Who pays for in-home care when an elder has no long term care insurance and insufficient assets to pay out of pocket? Medicare only covers skilled care and is not the answer. While some benefits exist under the VA Aid and Attendance program, the program is helpful to a point, but certainly not the cavalry to the rescue.

Americans are living longer as a result of better health care, medicine, technology and nutrition. Meanwhile society is becoming increasingly global. In the past, children often stayed on the farm or nearby as their parents aged.

A well-crafted estate plan considers the possibility that you or your spouse may not simply die, but might become incapacitated late in life and need long term care. Who would pay for such care? The federal government under Medicare? Generally not. The Commonwealth of Massachusetts under Medicaid/Masshealth?

Anyone who keeps abreast of the news can see that our federal government spends far more money than it earns in taxes and other sources. Many states have similar problems, including the inability to continue to pay for government employee pensions and health care benefits, for example, in Wisconsin.

When the time comes, all of us would like to die peacefully in our sleep or perhaps lying next to the ocean shore on a warm summer day. It doesn't always happen that way. In fact, many elders live long past the point where they can lead meaningful, productive and quality lives. None of us wants to live to become so frail that we can no longer manage independently. As you know, however, the reality is that this often happens.

I am sure there are readers out there who, like me, aren’t excited about the aging process. Most of us say, “well if I am going to age, I want it to be in my house, not in a home or facility.”

Medical technology, medications and improved nutrition along with other factors, have raised the life expectancy of Americans. People are living longer, and will live even longer as we move into the future.

Massachusetts law allows a competent person to designate a surrogate (substitute) medical decision-maker (the "proxy") for a resident, in the event that resident is later incapable of making health care decisions.

Massachusetts law allows a competent person (the "principal") to designate a surrogate medical decision-maker (the "proxy") in the event he or she later becomes incapable of making health care decisions.

There are a variety of situations where a person is deemed incapable of making decisions because of cognitive impairment. Some professionals use the word "capacity" while others refer to "competence." While some readers might believe that a person is either mentally competent or not, the issue is not that easy. There is actually a spectrum of decisions and/or actions that require varying degrees of competence.

Life is simple at birth. You have very basic needs, however, your needs beyond food, clothing and shelter become more complex as you age: love, career, hobbies, purpose. At each phase/stage of life your needs evolve.

Protection Against a Lien and Estate Recovery

Long-term care insurance has only been available in the last couple of decades.

In 2006 Masshealth expanded the look back period on asset transfers from 3 years to five years. Might it increase in the future? My guess is yes, given the sad condition of federal and state health care finances.

Medicaid (also known as Masshealth) is an insurer of last resort. It is a needs-based program. It was not intended for the wealthy nor historically, for the middle class. There are a variety of Medicaid programs; too many to list here. They are generally income and/or asset based. Several programs, such as long term nursing home Medicaid, are also concerned with elders who have transferred assets within the prior five years.

If I had a dime for every client who wanted to protect their savings from "the nursing home" or "the state," I would be a wealthy man.

If I had a dime for every client who wanted to protect their savings from “the nursing home” or “the state,” I would be a wealthy man. Many elders have heard war stories of how a neighbor or relative had all of his or her savings consumed by a long term nursing home stay.

The 1960s Woodstock generation, who often care for their elderly parents, are now older citizens enrolling in Medicare. Changes in demographics such as the baby boomer bubble, the drop in worker-to- retiree ratios and increased longevity are some of the factors that have created increasingly stringent health care financing frameworks.

If you’ve read my past columns, you know difficult it can be to get government funding to provide care in your home. Masshealth (also known as Medicaid) has a program called Personal Care Attendant (PCA). It can provide needed care into the home. But it is needs-based.

Who takes care of elders who live to the point where they are not independent, and who pays for that care? The answer is a hodgepodge.