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Old 01-07-2016, 05:13 AM
 
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Originally Posted by Robyn55 View Post
I'm in Florida. Don't know if Florida Mayo works the same as Arizona Mayo. It's a little complicated here. When it comes to Medicare Part B services - Mayo accepts Medicare patients - but does not "accept" Medicare. It bills patients directly for services. At approximately Medicare rates + 15% (the exact formula is kind of complicated). The patient is responsible for paying the bills. Mayo tells Medicare and your Medigap insurer what the charges are. And - if Medicare covers the work - you'll get checks from Medicare and your Medigap insurer which pretty much add up to the amount Mayo has billed you. Assuming your Medigap policy covers the 15% (most Medigap policies don't - but ours do).

Most services are covered by Medicare. But - if Mayo thinks the services might not be covered - it will give you an ABN (advance beneficiary notice) before services are rendered. Telling you how much you might have to pay out of pocket.

When it comes to Medicare Part A (hospitalization and similar - Mayo has a hospital here) - Mayo does "accept" Medicare. I think you'd be responsible for "the 20% Medicare doesn't cover" if you didn't have a Medigap policy (don't know - we all have Medigap policies).

Mayo here is not accepting new Medicare patients in its primary care practice here. Therefore - if you want a Mayo primary care doctor - you have to join the concierge practice. Which my husband and I and my father did. We get about 95% of our medical care at Mayo. Everything except things like routine skin cancer screenings - routine eye exams and the like. We are for the most part very happy with the care we get.

I do know that Mayo in Rochester Minnesota works differently than Mayo here. It has departments we don't have - like pediatrics. And it even accepts some local Medicaid patients. Which Mayo here doesn't. I think that's because Mayo is basically the only show in town in Rochester for locals. It's far from the only show in town here.

BTW - I really don't know any doctors here who "accept Medicare" in the old-fashioned sense. I.e., that they accept whatever Medicare pays and don't worry about collecting the 20% or so that Medicare doesn't pay. If you don't have a Medigap policy to cover the 20% - you'll have to pay it out of your own pocket. Robyn
Thanks,
I forwarded your reply to my sister. In 2001 my mother had surgery at the Mayo in Rodchester for a brain tumor. Medicare and her gap policy covered everything. We paid for a private room, which was very inexpensive. She got excellent treatment and we stayed at the hotel that is connected to the clinic.
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Old 01-07-2016, 05:23 AM
 
1,076 posts, read 1,121,270 times
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Originally Posted by crusinsusan View Post
I haven't read the whole thread yet, but I'm tired and wanted to get this up. If what I've said below has already been covered, well, then this is just another story like it.

I've never read anything supportive of reverse mortgages from a source I respect.

And while I have little first hand knowledge of recipients of medicaid (and only one case in which a lawyer fixed things so the wife could keep the house), what I have seen isn't the sort of care I want for myself. I (and everyone) deserves much better. Something along the lines of dignity. My friend's father seemed to get about the same sub-standard care in the early 2000's that my grandmother got in the 1960s. My friend still can't talk about it.

I also don't like the idea of my home being confiscated for my care. And, as a sub-55 year old, I think medical advances may very well get me in and out of a facility in a much shorter time frame then the current model. Thus, I want a home to come home to. (I should note that while I do have an adult child, he will inherit 7 figures from his father, so I feel no need to save anything for him.) Plus, I'm searching high and low with no success, for a reputable (that's the key) and recent source of the top 10 reasons for admittance into NHs, ALFs, etc, as I have no family history of alzheimer's, dementia, stroke, or cancer on any side of my extended family. Heart attacks do run on one side of my family, but in people with HBP; I am an anomaly on that front in my family, as I have very low blood pressure. So I'm trying to figure that all in. Tricky business, to be sure.

Also, I've been debating putting my house into a family trust to protect it from medicaid (care? I need to clear my head on the distinctions) should my planning not work out. (I've yet to make a decision about ltci, and am leaning towards self-insuring, thus, the idea of the trust). I'm not sure how others who have no one to add to a trust would work this out. ie: can a couple of friends set up a trust, or can only blood relatives? If so, can you do it with a cousin who is also single? Both of you save your homes that way? (It might be a good idea to call that cousin you haven't spoken to in years, if they're your age and single. They might welcome the call.)

Another idea that grew from that is renting out the house while I'm in a facility (again, all based upon whether I can do the trust, and how, and so forth...I'm in the very beginning stages of looking at the very end). But I would have my son set some of that up - such as if I'm in a facility for two months and it looks like it may last a while, he could empty my house and put my things into storage.

Although I would think someone could do this without a relative. Pre-plan and find a good, responsible, respected property manager to handle it all. (Overseen, hopefully, by your attorney.) Their take is usually a 10% cut of the monthly rent - frankly an outrageous sum for a home in a good area: property managers do hardly anything unless a tenant is a nightmare. But it is what it is. Even if I go this route myself, I would use a property manger, but have my son oversee him/her, jftr, and, honestly, just because I do have him. I should also note that it's not in the common job description for a property manager to put things into storage...that would be extra.

So, if I could manage it, putting it into a trust, and renting it out while I'm unable to care for myself, using my son to empty it and set up a property manger, ..well...seems possible. Cover the taxes, upkeep and so forth.

As to your last point, I don't need annuities, as I have a defined benefit plan.
There was no family history of Alzheimer's or dementia in our family either. But my mother died from complications of Alzheimer's in 2001. When she was first diagnosed she kept telling the doctors that no one in her family had Alzheimer's. One thing about the disease is when you go into a nursing home, you don't come out. You can last for years with the disease, so plan for that outcome.
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Old 01-07-2016, 06:21 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,969,752 times
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Quote:
Originally Posted by organic_donna View Post
Thanks,
I forwarded your reply to my sister. In 2001 my mother had surgery at the Mayo in Rodchester for a brain tumor. Medicare and her gap policy covered everything. We paid for a private room, which was very inexpensive. She got excellent treatment and we stayed at the hotel that is connected to the clinic.
My husband has been to Mayo in Rochester too. When Mayo JAX was a "a baby" - and before we were on Medicare. It's an amazing place.

Mayo Rochester seems to work the same way as Mayo JAX WRT to patients on Medicare:

Frequently asked questions about Medicare billing - Minnesota Patient and Visitor Guide - Mayo Clinic

I think this type of billing will become more common in the future. And encourage people going on Medicare to buy the best/most comprehensive Medigap policies they can possibly afford. Robyn
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Old 01-07-2016, 07:03 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,969,752 times
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Quote:
Originally Posted by crusinsusan View Post
...And, as a sub-55 year old, I think medical advances may very well get me in and out of a facility in a much shorter time frame then the current model. Thus, I want a home to come home to...
Very generally...

There are basically 2 types of care in a SNF. Rehab care and traditional long term care. Medicare - insurance for people over 65 - currently covers a limited amount of rehab care. So if - for example - you have a stroke - you will probably be able to get at least some rehab care that is covered by Medicare. Some rehab works (particularly for less serious things) - and you can move back home. Some doesn't. If rehab doesn't work and you're not in a position to return to a home environment - then you'll need long term care. In a SNF - an ALF or similar. Medicare does not cover this long term care.

Note that you can wind up needing long term care without having a need for rehab. This is most common for people with dementia. It is common for SNFs to have separate "wings" for people whose primary problem is dementia. There are also various non-SNF/ALF facilities that specialize in dementia care (they have names like "memory care" this or that).

Medicaid is a program to help poor people of various ages (including those 65+) with medical care. Medicaid eligibility varies from state to state. Medicaid also pays for care in a SNF. Although there are some facilities that provide excellent care to Medicaid patients - it is generally a case of you get what you pay for. And facilities are increasingly not accepting Medicaid patients (they don't have "Medicaid" beds).

If you're possibly interested in doing what is usually called "Medicaid planning" in most states - impoverishing yourself voluntarily so you will qualify for Medicaid - I strongly suggest consulting with a local estate planning or similar attorney so he/she can tell you what your options are - and explain their pros and cons. IIRC - off the top of my head - Medicaid - at least in Florida - will not force you to sell your house if there is any possibility you might move back to it. But I would definitely check out how things work in the state where you live. Note that even if you don't have any interest in Medicaid planning - it's generally a good idea to consult with an estate lawyer so you have all the legal planning documents you should have in order.

FWIW - it occurred to me that no one has mentioned a flip side of this Medicaid planning. Florida - where I live - is currently running pilot programs that *force* people on Medicaid to stay in their own homes instead of going into a SNF if they can get by with a relatively minimal amount of at home care. Because it's cheaper than care in a SNF. This might be a good thing for some people in some circumstances. But - for others - it might be a lonely miserable existence. Sitting around at home all day - disabled and alone - waiting for the home health care worker to show up. I have seen excellent SNFs and bad SNFs. And the excellent ones are better than sitting home alone all day.

In the end - I think this all comes down to choices. The more assets/money you have - the more choices you usually have. Robyn
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Old 01-07-2016, 07:06 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,969,752 times
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Originally Posted by mathjak107 View Post
...the irs can assume you live to some age on a chart and assume you got a certain amount of interest each year but the reality is nooooo you have gained nothing in return on capital spent until you go on their dime...
All I'm saying is the tax consequences of various transactions/products/investments can be important in deciding whether they make sense for any particular individual. Robyn
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Old 01-07-2016, 07:07 AM
 
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i am in agreement with that . that does matter . deferred variable annuity's as an example are taxed very different from immediate annuity's . but in the end how the irs decides to tax it has nothing to do with your actual roi .

an spia is buying a pension .
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Old 01-07-2016, 04:45 PM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,969,752 times
Reputation: 6723
Quote:
Originally Posted by mathjak107 View Post
i am in agreement with that . that does matter . deferred variable annuity's as an example are taxed very different from immediate annuity's . but in the end how the irs decides to tax it has nothing to do with your actual roi .

an spia is buying a pension .
But taxes have a lot to do with the money that's left in your pocket (after paying any taxes you owe). Which is - at the end - pretty much all that matters in terms of disposable income (unless you're a fund manager trying to attract more investment funds - in which case - you're putting your after-tax returns in small print footnotes).

I have found that in recent decades - it's often easier to make a dollar by saving a dollar in terms of paying taxes. That's why I've been very fond of municipal bonds in taxable accounts for a really long time. And why I can't see any reason to move from a no-income tax state like Florida.

I agree that buying a single premium immediate annuity is much like buying a pension. And - these days - a relatively high cost one. Because of low interest rates and longer life expectancy tables. I wouldn't necessarily rule them out for the rest of my life/forever. But don't think they're appropriate at our current ages - mine and my husband's - 70 and 68. Robyn
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Old 01-07-2016, 04:49 PM
 
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you need to use something like fidelity's retirement planner which shows you the effects on rmd's of the various annuity products .

immediate annuity's are taxed with a phantom interest rate a little bit at a time over many years .

variable deferred annuity's are taxed as if the gains are pulled first lessening the tax as time goes on .


they can have an effect on what happens when they team up with rmd's .
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Old 01-07-2016, 06:12 PM
 
Location: Close to an earthquake
890 posts, read 680,454 times
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Quote:
Originally Posted by Robyn55 View Post
All I'm saying is the tax consequences of various transactions/products/investments can be important in deciding whether they make sense for any particular individual. Robyn
I have a saying that goes like this: "Never let the tax tail wag the economic dog." You'll never go wrong being guided by economics but yes you do want to make comparisons on an after-tax basis. Once you've identified what you want to do guided by economics, then and only then do you explore if one option is more tax friendly than the other.

And quality of life trumps economics in my opinion. We all make "business decisions" to do something because we want to. That's the way it should be.
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Old 01-07-2016, 10:11 PM
 
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This thread over in the caregiving forum is also informative (in a sad way). One poster speaks of a >million dollar (I'm assuming ">" means "just under") buy-in for a CCRC, with $5-6k a month in maintenance fees on top of that. And what the care is like, which, as these things go, seems good. But the story of just trying to get a damn cup of tea, from a normally good cna who seems to have had a bad day....

Well. Those sorts of days for the patient can emotionally/mentally/ and, (in the case of him nearly bumping her bad leg because he's not being more careful) physically.

I just don't know.
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