What do you do when the ground suddenly gives way under your feet? My brother was calling from the emergency room. My mother had fallen. She’s in pain, and the doctor says the x-ray shows a fracture. The doctor wants to talk to me.
“Your mother,” the doctor tells me, “has broken the top of the thigh bone that joins the hip.”
I tell him I know a little bit about medicine. I know better than to say I’m a lawyer, especially a medical malpractice lawyer. “What exactly is broken?” I ask.
He tells me she has split the head of the femur. She’ll need surgery. I flash back to the broken hip cases I’ve handled over the years. In my mind, I see the X-rays of an artificial hip joint made of metal and plastic.
“No,” he says, “the surgery she needs is a metal rod down the thighbone and pins to the ball of the hip joint. Not as extensive as a hip replacement.”
Oh really? She’s 95 years old.
“So what are our options?” I ask. The doctor explains that without surgery, my mother will suffer constant pain and never walk again and will be at risk for infection, pneumonia, and pulmonary embolus—lethal clots traveling from her legs to her heart and lungs. The primary benefit of surgery, he tells me, is pain control and with a hope that she’ll stand and walk.
“We have to know,” he says, “if you want a full code if she arrests during surgery or DNR?” Suddenly, I felt a lump in my throat the size of an egg at the mention of a do-not-resuscitate order. In the space of five seconds, I had to decide whether my mother should live or die.
I flashed back to the dark, cold winter mornings in upstate New York, my mother making oatmeal for me and my little brother. On her knees zipping up our hooded coats. Walking us through the snow to the bus stop. What would mom want, I wondered.
I didn’t know. We never asked.
My wife had been on me for the last two years to talk to my mother about moving to assisted living. She’d placed her mother in a minimal assisted-living facility the first time her mother fell.
“You and your brothers need to step up,” she repeatedly reminded me. “Your mother shouldn’t be living by herself.”
There are different relationships between mothers and daughters and mothers and sons. To me, it seems that daughters are closer to their mothers and share more of their life.
Not so with me and my brothers. We either did what our mother told us, which we did most of the time, or we listened but went into I’ll-think-about-it mode. I forgot to mention my mother is Italian, Sicilian to be exact. There was no winning an argument with her. Every lawyer should have an Italian mother.
During the past few years, I occasionally mentioned assisted living. “Don’t you dare put me in one of those places,” she said in her most belligerent tone. “All they do is sit around a TV and watch game shows.”
Now I had only a few seconds to decide the fate of the most caring person in my youth, a 95-year-old woman, nearly deaf and mentally impaired from severe short-term memory loss.
“DNR,” I told the doctor. My brother agreed. The next day, problems spurted like leaks in a dyke.
Dealing with a loved one suffering from dementia or cognitive difficulties complicates medical care. It’s a problem we should have considered years before my mother fell, when there were only claims of items being stolen that we later found were simply misplaced.
The morning of surgery, we explained to my mother at least 10 times that she’d broken her hip. Each time she asked, “I broke my hip?” She couldn’t remember. Her faulty memory worsened over time.
Immediately after surgery, a social worker appeared and told my brother we had to select a rehab faculty. We soon realized that not all rehab facilities are five-star rated; thus beds in the more sought-after centers are in demand.
My mother had bought a Medicare Advantage insurance policy instead of a Medicare supplement. We didn’t know the difference between the two for filling Medicare coverage gaps.
Medicare supplements are superior to Advantage plans but more costly. Supplements pay more and allow more flexibility in your choice of doctors. They require a single premium, the network of physicians is wide open, and no preauthorization is required for many services. Advantage plans have many preauthorization requirements, restricted networks of physicians, and healthy co-payments along with high deductibles.
We’d placed my mother in a short-term, for-profit rehab facility. Her Advantage plan limited her stay to 20 days before a healthy co-pay kicked in. We had to find a skilled nursing facility and hope she’d transition to assisted living.
We were shocked to hear that skilled nursing care at an assisted-living facility with a rehab floor would cost the tidy sum of $115,000 annually for a resident requiring a two-person assist. If my mom could progress to a single assist, meaning only one aide to help her get into a wheelchair or to the bathroom, the yearly cost would be closer to $100,000.
We had to make quick decisions without time to examine assisted-living facilities for someone who needed support for “activities of daily living,” such as dressing and bathing. Independent living in a retirement community wasn’t an option. Assisted living wasn’t an option. We were in between skilled rehabilitation and long-term nursing.
There are three financial levels of assisted-living facilities. Private pay, Medicaid, and a private-pay facility that accepts Medicaid after the resident spends down personal assets. Medicare and Medicare supplements don’t cover room and board, and there can be large out-of-pocket costs for skilled nursing—even no coverage at all after a certain number of days. My brother found a private-pay facility that wouldn’t kick our mother out when the money ran out.
The facility we chose required evidence of a minimum amount of cash and assets to qualify for acceptance. Minimums vary depending on the facility’s resources. Once my mother exhausted her assets, we could apply for Medicaid. Initially, the assisted-living facility we chose didn’t take my mother’s low-cost Advantage plan. But somehow my youngest brother, the pick of the litter and also a lawyer, talked our way in.
It helped that this facility is funded by a faith-based nonprofit organization. Mom had lived off her savings and Social Security check for 30 years. More than half of her wealth was tied up in her condo, which meant we had to sell it.
It was a comfortable one-floor plan for the 55-and-older community. But our real estate agent said we needed $25,000–$35,000 in improvements to sell it. The first contractor we asked for an estimate said he couldn’t start for five months because he was short staffed. Turns out, all the contractors we talked to had employee shortages after COVID-19. So we had another time-consuming project with little time to do it.
Medicaid applications for indigency provisions are challenging. Medicaid has a five-year lookback policy for transfers of wealth. My mother’s only asset, besides a few diamond rings, was her car, which my brother sold. If she exhausted her assets, my brother would have to track down the deposit to her checking account to prove receipt of the cash for the car.
We also had to be ready in case our mom outlived her assets. If she ran out of money and the application sat in limbo for six to eight months, my brothers and I would be responsible to pay as much as $70,000 before Medicaid kicked in.
Looking back, there was an episode that should have prompted our efforts to move my mother to assisted living. I got a call from my brother to meet him at my mother’s condo. I could hear the smoke detector blaring over his cell phone.
That’s when my mother claimed a terrorist had broken in and placed a cooking mitten in the oven so that when she turned on the oven, the mitten would catch fire and incinerate the place. We couldn’t find signs of forced entry, and the terrorist, thankfully, took nothing of value. We should have begun talking about assisted living for someone living alone, and we should have reviewed her Medicare options.
Another missed opportunity occurred about three years before she fell. Her church group visited a congregant who’d recently gone to an assisted-living residence. The lady was lonely and resented her son for forcing her to live in this “depressing place.”
We should have found someone my mother knew or an acquaintance who enjoyed her new friends and assisted-living arrangements and suggested we stop by and visit that friend on a Sunday afternoon.
We also now realized we shouldn’t have split the power of attorney responsibilities. My brother Frank was my mother’s financial power of attorney, and I was her medical power of attorney. When it was time for hospice care, both of us had to sign off on legal documents. There were a couple of instances when it wasn’t clear which of us had to sign a contract.
Also, our mother was relatively healthy into her late 80s. We should have investigated her health care options then instead of waiting until her health was poor.
Keep in mind that as a parent or loved one’s memory fades, the cost of skilled nursing care escalates. At the first sign of cognitive decline, you should review Medicare gap coverages and Advantage plans and know the total assets available and whether Medicaid will be necessary.
Medicare Advantage plan monthly premiums can be less costly than Medicare supplements, which often makes them appealing to seniors. But once you choose a Medicare Advantage plan, you have only 12 months from your Part A effective date to switch to a Medicare supplement/Medigap plan and still be considered “guaranteed issue” by the insurance carrier. If the change is made within 12 months of the Part A effective date, you avoid underwriting by the health insurance carrier—this means the insurance company doesn’t consider heath status and pre-existing conditions in issuing a policy.
Suzanne McClain, senior Medicare specialist for National United Medicare Advisors, offers a caution about changing from a lower-cost Medicare Advantage plan to a Medicare supplement/Medigap plan. If the change is made after one year of the Part A effective date, say if you’re 75 and have a chronic illness, the insurer will engage in the underwriting process and rate your health and mortality risk—which can result in a higher premium or a policy not being issued at all.
“There’s a time frame in which the change needs to happen if you want the more comprehensive coverage that a Medicare supplement/Medigap policy offers,” states McClain. “If you’re beyond your 12-month window and your health status is poor or you have pre-existing conditions, the Medicare supplement/Medigap plan may be too costly or not offered at all.”
No doubt long-term health care insurance is the best option for your golden years. Absent a long-term policy and a helpful Medigap policy, two options remain: living with family caretakers or spending down personal assets to qualify for a facility that accepts Medicaid.
