
Anderson, JGIM, 2008
Living wills can help surrogates
Randomized control trial of advance care planning (ACP) in Australia
◦ 309 hospitalized people aged 80+
◦ Results - Family randomized to ACP intervention compared to family in control group
Decreased stress, anxiety, and depression
Increased patient and family satisfaction
Detering, BMJ, 2010
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
12
Advance care planning can help surrogates
Randomized trial of advance care planning for dialysis patients in US
◦ 210 patient/surrogate dyads
◦ 45 bereaved surrogates Intervention surrogates had less anxiety, depression
and PTSD than controls
Song, Am J Kidney Disease, 2015
What helps and hampers surrogate decision-making?Helps Experience with
decision-making
Knowing the patient’s preferences
Decision surrogate can live with
Support from others
Clinician recommendations
Positive reinforcement after decision-making
Hampers Surrogate ill health
Competing responsibilities
Family conflict about what to do
Not being able to follow the patient’s preferences
Too many involved clinicians saying different things
Vig, J Gen Int Med, 2007
Master's Level Elder Law CLE -
11/18/2016
Session 5 - "End of Life on One's Own
Terms": An In-depth Panel Discussion -
Vig - Palliative Care
13
Surrogates aren’t perfect, but…
They probably are best suited to make these decisions ◦ life w/ pt, ◦ emotional ties, ◦ will be most affected by
the decision
Rodin 1880
Questions?
Trudy James 1
The Responsibilities of Being a Health Care Proxy
(Agent, Surrogate, Power of Attorney for Health Care)
If you have been asked, or if you are in a position to make medical decisions for someone else, this
Memorandum is for you. If you have been named as someone’s medical power of attorney in an
advance directive, then you may be referred to as the person’s proxy, agent, attorney-in-fact,
surrogate, or representative. These are all essentially the same job. Even if you have not been named,
you may be called upon to participate in medical decisions for close family or friends who are in a
medical crisis and cannot speak for themselves.
Your duties depend on what the person’s Health Care Proxy and/or Living Will says and upon state
law. Read their advance directives and ask about state law. Your duties begin when the individual
loses the ability to make health care decisions on his or her own for either mental or physical reasons.
And you can also give support and be an important part of their decisions long before that happens.
In general, you will have authority to make any and all decisions a patient would make for him or
herself, if able. This includes:
1. Receiving the same medical information the individual would receive.
2. Conferring with the medical team.
3. Reviewing the medical chart.
4. Asking questions and getting explanations.
5. Discussing treatment options.
6. Requesting consultations and second opinions.
7. Consenting to or refusing medical tests or treatments, including life-sustaining treatment.
8. Authorizing a transfer to another physician or institution, including another type of facility (such as
a hospital or skilled nursing home).
The toughest decisions you may have to make will concern the beginning or stopping of “life-
sustaining treatments” (life supports). It is important to understand what the person themselves
would want.
Possible Steps to Follow When Making Decisions (some examples using the name Sally, or mother)
1. Find out the medical facts. This requires talking to the doctors and getting a complete picture of
the situation. Questions you can address to medical providers (using “mother” as an example):
Trudy James 2
• What is the name of mother’s condition? If you can’t say exactly what’s wrong, what are the
possibilities?
• Are tests needed to know more? Will the outcome of more testing make any difference in how you
treat her, or in how she wants to be treated? (If not, why do the test?)
• What is the purpose of each test? Do these tests have risks associated with them? Is the
information you need worth the risk of the test?
• What is her condition doing to her now? Please explain her symptoms to me?
• What usually happens with this disease/condition? What is the most likely course this disease or
condition might take?
• How severe or advanced is her case?
2. Find out the options. Make sure the physician describes the risks and benefits of each option.
Here are some questions you may want to ask:
• How will this option make Sally improve or feel better?
• What is the success rate statistically? How do you define success? ? (It may not be what
mother/Sally would consider a success.)
• Can this procedure be done on a trial basis and then reevaluated? What is an appropriate amount
of time for a trial? Are you willing to stop it after an agreed-upon trial?
• What will it mean to her quality of life?
• What is her prognosis? Do you feel she could die within six weeks? A year?
If she is to die, how might treatment affect the circumstances of her death? (For example, will it
likely require hospitalization instead of home care?)
• What are the possible side effects of this treatment?
• What option do you recommend, and why?
3. Try to figure out how Sally/mother would decide if she knew all the facts and options. You have
three possible approaches to making the decision:
• One - If you know her preferences, follow them. Even if you do not agree with them. It is still HER
life.
• Two - If you do not know Sally’s wishes for the specific decision at hand, but you have evidence of
what she might want, you can try to figure out how she would decide. This is called substituted
judgment, and it requires you imagining yourself in the patient’s position. Consider her values,
Trudy James 3
spirituality, religious beliefs, past decisions, and past statements she has made. The aim is to choose
as Sally/mother would probably choose, even if it is not what you would choose for yourself.
• Three - If you have very little or no knowledge of what mother would want, then you and the
doctors will have to make a decision based on what you believe any reasonable person in the same
situation would decide. This is called making decisions in the patient’s best interest. Evaluate the
benefits and burdens of the proposed treatment. For example, will the treatment cause her pain or
suffering? Or prolong her distress? Is it likely to make her better?
If a loved one or friend or fee-based client has named you as their Medical Power of Attorney…..
DO prepare in advance with the individual. Learn what is important to your loved one/friend/client in
making health care decisions. Do this long before he or she is ill or loses the ability to decide. Talk
about beliefs and values regarding living, and dying. Talk about spiritual beliefs.
DO make yourself and your role known to medical staff. Make sure the advance directive is in the
medical chart. Keep a copy for yourself, handy, to show to people involved in the individual’s medical
care. Keep in touch with these people.
DO stay informed about the person’s condition as it changes. Medical conditions change and staff at a
hospital or other facility can also change. Identify the person who can best keep you informed of the
individual’s condition. Stay involved and be flexible.
If you are not a family member, DO keep the family informed, if any and if appropriate. You may have
the legal authority to make medical decisions even if family members disagree. However most
proxies are more comfortable if there is agreement among loved ones. Good communication can
foster consensus; and you may also need help in resolving family disagreements. If needed, ask for a
palliative care consult, or for the facility’s patient representative or ombudsman, social worker, clergy
or spiritual advisor. Or ask for the ethics committee or ethics consultant.
DO advocate on the patient’s behalf and assert yourself with the medical team, if necessary. Some
medical people may not be as comfortable as others with your involvement. You may disagree with
the doctor’s recommendations. It can be challenging to disagree with medical professionals and
institutional authorities. Be tactful, but also be assertive. If their resistance becomes a problem, or if
you feel you are not being heard, ask for help. Again, you can ask for help from the facility’s patient
representative or ombudsman, a social worker, clergy or spiritual advisor, ethics committee or ethics
consultant.
It is an honor and a privilege to act on behalf of another when they cannot act on their own behalf.
Remember why the person asked you to serve and congratulate yourself for being willing to serve in
this compassionate capacity on behalf of a person you care about.
Master's Level Elder Law CLE
NOVEMBER 18, 2016
Session 6 - ABLE accounts and how they will change your
practice
Presented by: Robert Fleming, Fleming and Curti PLC
Master's Level Elder Law CLE - 11-18-2016 Session 6 - ABLE accounts and how they
will change your practice
1
ABLE Act
Robert B. FlemingFleming & Curti, PLC
Tucson, Arizona
ABLE Act Review Achieving a Better Life Experience Act
Adopted in late 2014 New §529A in Internal Revenue Code Inspired by (but quite different from) §529
education plans
2015 amendment eliminated residency Accounts now available in Ohio, Nebraska,
Tennessee and Florida (for Fla residents) On the table:
Employment earnings up to FPL (another $11,880 in 2016)
529 529A transfers Age 26 46
Master's Level Elder Law CLE - 11-18-2016 Session 6 - ABLE accounts and how they
will change your practice
2
ABLE Concepts
Key distinction between §§529 and 529A: ABLE Act accounts owned by beneficiary
Maximum annual contributions (from all sources): $14,000 or current gift tax exemption
Maximum account size for SSI to ignore account: $100,000
Maximum lifetime contribution keyed to 529 plan limits for state ($?? in Washington)
Disability must be before age 26 Payback
Social Security’s Big Adventure
Program Operations Manual System (POMS) explained
POMS § SI 01130.740 adopted March, 2016 Subsection (C)(4): “Do not count ABLE
account distributions as income” Even better: “Do not count distributions”
regardless of whether for housing, non-housing, otherwise ISM
In-Kind Support and Maintenance (ISM) treatment
Master's Level Elder Law CLE - 11-18-2016 Session 6 - ABLE accounts and how they
will change your practice
3
What Constitutes ISM?
Mortgage (including insurance if required by lender)
Real property taxes Rent Heating fuel Gas Electricity Water Sewer Garbage removal
ABLE Distributions Under POMS
Not income. Ever. Distributions not for Qualified Disability
Expenses? Not income. Distributions for ISM items? Not income. Distributions for food, gifts, whatever? Not
income.
Distributions could result in penalty as gifts Proceeds from distributions may be assets
if still available on 1st of next month Esp. if they are shelter Not if they are non-shelter QDEs
Master's Level Elder Law CLE - 11-18-2016 Session 6 - ABLE accounts and how they
will change your practice
4
When to Use ABLE?
Paying for shelter to avoid PMV (1/3 reduction) rule $735 SSI reduced by $245 for ISM – but not if
from ABLE account Titrating $1,000+ per month of contributions
Increasing autonomy Settling small (<$20K) personal injury
cases Handling chronic over-assets cases Enhancing earnings flexibility Avoiding SNT for small inheritances
Some other interesting stuff
SSA’s POMS provision on ABLE Act accounts: SI 01130.740
Fleming & Curti, PLC’s newsletter: http://issues.flemingandcurti.com/
Fleming & Curti on ABLE Act: http://issues.flemingandcurti.com/tag/able-accounts/