Making Medical Decisions During Incapacity

Medical decisions during incapacity are made by the individuals named in a Medical Power of Attorney and Living Will following your wishes.

Today, there is greater awareness that incapacity from disease or injury is not a hypothetical. It’s reality, and there are tasks that must be done, as explained in a recent article entitled “Now Is the Time to Protect Your Health Care Decision-Making Rights” from Kiplinger, for making medical decisions during incapacity.

You have a fundamental right to make your own decisions regarding your healthcare decisions.  However, that can change quickly.  Failing to have your healthcare wishes documented properly also leaves your family in the terrible position of having to guess what you want, which puts them in a difficult and stressful position.

An estate planning attorney works with clients to plan how their assets will be distributed after they die (using a will and trusts, among other tools). However, they also help clients prepare for incapacity. Both are equally important, and incapacity planning might even be more important. There are three basic solutions used in most states, although each state has its own specific rules, so you will want to work with an estate planning attorney from your geographic area.

A Living Will (Directive to Physicians in Texas) addresses what you want to happen if you are in an end-stage medical condition or permanently unconsciousness. The living will can serve as an advance written directive for the type of treatment you want to have, or what treatments you do not want to have. If you are unable to communicate your wishes, this document conveys them in a clear and enforceable manner and indicates who can make that decision for you.

A Medical Power of Attorney works differently than a Living Will. This covers health care decision making when you cannot convey your own wishes. You appoint one or more agents to make health care decisions for you. They use their personal knowledge of you and the direction you indicate to make decisions on your behalf.

If you have not executed documents like these before becoming incapacitated, there are laws which provide for default decision-makers.  These laws authorize a list of individuals in order of preference to act as your health care representative and make health care decisions for you. This is the last and worst option.

It is much better for you and your family to have a plan and the proper documents for making medical decisions during incapacity. First, the state decides who will make healthcare decisions on your behalf, based on the law and not based upon people who you feel comfortable making these very personal decisions for you. If more than one person is named and the family cannot come to an agreement as to what your care should be, they may end up gridlocked, and you are the one who suffers.  This may also lead to delay in making the decision as the medical providers have to access who can make the decision based upon your family make-up, all while your medical care needs to be addressed.

Create a plan for your healthcare when you are creating or updating your estate plan. It will give you the peace of mind that, even in the worst of situations, your loved ones will know what you wanted to occur clearly and be able to go forward in following your wishes.

Reference: Kiplinger (April 29, 2021) “Now Is the Time to Protect Your Health Care Decision-Making Rights”

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Retaining Assets While Being Medicaid Eligible

Medicaid is a program with strict income and wealth limits to qualify, explains Kiplinger’s recent article entitled “You Can Keep Some Assets While Qualifying for Medicaid. Here’s How.” This is a different program from Medicare, the national health insurance program for people 65 and over that largely doesn’t cover long-term care. In this system, clients often have a goal of retaining assets while being Medicaid eligible.

If you can afford your own care, you’ll have more options because all facilities (depending on the level of medical care) don’t take Medicaid. Even so, couples with ample savings may deplete all their wealth for the other spouse to pay for a long stay in a nursing home. However, you can save some assets for a spouse and qualify for Medicaid using strategies from an Elder Law or Medicaid Planning Attorney.

You can allocate as much as $3,259.50 of your monthly income to a spouse, whose income isn’t considered, and still satisfy the Medicaid limit. Your countable assets must be $2,000 or less, with a spouse allowed to keep half of what you both own up to $130,380. Countable assets include things like cash, bank accounts, real estate other than a primary residence, and investments.  However, you can keep a personal residence, personal belongings (like clothes and home appliances), one vehicle (2 for married couple), engagement and wedding rings and a prepaid burial plot.  There are more detailed rules for countable and exempt assets, but suffice it to say most things count.

If you have too much income over the $2,382 income per month for the application, you can use a Miller Trust aka Qualified Income Trust for yourself, which is an irrevocable trust that’s used exclusively to satisfy Medicaid’s income threshold. If your income from Social Security, pensions and other sources is higher than Medicaid’s limit but not enough to pay for nursing home care, the excess income can go into a Miller Trust. This allows you to qualify for Medicaid, while keeping some extra money in the trust for your own care. The funds can be used for items that Medicare doesn’t cover.

However, your spouse may not have enough to live on. You could boost a spouse’s income with a Medicaid-compliant annuity. These turn your savings into a stream of future retirement income for you and your spouse and don’t count as an asset. You can purchase an annuity at any time, but to be Medicaid compliant, the annuity payments must begin right away with the state named as the beneficiary after you and your spouse pass away.

These strategies are designed for retaining assets while being Medicaid eligible for married couples; leaving an asset to other heirs is more difficult. Once you and your spouse pass away, the state government must recover Medicaid costs from your estate, when possible. This may be through a a claim on your probate estate (usually means the house) before assets go to heirs, reimbursement from a Miller Trust or other items.  That is a topic unto itself, albeit an important one, so see here for more information on Medicaid recovery.  https://www.galliganmanning.com/protect-assets-from-medicaid-recovery/

Note that any assets given away within five years of a Medicaid application date still count toward eligibility. Property transferred to heirs earlier than that is okay. One strategy is to create an irrevocable trust on behalf of your children and transfer property that way. You will lose control of the trust’s assets, so your heirs should be willing to help you out financially, if you need it.

Reference: Kiplinger (May 24, 2021) “You Can Keep Some Assets While Qualifying for Medicaid. Here’s How”

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Estate Planning Checklist

Dying without an estate plan creates additional costs and eliminates any chance your wishes for loved ones will be followed after your death. Typically, people think about a will when they marry or have children, and then do not think about wills or estate plans until they retire. While a will is important, there are other estate planning documents that are just as important, says the recent article “10 Steps to Writing a Will” from U.S. News & World Report.  To help identify those needs, I prepared an estate planning checklist which you can find below.

Most assets, including retirement accounts and insurance policy proceeds, can be transferred to heirs outside of a will, if they have designated beneficiaries. However, the outcome of an estate may be more impacted by Power of Attorney for financial matters and Medical Power of Attorney documents.  To help figure out what you may need, you can use this article as an estate planning checklist.

Here are nine specific tasks that need to be completed for your estate plan to be effective. The documents should be prepared based upon your state’s law with the help of a qualified estate planning attorney.

  1. Find an estate planning attorney who is experienced with the laws of your state.
  2. Select beneficiaries for your estate plan.
  3. Check beneficiaries on non-probate assets to make sure they are current.
  4. Decide who will be the fiduciaries named in your estate plan (e.g. executor, trustee)
  5. Name a guardian for minor children, if yours are still young.

There are also tasks for your own care while you are living, in case of incapacity:

  1. Name a person for the Power of Attorney role. They will be your representative for legal and financial matters, but only while you are living.
  2. Name a person for the Medical Power of Attorney to make decisions on your behalf, if you cannot.
  3. Create a Directive to Physicians (Living Will), to explain your wishes for medical care, particularly concerning end-of-life care.
  4. Tell the these people that you have chosen them and discuss these roles and their responsibilities with them if you are ready

As you go through your estate planning checklist, be realistic about the people you are naming to serve as fiduciaries. If you have a child who is not good with managing money, a trust can be set up to distribute assets according to your wishes: by age or accomplishments, like finishing college, going to rehab, or maintaining a steady work history, and they should not be in charge of your money.

Do not forget to tell family members where they can find your last will and other estate documents. You should also talk with them about your digital assets. If accounts are protected by passwords or facial recognition, find out if the digital platform has a process for your executor to legally obtain access to your digital assets.

Finally, do not neglect updating your estate plan every three to four years or anytime you have a major life event. An estate plan is like a house: it needs regular maintenance. Old estate plans can disinherit family members or lead to the wrong person being in charge of your estate.  See this article for my ideas as to when to update your estate plan and what to consider.  You might find reviewing the estate planning checklist helpful at that time as well.  https://www.galliganmanning.com/when-to-update-your-estate-plan/

An experienced estate planning attorney will make the process easier and straightforward for you and your loved ones.

Reference: U.S. News & World Report (May 13, 2021) “10 Steps to Writing a Will”

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