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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

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Page 1: Master's Level Elder Law CLE AV CLE... · 2020-03-16 · Master's Level Elder Law CLE November 18, 2016 | 6.75 Law and Legal CLE Credits WSBA Activity ID #1022190 ... "End of Life

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

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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

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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.

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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

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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.

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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

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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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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)

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Master's Level Elder Law CLE

NOVEMBER 18, 2016

 

Working with Trauma Engaged Clients Presented by: Mark Sideman 

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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 

 

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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) 

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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

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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.

2

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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.

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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

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Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve

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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

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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

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Initiative 2Long‐Term Services and Supports

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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

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ALTSA Client Demographics ‐2015

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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.

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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

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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. 

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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 

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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

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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)

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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

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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

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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.

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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…

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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)

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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

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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

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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

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Initiative 3: Supportive housing and supported employment

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• 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.

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Initiative 3: Supportive Housing—Eligible Services

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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

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Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve

18

• 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

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Masters Level Elder Law CLE ‐ 11/18/2016 Session 4 ‐ Long Term Care ‐ 1115 Waiver ‐Rolley & Reeve

19

Q & A

Page 49: Master's Level Elder Law CLE AV CLE... · 2020-03-16 · Master's Level Elder Law CLE November 18, 2016 | 6.75 Law and Legal CLE Credits WSBA Activity ID #1022190 ... "End of Life

* 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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Page 52: Master's Level Elder Law CLE AV CLE... · 2020-03-16 · Master's Level Elder Law CLE November 18, 2016 | 6.75 Law and Legal CLE Credits WSBA Activity ID #1022190 ... "End of Life

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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Page 53: Master's Level Elder Law CLE AV CLE... · 2020-03-16 · Master's Level Elder Law CLE November 18, 2016 | 6.75 Law and Legal CLE Credits WSBA Activity ID #1022190 ... "End of Life

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.” 

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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.”

                                                                                                       

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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.

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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/

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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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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.

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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

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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

1

Lisa Stewart, MSW, LICSWAManager

EvergreenHealth Hospice and Palliative Care

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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

2

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

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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

3

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?

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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

4

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)?

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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

5

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

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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

6

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.

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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

7

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

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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

8

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.

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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

9

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

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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

10

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

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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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11

*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.

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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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12

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

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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

13

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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.

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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

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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

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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

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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

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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%

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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?

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Session 5 - "End of Life on One's Own

Terms": An In-depth Panel Discussion -

Vig - Palliative Care

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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

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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

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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?

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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

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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

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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?

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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):

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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,

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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.

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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

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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

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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

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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

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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/