She is currently stable and in comfortable, safe assistant living facility. My husband has POA and looks after her finances; however, we are searching for a suitable facility that can accommodate her as things change. Money is very tight - how should we help her plan for what comes next?
The real issue is AL vs NH & how to pay, isn't it???
Medicaid is available for NH in all states for those who have basically 2K in assets
(excluding their homestead & car). Medicaid is federal (like Medicare) BUT is administered by each state - so each state put's it's spin on the asset ceiling, applications & recoup (from the estate after death). Medicaid pays for NH facility, BUT in some states there is a Medicaid waiver program that will pay for AL (sometimes called "community care"). As AL is so much cheaper to do than having the elder in a NH. Ask social services at her current AL about this. If they aren't very informative, then you will have to go & speak with your states Dept of Aging/Senior Services/Health & Human Services about waiver programs. If you are lucky enough to live in a state that does this, she will need to do the Medicaid application and go onto a list for a slot at a AL that takes Medicaid waiver.
My experience is that AL that are free-standing don't participate in a waiver program, but AL that are part of a tiered system (ones that go from IL to AL to
LTC/NH) do but limit the # of residents on waivers. But the key is if your state does waivers to begin with.
Other than that AL is private pay or LTC insurance. And when that runs out IMHO you get them qualified for a NH so that Medicaid pays. Medicaid qualification will be both financial and medical. The financial you can take care of by spending down her assets in appropriate ways. For the medical you will need to work with her MD's & the medical director at the NH. Having Alz/dementia alone isn't enough to qualify a medical necessity for NH. When she goes into the NH, there will be an initial medical evaluation done by an RN or LVN within the first 30 days. This form will be sent to the state Medicaid program for medical necessity review for NH. They will need to have diseases and Rx's that need to be monitored and require skilled nursing. This can be as simple as daily 81 mg of aspirin for heart disease. Sometimes this can be done by changing how a medication is given, like having them go onto the Exelon patch rather than Aricept. The patch requires someone "skilled" to place/remove/evaluate, while the pill they could take on their own by themselves in theory.
With my mom, is mid-90's with LBD, she was rejected for medical necessity because 3 of her existing RX's were left off the form. So the NH had to file for an appeal, lots of rush, rush and faxes sent by NH to get her approved for medical necessity. I, as her DPOA, had to get an appeal off to DHHS too.
This country has got to figure out a way to deal with LTC. It will be a huge problem when all of us now in our 40's - 60's hit the new old age. Unless you are truly wealthy, if you live long enough, you will run out of money to pay for NH even with careful investing or insurance. So it's fab that you are being proactive in planning for MIL. Good luck!
IMHO you should have the following done:
- Durable Power of Attorney (not just POA)
- Medical Power of Attorney
- Living Will &/or Advance Directives (DNR)
- Declaration of Guardian in Event of Incapacity
- HIPAA Waiver
- Will or a Living Trust
Some NH require the POA's, DNR & incapacity done & on file for admission.
I'm a firm believer in having an elder care attorney take care of all this. It will not be expensive as most is done by the paralegals. You do want to go in prepared with what the information is for the documents (e.g. the residence located at 123 ABC street, aka parcel #5678; Ann Smith, wife of John Smith, with the info on all the births, deaths & prior marriages) as well as valid ID for the elder & citizenship or naturalization papers. If the decisions have been already made, this should simple, straightforward paperwork. Should take 1-2 hrs intake & 1 hr a couple of days later for the signatures to be done. Make sure you get enough originals done.
If mom has assets, then legal should be paid from her assets. This also is important if you ever get challenged. If you pay for all, and you benefit, then other family could go to court to find it a coerced document. Ugly.