Presented with the generous assistance and continued collaboration of the
Massachusetts Chapter of the National Academy of Elder Law Attorneys
www.MassNAELA.com
Keeping Older Adults Informed for 30
+
Years
2023 ELDER LAW EDUCATION GUIDE
14
th
Edition
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Updated: July 13, 2023
COMMUNITY AND PUBLIC SERVICES
May 2023
Dear Massachusetts Older Adults:
is year’s 14
th
annual edition of the Elder Law Guide (ELG) finds us finally seeing the light at the end of
this long, difficult COVID-19 experience for many older adults, with many of us now fully vaccinated with
the “booster shot.”
is year’s ELG reflects major revisions to Chapter 1, titled “Important Questions and Answers for Older
Adults,” and also useful as a summary of the chapters. We have also added a new and important section, and
major revisions, to Chapter 16, which deals with retirement planning. We reorganized other chapters so that
homesteads and life estate deeds are more easily found and explained, and most importantly, added two
new chapters. e first is on “Pensions,” thanks to the excellent work of the Pension Action Center affiliated
with the UMass Boston School of Gerontology. e second new chapter is on end-of-life decision-making,
hospice care, the use of MOLST forms, health care proxies and living wills.
We hope this year’s updated and revised ELG helps you more easily find information that is important to
you as we age and focus on how to be active, healthy and independent. We need your candid feedback to
make the ELG better each year and relevant to our changing needs.
We try to no longer use the terms “elder,” “elderly” and “senior,” since leaders in the aging community tell us
that those of us who are “older adults” really do not like any age-related labels. Like it or not, the consensus
now is “older adults.” As we all continue to age together, we also change and adapt.
Our volunteers keep expanding and are truly amazing, since a public service project of this magnitude requires
many skilled hands and eyes. e participation of experienced elder law attorneys who are members of both
the Massachusetts Bar Association (MBA) and the Massachusetts Chapter of the National Academy of Elder
Law Attorneys (MassNAELA) is the gold standard and the hallmark of what makes this annual publication
unique. e time, effort and commitment of these attorneys and other professionals is remarkable. e
MBA, together with MassNAELA, continues a long partnership that is committed to helping all older adults
face the opportunities and challenges of aging.
e Advisory Committee is especially grateful for the ongoing support of Elizabeth A. O’Neil, the director
of community and public services at the MBA, who provides the support to keep us organized, to meet all
the deadlines, and to implement numerous revisions, updates and edits to make the ELG happen.
Cordially,
Alex L. Moschella, Esq., chair
MBA Elder Law Advisory Committee
PAGE ii LEGAL ASSISTANCE
ADVISORY COMMITTEE
Alex L. Moschella, Esq., CELA,* Chair, Of Counsel, Mulvena Winston, PC, Stoneham
John J. Ford, Esq., Vice Chair, Northeast Justice Center, Lynn
Josephine Babiarz, Esq., Arlington
Luke C. Bean, Esq., Rico, Murphy, Diamond & Bean LLP, Natick
Chris Erchull, Esq., GLBTQ Legal Advocates & Defenders (GLAD), Boston
Anthony H. Gemma, Esq., Gemma Law Office PC, Braintree
Kristin A. Monaco, Esq., Nigro, Pettepit & Lucas LLP, Newburyport
Natalie A. Simon, Esq., Law Office of Natalie A. Simon, Gloucester
ACKNOWLEDGMENTS
e Massachusetts Bar Association (MBA) expresses its sincere appreciation to the below listed contrib-
uting authors, who graciously contributed many hours to review and update the chapters in this guide. e
MBA is grateful to the Massachusetts Chapter of the National Academy of Elder Law Attorneys (MassNAE-
LA) for its participation, generous assistance and continued collaboration on this public service. e MBA
would specifically like to thank Alex L. Moschella, Esq., chair, and John J. Ford, Esq., vice chair, of this 14
th
edition, for their oversight of this year’s guide and for their dedication to this program since its inception.
e MBA also extends a special thank you to Elizabeth A. O’Neil, MBA director of public and community
services, who provided extraordinary effort and staff leadership to the advisory committee.
CONTRIBUTING AUTHORS
Paula K. Almgren, Esq., Attorney at Law, Lenox
David S. Ardnt, Esq., Mulvena Winston PC, Stoneham
J. Patrick Burke, Esq., Attorney at Law, Lynn
Tyler Compton, Esq., Staff Attorney, University of Massachusetts Boston,
Gerontology Institute, Pension Action Center, Boston
Mary Kate Connolly, Esq., O’Sullivan & Connolly PC, Norwell
Michael R. Couture, Esq., Vidoli Couture LLP, Somerville
Patrick G. Curley, Esq., CELA,* Curley Law Firm LLP, Wakefield
John W. Donahue, Esq., LL.M., Wilchins, Consentino, Novins LLP, Wellesley
Kate E. Downes, Esq., Attorney at Law, Shelburne Falls
ACKNOWLEDGMENTS
*Certified as an Elder Law Attorney (CELA) by the nonprofit National Elder Law Foundation (NELF) (www.nelf.org), the only
national organization accredited by the American Bar Association (ABA) to offer certification to attorneys in the specialization of
elder law. The Massachusetts Supreme Judicial Court (SJC) does not recognize legal specialties for certification.
PAGE iii
ACKNOWLEDGEMENTS
Rick Fentin, CFP, Ed. M. Registered Investment Advisor, Cambridge Financial
Annette M. Hines, Esq., Special Needs Law Group of Massachusetts PC, Framingham
Karen B. Johnson, Esq., Madge & Johnson, Westford
Jill Sullivan Joyce, HUD Certified Housing and HECM Counselor, NeighborWorks
®
Housing Solutions
Emily Kennerley, Director of Development and Outreach, University of Massachusetts Boston,
Gerontology Institute, Pension Action Center, Boston
Joseph A. Latona, CLU, CLTC, CFP, Goldfinch Financial, Manchester, NH
Timothy R. Loff, Esq., Law Offices of Timothy R. Loff, Newton
Deborah D. Maloy, CFP, Insight Financial Horizons, Danvers
Nicole McGurin, Director of Family Services, Alzheimer’s Association of Massachusetts and
New Hampshire Chapter, Watertown
Elaine Miller, Regional SHINE Program Director, Minuteman Senior Services, Bedford
Michelle M. Mulvena, Esq., Mulvena Winston, PC, Stoneham
Mark F. Murphy, Esq., Mark Murphy Law Offices LLC, Norwood
Philip D. Murphy, Esq., CELA,* Law Offices of Philip D. Murphy, Milton
Stephen R. Pepe, Esq., Reverse Mortgage Consultant, Longbridge Financial LLC, Milford
Richard S. Ravosa, Esq., Ravosa Law Offices, Boston
David G. Saliba, Esq., Saliba & Saliba, Boston
Jordan L. Shapiro, Esq., Shapiro & Hender, Malden
Anna-Marie Tabor, Esq., Director and Managing Attorney, University of Massachusetts Boston,
Gerontology Institute, Pension Action Center, Boston
Laura Silver Traiger, Esq., Starr Traiger, Worcester
Daniel M. Surprenant, Esq., CELA,* Surprenant & Beneski PC, New Bedford
Cathrine A. Taglieri, PharmD., RPh., Associate Professor Emeritus, MCPHS University, Boston
Neal A. Winston, Esq., CELA,* Mulvena Winston PC, Stoneham, Stoneham
Liane Zeitz, Esq., CELA,* Law Office of Liane Zeitz, Waltham
*Certified as an Elder Law Attorney (CELA) by the nonprofit National Elder Law Foundation (NELF) (www.nelf.org), the only national
organization accredited by the American Bar Association (ABA) to offer certification to attorneys in the specialization of elder law.
The Massachusetts Supreme Judicial Court (SJC) does not recognize legal specialties for certification.
CONTRIBUTING AUTHORS (CONT.)
PAGE iv LEGAL ASSISTANCE
LEGAL ASSISTANCE
MASSACHUSETTS BAR ASSOCIATION PUBLIC
AND COMMUNITY SERVICES
Lawyer Referral Service
e LRS helps solve legal problems by referring
callers to lawyers or appropriate agencies. e LRS
is currently available Monday through Friday, from
10 a.m. to 3 p.m., but its hours of operation may
expand in the future. Referrals are available 24/7 via
www.MassLawHelp.com, the LRS website. e LRS
does not offer legal advice and there is no charge to
use the service.
Boston area: (617) 654-0400
Toll-free: (866) MASS LRS, (866) 627-7577
TTY: (617) 338-0585
Email: LRS@MassBar.org
Website: www.MassLawHelp.com
Dial-A-Lawyer
Call and speak to an attorney, free of charge, on
the first Wednesday of every month, from 5:30 to
7:30 p.m.
Statewide: (617) 338-0610
Toll-free: (877) 686-0711
MASSACHUSETTS CHAPTER
OF THE NATIONAL ACADEMY OF
ELDER LAW ATTORNEYS (MassNAELA)
e mission of the National Academy of Elder
Law Attorneys is to develop awareness of issues sur-
rounding legal services for older adults and those
with special needs. e approximately 500 attorney
members of NAELA’s Massachusetts Chapter work
for the older adult population in areas as diverse
as: planning for catastrophic care costs; disability
planning; age discrimination in employment and
housing; benefits planning, including Medicaid and
Medicare; and guardianships, probate and estate
planning.
e objective of both the national and Mas-
sachusetts chapters is to promote the highest stan-
dards of technical expertise while maintaining ethi-
cal awareness among attorneys who represent the
most frail and vulnerable members of society.
Contact information:
MassNAELA*
P.O. Box 600046, Newtonville, MA 02460
Phone: (617) 566-5640
Fax: (781) 2079027
Email: Clarence@MassNAELA.com
A copy of this guide can be found and
downloaded at https://www.massbar.org/docs/
default-source/elder-law-education-guides/elep_book-
let_05-23.pdf.*
is guide is being reproduced as a public service of the Massachusetts Bar Association and does not constitute legal
advice. Individuals should always consult with an attorney prior to relying on any information contained herein.
e information pertains only to the laws of Massachusetts at the time of publication and is intended for educational
purposes only; it is not substitute for legal advice specifically tailored to your personal situation. e MBA is grateful to
the many attorneys and law students who have given their time and effort to produce the publication.
*Updated 7/13/23
TABLE OF CONTENTS PAGE v
TABLE OF CONTENTS
CHAPTER 1
IMPORTANT QUESTIONS AND
ANSWERS FOR OLDER ADULTS
What Is Elder Law? ...............................................1
What Are the Essential Estate Plan Documents I
Should Have and What Happens If I Don’t Have
Them? ...................................................................1
If I Already Have Some of These Documents, Why
Should I Review and Update Them? .......................2
What Should Unmarried Couples Consider? ...............3
What Should I Consider with Respect to Joint
Ownership of Assets? ............................................3
What is a Trust, and What Forms of Trusts Are
Commonly Used? ...................................................3
What Options Do I Have if I Have to, or Want to, Sell
My Home? .............................................................4
What Should I Know if Considering a Reverse
Mortgage? (See Chapter 10) ................................... 4
What if I Incur Unmanageable Debt? Is Bankruptcy an
Appropriate Option? (See Chapter 15) .....................5
What Should I Know About Elder Abuse, Neglect and
Financial Exploitation? (See Chapter 11) ..................5
What Is the Difference Between Medicaid and
Medicare? (See Chapters 3, 4 and 5) ......................5
How Do I Know if VA Benefits Will Help Me? (See
Chapter 2) .............................................................6
What Is Long-Term Care Insurance (LTCI)? (See
Chapter 6) .............................................................6
If I Need Nursing Home Care, But My Spouse Does
Not, Will I Still Be Eligible for Medicaid? (See
Chapter 3)..............................................................6
What Are My Rights as an Older LGBTQ Person or
Person Living with HIV? .........................................6
What Is Probate? ....................................................... 7
What Does It Mean to Avoid Probate? ........................7
What if Property Is Located Out of State — What Is
Ancillary Probate? ..................................................7
What Are Federal and State Estate and Gift Taxes, and
How Do They Operate? ..........................................8
What Issues Should You Consider Before Making
Significant Lifetime Gifts? ......................................8
CHAPTER 2
VETERANS AFFAIRS FINANCIAL BENEFITS:
Pension and Compensation for Eligible
Veterans and their Surviving Spouses
Introduction ............................................................9
VA Pension with Aid and Attendance .....................9
Financial Limitations ..............................................9
Military Requirements ..........................................10
Disability Requirement .........................................11
Marriage Requirement ..........................................11
Service-Connected Compensation .......................11
Appeals .................................................................12
CHAPTER 3
MASSHEALTH (MEDICAID):
What You Need to Know About Medicaid
Eligibility and Transfer Rules for
Long-Term Care in a Nursing Home
Introduction ..........................................................13
Income Limitations .............................................. 13
Minimum Monthly Maintenance Needs Allowance
(MMMNA) and the Patient Paid Amount ............ 14
Asset Limitation .................................................. 14
Non-Countable Assets ......................................... 14
Special Rules for the Principal Residence ............. 15
Inaccessible Assets ............................................. 15
Countable Assets ................................................ 16
Jointly Held Assets .............................................. 16
Trusts ................................................................. 16
Community Spouse Resource Allowance (CSRA) .. 17
Permissible Spend-Down of Excess Assets .......... 17
Transfer Rules ..................................................... 18
Deeming Transfers to Be Gifts ............................. 19
The Spend-Down Process ................................... 19
PAGE vi TABLE OF CONTENTS
Estate Recovery .................................................. 19
MassHealth Application ....................................... 20
Conclusion ............................................................20
Contact Information ..............................................20
CHAPTER 4
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS:
Programs for Older Adults at Risk for
Institutionalization
Introduction ..........................................................21
Home- and Community-Based Services Waivers.. 21
Other Programs for Older Adults .......................... 24
Other Important Older Adult Programs . ..............24
Statewide Nutrition Programs .............................. 24
Prescription Advantage ........................................ 26
Pharmacy Outreach Program .................................... 26
Serving the Health Information Needs of Everyone
Program ........................................................... 27
Conclusion ...................................................................27
CHAPTER 5
MEDICARE:
What You Need to Know
Introduction ..........................................................28
What Are the Different Parts of Medicare? ........... 28
Medicare and Medicare Advantage Limitations .... 31
CHART: Medicare 2023 Costs At-A-Glance ..........32
Am I Eligible for Medicare and How Do I Sign Up/
Enroll? .................................................................33
What If I Turn 65, Still Working and Have Health
Insurance from My Employer? ..............................33
How Does Medicare Impact Other Health Insurance
and Personal Injury Monies? ............................. 34
Options to Enhance Original Medicare Coverage .. 36
CHART: Medigap in Massachusetts: Compare
These Plans Side-By-Side .................................37
CHART: Original Medicare & Medicare Advantage
Plans At-A-Glance .............................................39
Deciding Whether to Enroll in Original Medicare or
Medicare Advantage ......................................... 41
Changing Medicare Plans .................................... 42
Comparing Insurance Providers ........................... 42
What Can You Do if Medicare Denies a Service/
Coverage or Payment? ..................................... 42
Conclusion ............................................................43
CHART: Medicare Part A: 2023 .............................44
CHART: Medicare Part B: 2023 .............................45
CHART: Medicare Part B Premiums 2023 ............46
CHART: Medicare Part B Immunosuppressive
Premiums 2023 ..................................................46
Part D — Insulin Coverage ...................................47
CHART: Calculate Your Medicare Part D Premium
for 2023 ..............................................................48
CHAPTER 6
LONG-TERM CARE INSURANCE
Introduction ..........................................................49
What Are the Benefits of Long-Term Care
Insurance? ....................................................... 50
Potential Tax Advantages .................................... 51
When to Purchase Long-Term Care Insurance ...... 51
What to Consider When Comparing Policies ......... 51
LTCI/Life Insurance Policy (Hybrids) Contrasted
with Traditional LTCI ......................................... 52
Conclusion ............................................................53
CHAPTER 7
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
Continuum of Care ................................................54
What Is Nursing Home Care? ............................... 54
COVID-19 ...............................................................54
What Is Assisted Living? ...................................... 55
What Is a Continuing Care Retirement
Community?..................................................... 55
Nursing Home Care ...............................................55
Choosing a Nursing Home ................................... 55
Dementia Care Standard for Nursing Homes ........ 55
Nursing Home Resident Rights ............................ 56
TABLE OF CONTENTS PAGE vii
Nursing Home Transfers and Discharges in
Medicaid- and Medicare-Certified Facilities ...... 57
Department of Public Health Regulations ............. 58
Medicaid Regulations .......................................... 59
Attorney General’s Regulations ............................ 59
Consumer Resources for Nursing Home
Residents ......................................................... 59
Long-Term Care Ombudsman Program ................ 59
Assisted Living .....................................................60
Assisted Living Regulations ................................. 60
Assisted Living Resident Rights ........................... 60
Assisted Living Ombudsman Program .................. 60
Continuing Care Retirement Communities ..........61
Continuing Care Retirement Community
Oversight ......................................................... 61
Consumer Resources ..................................... 61–62
Appendix — DPH Guidelines ................................63
FORM: Executive Office of Elder Affairs Assisted
Living Certification Unit .....................................65
MassNAELA — Elder Advocates Spread the Word:
Just Say “NO” to Arbitration! ............................ 67
CHAPTER 8
HOMESTEADS AND LIFE ESTATES
Introduction ..........................................................70
Homestead Declaration ....................................... 70
What Is a Deed with a Life Estate? ...................... 71
FORM: Declaration of Homestead for Homes
Owned by Natural Persons ..........................72–73
FORM: Declaration of Homestead for Homes
Owned by Trustee(s) ......................................74–75
CHAPTER 9
TAX ABATEMENTS
How Exemptions and Deferrals Work .......................76
Exemptions .............................................................76
Deferring Taxes ....................................................... 76
Other Tax Exemptions and Credits for Older
Adults ..................................................................79
Additional Resources and Conclusion .................80
CHAPTER 10
REVERSE MORTGAGES:
Basic Information About a Potentially
Helpful Retirement Tool
Introduction ..........................................................81
What Is a Reverse Mortgage? ..............................81
How Does a Reverse Mortgage Compare with
the Other Mortgages? .......................................81
Types of Reverse Mortgages................................ 81
How Does an HECM Reverse Mortgage Work? ..... 81
Repaying an HECM Reverse Mortgage ................. 82
Reasons to Use an HECM Reverse Mortgage ....... 83
Determining Eligibility for an HECM Reverse
Mortgage ......................................................... 84
CHART: Loan Comparison .................................... 84
Fees Associated with Obtaining a Reverse
Mortgage ......................................................... 85
Reverse Mortgage Counseling .............................86
Approved HUD Housing Counseling Agencies .....86
CHAPTER 11
ELDER ABUSE, NEGLECT AND
FINANCIAL EXPLOITATION
Introduction ..........................................................87
What Is Elder Abuse? .......................................... 87
What Should I Know About Financial Exploitation
of Older Adults?................................................ 87
I Am Worried About Older Adults Who Cannot
Care for Themselves. Is Help Available? ............ 88
What Should I Know About Abuse in a Nursing
Home? ............................................................. 88
Who Can Report Elder Physical or Emotional
Abuse, Neglect or Financial Exploitation? .......... 88
Is There a Statewide Agency That Helps Older
Adult Victims? .................................................. 89
What Happens When Abuse Is Reported? ............ 89
Will an Older Adult Lose Their Rights Once
Protective Services Are Involved? ..................... 89
What Protections Are Available to LGBTQ Older
Adults? ............................................................ 89
PAGE viii TABLE OF CONTENTS
CHAPTER 12
SPECIAL CONSIDERATIONS FOR DISABLED
DEPENDENT ADULT CHILDREN
Introduction ..........................................................91
Government Benefits: SSI, SSDI and
MassHealth ...................................................... 91
Special Needs Trusts ........................................... 92
CHAPTER 13
WHAT YOU NEED TO KNOW ABOUT
SOCIAL SECURITY
Introduction ..........................................................94
Timing Retirement ............................................... 94
Factors Affecting the Calculations ........................ 95
Taxes and Other Factors to Consider ................... 95
How Working Affects Benefits ............................. 95
How Disability Affects Benefits ............................ 96
Family Benefits ................................................... 96
Contacting Social Security and Representation
by a Third Party ................................................ 97
Coordinating Social Security with Private
Retirement Benefits .......................................... 97
Social Security Benefits and Government
Pensions .......................................................... 98
CHAPTER 14
OLDER ADULT DRIVING
Introduction ........................................................100
The Aging Process ..............................................100
Mass. Registry of Motor Vehicles ......................101
Resources ...........................................................101
CHAPTER 15
OVERVIEW OF COMMON BANKRUPTCY AND
DEBT ISSUES FOR THE OLDER ADULT
Introduction ........................................................103
What Is Bankruptcy? ......................................... 103
Some General Considerations ............................ 104
How Chapter 7 Liquidation Bankruptcy Works .... 105
How Chapter 13 Reorganization Bankruptcy
Works ............................................................ 106
Alternatives to Bankruptcy ................................. 106
Conclusion ..........................................................110
CHAPTER 16
WHAT TO CONSIDER WHEN PLANNING
FOR RETIREMENT
Can I Afford to Retire? ........................................ 111
Understanding Timing for Claiming Social Security
Benefits and Taking Distributions
from Retirement Benefits ................................ 111
Will I Be Able to Afford to Stay in My
Own Home? ......................................................112
Do I Need a Financial Planner? .......................... 112
Understanding Fees and Expenses .................... 112
Using Binders and Organizers ............................ 113
Additional Resources .......................................... 113
CHAPTER 17
PENSION CONCERNS FOR RETIREES
Different Types of Pensions ............................... 114
Earning a Pension ............................................... 114
Forms of Benefits ............................................... 114
Taking Your Defined Benefit Pension as a
Lump Sum ........................................................ 115
Third-Party Interests .......................................... 116
Lost Pensions ...................................................... 116
Complie Your Documents ................................... 117
Seek Outside Help ............................................... 117
Sample Pension Benefit Request Letter ............119
CHAPTER 18
HEALTH CARE DECISIONS, MEDICAL
INFORMATION AND END-OF-LIFE CHOICES
Introduction ........................................................120
The Health Care Proxy ........................................120
TABLE OF CONTENTS PAGE ix
What Are the Differences Between a Health Care
Proxy and an Advance Directive? Do I Need a
Living Will Also? ..............................................121
Medical Orders for Life-Sustaining Treatment
(“MOLST”) ........................................................121
Accessing Medical Information ...........................121
Documents, Lists and Other Items to Bring With
You if You Are to be Hospitalized ....................122
Communicating With Your Health Care Providers,
Health Care Agent, and Family and Friends ...122
Choices at the End of Life ..................................122
Helpful Resources ............................................... 123
FORM: Massachusetts Health Care Proxy (HCP)
Instructions and Document .............................124
FORM: Massachusetts Department of Public
Health Authorization for Release of Information
Permission to Share Information ....................128
FORM: Massachusetts Medical Orders for
Life-Sustaining Treatment (MOLST) ...............129
CHAPTER 19
RESOURCE DIRECTORY .......................................130
IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS PAGE 1
CHAPTER 1
IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS
We are proud to present this 14th annual edi-
tion of the Elder Law Guide (ELG) and hope that
you find it helpful. is ELG is produced by the
Massachusetts Bar Association (MBA) in partner-
ship with the Massachusetts Chapter of the Nation-
al Academy of Elder Law Attorneys (MassNAELA).
It is designed as a resource for both attorneys and
non-attorneys alike. It is also used by volunteer at-
torneys during Elder Law Month (May) to conduct
presentations at councils on aging centers across the
state. e following questions and answers touch
upon important areas of elder law, many of which
are covered in more detail later in the guide
1. What Is Elder Law?
Elder law is a multi-disciplinary approach to the
legal needs of older individuals, and includes a wide
range of practice areas and subject matters:
(i) Health care decision-making and the use of
advanced medical directives;
(ii) Planning for disability and incapacity;
(iii) Estate planning and the use of durable pow-
ers of attorney, living trusts and wills;
(iv) Basic Social Security retirement planning;
(v) Planning strategies for Medicare, Medicaid
(MassHealth), veterans’ benefits and other
public benefits;
(vi) Housing options and alternatives to nursing
homes;
(vii) Probate avoidance strategies;
(viii) e interplay of long-term care and financial
planning;
(ix) e use of long-term care insurance; and
(x) Asset protection strategies for the family
home and other assets, including estate tax
minimization and potential long-term care
financing.
See the Resource Directory on page 130 to find an
experienced elder law attorney.
2. What Are the Essential Estate Plan
Documents I Should Have and What
Happens If I Don’t Have Them?
e following documents are essential building
blocks to your estate plan, together with some ex-
amples of potential consequences if you don’t have
them:
(i) Health care proxies and advanced medi-
cal directives
ese documents are essential in ensuring
that you have appointed individuals of your
choosing to make medical decisions for you
in the event of your incapacity and to set
forth any limitations upon their authority
to act. A discussion of these documents,
including their uses and sample templates, is
included in Chapter 18.
Absent direction, a health care provider has
the right to confer with “responsible parties”
related to you by blood or marriage to obtain
informed consent for medical care. However,
this approach may not be sufficient, particu-
larly if the circumstances require emergency
action, use of anti-psychotic medication or
the discharge to a nursing facility. It also
may not be clear who is going to act as the
responsible party, which may lead to fighting
among family about who has authority to
act on your behalf and what your wishes are.
In that event, the medical provider or family
may need to resort to the court to appoint
a guardian (a court-appointed fiduciary to
care for a person), for authority to make
medical decisions for you if you are incapaci-
tated. e guardianship process involves a
court proceeding, which is not ideal in an
emergency situation. Family members have
standing to petition the court for guardian-
ship, and the person the court deems the
This guide pertains only to the laws of Massa-
chusetts at the time of publication. It is intend-
ed for educational purposes only and is not a
substitute for legal advice specifically tailored
to your personal situation.
PAGE 2 IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS
most appropriate may be the last person you
would want to fill that role.
(ii) Durable powers of attorney
A power of attorney is a written legal docu-
ment created by you (the “principal”) that
authorizes an agent (the “attorney-in-fact”) to
legally act on your behalf in handling your
property and affairs. It is only effective dur-
ing your lifetime and will be void upon your
death. e attorney-in fact can be a spouse,
or a trusted family member, friend or profes-
sional person. You, as the principal, specify
in the document the powers you are granting
to the attorney-in-fact. You can authorize the
attorney-in-fact, for example, to sign checks,
invest assets, enter into contracts, make gifts,
create trusts (if the document provides) and
transfer property. is document is a very
powerful planning tool, and you should only
appoint someone you fully trust.
If you do not have a power of attorney, no
person automatically has control over or ac-
cess to your individually owned assets. Even
if assets are held jointly, the consent or in-
volvement of both joint owners may be re-
quired (e.g., selling a jointly owned home).
Without an authorized person to deal with
your assets, a conservator (a court-appoint-
ed fiduciary to manage a person’s property)
must be appointed. Again, this involves time-
consuming court proceedings, often at times
when immediate action is needed.
(iii) Wills and guardian/conservator designa-
tions for minors or disabled adult chil-
dren (if applicable)
A will leaves directions regarding several key
functions upon your death. It nominates fi-
duciaries to deal with your property and to
care for any minor or disabled adult children.
It empowers the fiduciaries to act, and it gives
direction regarding the disposition of your
assets. Every person needs a will, regardless
of whether a trust (see below) is also part of
your estate plan. In that case, your will would
direct that your assets pass to the appropriate
trust.
If you do not have a will, you are considered
to have died intestate. If you do not otherwise
dispose of your assets (e.g., joint ownership,
trusts or beneficiary designations), the com-
monwealth determines where they will go
by statute. is may not be in keeping with
your wishes (e.g., an estranged sibling could
inherit if you have no spouse, descendants or
living parents).
Depending upon your estate planning goals and
your current financial situation, you may also wish
to consider the following:
(i) Real estate deeds with life estates and realty
trusts (see Chapter 8, section B)
(ii) Revocable and irrevocable trusts (see section 6
in this chapter; also Chapter 3, section I)
(iii) Gifting plans (see Chapter 3, sections L and
M; see also question #20 in this chapter)
(iv) Tax plans (see questions 19 and 20 in this
chapter)
(v) Asset protection plans (see Chapter 3, sections
C, D, G, J and N)
3. If I Already Have Some of These
Documents, Why Should I Review and
Update Them?
(i) Your circumstances change over time, so it
is important to periodically review your plan
to ensure that your documents still reflect
your wishes and will accomplish your goals.
e laws change periodically (such as major
changes to the probate laws in 2012 and tax
law changes in 2017, 2020 and 2022), and
such changes can have significant and unin-
tended consequences for plans executed prior
to the changes.
(ii) Your goals may change as you progress to dif-
ferent stages of life (for example, planning
for minor children, planning for marriage or
remarriage, planning to minimize estate tax-
es, planning to avoid probate or to avoid the
cost of long-term care). Changes may occur
in your family makeup, and the persons you
named as beneficiaries in your will or trust
may no longer be appropriate due to death,
disability or bankruptcy. erefore, the plan
that made sense at an earlier time may need
to be updated.
IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS PAGE 3
(iii) It is important to reevaluate the people you
chose as fiduciaries in your health care proxy,
durable power of attorney, will and trust, to
determine whether those individuals are still
appropriate choices. Often, individuals list
parents or other family members who may no
longer be living or competent, or friends with
whom the individual has not kept in contact.
4. What Should Unmarried Couples Consider?
Unmarried couples have the same needs and
rights as anyone else, but it is particularly important
for these couples to protect one another through an
appropriate estate plan. A properly drafted estate
plan can establish rights for your partner that the
law does not otherwise provide to an unmarried
couple.
As noted above in section 2, should you become
incapacitated without a health care proxy and/or a
durable power of attorney, your partner may have
little or no right to participate in your medical care
or to assist and protect your financial or other in-
terests. In addition, absent proper estate planning,
your partner may not receive any intended post-
death gifts or inheritance from you. For example, if
you die owning a house in your sole name that you
shared with your partner and did not complete the
appropriate planning, your partner would have no
rights to the home. Often, the only options avail-
able to a partner in this situation are to vacate or
to engage in costly litigation to try to establish an
equitable interest in the home.
5. What Should I Consider with Respect to
Joint Ownership of Assets?
ere are a number of circumstances and risks
to consider with jointly owed assets, some of which
are the following:
(i) Using a joint account as a will substitute:
Many people name one child as a joint owner
on an account with the intent that the child
will distribute the asset to others (including
other children) after death, but there is no le-
gal obligation to do so. Even if the joint own-
er has the best intentions to effectuate your
wishes, if the joint owner is going through a
divorce or being sued, the joint owner may
not be able to transfer the joint asset as in-
tended;
(ii) Risking loss of your funds: Any joint owner
has the legal right to access 100% of joint as-
sets at any time. Likewise, you risk exposure
of your assets to the joint owner’s creditors
(lawsuit, divorce, bankruptcy) or;
(iii) Negative impact on your joint owner: ere
could be unintended negative consequences
to the joint owner (or their children); e.g., in
the context of an application for financial aid,
the joint asset must be disclosed and is count-
able as the joint owner’s asset on a financial
aid application.
6. What Is a Trust, and What Forms of Trusts
Are Commonly Used?
(i) Types of Trusts. Trusts are used to hold as-
sets for the benefit of an individual or indi-
viduals (beneficiary(ies)). e money or prop-
erty held in the trust is managed by a trustee
according to the grantor’s (your) instructions.
ere are many different types of trusts, but
the most common are (a) revocable trusts, (b)
irrevocable trusts and (c) supplemental needs
trusts (SNT).
(ii) Revocable Trusts. A revocable trust is a trust
over which you, the grantor or donor, retain
the ability to amend or revoke (terminate) the
trust later. A revocable trust is often used as
a will substitute designed to avoid probate by
transferring the title of assets into the name
of the trust. You generally serve as trustee
during your life and name those persons you
wish to be trustees after your passing to carry
out your wishes. If you have a revocable trust,
you should still also have a will to direct that
all assets that remain in your name at the
time of your death, or that later come into
the name of your estate (e.g., an inheritance
or abandoned property), will be distributed
to the trust. is type of will is sometimes
referred to as a “pour over” will.
(iii) Irrevocable Trusts. An irrevocable trust is a
trust that, once established, except for rights
retained at the outset, cannot be changed or
revoked by the grantor. For older adults, ir-
revocable trusts are commonly used for asset
protection planning for long-term care and
require careful thought and consideration
PAGE 4 IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS
amount is adjustable if the income increases
or decreases. If health or medical consider-
ations are the major concern, and your new
accommodations should include supportive
or health/medical services, you will want
to consider an assisted living facility (ALF),
a continuing care retirement community
(CCRC) or a long-term care facility. See
Chapter 7.
(iv) Older adults are exploring many innovative
housing models to ensure a better quality of
life, as an alternative to homeownership, in-
cluding a one-floor living space with no stairs
and a resulting lessened need for maintenance
concerns. ese housing options include age-
restricted communities, condominiums, in-
law apartments, shared living, conversion
housing models adjacent to or owned by col-
leges and universities, and market rentals of
new housing units.
8. What Should I Know if Considering a
Reverse Mortgage? (See Chapter 10)
(i) A reverse mortgage loan is secured by your
home. It is a non-recourse loan, which means
that your heirs are not responsible for paying
off what is due on your death.
(ii) You must be 62, living in the home as your
principal residence and be able to pay taxes
and the maintenance of the property. e
loan is due on your death or the sale of your
home, or if you have not lived in the home for
one year due to medical or other reasons.
(iii) A reverse mortgage could help if you do not
qualify for a home equity line of credit. Un-
like a line of credit, a reverse mortgage does
not have an asset or income test — only the
equity in your home is considered.
(iv) Before undertaking a reverse mortgage, you
should explore other ways that may be avail-
able for making your income cover your ex-
penses, such as a property tax deferral or oth-
er abatements offered by your city or town.
If you are eligible, you should compare the
monthly savings so that you can determine if
a reverse mortgage is worth pursuing. Elder
law attorneys can assist you in the process.
and, most importantly, the expertise of an ex-
perienced elder law attorney. e trust must
comply with MassHealth rules and regula-
tions, and the assets that are transferred to
the trust may trigger the “five-year look-back
period” for eligibility. is trust is also estab-
lished by you as the grantor but typically must
have an “independent trustee,” who may be
a family member. Your access to and control
of the trust will likely be limited to “interest
only,” so the principal is beyond your control,
and you may not have the right to change the
beneficiaries or other terms of the trust.
(iv) Special Needs Trusts or Supplemental
Needs Trusts. A supplemental or special
needs trust (SNT) is a specialized trust that
protects assets for a disabled individual and
supplements the needs of that individual by
funding things that are not otherwise cov-
ered by government benefits and/or other
sources of support. For government benefit
purposes, funds in a properly drafted SNT
are not counted as the beneficiary’s assets in
determining eligibility.
7. What Options Do I Have if I Have to, or
Want to, Sell My Home?
(i) Making the decision to sell your primary resi-
dence requires a good working knowledge of
what alternatives exist beyond the sale of your
home and buying a replacement. If financial
considerations are the major concern, you
may want to look at residential programs that
are affordable or even subsidized by the state
or federal government.
(ii) Most communities have elder housing de-
velopments, and your local council on aging
can connect you to an advocate who can help
identify potential accommodations and dis-
cuss the pros and cons of public housing.
(iii) Besides elder housing developments, there are
also subsidy voucher programs, like the so-
called Section 8 program (the housing choice
voucher program), where a tenant can enter
a lease with a willing landlord in the private
rental market. In these subsidized programs,
the tenant typically pays between 30 and
40% of monthly income for rent, and the
IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS PAGE 5
(v) e loan works like a home equity loan in
that you can draw as many funds as you
need. However, it is vitally important that
you understand how compounding of inter-
est impacts the balance due at the time of the
payoff of the loan. Chapter 10 has a number
of helpful examples and charts that explain in
detail how reverse mortgages work.
9. What if I Incur Unmanageable Debt? Is
Bankruptcy an Appropriate Option? (See
Chapter 15)
(i) As older adults reach retirement age, an an-
ticipated and often welcome event, they may
find that it is also a financial event that may
trigger unanticipated circumstances due to a
new economic framework that, in many cas-
es, shifts the older adult into a fixed income
situation.
(ii) is new financial status can be fraught with
unanticipated monetary consequences. ere
are many circumstances, such as a catastroph-
ic medical event, an uninsured accident, an
unexpected increase in household expenses,
poor credit card management, and the like,
that can leave older adults with debt beyond
their means.
(iii) In addition to the unpleasantness of be-
ing unable to pay your bills on time and to
make necessary purchases, you may become
a “debtor,” who then becomes subject to un-
pleasant contact by creditors. Options are
available to the debtor for managing the ram-
ifications of being in debt and for solving the
debt problem altogether.
(iv) ere are many considerations to navigate,
one of which is for the indebted older adult
to explore the option of initiating a bank-
ruptcy. It would benefit the indebted older
adult to consult with a professional for advice
in strategizing and deciding upon the right
option for solving the problem, and if initiat-
ing a bankruptcy is to be explored, it is im-
perative that the older adult consult with an
experienced bankruptcy attorney to explore
the pros and cons of this option, as the bank-
ruptcy process is complex and technical. See
Chapter 15.
10. What Should I Know About Elder Abuse,
Neglect and Financial Exploitation? (See
Chapter 11)
(i) Elder abuse, which can be committed by
anyone, including a caretaker, conservator or
guardian, can cause: (a) physical or emotional
injury, including sexual abuse; (b) financial
exploitation; or (c) denial of life necessities es-
sential for the physical and emotional well-
being of the older adult (neglect). Elder abuse
also includes self-neglect.
(ii) Financial exploitation comes in many forms,
from the misuse of powers of attorney, by
guardians or conservators who take advan-
tage of older adults, unscrupulous financial
advisers, planners, attorneys, accountants,
home care workers, and other scam artists and
professionals. Often, the older adult does not
know that the money has been mishandled,
that the trust has been betrayed and that such
predatory practices have taken place over long
periods of time.
(iii) e warning signs are unusual bank and
ATM withdrawals; late payments on bills;
abrupt changes in wills, trusts, powers of at-
torney, deeds and mortgages; and changes
in beneficiaries on insurance policies, bank
accounts and investments. Another warning
sign is that a new or significantly younger
“friend” of the older adult has been receiving
substantial “gifts.”
(iv) Elder abuse in a nursing home is especially
disturbing, resulting in willful infliction of
injury; unreasonable confinement; intimi-
dation, including verbal or mental abuse or
punishment with resulting physical harm,
pain or mental anguish; or assault and bat-
tery.
11. What Is the Difference Between Medicaid
and Medicare? (See Chapters 3, 4 and 5)
(i) Medicaid, known as MassHealth in Massa-
chusetts, is a joint federal-state medical as-
sistance program based on financial need.
It comprehensively pays for the medical and
health maintenance needs of those receiving
benefits. Medicaid also pays for long-term
PAGE 6 IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS
nursing home care or for home health aides
in the community. See Chapter 4.
(ii) Medicare is a federal health insurance pro-
gram associated with Social Security Insur-
ance benefits for older and disabled individu-
als. Medicare assists in paying for medical
expenses, including prescription drugs, du-
rable medical equipment and up to 100 days
of skilled nursing care each year. Medicare
does not pay for extended nursing home or
custodial care. Most citizens are eligible for
Medicare at age 65 based on their work his-
tory. See Chapter 5.
12. How Do I Know if Veterans Administration
Benefits Will Help Me? (See Chapter 2)
(i) e VA pension program is a needs-based
benefit for disabled veterans who suffered a
disabling injury during active military ser-
vice.
(ii) Older adults may be eligible, as either a single
veteran, a veteran with a spouse or a surviving
veteran with a spouse, for an important VA
benefit for home care or assisted living called
“VA pension with Aid and Attendance.” Lo-
cal Veteran Service Offices (VSO) are able to
assist with the eligibility and application pro-
cess.
(iii) A key eligibility requirement for the Aid and
Attendance benefit is that the veteran’s “un-
reimbursed recurring medical expenses” are
used to offset gross income. us, monthly
medical expenses must exceed monthly in-
come and must be “out of pocket,” meaning
non-reimbursable by insurance.
(iv) e veteran or surviving spouse must also
have limited net worth. e current net
worth is linked to the $148,620 spousal al-
lowance permitted by MassHealth (see section
14 on this page).
(v) e MassHealth asset and transfer rules are
also currently followed.
(vi) ere are other service-connected compensa-
tion plans for which a surviving spouse meet-
ing certain conditions may qualify under the
“Dependency and Indemnity Compensation”
(DIC) program. A local VSO or an elder law
attorney can assist you in understanding how
these complex benefits apply as well as the ap-
plication process.
13. What Is Long-Term Care Insurance (LTCI)?
(See Chapter 6)
Long-term care insurance (LTCI) is an insur-
ance product that provides benefits to help cover
the costs associated with in-home care or assisted
living care, or the costs of care in a skilled nursing
facility. LTCI products have many options and are
complex contracts that require careful consideration
and planning. A proposed policy should be reviewed
with your financial adviser and elder law attorney
to weigh the pros and cons of using LTCI in your
particular circumstances.
14. If I Need Nursing Home Care, But My
Spouse Does Not, Will I Still Be Eligible for
Medicaid? (See Chapter 3)
You can still be eligible for Medicaid assis-
tance, and your spouse may keep their income
and your assets up to certain limits. e Medicaid
(MassHealth) regulations are designed to protect
the healthy spouse (referred to as the “community
spouse”) from poverty when the other spouse en-
ters a skilled nursing facility. e community spouse
is currently allowed to keep $148,620 in countable
assets. is amount is known as the Community
Spouse Resource Allowance (CSRA).
ere are strategies available to preserve addi-
tional assets that exceed the CSRA. Medicaid will
not place a lien on the couple’s home as long as the
home is the principal residence of the community
spouse. In certain situations, the community spouse
may also keep a portion of the institutionalized
spouse’s income. See Chapter 3.
15. What Are My Rights as an Older LGBTQ
Person or Person Living with HIV?
You have the absolute right to age with dignity.
If you experience discrimination based on your sex-
ual orientation, your gender identity or your HIV
status, you should contact an attorney right away.
You are entitled to competent care in all aspects of
your life, including health and medical services,
continuing care and long-term residential care. You
are entitled to live free from discrimination and ha-
IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS PAGE 7
rassment. For example, if you are transgender and a
long-term care provider tells you that you may not
be placed in a semi-private room consistent with
your gender identity, you should seek legal help im-
mediately. Most people who provide elder services
at home or in assisted living facilities are required
by law to have special training to care for LGBTQ
older adults. However, this training has not yet been
expanded to include those providing care in a skilled
nursing environment. erefore, asking questions of
prospective skilled nursing facilities such as, “Do
you have any LGBTQ residents?” can shed valuable
light on the facility’s attitudes and sensitivity toward
LGBTQ residents.
16. What Is Probate?
Probate is a court process that may be neces-
sary when someone dies with property in their in-
dividual name to transfer the assets to that person’s
heirs or to the beneficiaries named in their will. e
probate process is necessary when the asset itself
does not establish the subsequent owner after the
decedent’s death (i.e., assets held in a person’s name
individually with no joint owner, designated ben-
eficiary, or other payable on death clause or provi-
sions). rough the probate process, the court will
determine if the decedent’s will is valid (or that the
decedent did not have a will, as the case may be) and
who the heirs of the estate are, and will appoint a
“personal representative” (usually nominated in the
will and commonly known as an executor or execu-
trix) to handle the business of the estate.
ere are several different types of probate. An
estate may qualify for a simplified probate proce-
dure called voluntary administration provided that
the estate assets are under $25,000 (excluding an au-
tomobile), as long as there is no real estate involved.
Any interested person (see M.G.L. ch. 190B, section
1-201(24)) can use this procedure by filing a volun-
tary statement with the probate court.
For estates greater than $25,000, there are two
basic types of probate:
(i) Formal probate, which is a judicial proceed-
ing often used when there is Massachusetts
real estate involved. is process legally de-
termines who the heirs are and allows a will,
if any.
(ii) Informal probate, which is an administrative
proceeding that is quicker, but does not legal-
ly determine heirs or allow wills. You should
consult a lawyer to determine whether you
should use this procedure if there is real estate
involved.
17. What Does It Mean to Avoid Probate?
Avoiding probate simply means that the probate
court is not needed to determine who owns assets at
death because the assets expressly indicate who will
inherit them. For example, assets with a beneficiary
designation, joint property (e.g., jointly held bank
accounts, real estate, stock accounts, etc.) and prop-
erty passing by contract (e.g., 401(k)s, IRAs, life
insurance, annuities, etc.) are usually non-probate
property.
Avoiding probate can be accomplished in the
following ways:
(i) By placing all assets in a trust.
(ii) By making accounts payable on death to
another, or ensuring that retirement and
brokerage accounts, annuity contracts and
life insurance policies have named beneficia-
ries.
(iii) By placing all assets (e.g., bank accounts,
real property, brokerage accounts, mutual
funds, stocks, etc.) into joint ownership
with another person or persons, who would
inherit the joint assets after the individual’s
death.
In addition, there are simplified methods for
dealing with specific probate assets without utiliz-
ing the court:
(i) A spouse (or heirs, if the spouse is deceased)
may collect bank and/or credit union ac-
counts that do not exceed $10,000 (See
Mass. G.L. ch. 167D, § 12 and Mass. G.L.
ch. 171, § 42); and
(ii) A spouse may sell or reregister title to the
decedent’s automobile(s) (see Mass. G.L. ch.
90D, § 15A).
18. What if Property Is Located Out of State —
What Is Ancillary Probate?
Your family could be required to file a second
probate, known as “ancillary” probate, if you die
PAGE 8 IMPORTANT QUESTIONS AND ANSWERS FOR OLDER ADULTS
owning real property (land or a house) in another
state. People who own property in another state
should consult with an attorney to discuss how to
avoid an ancillary probate.
19. What Are Federal and State Estate and Gift
Taxes, and How Do They Operate?
(i) Both state and federal governments can im-
pose an estate tax on high-net-worth estates.
In 2023, the federal combined estate and gift
tax exemption is $12,920,000, and the Mas-
sachusetts estate tax exemption is $1,000,000.
With proper estate planning, a married cou-
ple may maximize the use of their estate tax
exemption amounts and possibly reduce or
avoid state and federal estate taxes. Currently,
the federal estate tax rate is 40%, and in Mas-
sachusetts, the rate is as high as 16%, depend-
ing on the size of the decedent’s gross estate.
(ii) ere is no estate tax on property that passes
to a spouse, as long as the spouse is a U.S. citi-
zen and the property otherwise qualifies for
the unlimited marital deduction (IRC 2056).
Decedents may also reduce their gross estate
by leaving certain assets to qualified chari-
ties using the unlimited charitable deduction
(IRC 2055).
(iii) If one or both members of a married couple
are not U.S. citizens, couples should consult
with a qualified estate planning attorney to
plan for the limited estate tax exemption al-
lowed to a surviving non-U.S.-citizen spouse.
20. What Issues Should You Consider Before
Making Significant Lifetime Gifts?
(i) You should always consult with a qualified
attorney and tax professional before making
significant gifts. Large gifts may have unan-
ticipated consequences, including tax conse-
quences, effects on eligibility for government
benefits and consequences to your own future
financial needs.
(ii) Massachusetts does not impose a gift tax.
ere is a federal gift tax, however. Individu-
als may give up to $17,000 (married couples
up to $34,000) per person per year (the 2023
gift tax annual exclusion amount) without
the need to file a federal gift tax return or
pay a gift tax. Gifts in excess of the annual
exclusion amount must be reported on a gift
tax return but will not cause a gift tax to be
due unless a person’s total lifetime gifts ex-
ceed the exemption amount ($12,920,000
in 2023). Gifts for a person’s medical care or
education made directly to institutions may
be non-reportable exempt transfers even if in
excess of the annual exclusion (IRC 2503(e)).
(iii) Gifts of assets that have appreciated in value
(e.g., stock or real estate) may reduce poten-
tial estate tax liabilities, but could adversely
impact a later capital gains tax on the sale of
the gifted asset.
(iv) Gifts may also adversely impact eligibility for
Medicaid benefits. For example, if a person
makes a significant gift and needs to enter
a long-term care facility within five years of
vmaking the gift, they could be denied eli-
gibility for Medicaid benefits for a period of
time based on the total amount gifted.
VETERANS AFFAIRS FINANCIAL BENEFITS PAGE 9
CHAPTER 2
VETERANS AFFAIRS FINANCIAL BENEFITS
Pension and Compensation for Eligible Veterans
and their Surviving Spouses
INTRODUCTION
e U.S. Department of Veterans Affairs (VA)
provides two distinct financial benefit programs to
qualified veterans or to their surviving spouses: 1)
non-service-connected pension and 2) service-con-
nected compensation. e VA pension is a needs-
based benefit for disabled and elderly claimants who
meet a specific set of financial and non-financial
criteria. VA compensation, on the other hand, is a
benefit for veterans who suffered a disabling injury
during active military service.
VA PENSION WITH AID AND ATTENDANCE
Non-service-connected pension is a benefit that
provides monthly payments to low-income wartime
veterans, or their dependents, who are disabled or
over the age of 65. Pension claimants who are house-
bound or require the aid and attendance of another
person are eligible for a higher payment amount. is
enhanced pension is commonly referred to as “Aid
and Attendance.” Aid and Attendance can serve as
a critical source of funds that can help veterans and
their surviving spouses offset the costs of their home
care, assisted living or nursing home care.
e maximum amount a claimant is eligible
to receive for pension with Aid and Attendance is
based on that claimant’s payment category. A vet-
eran, a veteran with a spouse and a surviving spouse
of a veteran fall into different payment categories.
Claimant’s Payment
Categories
2023 Maximum Monthly
Payment for Pension with
Aid and Attendance
Single veteran $2,229
Veteran with a spouse $2,642
Surviving spouse
of a veteran
$1,432
All VA pension payments are tax-free, as it is a reim-
bursement for care costs.
FINANCIAL LIMITATIONS
e VA pension benefit is needs-based, and
therefore, the claimant must meet income and as-
set limitations. If a claimant is married, then the
VA includes income and medical expenses of both
spouses to determine total net income. All earned
and unearned income is added together, such as So-
cial Security, pension income, interest, dividends
and business income. e claimant must also report
lump-sum income, including inheritances, lottery
winnings, gifts and awards.
All recurring unreimbursed medical expenses
(UMEs) are used to offset gross income. ese ex-
penses can include nursing home costs, assisted liv-
ing costs, home health care and health insurance
premiums. ese expenses, however, must be “out
of pocket” and not reimbursable by insurance or a
third party. e difference between the claimant’s
gross income and unreimbursed medical expenses is
the “Income for Veterans Affairs Purposes” (IVAP).
If the IVAP is less than zero (if medical expenses ex-
ceed gross income), then the claimant can be eligible
for the maximum pension payment with Aid and
Attendance. If the IVAP is greater than zero, but
less than the monthly Aid and Attendance benefit,
then the claimant can receive benefits equal to their
monthly benefit minus the IVAP.
e claimant must also have limited assets to
qualify for the non-service-connected pension pro-
grams, including Housebound and Aid and Atten-
dance. e VA uses a net worth test. It calculates
the applicant’s IVAP (if a married veteran, the IVAP
of both spouses is considered) and adds that to the
countable assets. Please note that the IVAP is of-
ten zero, as the IVAP calculation is based on the
initial application for pension with Aid and Atten-
dance, and recurring care costs generally exceed the
income. For 2023, the net worth must be no more
than $150,538. e VA’s net worth limit increases
every Dec. 1 to match the Consumer Price Index
PAGE 10 VETERANS AFFAIRS FINANCIAL BENEFITS
inflation percentage increase for Social Security.
In calculating the claimant’s net worth, the
claimant’s primary residence and up to two acres of
attached land, vehicles for personal use and personal
belongings are excluded. e recent rule changes
specify that the exclusion of the primary residence
is limited to the dwelling and a lot area of two acres.
Excess acreage is counted but only to the extent that
the excess land is marketable. If it is not marketable,
then it will have no value. If the claimant’s primary
residence is sold, the sale proceeds will be considered
as part of the claimant’s net worth, unless the claim-
ant purchases a new primary residence in the same
calendar year. For example, if the claimant sold the
primary residence on Dec. 10, they would only have
21 days to purchase the replacement residence, or
the sale proceeds would be part of the claimant’s net
worth.
All assets that can be liquidated (with the excep-
tion of the primary home as described above, person-
al effects suitable for a “reasonable mode of life” and
a vehicle), whether owned by the veteran or the vet-
eran’s spouse, such as CDs, annuities, stocks, bonds,
savings accounts, checking accounts and IRAs, are
included in the claimant’s net worth. Term or group
life insurance and other financial investments that
do not have a cash surrender value are not countable
assets. Lastly, the VA includes the annual income of
the claimant and the claimant’s dependents in the
net worth calculations. For example, if a claimant
has $100,000 in countable assets and an annual in-
come of $12,000, then the VA will determine the
net worth of the claimant to be $112,000. Howev-
er, as stated above, the income is often zero, as the
IVAP is generally a negative number.
On Oct. 18, 2018, the VA implemented a three-
year look-back period and a penalty period for cer-
tain asset transfers for claimants seeking non-ser-
vice-connected pension and Aid and Attendance.
e VA will penalize a claimant who has, within
the look-back period, transferred a “covered” asset
on or after Oct. 18, 2018 (all transfers prior to Oct.
18, 2018, are exempt). A covered asset is the amount
by which a claimant’s net worth would have exceed-
ed the $150,538 limit if the uncompensated value of
the covered asset had been included in net worth.
For example, if a single claimant has $0 in IVAP
and $140,000 in assets but gave away $20,000 in
2022, the claimant has a “covered asset” that was
transferred in the amount of $9,462. In contrast, if
a single claimant has $0 in IVAP and $120,000 in
assets and gave away $20,000 in 2022, no transfer
of a “covered asset” has occurred because when the
transferred asset is added back in, the claimant is
still under the $150,538 net worth limit. In other
words, if a claimant’s transfer of assets qualifies a
claimant for a VA pension, then the VA will imple-
ment a penalty. If, on the other hand, a claimant’s
transfer had no effect on eligibility because the
claimant was already asset eligible before the trans-
fer, then the VA will not apply a penalty and there is
no “covered asset.”
e length of the penalty is calculated by deter-
mining the value of the covered assets transferred
and dividing that amount by the monthly penalty
rate. e monthly penalty rate is determined by
the Maximum Annual Pension Rate (MAPR) in
effect on the date of the pension claim at the Aid
and Attendance level for a veteran with one depen-
dent, divided by 12. e penalty period will begin
the month following the date of the last transfer.
e monthly penalty rate for a veteran with one de-
pendent in 2023 is $2,642. For example, a claimant
seeking eligibility in January 2023 who transferred
$2,642 in covered assets on Nov. 1, 2022, will be
penalized for one month. e VA will not issue a
penalty that exceeds five years, and the VA allows a
claimant to “cure” a disqualifying transfer within a
certain amount of time.
MILITARY REQUIREMENTS
e veteran must also meet specific military re-
quirements to qualify for the VA pension. e vet-
eran must have served at least 90 days of active duty,
one day of which was served during a period of war.
For veterans of the Gulf War to present, the service
requirement is 24 months or completion of the re-
quirement for active-duty service, whichever comes
first. Periods of war fall within the following time
frames:
VETERANS AFFAIRS FINANCIAL BENEFITS PAGE 11
World War II:
Dec. 7, 1941–Dec. 31, 1946
Merchant Marines (Dec. 7, 1941–Aug. 15, 1945)
Korean War:
June 27, 1950–Jan. 31, 1955 (inclusive)
Vietnam War:
Nov. 1, 1955–May 7, 1975, These dates apply for
veterans who served “in-country” in the Republic of
Vietnam during this time period otherwise.
Aug. 5, 1964–May 7, 1975, inclusive for all others.
Gulf War:
Aug. 2, 1990– currently undetermined. A date to be
set by law or presidential proclamation (for VA benefits
purposes, this time of war is still in effect).
Active duty does not include “reserve” duty. Fi-
nally, the veteran must have been discharged under
conditions other than dishonorable.
DISABLITY REQUIREMENT
e VA pension is “non-service-connected” be-
cause the veteran’s or veteran’s surviving spouse’s
disability does not need to be connected to or result-
ing from the veteran’s military service. To medically
qualify for base pension, veterans must be either age
65 or older, or totally and permanently disabled or a
resident in a nursing home. To receive the enhanced
pension with Aid and Attendance, the claimant
must require the aid of another person or require
supervision from harm in order to perform personal
functions required in everyday living.
MARRIAGE REQUIREMENT
e pension benefit paid to a surviving spouse
is referred to as Survivor’s Pension or Death Pen-
sion. In order for a surviving spouse of a veteran to
qualify, the spouse must also satisfy certain marital
requirements. e surviving spouse must have been
married to the veteran for at least one year or, in
the alternative, had a child with the veteran. e
surviving spouse must also have remained married
to the veteran and cohabitated with the veteran
continuously until the veteran’s death. A divorce or
separation from the veteran terminates the former
spouse’s entitlement to Survivor’s Pension. Likewise,
a surviving spouse who remarries after the veteran’s
death terminates survivor’s eligibility. Benefits are
available to the same-sex spouse of a veteran on the
same terms as an opposite-sex spouse. e VA has
provided guidance on marriage benefits for same-sex
couples, available here: www.va.gov/opa/marriage/.
SERVICE-CONNECTED COMPENSATION
e VA’s service-connected compensation is dis-
tinct from the VA’s non-service-connected pension
in several ways. Unlike the VA pension, VA com-
pensation is not based on financial need, and there
is no income or asset test to qualify. e asset limits
and transfer penalties described above do not apply
to service-connected eligibility. e compensation is
a monetary benefit paid to a disabled veteran whose
disability was incurred or aggravated while serv-
ing in active military service. Incurred in the line
of duty does not mean combat-related. Unlike the
VA pension, wartime service is not required. For ex-
ample, a veteran who suffered from post-traumatic
stress disorder (PTSD) during the Vietnam conflict
could qualify for compensation, as could a veteran
who injured their back on a military base during
peacetime.
e VA pays compensation on a scale from 10%
to 100% in increments of 10%. Effective Dec. 1,
2023, the VA pays a veteran with no dependents
rated at 10% disability $165.92 per month, while
the VA pays the same veteran rated at 100% disabil-
ity $3,621.95 per month. e veteran with a rating
ranging from 30% to 100% will receive a higher
amount if the veteran has a spouse and/or depen-
dent children.
e key component with compensation is es-
tablishing the nexus between the veteran’s disability
and the veteran’s military service. is connection
must be established with sufficient medical evi-
dence. ere are some disabilities, however, that are
presumed to be caused by a veteran’s military ser-
vice. is presumption relieves the claimant from
the burden of proving the connection between the
disability and the veteran’s military service. For ex-
ample, the VA presumes that a veteran with respi-
ratory cancer who was exposed to Agent Orange
during the Vietnam conflict has a service-connected
illness and may qualify for compensation.
Nursing home coverage is available for veterans
who need nursing home care for a service-connect-
ed disability. A veteran with a minimum service-
PAGE 12 VETERANS AFFAIRS FINANCIAL BENEFITS
connected disability rating of 60% for one condi-
tion who has been deemed permanently and totally
disabled or has a 70% combined disability rating
is similarly eligible. In the case of a private nurs-
ing home contracted with the VA, there may be a
copayment.
A surviving, dependent child or parent of a vet-
eran who died in the line of duty, or who died from
a service-related injury or illness, may also qualify
for compensation under certain conditions. is
survivor’s benefit is called “Dependency and Indem-
nity Compensation” (DIC). To qualify for DIC, for
surviving spouses, they must have been married to
a veteran who died while in the service, or married
to a veteran who was rated as 100% disabled for at
least 10 years prior to the veteran’s death (other con-
ditions may apply as well). If the surviving spouse
remarries, then potential eligibility for DIC is ter-
minated.
APPEALS
e Appeals Modernization Act took effect in
February 2019 and significantly changed the ap-
peals process. Any claimant who receives an initial
VA claim decision after February 2019 will follow
the new Appeals Modernization process if they dis-
agree with the decision. ere are three ways to ap-
peal: (1) higher-level review; (2) supplemental claim;
or (3) appeal to the Board of Veterans’ Appeals. e
VA brochure that explains the process is located at:
https://benefits.va.gov/BENEFITS/factsheets/ap-
peals/Appeals-Brochure.pdf.
MASSHEALTH (MEDICAID) PAGE 13
CHAPTER 3
MASSHEALTH (MEDICAID)
What You Need to Know About Medicaid Eligibility
and Transfer Rules for Long-Term Care in a Nursing Home
INTRODUCTION
For most older adults, the prospect of long-term
care in a nursing home is, to say the least, unpleas-
ant. Older adults worry that the cost of long-term
care will deplete their estates. e cost of nursing
home care in Massachusetts, which typically ranges
from $140,000 to $190,000 per year (the daily rate
is often over $400), only serves to compound these
fears. e premiums to purchase long-term care in-
surance to pay for the cost of long-term care are fre-
quently beyond the means of middle-income older
adults, or long-term care insurance may not even
be available to some older adults due to preexisting
medical conditions. See Chapter 6.
Many older adults receive assistance from the
federal Medicare program to help pay for medical
expenses and the cost of prescription drugs. Gener-
ally, Medicare may pay for a portion of short-term
rehabilitation in a skilled nursing facility but not for
non-skilled (custodial) care (see Chapter 5 for further
information). Medicaid (known as MassHealth in
Massachusetts), on the other hand, is a joint federal-
state program that pays for nursing home care for
individuals who meet complex financial eligibility
and clinical rules.
1
e term “MassHealth” will be
used throughout this chapter. A growing percent-
age of older adults are seeking alternatives to nursing
homes, including remaining at home with caregivers
or moving to independent living communities, con-
tinuing care retirement communities or assisted liv-
ing facilities. Options to help finance long-term care
outside of nursing homes are addressed in Chapter
4.
In determining an applicant’s financial eligibil-
ity, MassHealth looks at the individual’s income
and assets.
INCOME
All money an applicant
receives, such as:
ASSETS
Anything an applicant
owns, such as:
Social Security Cash
Dividends Mutual Funds
Pensions Automobile
Rental Income Real Estate
Retirement Accounts
Whole Life Insurance
MassHealth is a complex area. Rules and regula-
tions change frequently, and there are many excep-
tions to the rules. Unlike private health insurance,
MassHealth has the right to recover its costs from
your estate. (See Section O.) It is important to con-
sult with an experienced elder law attorney.
A. Income Limitations
ere are no income thresholds for nursing
home residents so long as the applicant’s income
does not exceed the private pay rate at the nursing
home. Instead, the resident contributes all of their
income toward the monthly cost, minus certain al-
lowed deductions for health insurance premiums
and a Personal Needs Allowance (PNA), which is
currently $72.80, and MassHealth covers the dif-
ference.
If there is a non-applicant spouse, called a “com-
munity spouse,” they will be able to keep all of their
own income. If that income is low and falls below a
certain minimum, the community spouse will then
be allowed to keep a portion of the nursing home
spouse’s income, as outlined in Section B of this
chapter.
PAGE 14 MASSHEALTH (MEDICAID)
EXAMPLE 1
MassHealth
Charlotte is 70 years old and unmarried. She is admit-
ted to a nursing home for long-term care and applies
for MassHealth. She receives Social Security income
of $1,000 per month. She pays a Medicare supplement
health insurance premium of $220 per month. She must
pay $707.20 ($1,000 - $220 - $72.80) of her Social Se-
curity to the nursing home each month as Patient Paid
Amount (PPA), assuming she has less than $2,000 of
countable assets and is otherwise eligible. MassHealth
will pay for the balance of her nursing home and medical
care.
B. Minimum Monthly Maintenance Needs
Allowance (MMMNA) and the Patient Paid
Amount
MassHealth rules provide that a community
spouse needs income equivalent to 150% of the fed-
eral poverty level for two persons, which through
June 2023 is $2,288.75,
2
and is referred to as the
Minimum Monthly Maintenance Needs Allowance
(MMMNA). MassHealth will determine the com-
munity spouse’s actual income as well as their ac-
tual expenses. In addition to the basic MMMNA,
MassHealth makes an adjustment if the community
spouse’s shelter expenses exceed 30% of the mini-
mum (which is currently $686.63).
EXAMPLE 2
Mrs. Smith, a community spouse, has monthly income
of $1,800. Her shelter costs (mortgage payments or
rent, condo fees, real estate taxes, homeowners in-
surance, utilities) total $1,086.63, which is $400 more
than the federal minimum of $686.63. As a result, Mrs.
Smith’s MMMNA is $2,200, which is the total of her
$1,800 income plus the $400 excess shelter costs. Be-
cause Mrs. Smith requires additional funds above her
$1,800 income to satisfy her $2,200 MMMNA, she is
granted a $400 Spousal Monthly Maintenance Income
Allowance from Mr. Smith’s monthly income.
MassHealth calculates the MMMNA at the time
it determines the nursing home spouse’s PPA, which
is the amount of income the nursing home spouse
must pay to the nursing home toward the costs of
care each month. A MassHealth-eligible nursing
home resident must pay all of their monthly income
to the nursing home as PPA, minus certain allowed
“deductions,” which include a PNA ($72.80) to be
used to meet the resident’s personal needs (e.g., hair-
cuts, newspapers, etc.). Other deductions include
the costs of any medical or health insurance pre-
miums and, in Example 2 on this page, a Spousal
Monthly Maintenance Income Allowance of $400.
If the community spouse and nursing home
resident’s combined income is insufficient to satisfy
the MMMNA, a community spouse may file and
present evidence at an administrative appeal to
request an increased asset limit sufficient to generate
additional income to satisfy the MMMNA. An
experienced elder law attorney should be consulted
to evaluate the merits of and prepare for such a
hearing.
C. Asset Limitation
MassHealth imposes a $2,000 asset limit for an
individual applicant age 65 or older, or a single ap-
plicant of any age in a skilled nursing facility. Ad-
ditionally, in 2023, the community spouse (if any) is
generally allowed to keep up to $148,620 of count-
able assets, as discussed more fully in Section J of
this chapter. MassHealth divides assets into three
categories:
1. Non-countable assets;
2. Inaccessible assets; and
3. Countable assets.
Only countable assets are considered with re-
spect to asset limitations. e assets of a married
couple age 65 and older, when one member resides
in a nursing home, are treated differently and dis-
cussed more fully in Sections E, H and J of this
chapter.
D. Non-Countable Assets
• A principal residence in Massachusetts (See
special rules for the principal residence in Sec-
tion E);
• Household belongings and furnishings;
• Personal belongings (e.g., clothing, jewelry,
furniture, etc.);
• Burial plots for the applicant and members of
their family;
• Pre-paid irrevocable burial contracts;
• A $1,500 burial bank account for miscella-
MASSHEALTH (MEDICAID) PAGE 15
neous funeral and burial expenses;
• Term, group or other life insurance policies
that have no cash surrender value;
• Life insurance policies with face values total-
ing up to $1,500, regardless of cash surrender
value; and
• One automobile for use by the applicant or
their family. See Example 3.
EXAMPLE 3
Countable and Non-Countable Assets
Richard owns his home worth $250,000, a car worth
$4,00 and mutual funds worth $50,000. MassHealth
does not consider the value of Richard’s home or
car when calculating Richard’s countable assets.
MassHealth does consider the $50,000 Richard owns
in mutual funds as a countable asset.
E. Special Rules for the Principal Residence
MassHealth will treat equity in an applicant’s
home, up to $1,033,000 (as of 2023), as a non-
countable asset if it is located in Massachusetts, and
if the applicant, living in a nursing home, expresses
in the MassHealth application an intent to return
to that home. MassHealth may place a lien on the
property for services rendered, which lien would be
paid back upon either the sale of the home or pro-
bate of the individual’s estate. Even if an applicant
does not intend to return home, an applicant’s home
may be classified as non-countable if any one of the
following conditions is met:
1. e applicant owns a long-term care insurance
policy, meeting strict MassHealth require-
ments (see Chapter 6).
2. Any one of the following persons lives in the
home:
• e applicant;
• e applicant’s spouse;
• A child under age 21;
• A disabled or blind child of any age;
• A relative who is dependent on the applicant;
• A child who lived in the home for at least
two years immediately before the applicant
moved into a nursing home, and provided
care that permitted the applicant to remain
at home; or
• A sibling who has an equity interest in the
home and has lived there for at least one year
before the applicant moved into a nursing
home.
NOTE: If the applicant checks the box indi-
cating that they do not intend to return home,
the home becomes a countable asset and must
be put on the market for sale.
Older adults often want to “protect their home.”
ere is, unfortunately, no uniformly agreed upon
strategy to accomplish this goal. e various legal
strategies that may be employed in an attempt to
protect a home, including, but not limited to, ir-
revocable trusts, life estate deeds and outright gifts,
each present complex pros and cons for an older
adult to consider. Among the relevant issues are:
• e options available if MassHealth cover-
age is required during the five-year look-back
period (see Section L of this chapter);
• e degree to which a strategy does, in fact,
successfully protect homes during current
MassHealth applications, administrative fair
hearings and/or court appeals;
• e level of control retained by the older
adult over their home;
• e older adult’s access to equity in their
home in the future (e.g., through a reverse
mortgage);
• e tax impacts on the older adult and their
family; and
• e risks to an older adult’s ongoing right to
reside at home.
In addition to the extraordinary complexity of
these issues, we continue to see changes in the rel-
evant statutes, case law, regulations and MassHealth
practices.
F. Inaccessible Assets
Like non-countable assets, inaccessible assets are
also not included in the calculation of an applicant’s
assets for MassHealth purposes. Inaccessible assets
are those to which the applicant has no legal access,
such as expected inheritances before probate is com-
pleted, or divorce assets prior to a final decree. See
Example 4.
PAGE 16 MASSHEALTH (MEDICAID)
EXAMPLE 4
An Inaccessible Asset Can Become Countable
Karen’s sister Betty died six months before Karen
applied for MassHealth. Under Betty’s will, Karen is
entitled to one-half of Betty’s estate, which is worth
$200,000. Karen has not yet received any money from
Betty’s estate. The $100,000 Karen expects to receive
from Betty’s estate is an inaccessible asset. Once
Karen receives the $100,000, it becomes a countable
asset.
G. Countable Assets
All assets not considered non-countable or in-
accessible are considered countable assets; that is,
they are counted toward an applicant’s $2,000 asset
limit, or the community spouse’s $148,620 limit. In
some cases, both jointly held assets and assets in a
trust will be viewed as countable assets.
H. Jointly Held Assets
MassHealth presumes that all funds held in joint
bank accounts belong to the applicant. is pre-
sumption can be overcome if the non-applicant joint
owner can demonstrate that they contributed part or
all of the funds to the account. See Example 5.
EXAMPLE 5
Who Contributed to a Joint Account?
Andy owns a joint bank account with his daughter,
which totals $10,000. His daughter contributed $8,000
of that amount when she was going through a divorce.
When Andy applies for MassHealth, it is presumed that
Andy owns all of the $10,000 in the joint account. If,
however, Andy can prove that $8,000 of this account is
attributable to his daughter, only $2,000 will be count-
ed as Andy’s assets.
Other assets held jointly, such as real estate,
stocks, bonds and most mutual funds, are presumed
to be owned proportionately by each owner. is
presumption can also be overcome (see Example 6),
and in some cases, the entire asset may be deemed
inaccessible.
EXAMPLE 6
A Joint Account Presumption
Edna and Charley are joint owners of a stock and bond
mutual fund with a value of $20,000. If Edna applies for
MassHealth, it may be presumed that she owns 50% of
the mutual fund, or $10,000. (See Section L regarding
transfer penalties for additions to joint accounts made
during the five-year look-back period.)
I. Trusts
3
If a MassHealth applicant is the beneficiary and
grantor of a trust, and if, under any circumstance,
trust principal (as opposed to trust income) can be
paid to the grantor, then any amount of principal that
the trustee has the discretion to pay to the applicant
is considered a countable asset. Even principal that
can be paid by a trust not created by the applicant
may be countable under certain circumstances. e
assets are considered countable even if a trustee
never pays principal to the applicant. See Example 7.
EXAMPLE 7
A Beneficiary of Trust Assets
Paul is the beneficiary of a trust, which he set up him-
self. The trust holds $100,000 in assets, and the trustee
has the authority to make any amount of distributions
of interest and principal to Paul on a regular basis. Paul
applies for MassHealth. MassHealth will consider the
entire $100,000 as a countable asset for Paul.
If the applicant or their spouse is the grantor of a
revocable trust, all assets in the trust are considered
countable assets. e result is the same even if the
applicant or their spouse is not a beneficiary of the
revocable trust. See Example 8.
EXAMPLE 8
Revocable Trust Assets
Sam funds a revocable trust where his brother is
trustee and his nephew is beneficiary. The trust holds
$100,000. Sam applies for MassHealth. MassHealth
will consider the entire $100,000 as a countable asset
for Sam because Sam can revoke the trust at any time.
Not all trust assets are countable assets, though.
For example, certain types of trusts, including care-
fully drafted irrevocable trusts funded before the
MASSHEALTH (MEDICAID) PAGE 17
look-back period, pooled trusts qualifying under 42
U.S.C. s. 1396(d)(4)(C) and qualifying testamen-
tary supplemental needs trusts, may prevent assets
in such trusts from being deemed countable assets
by MassHealth.
Treatment of trusts is a very complex area of law
due to requirements of federal law, state regulations
and court decisions. Questions regarding the cre-
ation of and transfers of assets to and from trusts
should be carefully reviewed with an experienced
elder law attorney.
J. Community Spouse Resource Allowance
(CSRA)
When a nursing home spouse has a spouse at
home (called a community spouse), the resource
rules are more complex. A married couple’s assets are
pooled for the purpose of determining the nursing
home spouse’s eligibility. MassHealth will calculate
the couple’s total countable assets (sometimes called
the “snapshot date”) as of the first day of a nurs-
ing home stay lasting 30 days or more. e couple’s
assets are pooled without regard to which spouse
actually owns the asset. e community spouse is
allowed to keep a portion of the assets, called the
Community Spouse Resource Allowance (CSRA),
based on the equivalent of 120% of the federal pov-
erty level for two persons. In 2023, the maximum
CSRA is $148,620. If the countable marital assets
exceed that amount, the excess assets disqualify the
nursing home spouse, and must be spent down or
applied to the costs of their nursing home care. Un-
der certain circumstances, the community spouse
may request an increased CSRA to meet living ex-
penses (see Section K), but that is a rare occasion be-
cause MassHealth will not grant an increased CSRA
unless the community spouse needs more than the
combined monthly income from both spouses to
meet their living expenses.
Where MassHealth approves the nursing home
spouse for eligibility, any assets higher in value than
the $2,000 asset limit still held in their name must
be placed in the community spouse’s name within
90 days. If the nursing home spouse has assets ex-
ceeding the $2,000 after 90 days, it will trigger a
disqualification. See Example 9.
EXAMPLE 9
Asset Transfer Between Spouses
Mr. Smith is entering long-term care in a nursing home
and is entitled to retain a CSRA of $148,620. Mrs.
Smith has $79,000 in her name alone. There remains,
however, $20,000 in assets in Mr. Smith’s name. The
Smiths are allowed 90 days to transfer all but the
permissible $2,000 from Mr. Smith’s name into Mrs.
Smith’s account.
In situations where one spouse refuses to coop-
erate with MassHealth, such as by refusing to sup-
ply the necessary documents, or the spouse has been
physically separated from the applicant for reasons
other than the MassHealth application, MassHealth
may disregard the uncooperative or physically sepa-
rated spouse’s assets, though an appeal may be nec-
essary. In such a situation, the uncooperative or
physically separated spouse will not be entitled to
any of the applicant spouse’s income.
K. Permissible Spend-Down of Excess Assets
A married couple need not necessarily spend
down any assets that exceed the CSRA on nursing
home expenses. For example, the excess assets can
be used to pay off existing debt, e.g., a mortgage
balance, or to make repairs or necessary purchases,
such as a pre-need funeral contract, but timing is
very important. Another option to consider is for
the community spouse to purchase a MassHealth-
compliant annuity, which converts excess count-
able assets into an income stream to the community
spouse. e annuity income can be retained by the
community spouse because the community spouse
is not subject to an income limit. e MassHealth-
compliant annuity must satisfy very specific require-
ments, including that it must be immediate, cannot
have a balloon payment, must be irrevocable, can-
not exceed the purchaser’s life expectancy, cannot
be assignable, and must satisfy MassHealth require-
ments concerning naming the Commonwealth of
Massachusetts as beneficiary (litigation is pending
on the beneficiary requirement). Typically, the com-
munity spouse prefers an annuity with the shortest
term possible, so as to recover funds more quickly.
Non-MassHealth-compliant annuities can result
in MassHealth disqualifying transfer penalties. An
elder law attorney may present yet further spend-
down options for consideration.
PAGE 18 MASSHEALTH (MEDICAID)
L. Transfer Rules
Medicaid, as implemented by MassHealth, was
designed to provide medical-related coverage to those
individuals and families who do not have enough as-
sets to meet these needs themselves. rough a num-
ber of regulations, the program discourages individ-
uals from intentionally impoverishing themselves by
gifting to qualify for MassHealth. MassHealth will
review financial records and penalize the applicant
and/or their spouse for gifts or transfers made for
less than fair market value during the 60-month pe-
riod prior to applying for MassHealth (known as the
five-year look-back period). MassHealth will deem
a transfer to be disqualifying if the applicant and/
or community spouse transfers any assets, whether
countable or non-countable, for less than fair mar-
ket value during the look-back period, unless an
exemption applies. (See Example 10.) MassHealth
determines the period of ineligibility by dividing the
total amount of disqualifying transfers by the ap-
plicable MassHealth divisor rate, which is currently
$427 and is regularly adjusted by MassHealth.
MassHealth does have several exemptions to its
transfer penalties. For example, no penalties are ap-
plied when an applicant or their spouse transfers any
assets to a spouse or to a blind or qualifying disabled
child or to a qualifying trust for such disabled child.
Further, there are no penalties when an applicant
or their spouse transfers the principal residence to a
child who is under age 21, a sibling who has lived in
the home during the year preceding the applicant’s
institutionalization and who already holds an equity
interest in the home, or to a qualifying caretaker
child. A caretaker child is a child of the applicant
who lived in the house for at least two years imme-
diately prior to the applicant’s institutionalization
and who, during that period, provided care that al-
lowed the applicant to remain in the home.
CAUTION: It is important to note that the annual
federal gift tax exclusion ($17,000 per person in
2023) will be deemed a disqualifying gift transfer
under the MassHealth regulations unless it fits un-
der an allowable exemption.
EXAMPLE 10
How the Look-Back Period Works
Florence owns a condo with a fair market value of
$182,329. On April 1, 2023, Florence transfers the con-
do to her non-caretaker, non-disabled daughter as a
gift. On June 1, 2023, Florence enters a nursing home
and applies for MassHealth. Because the gift occurred
during the 60-month period prior to the MassHealth
application, MassHealth imposes a disqualifying trans-
fer penalty of 427 days ($182,329 ÷ $427 per day).
As a result, MassHealth will not approve benefits for
the applicant during the 427-day period commencing
on June 1, 2023, assuming she is otherwise eligible for
MassHealth on that date.
MassHealth applies the disqualifying transfer
penalty period beginning on the date when an appli-
cant is “otherwise eligible” for MassHealth benefits.
If an applicant delays the MassHealth application
for more than 60 months after making a disqualify-
ing transfer, it is not necessary to report the transfer
to MassHealth. In this manner, an applicant can es-
sentially cap their ineligibility at a maximum of 60
months. Applying for MassHealth too soon after a
large transfer for less than the fair market value of
the asset transferred can cause a much longer than
necessary disqualification period. In the unfortu-
nate event that an applicant is deemed ineligible, or
disqualified from receiving benefits, it is imperative
that the applicant consult with an elder law attorney
to discuss what options, if any, are available.
EXAMPLE 11
Timing is Important When Looking at When
to Apply for MassHealth
Mike owned a house with a fair market value of
$640,500. On April 1, 2018, Mike transferred the house
as a gift to his non-caretaker, non-disabled son. On
June 1, 2022, Mike applied for MassHealth. MassHealth
looked back 60 months from the date of Mike’s applica-
tion and flagged the disqualifying transfer. MassHealth
calculated a 1,500-day ineligibility period ($640,500 ÷
$427 per day). This ineligibility period will commence
on June 1, 2022, and last 1,500 days (4.1 years). If
Mike had waited to apply until after April 1, 2023, the
transfer would not have been included in the look-back
period and he could have been eligible for benefits on
April 2, 2023.
MASSHEALTH (MEDICAID) PAGE 19
M. Deeming Transfers to Be Gifts
A long-standing regulation, found at 130 CMR
520.019(F), states that MassHealth will not pe-
nalize an individual for transfers made for less
than fair market value if the applicant proves, to
MassHealth’s satisfaction, that the assets were
transferred exclusively for a purpose other than to
qualify for MassHealth. Despite this regulation and
the reason for the transfer, MassHealth routinely
considers transfers made for less than fair market
value to be disqualifying gifts, resulting in a penalty
period. us, gifts made for the purpose of paying
for a grandchild’s tuition, wedding plans, a down
payment on a child’s home, etc., may be viewed by
MassHealth as disqualifying transfers, regardless of
the donor’s actual intent.
N. The Spend-Down Process
When a single applicant has countable assets that
exceed the amount allowed by MassHealth, they will
want to reduce these assets below the $2,000 lim-
it. is process is called a “spend-down.” ere are
many ways to achieve a spend-down, including pur-
chasing non-countable assets, paying debts, purchas-
ing an annuity and even gifting assets, knowing that
there will be a controlled period of disqualification.
Regardless of the options used to achieve the
spend-down, the applicant will usually want to qual-
ify for MassHealth as quickly as possible.
4
A married
couple has a greater range of options to achieve eli-
gibility (and to save more assets) than a single indi-
vidual.
EXAMPLE 12
How the Spend-Down Process Works
Jack is single, requires nursing home care and has
countable assets totaling $34,000. In order to become
eligible for MassHealth, Jack will need to spend down
$32,000. Jack is allowed to keep $2,000 in assets.
Jack spends his money in the following manner:
Balance to be spent down $34,000
Purchase of a pre-paid burial contract $10,000
Purchase of a burial plot $2,000
Pay off credit card debt $10,000
Attorney and professional fees
(for illustrative purposes only) $8,500
Burial account $1,500
Total remaining (allowable) $2,000
O. Estate Recovery
MassHealth can recover for long-term care or
nursing home benefits provided on behalf of a recip-
ient of any age. Recovery, however, is limited under
current law to collecting from the recipient’s probate
estate and, in the case of the recipient’s home, can
only be pursued if there is no surviving spouse, child
under age 18, or disabled child of any age living in
the home. MassHealth’s current policy is that they
will not pursue any estate recovery if the value of the
member’s estate is $25,000 or less.
If the recipient owns real property, MassHealth
may place a lien on such real property for the amount
of funds expended on the recipient’s behalf after the
recipient reaches age 55. is lien may be placed on
the recipient’s real property (including, but not lim-
ited to, their primary residence) even before the re-
cipient’s death, provided that all the following con-
ditions are met:
1. e recipient permanently resides in a nursing
home and is not expected to return home;
2. e recipient receives notice of the lien; and
3. ere is no spouse, child under age 18, or dis-
abled child of any age residing in the house.
ese pre-death liens are simply notice liens.
MassHealth has no claim against the real estate un-
til the recipient dies. If the house is sold during the
recipient’s life, however, MassHealth can seek recov-
ery from the proceeds of the sale. MassHealth regu-
lations also include circumstances in which estate
recovery can be delayed or waived, so it is important
to consult the latest regulations upon the death of a
MassHealth member to determine whether and the
extent to which MassHealth can recover against the
estate. Estate recovery will not be required until af-
ter the death of a surviving spouse, if any, or while
there is a surviving child who is younger than 21
years old or a child of any age who is blind or per-
manently disabled. is request is time-sensitive.
PAGE 20 MASSHEALTH (MEDICAID)
Note to SCO and PACE members: If you enroll in
MassHealth and leave a probate estate, MassHealth will
have an automatic lien against your estate. MassHealth
will seek reimbursement not for the costs of medical
care and treatment, but for the monthly premiums,
which MassHealth pays to Senior Care Options (SCO) or
the Program of All-Inclusive Care for the Elderly (PACE)
on your behalf. MassHealth starts making the premium
payments in the month after you enroll, and the pay-
ments could be as much as $3,000 per month.
If you are enrolled in SCO or PACE, you should discuss
ways to avoid probate with an elder law attorney in or-
der to avoid any estate recovery lien.
P. MassHealth Application
e MassHealth application is often difficult
and time-consuming to complete. Applications
are submitted to a central office of the Division of
Medical Assistance, which scans the application and
assigns it to one of the long-term care units for pro-
cessing. Final determinations on an applicant’s eligi-
bility may take several months or more.
e supporting documentation required for a
successful application is substantial and includes,
among other things, copies of health insurance
cards and premium information, 60 months of
bank and investment account statements, copies of
checks, verifications of all withdrawals and trans-
fers, two years of income tax returns, life insurance
policies, gross and net income, trust documents (if
applicable) and, if the applicant is married, a copy
of the certificate of marriage and household expense
information.
Withdrawals, transfers, and sales of assets occur-
ring in the 60-month period preceding the applica-
tion must be explained, or disqualification periods
may result. Many practitioners compare the process
to the complexity of a multi-year tax audit. Under
these circumstances, the use of a qualified elder law
attorney experienced in the preparation and submis-
sion of MassHealth applications is strongly recom-
mended.
CONCLUSION
Careful long-term care planning with an expe-
rienced attorney, particularly an elder law attorney,
prior to a hospitalization or medical crisis ensures
that families understand their rights. Such planning
allows families to evaluate their options and, ide-
ally, enables families to protect the family home and
other substantial assets.
Generally, the more a person or family plans
before a medical crisis occurs, the more assets the
family can save. Good planning involves protect-
ing the independence, integrity and wishes of the
older adult or couple, as well as protecting assets.
MassHealth may implement current and/or future
proposed regulations to modify the law, or change
the way it interprets the law.
An experienced attorney will be able to conduct
a complete review of your personal and financial sit-
uation, make appropriate recommendations to ad-
dress your health care needs, and provide you with
a framework of recommendations to protect your
assets according to your own personal wishes.
CONTACT INFORMATION
If you or a loved one is a current MassHealth
beneficiary or you have questions about eligibility
or an application, you may call the state’s toll-free
number at (888) 665-9993. is service is available
24 hours a day, seven days a week, and can provide
information on case status, key eligibility dates, plan
information, items needed to process your case, ex-
amples of acceptable verifications, address informa-
tion and more.
You may also find an elder law attorney in the
Resource Directory in Chapter 19 of this guide.
1. MassHealth is also available to blind and disabled individuals who meet the
eligibility guidelines.
2. The minimum and maximum monthly maintenance needs allowance figures
usually increase each year due to a cost-of-living allowance.
3. Specific rules pertaining to trusts vary according to the date the trust was
established and the specific terms of the trust.
4. In some circumstances, a disqualifying transfer may be an effective MassHealth
planning tool.
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS PAGE 21
CHAPTER 4
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS
Programs for Older Adults at Risk for Institutionalization
INTRODUCTION
In addition to providing long-term care (LTC)
coverage, Medicaid (known as MassHealth in Mas-
sachusetts) offers community benefits that enable
older adults to stay at home while still receiving
necessary care. Community MassHealth offers vari-
ous programs and services to individuals age 65 and
older who meet both financial and medical qualifi-
cations. ose under age 65 can also qualify if they
are permanently disabled, although different rules
apply. Individuals who are eligible for MassHealth
insurance can also be covered by their own private
insurance. For those older adults who wish to live at
home, MassHealth offers various programs that al-
low an older adult to receive care within their home.
Adult and supportive day care, transportation and
caretaker services are among a multitude of benefits
that MassHealth provides to empower older adults
to live at home. An experienced elder law attorney
can help an individual determine which program
might be most appropriate for each older adult’s par-
ticular circumstances.
Note that qualifying for MassHealth in a com-
munity setting does not translate into coverage
in a nursing home setting. Planning for commu-
nity MassHealth may have adverse consequences
for achieving nursing home eligibility if not done
properly, as the income and asset rules vary for all
benefits. For example, the transfer rules differ in a
community setting from the long-term care nursing
home rules. In addition, be advised that there could
be estate recovery claims. See Chapter 3, Section O
for more information. erefore, one should consult
with an attorney who is well-versed in these mat-
ters. Regulations and agency practices also change
regularly.
A. Home- and Community-Based Services
Waivers
For older adults who require nursing home-level
care, but would like to live at home or in a resi-
dential community, Home- and Community-Based
Services Waivers, also referred to as the Frail Elder
Waiver (FEW), authorize MassHealth to pay for
those services, regardless of the number of hours
needed. e waiver program serves three important
purposes: (1) saves the state money; (2) allows the
older adult to remain at home with care; and (3)
provides older adults with greater choices in their
care. Under the FEW program, the responsibility of
care for the older adult is shifted to family members,
home care agencies or other designated caregivers.
e goals of the program are to help older adults age
outside of a nursing home, and to promote indepen-
dent living. If an older adult qualifies for the FEW,
they can participate in the Community Choices or
Personal Care Attendant (PCA) programs, the Pro-
gram of All-inclusive Care for the Elderly (PACE),
or senior care options (SCOs), if eligible.
e FEW allows those older adults who are
eligible for nursing home care to receive services
at home.
1
To qualify for the waiver, an older adult
must either be at least 65 years old or, if under 65,
be permanently and totally disabled.
2
Additionally,
the individual must meet a clinical requirement
and show that, if they did not receive waiver ser-
vices, they would require institutionalization (nurs-
ing home care).
3
In addition to the typical asset
limitation of $2,000 for MassHealth services, the
waiver imposes a 2023 income threshold of $2,742
per month. For couples, the income of the healthy
spouse is not counted in determining eligibility. e
non-applicant spouse’s assets, however, are limited
to $148,620 (2023) (other than for the PACE pro-
gram), but it is often beneficial to apply for only
one spouse or to apply separately. Note that a re-
cent MassHealth hearing decision found that LTC
insurance benefits are not considered income when
determining eligibility for the FEW program. Al-
though the administrative decision is not binding
on MassHealth, it should be mentioned at the time
of application, if appropriate.
If an individual’s gross monthly income is great-
er than $2,742, there will be a recurring six-month
PAGE 22 COMMUNITY MEDICAID (MASSHEALTH) BENEFITS
deductible that must be met before MassHealth
coverage will begin. For example, if a single appli-
cant’s gross monthly income is $2,792 ($50 over the
income limit), the Medicaid $522 standard (less a
$20 income disregard) is applied and subtracted
from $2,792. at figure, $2,250, is then multiplied
by six, and as a result, a $13,500 deductible must
be met every six months before MassHealth benefits
will begin/resume. is amount has to be paid out
of pocket for medical or remedial expenses by the
individual (remember, this individual can only have
$2,000 of assets) every six months, and then proof
of payment has to be sent to MassHealth before
becoming eligible for benefits. is approval is not
retroactive, and then the individual has to meet this
deductible every six months. *Note, if the income of
an individual who was deemed eligible for the FEW
(300% of the Federal Benefit Rate (FBR) or less)
increases to a sum that exceeds this amount, the
individual may still continue receiving benefits by
paying the difference between their actual income
and 300% of the FBR as a co-pay.
Applicants seeking coverage under the PCA pro-
gram may have lower recurring deductibles, since
an additional $1,094 PCA disregard is subtracted
from their gross income, resulting (using the prior
example) in a monthly deductible of $1,176, which,
when multiplied by six, imposes a $7,056 deduct-
ible (as opposed to a $13,500 deductible) that must
be met every six months to maintain eligibility. An
individual needing only 12-15 hours of care each
week might benefit from applying for MassHealth
benefits to cover care after the deductible is met.
Applicants must meet any deductible by paying
qualifying medical expenses, including Medicare
and supplemental health (Medigap), prescription
and dental insurance premiums. Once the deduct-
ible is satisfied, MassHealth covers services for the
balance of the six-month period, and the individual
may retain all of their income. In many cases, how-
ever, individuals find that they can meet the recur-
ring six-month deductible only if they have access
to other resources (non-countable VA Aid and At-
tendance benefits, or family or spousal assets, for
example, as assets are limited to $2,000 for a single
individual and $3,000 for a married couple). Advo-
cacy and legislative efforts are underway to reduce
the deductible amounts, with the goal of ensuring
that more individuals may remain at home, but it
is unclear whether or when they will be successful.
Because MassHealth does not impose penalties
for transferred assets in community cases, it is im-
perative that all applicants, but particularly those
who anticipate having the recurring deductible,
do not spend down their assets to $2,000. Instead,
they should move excess assets out of their name to
a trusted individual (who may have to return them,
if long-term nursing home care is needed later), so
that funds will be available for medical and non-
medical expenses. is should be done ONLY with
the advice of an experienced elder law attorney.
Services and benefits of the FEW include
MassHealth coverage of adult day health and sup-
portive day programs. Supportive day is a social
model day program, and adult day health is a medi-
cal model day program for older adults who need
supervision and health services during the day, but
will return home at the end of the day (the indi-
vidual can leave home for services and be covered by
the waiver). In addition, MassHealth covers home
health services under the waiver. Additional benefits
may include home-delivered meals, home modifica-
tions to improve accessibility, and transportation as-
sistance for medical or other appointments.
1. Community Choices (FEW)
Community Choices is a more care-intensive
program for FEW participants who either face im-
minent nursing home placement or currently reside
in a nursing home but wish to return home or to
the community. To be eligible, the older adult must
be already enrolled in or eligible for the FEW. e
program provides extensive home- and community-
based services to older adults who require nursing
home-level care and exhibit at least one of four indi-
cations of frailty:
• Actively sought nursing home facility care
within the last six months;
• Recently experienced a serious medical
event, regression in physical or cognitive
functional ability, or a cumulative deteriora-
tion in functional ability;
• Was discharged from a nursing facility with-
in the last 30 days; or
• Is at risk of nursing facility admission due to
the instability or lack of capacity of informal
or formal supports.
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS PAGE 23
Services are also provided to older adults who
exhibit at least one of five clinical characteristics
demonstrating risk:
• Needs 24-hour supervision because of com-
plex health conditions;
• Experiences a significant cognitive impair-
ment;
• Is unable to manage/administer prescribed
medications;
• Experiences frequent episodes of inconti-
nence; or
• Requires daily supervision and assistance
with two activities of daily living (ADLs).
ADLs are activities performed by a PCA to
physically assist a member to transfer, take
medications, bathe or groom, dress and
undress, engage in passive range of motion
exercises, eat and toilet.
4
Services are provided by an agency hired
through MassHealth and administered through
the local Aging Service Access Point (ASAP).
Community Choices offers more hours of ser-
vice than any other similar program, and the
care can often be put in place more quickly than
other community care programs. Services offered
include personal care, homemakers, nursing,
companions, chore assistance, delivered meals,
grocery delivery, laundry, transportation, home-
based wander response systems, transitional assis-
tance, and supportive day and adult day health.
5
2. PACE
e PACE program provides comprehensive
medical and social services to frail older adults
so as to allow them to live in their communities
and to receive all of their health services under
the same umbrella.
6
To be eligible, an individual
must: (1) be 55 years of age or older; (2) live in a
service area of a PACE organization; (3) be able to
live safely in the community; (4) be certified by
the state as eligible for nursing home care; and (5)
agree to receive health services exclusively through
the PACE organization.
7
All of the medical ser-
vices are provided by MassHealth at no cost to the
older adult. Financial eligibility is in accordance
with all other MassHealth programs, and there-
fore, an individual’s assets cannot exceed $2,000
and a couple’s assets cannot exceed $3,000
8
if both
are seeking coverage. Under current practice, if
only one member of a couple needs services, the
non-applicant spouse’s income and assets will be
disregarded. In addition, the income threshold for
an individual is $2,742 (with a deductible imposed
if the applicant’s income exceeds this figure).
rough PACE, MassHealth will coordinate
care for the older adult and provide the individ-
ual with medical professionals, including doctors,
nurses, aides, therapists and social workers. Under
this program, the older adult receives their primary
care, emergency care, prescription drugs, in-home
services, transportation and more. e services are
available 24 hours a day, seven days a week.
3. Personal Care Attendant (PCA) Program
e PCA program provides personal care ser-
vices to older and disabled Massachusetts residents
who wish to remain living at home. e PCA pro-
gram is administered by MassHealth and seeks to
enable independent living and prevent unnecessary
or premature nursing home institutionalization.
While MassHealth pays the caregivers, participants
in this program or their surrogates are responsible
for directing the care to assist with ADLs and in-
strumental activities of daily living (IADLs). A PCA
participant or their surrogate acts as an employer,
and can hire friends, neighbors or certain family
members (spouses and legal guardians are not eli-
gible) to be their personal care attendant.
9
Effective
April 1, 2023, the PCA wage rate is $18 per hour.
Based on the federal poverty levels, effective Jan.
13, 2023, the MassHealth PCA disregard amount
is $1,094 for an individual and $1,536 for a couple.
To be eligible for the program, an individual
must have a permanent or chronic disability that re-
quires them to receive assistance to perform at least
two ADLs. ADLs are activities performed by a PCA
to physically assist a member to transfer, take medi-
cations, bathe or groom, dress and undress, engage
in passive range of motion exercises, eat and toilet. A
doctor or nurse practitioner must prescribe the ser-
vices for the older adult, and the services must be
medically necessary.
10
Additionally, the older adult
must meet the $2,000 asset limitation to qualify
for MassHealth and a $3,000 asset limitation for a
couple. Each PCA applicant is assessed by a nurse
and occupational therapist during enrollment in
the program to determine the number of hours per
PAGE 24 COMMUNITY MEDICAID (MASSHEALTH) BENEFITS
week assistance is required; MassHealth will then
provide a budget for care services. Benefits include
assistance with ADLs (e.g., bathing, grooming, eat-
ing, etc.), IADLs (e.g., homemaker services, laun-
dry, meal preparation, etc.) and transportation. A
personal care attendant may not be paid: (a) to help
an older adult who is in a hospital, nursing facility
or in a community program funded by MassHealth;
(b) to provide social services, such as babysitting,
recreation or educational activities; or (c) to pro-
vide medical services that are available from other
MassHealth providers.
11
4. Senior Care Options
Senior Care Options (SCO) is a no-cost health
insurance and care program for individuals eli-
gible for MassHealth and Medicare who are 65 or
older, and it offers health services with social sup-
port services. SCO members receive all covered
health services through the SCO plan, and they
have a primary care physician (PCP) who is affili-
ated with the SCO, 24-hour access to care and ac-
tive involvement in decisions about their care. All
services are provided by the SCO and the PCP, and
a team of nurses, specialists, and geriatric support
services professionals develops an individualized
plan of care. Enrollment is voluntary and open to
MassHealth standard members who: (1) are 65 or
older; (2) reside in an area serviced by an SCO; (3)
live at home or in a long-term care facility; (4) do
not have to meet a recurring six-month deductible;
and (5) do not have end-stage renal disease. e
benefits for SCO members include all health ser-
vices covered by MassHealth Standard, as well as
coordination of care, including a centralized record
of medical information, individualized assessment,
primary and specialty medical care, preventive care,
emergency care, X-rays and lab tests, medical sup-
plies and equipment, prescription drugs, mental
health and substance abuse treatment, rehabilitative
therapy, nursing facility care (if needed), transporta-
tion for services, geriatric support services, adult day
care, dental care and eye care, home care services
and family caregiver support.
NOTE TO SCO AND PACE MEMBERS: If you enroll in
MassHealth, and leave a probate estate, MassHealth
will have an automatic lien against your estate.
MassHealth will seek reimbursement not for the costs
of medical care and treatment, but for the monthly pre-
miums, which MassHealth pays to the SCO on your be-
half. MassHealth starts making the premium payments
in the month after you enroll, and the payments could
be as much as $3,000 per month.
If you are enrolled in SCO or PACE, you should discuss
ways to avoid probate with an elder law attorney in
order to avoid any estate recovery lien.
B. Other Programs for Older Adults
MassHealth also offers community programs to
those older adults who are not at risk for institution-
alization, but nonetheless require help within the
home. ese programs help prevent an older adult
from entering a long-term care facility and aim to
promote independent living among older adults.
1. SSI-G/Group Adult Foster Care
e SSI-G (the Supplemental Security Income
assisted living benefit) and Group Adult Foster
Care (GAFC) programs are designed for older
adults who wish to transition to assisted living
facilities (by statute referred to as assisted living
residences), but cannot afford the monthly rates.
e GAFC program pays a daily rate to the
assisted living facility directly for personal care
and services, while the SSI-G component helps
pay for the rent portion at an assisted living
facility to the individual directly. An individual
can get GAFC benefits without SSI-G. GAFC
pays $43.53 per day ($1,324 per month) directly
to the assisted living facility for services, such
as daily personal care, homemaking, meals and
transportation. e assisted living facility may
combine the GAFC services with the room and
board, which is paid by the resident, and the
SSI-G program. e resident does not have to
apply for or be eligible to receive SSI-G in order
to qualify for GAFC. New regulations have been
implemented for GAFC and can be found at 130
CMR 408.502 through 408.527.
Certain assisted living facilities offer a limited
number of beds for applicants who meet certain
eligibility criteria: (1) over the age of 60 or
chronically disabled; (2) have a medical, physical,
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS PAGE 25
cognitive or mental condition that limits their
ability to care for themselves; (3) need daily
help with one or more ADLs (e.g., dressing,
bathing, eating or toileting); (4) have the ability
to live independently, with support services; (5)
meet eligibility requirements for public housing,
GAFC, ElderChoice subsidized rents and/or
SSI-G; (6) do not need full-time skilled nursing
care; and (7) are medically approved for assisted
living by their physician and Aging Services
Access Point (ASAP).
To qualify for GAFC, an individual may
not have more than $2,000 in countable assets,
and a couple may not have more than $3,000
in countable assets. Because MassHealth does
not impose penalties for transferred assets
in community cases, it is imperative that all
applicants, but particularly those who anticipate
having the recurring deductible, do not spend
down their assets to $2,000. Instead, they should
move excess assets out of their name to a trusted
individual (who may have to return them, if
long-term nursing home care is needed later), so
that funds will be available for medical and non-
medical expenses. is should be done ONLY
with the advice of an experienced elder law
attorney.
In addition, if an individual’s income is greater
than $1,215 (2023), or a couple’s income is greater
than $1,643 if both spouses are applying (100%
of federal poverty level), there will be a recurring
six-month deductible.
Applicants must satisfy the deductible by
paying qualifying medical expenses, including
Medicare and supplemental health insurance
premiums. Because only a portion of the monthly
assisted living fee qualifies as a medical expense
(the majority is considered room and board),
individuals who are required to meet deductibles
may have to pay as much as four times the amount
of the deductible figure. erefore, in cases where
an applicant needs to meet a recurring six-month
deductible, GAFC eligibility can be maintained
only if the individual has access to other resources
(non-countable VA Aid and Attendance benefits,
or spousal or family assets, for example). Once
GAFC benefits are in effect, the resident is
required to contribute their income toward the
monthly rent portion; GAFC pays the medical
portion.
2. Massachusetts Adult Family Care
e Adult Family Care program is a relatively
new MassHealth program that provides care to
older or disabled individuals by having the older
adult move into a caregiver’s home or having a
caregiver move into the older adult’s home. Similar
to all MassHealth programs, the applicant must
have less than $2,000 in assets to qualify. Eligible
caregivers include family members, friends or a
professional service. Spouses and legal guardians
are not eligible caregivers. Care givers are paid
for the 24-hour personal care they provide,
and typically offer assistance with ADLs and
instrumental ADLs. Although MassHealth will
not pay for the room and board of the individual,
depending on the level of care, caregivers receive
an annual tax-free payment of between $9,000
and $18,000 from MassHealth, with the payment
based on the level of care needed. Caregivers also
can receive as many as 14 respite care days per
year.
To be eligible for Adult Family Care, the ap-
plicant must be 16+ or disabled and require either
help with one ADL (level 1) or 24-hour assistance
with ADLs (level 2). Care requirements, however,
cannot be so severe as to necessitate residency in
a nursing home.
OTHER IMPORTANT OLDER ADULT PROGRAMS
A. Statewide Nutrition Programs
e Elderly Nutrition Program, administered by
the Executive Office of Elder Affairs, allows local
agencies to provide nutritious meals to older adults.
Meals are provided at congregate meal sites, such
as senior centers, churches, schools and other loca-
tions. e congregate setting provides opportunities
for socialization and companionship. It also offers
programs related to nutrition education, exercise
activities, health promotion and disease preven-
tion. Some programs also offer meals on weekends.
Transportation is often available for those who have
trouble getting around on their own. e Elderly
Nutrition Program also provides home-delivered
PAGE 26 COMMUNITY MEDICAID (MASSHEALTH) BENEFITS
meals to older adults (age 60 or older) and handi-
capped or disabled people under age 60 who live in
housing facilities occupied primarily by older adults
where congregate meals are served.
Each meal contains at least one-third of the
current daily Recommended Dietary Allowance
of nutrients and considers the special dietary needs
of older adults. In addition to providing meals, the
Elderly Nutrition Program provides access to social
and rehabilitative services.
To apply for one of the elderly nutrition pro-
grams, contact the Executive Office of Elder Affairs
at (800) 882-2003 to find the elderly nutrition agen-
cy nearest to you.
B. Prescription Advantage
Prescription Advantage is a prescription drug in-
surance plan available to all Massachusetts residents
age 65 and older, as well as younger individuals
with disabilities who meet income and employment
guidelines. An older adult is eligible for the program
if they are not receiving prescription drug benefits
under Medicaid. Individuals receiving Medicare
benefits may be eligible for assistance with paying
for prescription drug costs (also known as “Extra
Help”) from Social Security. In order to receive this
assistance, an application must be submitted to So-
cial Security.
C. Pharmacy Outreach Program
e Massachusetts College of Pharmacy and
Health Sciences (MCPHS) Pharmacy Outreach
Program is a community service offered by the
university. e purpose of the Pharmacy Outreach
Program is to work closely with local and statewide
health care resources, physicians and older adults to
help relieve the burden of medication expenses. Any
Massachusetts resident may utilize the MCPHS
Pharmacy Outreach Program toll-free telephone
number, (866) 633-1617, to inquire about prescrip-
tion drug medication support programs that are
available at low cost or free of charge. e website is
www.MCPHS.edu/PharmacyOutreach. Consum-
ers can ask any questions regarding their medica-
tions and general health
D. Serving the Health Information Needs of
Everyone Program
e Serving the Health Information Needs of
Everyone (SHINE) program provides health insur-
ance counseling services to older and disabled adults.
SHINE counselors are trained to handle complex
questions about Medicare, Medicare supplements,
Medicare Health Maintenance Organizations, pub-
lic benefits with health care components, Medicaid,
free hospital care, prescription drug assistance pro-
grams, drug discount cards and long-term health
insurance.
SHINE counselors help older adults and
Medicare beneficiaries understand their rights and
benefits under Medicare and other health insurance
coverage. Counselors can identify and compare
current options, and protect older adults from paying
too much for their medical care. SHINE counselors
also help older adults learn how to fill out insurance
claims forms and public benefits applications.
SHINE counselors are available at most councils
on aging, senior centers and Aging Services Access
Points, hospitals and libraries. Counselors are also
available for homebound clients. To locate a SHINE
counselor in your community, contact your regional
SHINE program at https://www.sec.state.ma.us/cis/
ciscig/o/o3.htm.
CONCLUSION
A long-term nursing facility is not the only
choice for an older adult. ere are a multitude of
options for older adults who require medical care
or assistance with everyday life, but do not wish to
enter a nursing home. One of MassHealth’s com-
munity programs might be the solution for a quali-
fied older adult to remain at home and independent.
Applying for the above programs can be very com-
plicated. Practices and policies often differ among
MassHealth workers and offices. Individuals seeking
eligibility should consult with an experienced elder
law attorney knowledgeable about these programs.
COMMUNITY MEDICAID (MASSHEALTH) BENEFITS PAGE 27
1. 130 C.M.R. 519.007(B).
2. 130 C.M.R. 519.007(B)(1)(a); see also 56 MASS PRACTICE SERIES ELDER LAW §
7.46.
3. 130 C.M.R. 519.007(B)(1)(b).
4. 130 C.M.R. 456.409(B); 130 CMR 422.410(A).
5. “About Home and Community Based Services (HCBS) Waiver,” www.mass.
gov/doc/waiver-brief-0/download
.
6. 130 C.M.R. 519.007(C).
7. 130 C.M.R. 519.007(C)(2).
8. 130 C.M.R. 520.003(A)(2).
9. 130 C.M.R. 422.404(A)(4).
10. 130 C.M.R. 422.403(C).
11. 130 C.M.R. 422.412.
PAGE 28 MEDICARE: WHAT YOU NEED TO KNOW
INTRODUCTION
Medicare is a health insurance plan adminis-
tered by the federal government through the Cen-
ters for Medicare and Medicaid Services (CMS).
Established in 1966 under Title XVIII of the Social
Security Act, Medicare serves more than 63 million
people (as of 2022). is vast program insures U.S.
citizens and legal residents who are age 65 or older
and people under age 65 year with certain disabili-
ties. e “Medicare & You”
1
2023 guide, available
from CMS, is the national handbook as well as an
excellent reference, published annually for Medicare
beneficiaries.
Medicare cards are mailed to all Medicare re-
cipients (“beneficiaries”) upon enrollment. e
cards do not use your Social Security number, but a
special Medicare number that only you have. Medi-
care will NEVER call you to check on your Medi-
care account; Medicare only writes to you. Do not
give your Medicare number over the telephone. If
you need to discuss your account, you can sign in
to Medicare at www.medicare.gov/account/login or
call 1-800-MEDICARE (1-800-633-4227). Since
the Social Security Administration (SSA) handles
Medicare enrollment, you may contact a district
SSA office for enrollment issues. You may also enroll
in Medicare online at www.ssa.gov.
A. What Are the Different Parts of Medicare?
Medicare has four different parts: Part A, Part
B, Part C and Part D. ese parts are separate from
each other, cover different aspects of health care and
have different rules and costs.
1. Part A : Helps cover inpatient hospital services,
including a semi-private room, meals and gen-
eral nursing services; Part A also covers some
home health care, limited skilled nursing facil-
ity care, certain hospice services and most in-
patient drugs. In order to receive Part A hos-
pital benefits, a person must be admitted as an
“inpatient” when the person’s doctor AND the
hospital both agree to the admission. If the hos-
pital does not agree, the person’s stay will not
be covered by Part A. Going to the emergency
department is NOT a Part A admission. Part A
does not cover all inpatient costs; certain costs
will be covered by Part B. A common miscon-
ception is that Part A covers custodial nursing
home care; Part A ONLY covers skilled nurs-
ing facility (SNF) stays under certain condi-
tions, as discussed below.
When a person is first admitted as an inpa-
tient to a hospital, the Part A benefit begins
and beneficiaries are responsible for the Part A
deductible, unless the person has a Medicare
Supplement, discussed below. e Part A ben-
efit period ends when the person has not been
an inpatient or receiving skilled nursing care
for a period of 60 CONSECUTIVE days. Un-
der Part A, benefits can expire before the ben-
efit period ends. ere can be more than one
benefit period in a year, as long as the 60-con-
secutive-day interval requirement has been
met. e Part A deductible is due for each new
benefit period. Going to the emergency room
under Part B without a hospital admission will
not affect the 60-day count and force a restart
of the 60 consecutive days. In 2023, the Part A
deductible is $1,600.
Your Medicare card shows Part A coverage as
“HOSPITAL.”
2. Part B: Helps cover services from doctors and
other health providers, some preventative care,
emergency department visits, urgent care vis-
its, medically necessary outpatient services, lab
work, durable medical equipment and ambu-
lance services. Part B also covers certain drugs
that must be administered by a physician and
vaccines administered by a pharmacist or other
health care provider. Part B covers outpatient
surgery (sometimes called “day surgery”) and
time spent in the hospital for “observation.” A
person who is in the hospital for observation
C H A P T E R 5
MEDICARE
What You Need to Know
MEDICARE: WHAT YOU NEED TO KNOW PAGE 29
or in the emergency room does not qualify for
Part A benefits. Part B has an annual deduct-
ible, paid only once per year as you use ser-
vices. e Part B plan deductible is due when
you start using services at the plan beginning.
Plan B generally starts in January, except the
first year you are enrolled, when the plan starts
with your date of enrollment and the deduct-
ible is due when you first start using services.
e deductible for 2023 is $226. Part B also
requires a monthly premium and pays for 80%
of the approved costs of covered services. e
monthly premium increases above the stan-
dard premium as your income increases; the
amount is based on tax returns from two years
earlier (e.g., for 2023 Part B premium, the in-
come tax filing for 2021). Specific amounts
can be calculated using the table on page 46.
Note that Part B premiums for certain trans-
plant patients are different, as shown on the
table on page 46.
3. Medicare Part C (Medicare Advantage): In-
cludes all the benefits and services under Parts
A and B and may or may not offer outpatient
prescription drug coverage. Medicare C/Advan-
tage plans are run by private health insurance
companies, approved by Medicare and may
include extra benefits and services for an extra
cost, such as vision, hearing and dental cover-
age, and rides to medical appointments that are
not covered by original Medicare. Generally,
you are in a network and must use the provid-
ers in that network for your health care; see the
TIP on this page for additional details on these
plans. Medicare Advantage plans have a yearly
limit on out-of-pocket costs for Medicare Part
A- and B-covered services. Once the yearly lim-
it is reached, no additional payments from the
beneficiary are necessary for the remainder of
the year.
Part C will generally have its own premium, in ad-
dition to the Part B (and Part A, if any).
2
TIP: Part C plans may or may not include prescrip-
tion drug costs. You can check each plan’s benefits
on the Medicare website,
www.medicare.gov/plan-
compare/#/?lang=en
. If you have a Medicare Advan-
tage HMO or PPO plan that includes prescription drug
coverage, you may not enroll in a separate Part D plan
for prescription drug coverage or in a Medigap (supple-
mental) plan.
4. Medicare Part D: Helps cover the costs of
outpatient prescription drugs. To get prescrip-
tion drug coverage, you must enroll in either
a free-standing Part D plan or in a Medicare
Advantage plan that includes drug coverage.
Medicare mandates that all drug plans cover
certain drug classes but not all prescription
drugs. You should check the plans when en-
rolling and annually during open enrollment
to see if your prescriptions are covered by the
plans. In addition to the premium charged
by the drug plan, Medicare beneficiaries with
higher incomes are charged a Part D Income-
Related Monthly Adjustment Amount (IR-
MAA). IRMAA means that you pay premi-
ums to two different places each month, one to
your insurer and the other to Social Security.
e Part D Premium chart is located at the
end of this chapter. us, if your 2021 income
(the earliest Medicare can verify from tax re-
turns) is above $97,000 if you file individually,
or $194,000 if you are married and file jointly,
you will pay an extra amount for the prescrip-
tion drug coverage. Changes to Part D insulin
coverage are discussed on page 47.
TIP: The Medicare Planfinder tool can help you estimate
your annual medical costs; be sure to use the one at
www.
medicare.gov
for full information. Ask your doctor or
pharmacist for your current drug list to use in your search.
Private insurers have similar information but usually only
list the plans they offer, not the full range of choices you
have. Private plans generally end with “.com.” The planners
do not include information on premium adjustments. Note:
these plans did not include the $35/month insulin pricing
in 2023.
Specific information regarding Part D insulin cov-
erage and diabetic supplies is located in “Part D — In-
sulin Coverage” on page 47.
PAGE 30 MEDICARE: WHAT YOU NEED TO KNOW
Part A and Part B are called “Original Medi-
care.” Under Original Medicare, you can choose
any available provider anywhere in the country
who accepts Medicare. Payment is fee-for-service.
You should purchase a Medicare Supplement, also
called Medigap, if you have Original Medicare to
help cover certain out-of-pocket costs. You may au-
tomatically qualify for Part A (read below), but you
must enroll in and pay a monthly premium for Part
B. You must also choose a Part D plan if you want
prescription drug coverage, and you pay a premium
and may pay an additional amount (called IRMAA)
for Part D. e premium charts are listed at the end
of this chapter.
If you enroll in Original Medicare, you should
strongly consider purchasing a Medicare Supple-
ment. e supplement has an additional premium
but covers the deductibles and co-insurance you
would otherwise have to pay. If you have preexist-
ing conditions that require regular physician visits,
you may find that a supplement will save you money.
ere are decision charts on page 32 to help you de-
cide.
An “Accountable Care Organization,” or ACO,
is a type of original Medicare plan. When your
physicians participate in an ACO, your doctors co-
ordinate your care and share your medical records,
which means you don’t have as many repeated tests.
An ACO does not limit your choice of providers or
change your Medicare benefits, which is different
from any Advantage Plan.
3
Medicare Advantage Plans cover Part A, hospital,
and Part B, medical benefits, and are sold and man-
aged by private insurers. ese plans manage your
Medicare A and B benefits. ey have a range of
premiums, costs and rules, and may or may not offer
prescription drug coverage. Some also offer limited
dental, vision, fitness, transportation and hearing
device insurance. You pay your Part B premium and
usually another separate premium to the Medicare
Advantage Plan.
4
ere are generally two types of Medicare Ad-
vantage plans — a Health Maintenance Organiza-
tion (HMO) and a Preferred Provider Organization
(PPO). If you purchase an HMO, you are restricted
to the doctors, other health care providers and hos-
pitals in the HMO network. is means that if you
go to a provider not listed in your network, you will
likely not have insurance coverage for the visit, even
if the provider accepts Medicare. ere are special
rules for emergencies. Under an HMO, you must
have a primary care physician, who then authorizes
medical care and referrals before you can see special-
ists.
5
Medicare Advantage plans are also sold as PPOs.
PPOs establish a network of physicians for whom
you pay less than if you go outside the network. A
PPO plan isn’t the same as Original Medicare with a
Medigap Supplement; usually, you pay extra for the
additional benefits.
6
Private Fee-for-Service plans (PFFS) are another
form of Medicare Advantage option. Under a PFFS
plan, you can go to any Medicare-approved doctor;
there is no network or restriction. However, a doctor
does not have to agree to treat you under a PFFS plan,
even if the doctor has treated you before. e PFFS
plan works differently than Original Medicare. e
PFFS plan determines how much it will pay doctors,
other health care providers and hospitals, and how
much you must pay when you get care.
7
Finally, Part C, Medicare Advantage, includes
Special Needs Plans (SNP), which are limited to
people with specific conditions or living in institu-
tions, or dual beneficiaries (qualified for Medicare
and Medicaid/MassHealth).
8
Before you decide on a Medicare Advantage
Plan, you should compare the costs. ere is an on-
line cost calculator and plan comparison tool run by
CMS, at www.medicare.gov/find-a-plan/questions/
home.aspx.
When you have a Medicare Advantage Plan,
you cannot buy Medigap insurance to cover your
deductibles, co-pays and co-insurance. You can use
a Medicare Medical Savings Account (MSA) if you
have a high-deductible Medicare Advantage Plan.
You contribute nothing to the MSA. Medicare de-
posits money in your MSA to apply against the high
deductible costs of your Medicare Advantage Plan;
this money is usually less than the plan deductible.
e Advantage Plan that you choose describes how
much Medicare pays into the MSA. Any money left
in the account at year end can be used toward next
year’s deductible, in addition to whatever Medicare
contributes to the account for the new year. To avoid
income taxes on withdrawals from your MSA, you
must file Form 8853 with your Form 1040 income
tax return, listing your qualified medical expenses
(generally, expenses eligible for coverage under Parts
MEDICARE: WHAT YOU NEED TO KNOW PAGE 31
A and B of Medicare). If you use all of the money in
your MSA account and you have additional health
care costs in a year, you’ll have to pay for your Medi-
care-covered services out of pocket until you reach
your Advantage Plan’s deductible. You may use your
MSA to pay for prescription drugs, but that does
not count toward your deductible. Consider add-
ing drug coverage through a Medicare Prescription
Drug Plan (a Part D plan) if you choose a Medicare
Advantage Plan that does not include drug cover-
age; without prescription drug coverage at the be-
ginning, you will likely have to pay a penalty to pur-
chase Part D in the future.
If you have an existing health savings account
(HSA), you should stop contributing to your HSA
at least six months before you apply for Medicare.
If you make HSA payments after you start Medi-
care, you may have to pay a tax penalty. You can
use your HSA money after you enroll in Medicare
to pay for deductibles, premiums, co-payments and
co-insurance, but you cannot make additional HSA
contributions when you enroll in Medicare.
B. Medicare and Medicare Advantage
Limitations
Payroll and federal income taxes all Medicare
beneficiaries pay over their working life cover about
75% of the Medicare program costs. e remaining
25% is paid by individual beneficiaries, or through
the help programs discussed below. Medicare, in-
cluding Medicare Advantage plans, does not pay all
medical bills, even for covered services. e benefi-
ciary pays premiums, deductibles, co-payments and
co-insurance for many services. (See Medicare 2023
Costs at-a-Glance chart on pag 32.)
Part A benefits cover inpatient hospitalization,
skilled nursing facility (SNF) care, hospice and
home care. Part A benefits do not automatically start
when you go to the hospital. In order to get Part A
benefits, you must be admitted as an inpatient by
both your doctor and the hospital. If your doctor
tells you to go to the emergency department, you are
NOT covered by Part A, only Part B. When you are
admitted as an inpatient, you will pay a deductible
of $1,600 for 2023. is is not prorated; you pay
this if you stay one day or for 60 days. You pay this
deductible each time you start a new Part A period,
not just once a year. A Part A period ends only when
you have been out of the hospital or not using any
skilled nursing care for 60 consecutive days. Part A
does not cover any doctor’s services while you are
hospitalized; doctor’s services are billed under Part
B and you pay for them separately.
Part A covers care in an SNF as long as you meet
certain conditions, for up to 100 days per benefit
period. To qualify, you must first be admitted as an
inpatient in a hospital or Acute Care Unit for a min-
imum of three Medicare days (counted from mid-
night to midnight). Additionally: 1) you must need
skilled services that must be performed by profes-
sional personnel for a condition for which you were
in the hospital; 2) you must need these services on a
daily basis; 3) as a practical matter, the daily skilled
services can only be provided on an inpatient basis;
and 4) the services must be reasonable and neces-
sary (consistent with the nature and severity of the
illness or injury). If you do not meet all four of these
criteria, you cannot receive SNF benefits under Part
A, even if you have been an inpatient, or have avail-
able or unused SNF days. Part A does NOT cover
custodial care, even in hospice.
Medicare does provide skilled care (nursing,
physical therapy, occupational therapy) for services
that are required to maintain the patient’s current
function or to prevent or slow further deteriora-
tion. is requirement for care is referred to as the
“Jimmo” standard, named after the court case that
changed Medicare practice. Jimmo care must meet
certain requirements. ese services must be of such
complexity and sophistication that the skills of a
qualified therapist are required to perform the pro-
cedure safely and effectively. If a service can be safely
and effectively performed (or self-administered) by
an unskilled person, without the direct supervision
of a nurse, the service CANNOT be regarded as a
skilled nursing service although a nurse actually pro-
vides the service. A service is not considered a skilled
nursing service merely because it is performed by or
under the supervision of a nurse. e unavailabil-
ity of a competent person to provide a non-skilled
service, regardless of the importance of the service
to the patient, does NOT make it a skilled service
when a nurse provides the service. In addition, these
services to “maintain” the patient’s current condi-
tion or to prevent or slow further deterioration that
do require skilled nursing cannot be provided in a
hospital or skilled nursing facility, or most Medicaid
nursing facilities. ese services are only provided in
PAGE 32 MEDICARE: WHAT YOU NEED TO KNOW
Many Medicare beneficiaries express concern
that the deductibles, the 20% Part B co-insurance
(without a cap or out-of-pocket maximum), the
costs of Part A hospital and SNF days, and the lack
of prescription coverage may cause major financial
difficulties in the case of a medical issue. To address
these concerns, Medicare beneficiaries have oppor-
tunities to purchase supplemental Medicare, which
fills the gaps in Medicare.
the “home.”
9
Part B has a yearly $226 deductible before pro-
viding coverage for covered services. Once the de-
ductible is satisfied, Part B pays 80% of the approved
cost of the majority of covered services; limited office
visits have co-pays. Furthermore, Original Medicare
generally does not cover the prescription medicines
you would normally pick up at a pharmacy. ere
are some exceptions — COVID vaccines and boost-
ers, flu shots, Hepatitis B shots, pneumococcal shots
and some insulin devices are covered under Part B.
MEDICARE 2023 COSTS AT-A-GLANCE
Part A premium Most people don’t pay a monthly premium for Part A. If you buy Part A, you’ll pay up to $506 each
month for the entire time you have Part A.
Part A hospital
inpatient
deductible and
co-insurance
You pay:
• $1,600 for each benefit period
• Days 1–60: $0 co-insurance for each benefit period
• Days 61–90: $400 co-insurance per day of each benefit period
• Days 91 and beyond: $800 co-insurance per each “lifetime reserve day” after 90 for each benefit
period (up to 60 days over your lifetime)
• Beyond lifetime reserve days: all costs
Skilled nursing
facility stay when
Medicare Part
A-eligible
First 20 days: $0 for each benefit period
• Days 21–100: $200 co-insurance per day of each benefit period
• Days 101 and beyond: all costs
Part B premium For those enrolling in Part B for the first time, the standard Part B premium is $164.90 (or higher
depending on your income); those in the highest bracket pay $560.50 per month. Medicare uses your
income from two years ago (2021) to calculate your premium.
(For immunosuppressive drug premiums, see chart on page 46.)
Part B deductible
and co-insurance
$226 per year. After your deductible is met, you typically pay 20% of the Medicare-approved amount
for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient
therapy and durable medical equipment.
Part C premium The Part C monthly premium varies by plan. Compare costs for specific Part C plans. You usually also
have to pay the Part B premium.
Part D premium There are now two types of Part D monthly premiums. One must be paid to the insurance plan to
obtain the insurance. This amount varies by plan. There is also an income-adjusted premium where
higher-income consumers pay more. This premium, called the Medicare Part D IRMAA, is paid directly
to Medicare and NOT to the insurance company. Social Security determines if you owe this extra pre-
mium, which can range from $12.20 per month to $76.40 per month. If your yearly income in 2021
was $194,000 or less filing jointly, or $97,000 filing singly, you pay only your plan premium. Compare
costs for specific Part D plans.
Home Health
Care
Whether under Part A or Part B: $0 for approved home health care services; 20% of the Medicare-
approved amount for durable medical equipment.
Hospice Care $0 for hospice care and limited costs for outpatient care; does not include custodial care. There is
a small co-payment of $5 to $10 for each prescription drug and similar products for pain relief and
symptom control. You can also use your Part D plan to cover this cost. Medicare does not cover room
and board when you get hospital or hospice care in your home or another facility.
MEDICARE: WHAT YOU NEED TO KNOW PAGE 33
C. Am I Eligible for Medicare and How Do I
Sign Up/Enroll?
• To be eligible for Medicare, you must be a U.S.
citizen or a legal resident (green card holder).
• If you are already getting benefits from Social
Security or the Railroad Retirement Board,
you will automatically get Part A and Part B
starting the first day of the month you turn 65.
If you are not already receiving those benefits,
you will need to contact Social Security three
months before your 65
th
birthday during the
initial enrollment period. e initial enroll-
ment period is the seven-month period that
begins three months before you turn 65 and
ends three months after you turn 65.
• Most people must actively enroll in Medicare.
You must contact Social Security during the
initial enrollment period. You can enroll in
person at your local Social Security Adminis-
tration office, enroll online at www.SSA.gov,
or call the Social Security Administration at
1-800-772-1213, Monday through Friday
from 7 a.m. to 7 p.m. As of the date of print-
ing, SSA recommends you enroll online.
If you or your spouse has paid Medicare taxes
for at least 10 years (40 quarters), then you do
not have to pay a premium for Part A Medi-
care. If you have not paid Medicare taxes for
40 quarters for that period of time (not how
much in taxes you paid), then you will pay a
monthly premium. If you worked more than
30 quarters but less than 40, it costs $278/
month; if you worked less than 30 quarters,
then $506 each month for the entire time you
have Part A. If you work additional quarters,
you can add these to your Social Security Ad-
ministration account and reduce your lifetime
premiums. Request an update from Social Se-
curity so you get the credits earlier.
Medicare is also available to people younger
than 65 who have certain disabilities:
°
If you have end-stage renal disease (ESRD) or
amyotrophic lateral sclerosis (ALS), you are
eligible for Medicare at any age. Individuals
under age 65 with disabilities other than
ESRD or ALS must have received Social
Security Disability benefits for 24 months
before becoming eligible for Medicare. A
five-month waiting period is required after a
beneficiary is determined to be disabled before
a beneficiary begins to collect Social Security
Disability benefits.
NOTE: Individuals with ESRD and ALS,
however, do not have to collect Social Security
Disability benefits for 24 months in order
to be eligible for Medicare. Individuals with
ESRD are eligible for Medicare generally
three months after a course of regular dialysis
begins or after a kidney transplant. Individuals
suffering from ALS are eligible for Medicare
coverage immediately upon approval for
Social Security Disability benefits (but after
the five-month waiting period).
NOTE: Beginning in 2023, certain Medicare
enrollees who are 36 months post-kidney
transplant and no longer eligible for full
Medicare coverage can elect to continue Part
B coverage of immunosuppressive drugs by
paying a premium based on earnings; see the
chart on page 46.
CAUTION: If you do not sign up for Part A and/or Part
B during the initial enrollment period, or when you are
first eligible, or when you lose your employer health in-
surance, your monthly Part B premium may increase
10% for each year you delayed as a late enrollment
penalty for as long as you have Medicare. This late en-
rollment penalty is paid as an increase in your monthly
premium and is permanent if you are 65 or older. If you
are younger than 65, the penalty ends at 65. In addi-
tion, there is a coverage gap. You can sign up between
Jan. 1 and March 31 of the following year, but coverage
does not begin until July 1. If you have incurred such a
sanction, you should look into filing for “equitable re-
lief.” A successful claim for equitable relief may waive
the Part B late enrollment penalties and win a “special
enrollment date” if the federal government has misled
you about enrollment rules.
D. What if I Am Turning 65, Still Working and
Have Health Insurance from My Employer?
Full retirement age for Social Security benefits
is now based on the year you were born, and the
age when full benefits start has been raised. is
means that you may qualify for Medicare before you
qualify for Social Security benefits. See Chapter 13
for full information on Social Security. Consequently,
PAGE 34 MEDICARE: WHAT YOU NEED TO KNOW
many people work beyond age 65. If you are turning
65, still working and have health insurance coverage
through your employer, there are additional consid-
erations.
“By law, people who continue to work beyond
age 65 still must be offered the same health insur-
ance benefits (for themselves and their dependents)
as younger people working for the same employer.”
10
If your employer has more than 20 employees, the
employer’s health insurance is primary. Your em-
ployer cannot require you to enroll in Medicare
when you turn 65 or offer you a different kind of
insurance, unless your employer has fewer than 20
employees. If your employer has fewer than 20 em-
ployees, Medicare is primarily responsible for your
health care costs. e group health plan pays sec-
ondarily, after Medicare, up to covered costs. In this
case, if you fail to enroll in Medicare when you are
first eligible, you may have little or no health cover-
age.
If you do enroll in Part A while working, and
you keep your group insurance plan, you can delay
enrolling in Part B. When you leave work, you will
have a special enrollment period to enroll in Part B.
You can enroll anytime when you are still covered by
the group health plan and during the eight-month
period that begins after the employment ends or the
coverage ends, whichever happens first.
11
Note that
neither COBRA nor retirement health insurance
coverage can extend the enrollment period for Part
B or protect you from penalties.
Be sure to sign up for Medicare Parts A and B
(and also Medigap) when first eligible or upon losing
employer group coverage. COBRA is not considered
credible coverage. ose who go for extended peri-
ods of time without creditable coverage may be as-
sessed a late enrollment penalty upon electing Part
B at a later date. Your monthly premium for Part B
will go up 10% for each full 12-month period that
you could have had Part B but did not sign up for
it. It is generally not advisable to go without cover-
age “until needed” to save on the monthly premium
costs.
TIP: Your employer’s insurance may coordinate ben-
efits with Medicare; in some instances, the employer’s
insurance will act like a Medicare Supplement and pay
deductibles and co-insurance. Check the details where
you work.
E. How Does Medicare Impact Other Health
Insurance and Personal Injury Monies?
You cannot have two different insurances pay
the same amount on a bill. One insurance will pay
some money first, and then the second insurance
will pay some money. For more information when
you have two insurances or sources of payment for a
health-related injury, see “Medicare Guide to Who
Pays First,” from www.Medicare.gov.
If you have Medicare and other health insurance
or coverage, be sure to tell your doctor and other
providers. ey will be able to send your bills to the
correct payers to avoid delays. If you have questions
about who pays first or if your insurance changes,
call 1-800-MEDICARE and ask for the Medicare
coordination of benefits contractor.
For information on End-Stage Renal Disease,
refer to www.medicare.gov/basics/end-stage-renal-
disease.
If you receive money from a personal injury
settlement, workers’ compensation claim, car acci
-
dent, medical settlement or other compensation for
personal injury, this will likely affect your Medicare
benefits. You may owe Medicare money for your
care. You should notify Medicare and speak with
the Medicare coordination of benefits contractor.
Failure to follow these rules can result in loss of
Medicare coverage for certain conditions and a fine,
possibly as much as $1,000 per day.
Medicare will first send a demand for reimburse
-
ment. e procedure is found at www.cms.gov/
Medicare/Coordination-of-Benefits-and-Recovery/
Coordination-of-Benefits-and-Recovery-Overview/
Reimbursing-Medicare/Reimbursing-Medicare-.
e time to respond is 30 days, before interest be
-
gins to accrue. ere, is however, a waiver of recov-
ery process described there.
Medicare has legal authority to recover money
from these third-party payments. See www.cms.gov/
Medicare/Coordination-of-Benefits-and-Recovery/
Beneficiary-Services/Medicares-Recovery-Process/
Medicares-Recovery-Process for a description of the
various steps. Note that interest accrues on unrecov
-
ered payments. Medicare has an automatic lien on
any funds you are paid.
MEDICARE: WHAT YOU NEED TO KNOW PAGE 35
IF YOU CONDITION PAYS FIRST PAYS SECOND
Are age 65 or older and
covered by a group health
plan because you are
working or are covered by
a group health plan of a
working spouse of any age
Entitled to Medicare and the
employer has 20 or more
employees
The employer has less than
20 employees and has no
Medicare exceptions
Group Health Plan
Medicare
Medicare
Group Health Plan
Have an employer group
health plan after you retire
and are age 65 or older
Entitled to Medicare Medicare Retiree coverage
Are disabled and covered
by a large group health
plan from your work or
a family member who is
working
Entitled to Medicare and:
1. The employer has 100 or
more employees, or
2. The employer has less
than 100 employees and no
Medicare exceptions
1. Large Group Health Plan
2. Medicare
1. Medicare
2. Group Health Plan
Have been in an accident
where no-fault or liability
insurance is involved
Entitled to Medicare
No-fault or liability
insurance for services
related to accident claim
Medicare
Are covered under
workers’ compensation
because of job-related
illness or injury
Entitled to Medicare
Workers’ compensation
for workers’ compensation
claim-related services
Are a veteran and have
veteran’s benefits
Entitled to Medicare and
veteran’s benefits
1. Medicare pays for
Medicare-covered services;
2. Veterans Affairs pays for
VA-authorized services
NOTE: Generally, Medicare
and VA can’t pay for the
same service
Usually doesn’t apply
Are covered under
TRICARE
Entitled to Medicare
and TRICARE
Medicare pays for
Medicare-covered services
TRICARE pays for services
from a military hospital or
any other federal provider
TRICARE may pay second
Are age 65 or older OR
disabled and covered by
Medicare and COBRA
coverage
Entitled to Medicare Medicare COBRA
PAGE 36 MEDICARE: WHAT YOU NEED TO KNOW
F. Options to Enhance Original Medicare
Coverage
1. Buy a Medigap Plan for Supplemental
Insurance
Medigap plans cover many of the expenses you
owe under Original Medicare A and B. Medigap
does not cover more services or give you more
coverage than Original Medicare. Here are two
examples. First, Medicare does not cover hear-
ing aids, so Medigap does not cover hearing aids.
Second, under Part A, you would have up to 100
days in a skilled nursing facility (rehabilitation
center) provided you meet the requirements. You
would pay nothing for the first 20 days, and co-
insurance of $400 per day for days 21 through
100. A Medigap plan will pay the co-insurance of
$400 per day for all of the days when you qualify
for Medicare coverage but will not pay for any
costs beyond the 100 days. is is because Medi-
care itself does not cover more than 100 SNF
days in any one period. Medigap will not pay if
you are not receiving skilled care, even if you have
not used all your days.
You have to pay a premium for Medigap plans.
Currently, in Massachusetts, you can purchase a
Medigap plan at initial enrollment or during any
annual renewal. is is not true in all states, and
may not be true in the future. In some states, if
you do not enroll in a Medigap plan when you
first enroll in Medicare, you may not be able to
buy a Medigap plan after, or you may have to take
a physical exam to get Medigap, and it may cost
considerably more.
12
Massachusetts Medigap options are different
than those in other states, but Massachusetts of-
fers three options of Medigap plans: the Core
plan, Supplement 1 and Supplement 1A.
1) Core: e Core plan is the least expensive of
the three options and covers the Part B co-
insurance amount, paying for the 20% of ap-
proved amounts that Part B would normally
require the Medicare beneficiary to pay out of
pocket. With this option, policyholders would
still pay the Part B deductibles out of pocket
and the Part A deductibles and co-insurance.
2) Supplement 1: Like the Core plan, this option
covers the 20% Part B co-insurance amount.
Additionally, Supplement 1 covers the Part A
and Part B deductibles, providing more robust
coverage than the Core plan. Due to the en-
hanced coverage, the Supplement 1 premium
is higher than the Core plan offerings.
3) Supplement 1A: is plan covers the Part A
deductible, but not the Part B deductible.
If you are purchasing a Medigap plan, check
if the plan covers Massachusetts state-mandated
benefits, including yearly Pap tests and
mammograms.
IMPORTANT NOTICE: Medicare Supplement premium
rates are required to be in effect for no less than 12
months. Effective dates shown for each carrier are
based on the most recent filing on record with the
Division of Insurance.
TIP: Use this Medicare Planfinder tool to compare
Medicare Supplement plans and prices available:
www.
medicare.gov/medigap-supplemental-insurance-
plans/#/m/?year=2023&lang=en
.
The Advantages and Disadvantages of
Medicare Supplements
• Medicare supplements in Massachusetts work
with Original Medicare; policyholders gener-
ally have low out-of-pocket costs when receiv-
ing covered services and flexibility in choosing
providers. ere are no networks and no refer-
rals are necessary.
• Premiums for Medicare supplements may ex-
ceed $200 a month, paid to the insurance
company.
• Also, the supplements do not cover most pre-
scription medicines. In many cases, retirees in-
cur the additional cost of a Part D plan.
Medigap in Massachusetts
e chart on page 37 compares Massachusetts
Medigap plans.
MEDICARE: WHAT YOU NEED TO KNOW PAGE 37
MEDIGAP IN MASSACHUSETTS:
Compare These Plans Side-by-Side
If a “yes” appears, the plan covers the described benefit. If “no” appears, the policy doesn’t cover that benefit.
MEDIGAP BENEFITS
MEDIGAP PLANS
Core Plan Supplement 1 Supplement 1A
BASIC BENEFITS
Yes Yes Yes
Part A: inpatient hospital deductible
No Yes Yes
Part A: skilled nursing facility co-insurance
No Yes Yes
Part B: deductible*
No Yes* No
Foreign travel emergency
No Yes Yes
Inpatient days in mental health hospitals
60 days per
calendar year
120 days per
benefit year
120 days per
benefit year
State-mandated benefits (yearly Pap tests and
mammograms. Check your plan for other state-
mandated benefits.)
No Yes Yes
*Supplement 1 Plan (which includes coverage of the Part B deductible) will no longer be available to people who are
new to Medicare on or after Jan. 1, 2020. These people can buy Supplement 1A Plan. However, if you were eligible for
Medicare before Jan. 1, 2020, but not yet enrolled, you may be able to buy Supplement Plan 1.
TIP: If your Medicare costs are too expensive, there
are four types of Medicare Savings programs that may
help. To find out if you are eligible, and how much help
you qualify for, go to
https://www.medicare.gov/ba-
sics/costs/help/medicare-savings-programs.
2. Part D: Buy a Medicare Part D Plan for
Prescription Drug Coverage
Original Medicare Parts A and B, even with a
Medigap Supplement, do not offer prescription
drug coverage. Some Medicare Advantage plans
(Medicare Part C, see Section 3) do not offer drug
coverage. If you elect Medicare Parts A and B, or
a C plan without prescription drug coverage, you
should always consider prescription drug costs
and which Part D plan is right for you.
Medicare Part D is an option that provides pre-
scription drug coverage to Medicare beneficiaries
through a private insurance company. is pro-
gram provides coverage for many common medi-
cines that can be obtained at participating local
pharmacies or mail-order programs.
Coverage levels and monthly premiums vary by
insurance company, but the basic structure and
minimum coverage levels are specified by Medi-
care. Part D plans have four basic components:
1) Deductible: Some plans (especially lower pre-
mium options) have a deductible. A deduct-
ible is a dollar amount a policyholder must pay
out of pocket before the insurance company
pays benefits. e deductible may apply to all
medicines the plan covers or only certain drugs
(e.g., brand-name medicines). Insurance com-
panies may choose not to include a deductible;
in such cases, coverage begins immediately.
2) Initial Coverage Stage: is stage provides
benefits with a co-pay (fixed dollar amount) or
co-insurance (percentage of cost) for covered
drugs. Insurance providers classify medicines
in tiers. Tiers are often divided in categories like
preferred generics, non-preferred generics, pre-
ferred name brand, non-preferred name brand
and specialty drugs. Generally, the higher the
tier, the higher the amount the policyholder
pays out of pocket. ese co-pays change if the
policyholder reaches the coverage gap.
3) Coverage Gap: Although Medicare has offi-
cially removed the coverage gap from Medicare
Part D plans, most private insurers still use a
coverage gap in their policies. e coverage
gap (also called the “donut hole”) goes into ef-
fect when the total cost of drugs covered un-
PAGE 38 MEDICARE: WHAT YOU NEED TO KNOW
der the plan reaches $4,660 (2023 numbers)
in one calendar year and extends until $7,400.
In the gap, policyholders generally pay 25% of
the cost of both their generic and brand-name
medicines, usually more than the co-pay.
4) Catastrophic Coverage: If a policyholder’s
out-of-pocket cost reaches $7,400 during 2023,
the coverage gap is closed and the policyhold-
er moves into the catastrophic coverage stage.
As of publication, there were no prices on the
CMS website, but they are expected to be low.
Please note, on Jan. 1, the plan resets for the
new year, returning to the initial coverage stage
(or deductible stage).
TIP: Medicare has two websites that will help you
with Part D coverage. One site helps you determine
which type of plan is right for you (e.g., which type
of plan works for people who take a lot of expensive
prescription medications, or those who don’t take any);
this site is at
www.medicare.gov/drug-coverage-
part-d/how-to-get-prescription-drug-coverage/6-
tips-for-choosing-medicare-drug-coverage
. One site
also helps you select between plans in your coverage
area, which is
https://www.medicare.gov/plan-
compare/#/?lang=end&year=2023
.
Be sure to use the “medicare.gov” websites for
full comparisons. Private insurers’ websites will
not include information on competitors’ prod-
ucts.
Part D Formularies, Tiers and Quantity
Limitations
Medicare requires each plan to cover certain
classes of drugs, but the plans vary widely in what
specific medicines are covered. It is very impor-
tant to obtain the plan’s formulary, which lists
each medicine covered and its tier. In addition,
many drug companies impose “utilization man-
agement,” requiring prior authorization and step
therapy (meaning that you are prescribed the
most commonly used generic drug for your con-
dition, to see if it works for you; you must fail on
that drug before you can move up a “step” to a
more expensive drug) before covering the drug, as
well as quantity limits. For many common drugs,
there are major differences in coverage levels be-
tween insurance companies, so it makes sense to
check the tier and quantity limitations for each of
your medications with prospective insurance pro-
viders before enrolling. An insurer cannot remove
a therapeutic category (e.g., high blood pressure
medication) during a plan year, but can remove
any single drug from its coverage with 60 days’
notice to the insured.
If a plan does not carry a drug you need, you
and your physician may request an “exception.”
Not all plans provide for formulary exceptions if
a medically necessary medicine is generally not
covered. If your plan allows exceptions, you con-
tact the plan’s customer service department and
request a “formulary exception” for the medicine.
If your request is denied, you can appeal this de-
cision. Follow all the steps listed at https://medi-
care.gov/medicare-prescription-drug-coverage-
appeals.
If a prescription drug you need is listed on
the formulary, but you are denied coverage un-
der Medicare, you can also appeal this denial of
coverage. is is useful to know if you have just
enrolled in Medicare, and have been successfully
taking a drug for your condition, and Medicare
requires that you utilize step therapy.
If Medicare does not cover your drugs, or you
have not been successful with an appeal, you can
see if that drug is covered under a different pro-
gram, such as SimpleCare or GoodRx, discussed
in more detail on page 40 . If you use these plans,
you cannot use Medicare for the same prescrip-
tion, and the costs will not be included in your
Medicare coverage limits.
TIP: Your pharmacist can discuss insurance plans you
research on the CMS website, but cannot market any
specific plan to you. Select your Medicare Part D plan
using the Medicare Part D plan finder tool, from the
CMS website, found at
www.medicare.gov/find-a-
plan/questions/home.aspx.
Recent studies show that
some plans can cost up to $100,000 more for the same
drugs. If you take any single prescription that costs
more than $600 a month, you should take great care
to evaluate these plans. Mail order is not automatically
cheaper than retail.
New this year: Change to Part D insulin
costs starting Jan. 1, 2023. Plans cannot charge
you more than $35 for a one-month supply of each
Medicare Part D-covered insulin you take, and
MEDICARE: WHAT YOU NEED TO KNOW PAGE 39
cannot charge you a deductible for insulin. is
means that the $35/month fee does not reduce your
deductible. https://medicareadvocacy.org/ira-part-
d-improvements-start-january-2023/. is benefit
is NOT reflected in the plan information posted
on the Medicare Planner for Part D website. See
the end of the chapter for specific information on
how to determine drug costs, including insulin,
for Part D.
If you have difficulty paying for insulin,
see if you qualify for Extra Help, and your co-
payment for insulin would be lower. You apply
for Extra Help through Social Security; for the
Massachusetts-specific Medicare Savings Plan,
call SHINE for Massachusetts — Serving the
Health Insurance Needs of Everyone — at 1-800-
243-4636.
Late Enrollment Penalty for Part D
If you do not enroll in a Part D plan when
initially eligible, have creditable coverage from
another source or have drug coverage through a
Medicare Advantage plan, you will be subject to a
Part D late enrollment penalty even if you do not
currently require medication. If you go without
coverage for more than 63 consecutive days, you
ORIGINAL MEDICARE & MEDICARE ADVANTAGE PLANS AT-A-GLANCE
Original Medicare
(Parts A & B)
Original Medicare &
Medigap
HMO Part C (Medicare
Advantage)
PPO Part C (Medicare
Advantage)
What do I pay?
Part B premiums,
deductibles and
co-insurances
Medigap premiums,
Part B premiums,
generally no
co-payment
Medicare premiums
and plan premium;
your plan sets its
own deductibles and
co-pays
Medicare premiums
and plan premium;
your plan sets its
own deductibles and
co-pays
Can I go to any
doctor?
Yes, if they accept
Medicare
You can go to any
doctor, regardless of if
they accept Medicare
No, you must go to
in-network providers
Yes, though PPOs
have provider net-
works, you may go
out of network for a
higher co-pay
Where can I get
routine, non-
emergency care?
Anywhere in the
country
Anywhere in the
country
For most plans, in
your local geographic
area
For most plans, in
your local geographic
area
Where can I get emer-
gency care?
Anywhere in the
country
Anywhere in the
country
Anywhere in the
country
Anywhere in the
country
How do I get
prescription drug
coverage?
Part D Part D
You must join a plan
that includes drug
coverage, also called
MA-PD
You must join a plan
that includes drug
coverage, also called
MA-PD
Will I need a referral to
see a specialist?
No
No, unless you have a
Medicare SELECT plan
Usually
No, but you may pay
more out of pocket if
you go to a provider
who is out of network
Is there a limit to
my out-of-pocket
spending?
No No
Yes, all Medicare
Advantage plans must
have limits on out-of-
pocket spending
Yes, all Medicare
Advantage plans
must have limits
on out-of-pocket
spending
Will it pay for extras,
like vision and hearing
aids?
No, Medicare does not
cover dental, hearing
or vision
No
Maybe, some plans
offer these additional
benefits
Maybe, some plans
offer these additional
benefits
* Based on 2020 costs
PAGE 40 MEDICARE: WHAT YOU NEED TO KNOW
drug listed in the formulary to reduce co-pays.
Of course, only consider changing in consulta-
tion with a medical professional.
2) Local discount programs: Some grocery stores
and pharmacy chains offer discount programs
that work in conjunction with your insurance
plan. Please be sure to ask your pharmacist if
your pharmacy offers such programs. You can
compare the price on a national discount plan,
like GoodRx, SimpleCare or Costplusdrugs,
with your insurance price. You can buy the
drug with a national discount plan, but you
CANNOT combine the Medicare Part D ben-
efit with the national discount plan.
3) State pharmacy assistance: Massachusetts of-
fers a state pharmacy assistance program, Pre-
scription Advantage, for those with lower in-
comes who do not qualify for MassHealth. is
program provides out-of-pocket maximums
on co-pays and extra help in the coverage gap.
Unlike Medicare Extra Help and MassHealth,
there is no asset test; qualification is based upon
income. You can reach Prescription Advantage
at 1-800-AGE-INFO, option 2.
4) Medicare Extra Help: Medicare offers “extra
help” (also known as a low-income subsidy) to
beneficiaries with lower income and assets. is
program can reduce or eliminate your Part D
premium and reduce deductibles and co-pays.
Application for this program can be made
through the Social Security Administration di-
rectly after you have enrolled in a Part D plan.
5) Veterans’ Benefits: e Veterans Administra-
tion (VA) offers prescription benefit programs.
For our readers who are veterans, please inquire
with the VA to see if you qualify for benefits
that may enhance the Part D benefit from your
plan.
6) Primary Outreach Programs: Refer to the
Pharmacy Outreach Program information in
Chapter 4.
4. Change from Original Medicare to
Medicare Part C (Medicare Advantage)
While the CMS website will clearly state pre-
miums, deductibles, co-pays and co-insurance for
Parts A and B, each Part C plan must be separately
researched. e information about coverage options
will face a 1% monthly sanction if you ever need
Part D coverage in the future. It is important to
enroll in a Part D plan when first eligible or make
sure you have creditable coverage (or a Part C plan
that includes Part D benefits). ere are some Part
D plans that do not require premiums, which may
benefit those who need little or no prescription
medication.
ese penalties can be significant. Medicare
calculates the penalty by multiplying 1% of the
“national base beneficiary premium” ($32.74 in
2023) times the number of full, uncovered months
you didn’t have Part D or creditable coverage. e
monthly premium is rounded to the nearest $.10
and added to your monthly Part D premium. In
Medicare’s example, a person who delayed Part D
coverage for 24 months pays an additional $7.90
per month in premium. e national base benefi-
ciary premium can change each year, so your pen-
alty amount can also change each year.
If you already have incurred a late enrollment
penalty, you may seek a waiver based on specified
reasons. Waivers may be available for those with
lower incomes.
3. What Options are Available if Your
Medicines are Still Too Expensive?
ere are multiple options for beneficiaries
who have difficulty paying for medicines. In
addition to “Extra Help” or the “Low-Income
Subsidy” provided to low-income beneficiaries,
the following options may apply. Some notable
options include:
1) Explore alternative medicines with your
pharmacist and doctor: Ask your regular
pharmacist for a Drug Utilization Review
(DUR), which is free. is report identifies
duplicate drugs and suggests drugs that may
be more appropriate for you; then show this
report to your doctor(s). Be sure that the
DUR lists all the drugs you take, even those
that you do not fill at that pharmacy. Ask your
doctor if a safe and effective generic medicine or
an alternative therapeutic may work better for
you. Often, co-pays for generics can be more
than 75% less than the brand-name medicines.
Also, it may be possible to switch to a preferred
brand-name from a non-preferred brand-name
MEDICARE: WHAT YOU NEED TO KNOW PAGE 41
is found above. One limitation to consider is that
not all Part C plans cover prescription drugs.
e website, www.Medicare.gov, lists all the
Part C plans available in your area; the website iden-
tifies those Part C plans with drug coverage. ese
plans work similarly to employer-sponsored health
insurance plans, often combining doctor, hospital
and additional services in one comprehensive plan.
e plan options vary by county of residence, and
all plans are not available in all areas. Not all plans
continue from one year to the next and some do not
take new patients. Check if the plans you want pro-
vide these benefits:
• Out-of-pocket maximums;
• Reduced co-insurance amounts and co-pays for
certain services;
• Coordination of care;
• Prescription drug benefits;
• Elimination of deductibles; and
• Low (or zero) monthly premiums.
Star Rating — Pay particular attention to the
star rating for both Part C and Part D plans; the star
rating is a measure of quality.
Medicare Advantage plans are generally one-
year programs. During each annual election period
(usually starting in early October and ending in the
first week of December), Medicare beneficiaries may
change plans or disenroll from Part C and select
other options (like standalone Part D plans), or re-
turn to Original Medicare. Such changes take effect
on Jan. 1.
During the year, there are options to change
coverage if you have certain special circumstances.
Some of the more common situations include:
1) Moving your primary residence outside the
plan service area;
2) Obtaining/losing employer coverage;
3) Qualifying for MassHealth;
4) Obtaining a low-income subsidy;
5) Qualifying for state pharmacy assistance (Pre-
scription Advantage); and
6) Enrolling in Part B.
In such circumstances, you may change plans
with an effective date of the first of the following
month.
G . Deciding Whether to Enroll in Original
Medicare or Medicare Advantage
ere are many considerations in deciding
which type of Medicare plan is best for you. e
chart taken from the National Council on Aging
(NCOA) website, under My Medicare Matters (a
nonprofit group),
13
will help you evaluate your op-
tions and give you personalized advice.
TIP: Before enrolling, ask if your preferred physician is
part of the plan you are thinking about choosing. The
answer may determine what plan you ultimately take.
While most physicians accept Medicare, not all physi-
cians and hospitals are part of the various Advantage
plans.
e following are specific questions the NCOA
asks you to consider:
1. Which option is more stable from year to year?
Each year, Part C (Medicare Advantage) plans
choose if they want to stay in Medicare or not.
ey can also change costs, providers and ben-
efits each calendar year. Original Medicare will
always be there, but its premiums, deductibles
and co-insurance amounts increase slightly each
year.
2. How can I measure quality for all of the vari-
ous plans?
Medicare uses a 5-star rating system to assess the
quality of Medicare Advantage and Part D plans,
with 5 stars being “excellent,” 4 being “above av-
erage” and 3 being “average.” ese ratings are
based on a variety of factors, including how well
the plans help members manage chronic diseases,
member satisfaction and how often members get
screening exams and vaccines, among others. e
ratings are posted on the Medicare Planfinder
website at Medicare.gov.
Some key information from the NCOA site:
Advantages of choosing Original Medicare
combined with a Medigap policy (versus Medi-
care Advantage)
e most significant advantage is that it provides
a better fit for individuals with ongoing medical
issues. If you purchase a Medigap policy within
six months of starting Part B at age 65 or older,
the insurance agency cannot reject the applica-
PAGE 42 MEDICARE: WHAT YOU NEED TO KNOW
tion for any reason. Having a history of cancer
or a recent diagnosis of heart disease, chronic ob-
structive pulmonary disease (COPD), diabetes, or
another chronic condition that will require fre-
quent doctor visits, may indicate a Medigap poli-
cy is a better fit. e monthly payment will be the
same every month, no matter how many doctor
visits occur — so a Medigap policy may reduce
total costs. is can be especially helpful when
you are trying to diagnose a new health condition
and need to seek second opinions. Original Medi-
care offers more flexibility with treatment options.
Tip for “snowbirds” or others who spend time out
of state: If your physician is licensed in Massa-
chusetts, they cannot treat you, even via telemedi-
cine, if you are not physically in Massachusetts.
e only exception is if you are in the emergency
department — then the emergency department
physicians can CONSULT with your physician.
is limitation is set by the Massachusetts board
of licensing, and not regulated by Medicare. An
alternative is to have a “backup” physician in your
second home, to continue routine care. Network
plans will not commonly have practitioners out of
state.
ere are growing complaints that Advantage
plans reduce benefits under Original Medicare.
For example, Medicare will agree to provide oxy-
gen support when the blood oxygen level is X; an
Advantage plan may not provide oxygen support
unless the blood oxygen level is X-Y. ere are also
complaints that Advantage plans restrict access to
various cancer centers, which limits a patient’s
treatment options.
Choosing a primary care physician (a require-
ment of some Medicare Advantage plans) is not a
requirement for Original Medicare. e plan al-
lows the patient to see any physician who accepts
Medicare. Conversely, Medicare Advantage plans
are more restricted in terms of the provider net-
works they work with. Individuals in rural and
isolated areas may have difficulty finding plans in
Massachusetts that work with their local health
care services.
Massachusetts Medigap has three types of poli-
cies, which makes comparing costs relatively sim-
ple.
H. Changing Medicare Plans
As long as you are enrolled in Medicare, you can
change plans during the open enrollment period.
is generally becomes available in early October,
and decisions must be made by early December. e
new plans go into effect Jan. 1. In certain circum-
stances, you can switch between Medicare Part D
plans during the year; consult “Medicare & You” for
further information. If you select an Advantage Plan
in the first enrollment period, you can make ONE
change to a different Medicare Advantage plan or
switch to Original Medicare and Part D between
Jan. 1 and March 31, 2023.
I. Comparing Insurance Providers
When shopping for Medicare Part C, Part D
and Medigap supplements, it is important to com-
pare premiums among insurance companies. As
coverage is standardized, please consider the follow-
ing criteria when evaluating options:
• Consider customer service quality and reputa-
tion: Are claims processed accurately, and are you
able to obtain prompt and professional service
when questions arise?
• Premium consistency: By how much do rates
tend to change annually? How will those changes
impact your budget?
• Discount programs and value-added services:
Does the insurance company you are consider-
ing offer any discounts (based upon age, paying
by automatic bank draft) or savings programs for
dental or vision?
J. What Can You Do if Medicare Denies a
Service/Coverage or Payment?
1. Medicare can deny coverage for a service be-
fore you receive it, or may deny a service or full
payment after it is received. Medicare should
notify you in writing that a future service will
not be covered. Medicare does this by sending
an “Advance Beneficiary Notice of Non-Cov
erage.” In this case, if you get the service be-
fore you appeal, you are agreeing that Medi-
care will not pay for it. You can still file an
MEDICARE: WHAT YOU NEED TO KNOW PAGE 43
appeal, but you will have to pay for the service
first.
You can get this advance notice from a skilled
nursing facility when the facility believes that
Medicare will not cover your stay or certain
items or services.
2. You can file an appeal if Medicare denies a ser-
vice/coverage or payment. e process depends
upon what type of Medicare coverage you have.
You will be required to submit medical records
and documentation, and may need a qualified
physician to work with you on the appeal. Be
careful not to miss a deadline. General infor-
mation on appeals is found at www.medicare.
gov/claims-appeals/how-do-i-file-an-appeal.
TIP: You can find additional information on Medicare
Benefits at
www.medicareinteractive.org/resources/
toolkits/medicare-advocacy-toolkits
. There is a non-
profit organization that can help you with appeals. This is
Medicare Interactive, found at
www.medicareinteractive.
org/get-answers/medicare-denials-and-appeals.
CONCLUSION
Navigating the Medicare system is confusing,
but there are resources available to help. Please be
sure to consult www.Medicare.gov, particularly
“Medicare & You,” or call 1-800-MEDICARE for
detailed information. Consult your trusted advis-
ers and request written information from insurance
companies before enrolling in any plan. Beginning
on page 44 is a chart of Medicare benefits and costs
for Part A and Part B. Medicare is an exceedingly
complex program. For every rule cited in this chap-
ter, many other rules and exceptions apply. “e
devil,” practitioners in this field are quick to point
out, “is in the details.”
1. https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-
You.pdf
.
2. https://www.medicare.gov/sign-up-change-plans/types-of-
medicare-health-plans/medicare-advantage-plans/how-do-
medicare-advantage-plans-work
.
3. https://www.medicare.gov/manage-your-health/coordinating-
your-care/accountable-care-organizations
.
4. https://www.medicare.gov/sign-up-change-plans/joining-a-
health-or-drug-plan
.
5. https://www.medicare.gov/sign-up-change-plans/types-of-
medicare-health-plans/medicare-advantage-plans
.
6. https://www.medicare.gov/sign-up-change-plans/types-of-
medicare-health-plans/preferred-provider-organization-ppo
.
7. https://www.medicare.gov/sign-up-change-plans/types-of-
medicare-health-plans/private-fee-for-service-pffs-plans
.
8. https://www.medicare.gov/sign-up-change-plans/types-of-
medicare-health-plans/special-needs-plans-snp
.
9. For resources on the Jimmo decision and settlement, see Jimmo decision
FAQ: https://www.cms.gov/Center/Special-Topic/Jimmo-
Settlement/FAQs
; CMS manual updates can be found at https://
www.cms.gov/Outreach-and-Education/Outreach-and-
Education?bucket-filter=MM8458.pdf
; for detailed information on
the need for skilled nursing care when there is no likelihood of improvement, see
http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/
CFR-2011-title42-vol2-sec409-32.pdf
.
10. “Age Discrimination in Employment Act of 1967,” 29 USC § 621-34, at https://
www.eeoc.gov/statutes/age-discrimination-employment-
act-1967
.
11. “Medicare & You,” 2023.
12. “When Can I Buy Medigap?” https://www.medicare.gov/
supplements-other-insurance/when-can-i-buy-medigap
.
13. https://www.ncoa.org/age-well-planner/medicare.
PAGE 44 MEDICARE: WHAT YOU NEED TO KNOW
MEDICARE PART A: 2023
SERVICES BENEFIT MEDICARE PAYS
YOU PAY*
Hospitalization:
• Semi-private room and board
• General nursing
• Other hospital services and supplies (Medicare
payments based on benefit periods)
Hospitalization does NOT include Medicare-approved
doctors’ services; you will pay an additional 20% of
that amount while you are an inpatient.
Hospitalization includes mental health inpatient stay,
with the same benefits. Additionally, you will pay
20% of the Medicare-approved amount for mental
health services you get from doctors and other pro-
viders while you’re a hospital patient.
First 60 days All but $1,600 $1,600 (deductible)
61
st
to 90
th
day All but $400 per day
$400 (co-insurance)
per day
91
st
to 150
th
day (lifetime)**
All but $800 per day
$800 (co-insurance)
per day
Beyond 90 (or
150 if lifetime is
used) days
Nothing All costs
Skilled Nursing Facility Care:
(Have to be inpatient for 3 days beforehand)
• Semi-private room and board
• Skilled nursing and rehabilitative services
• Other services
First 20 days
100% of approved
amount
Nothing
Additional 80
days
All but $194.50
per day
$194.50/day
(co-insurance)
Beyond 100
days
Nothing All costs
Home Health Care:
• Intermittent skilled nursing care
• Physical therapy, speech language, pathology
services
• Home health aide services
• Durable medical equipment (e.g., wheelchairs,
hospital beds, oxygen and walkers)
• Other services and supplies
• No custodial care — Must be recovering
Unlimited as
long as you
meet Medicare
conditions
• 100% of
approved amount
• 80% of approved
amount for
durable medical
equipment
• Nothing for services
• 20% of approved
amount for durable
medical equipment
Hospice Care:
• Pain and symptom relief
• Support services for the management of mental
illness
• DNR
For as long as
doctor certifies
need (6 months
to live or less)
All but limited costs
for outpatient drugs
and inpatient
respite care
Limited costs for outpa-
tient drugs ($5 co-pay)
and inpatient respite
care (5% of approved
amount)
Blood:
If the hospital or provider does not have to pay for the
blood, there is no charge to the patient. The charges
apply only if the hospital or provider has to pay.
Blood paid for or replaced under Part A of Medicare
during the calendar year does not have to be paid for
or replaced under Part B and vice versa.
• Pints 1–3
• Pints 4 and
over
• Nothing
• All
• Patient must pay for
1–3 pints or have
them replaced (self
or usually family
member)
• Patient deductible is
satisfied at 3 pints.
Medicare “beneficiaries” receive “medically necessary and reasonable” (least expensive) treatment. Not all
services/tests are provided under Medicare.
* 2023 Part A Monthly premium: Most people don’t pay a monthly premium for Part A (sometimes called “premium-free Part A”). If you buy Part A, you’ll pay up to $506 each month in 2023. If you
paid Medicare taxes for less than 30 quarters, the standard Part A premium is $506 in 2023. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $278 in 2023. This
premium is paid for the entire time the person is on Medicare Part A.
**You must pay the amounts listed in the “You Pay” column; Medigap insurance will only pay the deductibles and co-insurance, but does not cover services Medicare itself doesn’t cover. For
example, Medigap will NOT add days to the skilled nursing benefit; when Medicare stops at 100, so does Medigap.
MEDICARE: WHAT YOU NEED TO KNOW PAGE 45
MEDICARE PART B: 2023
SERVICES BENEFIT MEDICARE PAYS YOU PAY
†
Medical Expenses:
• Doctors’ services, inpatient and
outpatient
• Surgical services and supplies
• Podiatrist services
• Physical, occupational and speech
therapy
• Diagnostic tests (e.g., X-rays, hearing
exams)
• Durable medical equipment
• Urgent and emergency services
(including ambulances)
Unlimited if medically
necessary
• 80% of the approved
amount after $226
deductible
• 80%** for most
out-patient services,
including mental
health
• $226 deductible (pay
once per year)
• 20% of approved
amount after
deductible
• 20% for tests and
durable medical
equipment
• 20% for all physical
and occupational
therapy
Outpatient Mental Health Services:
• Yearly depression screening
• Visits for mental health
• Everything
• 80% of the approved
amount after $226
deductible
• Nothing if your
provider accepts
assignment
• 20% of the approved
amount after $226
deductible
Clinical Laboratory Services:
• Blood tests, urinalysis and more
Unlimited if medically
necessary
100% of approved
amount
Nothing for services
Home Health Care: (if you don’t have
Part A)
• Intermittent skilled care
• Home health aide services
• Durable medical equipment
• Other services and supplies
• No custodial care — must be recov-
ering
Unlimited as long as
you meet Medicare
conditions
• 100% of approved
amount
• 80% of approved
amount for durable
medical equipment
• Nothing for services
• 20% of approved
amount for durable
medical equipment
Outpatient Hospital Treatment:
Services for the diagnosis or treatment
of an illness or injury
Unlimited if medically
necessary
Medicare payment
to hospital based on
hospital cost
20% of Medicare
payment amount (after
$226 deductible)
PREMIUMS (2022)
‡
— Premiums are “means adjusted.”
All others: Premium Income Level (Indi-
vidual MAGI for 2020)
Income Level (Joint MAGI for 2020)
$164.90 $97,000 or less $194,000 or less
$230.80 $97,001–$123,000 $194,001–$246,000
$329.70 $123,001–$153,000 $246,001–$306,000
$428.60 $153,001–$183,000 $306,001–$366,000
$527.50 $183,001–$500,000 $366,001–$750,000
$560.50 $500,00 and above $750,000 and above
*PREMIUM MAY BE HIGHER IF YOU ENROLL LATE: Premiums for high income, married, filing separately are different —
See CMS Medicare site for additional information.
Married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses,
please refer to www.Medicare.gov.
MEDICARE PART C: MEDICARE “ADVANTAGE” — MANAGED CARE PLAN
MEDICARE PART D: PRESCRIPTION DRUG BENEFIT
† You must pay the amounts listed in the “You Pay” column; Medigap insurance will only pay the deductibles and co-insurance, but does not cover services Medicare itself doesn’t cover.
‡ Part B premiums must pay for 25% of Part B costs, including reserves. The government pays 75%; the premium increase cannot exceed the COLA (cost of living adjustment) in SSI for older adults.
**Updated 7/13/23
PAGE 46 MEDICARE: WHAT YOU NEED TO KNOW
Medicare Part B Premiums 2023
Full Part B Coverage
Beneficiaries who file
individual tax returns
with modified adjusted
gross income:
Beneficiaries who file joint tax
returns with modified adjusted
gross income:
Income-related Monthly
Adjustment Amount
Total Monthly Premium
Amount
Less than or equal to
$97,000
Less than or equal to $194,000 0 $164.90
$97,001 and less than
or equal to $123,000
$194,001 and less than or
equal to $246,000
$65.90 $230.80
$123,001 and less
than or equal to
$153,000
$246,001 and less than or
equal to $306,000
$164.80 $329.70
$153,001 and less
than or equal to
$183,000
$306,001 and less than or
equal to $366,000
$263.70 $428.60
$183,001 and less
than $500,000
$366,001 and less than
$750,000
$362.60 $527.50
Greater than or equal
to $500,000
Greater than or equal to
$750,000
$395.60 $560.50
Note that Part B premiums for certain transplant patients are different. Certain Medicare enrollees who are 36
months post-kidney transplant and therefore no longer eligible for full Medicare coverage can elect to continue
Part B coverage of immunosuppressive drugs by paying a Part B premium.
Medicare Part B Immunosuppressive Premiums 2023
Immunosuppressive Part B Coverage ONLY
Beneficiaries who file individual
tax returns with modified
adjusted gross income:
Beneficiaries who file
joint tax returns with
modified adjusted gross
income:
Income-related Monthly
Adjustment Amount
Total Monthly Premium
Amount
Less than or equal to $97,000
Less than or equal to
$194,000
0 $97.10
$97,001 and less than or equal
to $123,000
$194,001 and less than
or equal to $246,000
$64.70 $161.80
$123,001 and less than or
equal to $153,000
$246,001 and less than
or equal to $306,000
$161.80 $258.90
$153,001 and less than or
equal to $183,000
$306,001 and less than
or equal to $366,000
$258.90 $356
$183,001 and less than
$500,000
$366,001 and less than
$750,000
$356 $453.10
Greater than or equal to
$500,000
Greater than or equal to
$750,000
$388.40 $485.50
MEDICARE: WHAT YOU NEED TO KNOW PAGE 47
Part D — Insulin Coverage
In 2022, a new rule went into effect that caps insulin at a $35 co-payment for a one-month supply. e
medicare.gov 2023 website doesn’t seem to be updated (as of 12/1/22) for all insurers to reflect the correct
insulin co-pay of $35 per month. Insulin pen needles to be used with insulin pens and insulin needles
and syringes to be used with insulin vials are covered under Part D and Medicare Advantage plans (if the
Medicare Advantage plan covers prescription drugs) and can be put into the Medicare.gov website. Other
insulin supplies, such as alcohol pads and glucose testing equipment, glucometers, test strips, lancets and
control solution, are covered under Medicare Part B. Some community pharmacies accept assignment and
can provide these additional diabetes supplies, but if your pharmacy doesn’t, you may want to try a specialty
or mail-order pharmacy or durable medical equipment provider. Most Medicare Advantage plans will cover
diabetes testing supplies at the pharmacy because they cover both Part B and Part D items.
TIP: Planning for 2023 and beyond: Leave insulin off your list of drugs when you are on the medicare.gov website. The
$35 co-pay is a universal rule, so all insurers should charge you $35/month in 2023. Since insulin will have a standard
co-pay and the planning tool is not accurately reflecting the $35 co-pay, it may be confusing. In your calculations, add
$35/month for each different type of insulin to your out-of-pocket costs so you can accurately plan, if you use insulin.
The only step you should take is to make sure your insulin brand is on the drug formulary of your Medicare Part D plan or
Medicare Advantage Plan (if your plan covers prescriptions drugs).
TIP: When starting or adjusting insulin, have your provider write the prescription for insulin with specific directions to
increase the insulin dose up to a ceiling amount. This will allow the pharmacist to calculate an accurate amount of insulin
you will need per month as you increase the dose. For example, if your provider starts you on 10 units daily and writes the
prescription that way, you will get one 3mL pen for the month. If the provider tells you to increase the insulin dose by 2
units every 3-4 days and stop at 20 units daily, that one 3mL pen will only last you 25 days. This would mean you would
have trouble refilling the prescription, and you would pay another $35 co-pay for another prescription of one 3mL pen,
which, at 20 units daily, will only last you 15 days. With the prescription reflecting the provider’s spoken directions to you,
increasing the dose to 20 units daily, you would get two 3mL pens per month.
PAGE 48 MEDICARE: WHAT YOU NEED TO KNOW
CALCULATE YOUR MEDICARE PART D PREMIUM FOR 2023
If your filing status and yearly income in 2021 was:
Filed individual
tax return
Filed joint tax return
Filed married and
separate tax return
You pay each month
(in 2022)
$97,000 or less $194,000 or less $97,000 or less your plan premium
above $97,000
up to $123,000
above $194,000
up to $246,000
not applicable $12.20 + your plan premium
above $123,000
up to $153,000
above $246,000
up to $306,000
not applicable
$31.50 + your plan
premium
above $153,000
up to $183,000
above $306,000
up to $366,000
not applicable
$50.70 + your plan
premium
above $183,000
but less than $500,000
above $366,000 but
above $97,000 and
less than $403,000
$70 + your plan premium
$500,000 and above less than $750,000 $403,000 and above
$76.40 + your plan
premium
Note: These figures do not include any Part D late enrollment penalty, discussed above. The 2022 Part D
national base beneficiary premium is $33.37.
Social Security calculates your Part D IRMAA; if your income goes down or you disagree with the calculations,
file a dispute at: Medicare Income-Related Monthly Adjustment Amount — SSA https://www.ssa.gov/forms/
ssa-44.pdf.
FROM MEDICARE:
e extra amount you have to pay isn’t part of your plan premium. You don’t pay the extra amount to
your plan. Most people have the extra amount taken from their Social Security check. If the amount isn’t
taken from your check, you’ll get a bill from Medicare or the Railroad Retirement Board. You must pay
this amount to keep your Part D coverage. You’ll also have to pay this extra amount if you’re in a Medicare
Advantage Plan that includes drug coverage.
For a list of specific premiums, see www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-
coverage/monthly-premium-for-drug-plans.
LONG-TERM CARE INSURANCE PAGE 49
CHAPTER 6
LONG-TERM CARE INSURANCE
INTRODUCTION
Although most adults expect to remain healthy
and independent throughout their lives, some de-
velop chronic illnesses or conditions that require
care over a prolonged period of time. Such care can
range from assistance at home to more extensive
care in assisted living facilities or nursing homes.
Long-term care in any setting can be expensive. For
example, the published average cost in Boston, Mas-
sachusetts, for a licensed home health aide is $31
per hour, for an assisted living facility is $81,816 per
year, and for a semi-private room in a nursing facil-
ity is a staggering $172,824 per year, according to
AARP’s cost of care calculator.
Unfortunately, Original Medicare, Medicare
Supplements, Medicare Advantage Plans and ordi-
nary health insurance generally do not cover long-
term care expenses. As a result of this gap in cov-
erage, the cost of long-term care is often borne by
the individual, who is forced to either privately pay
or apply for MassHealth (Massachusetts Medicaid)
coverage when the individual can no longer pay
through their own financial resources. Due to the
costs associated with long-term care and the strict
asset requirements of MassHealth eligibility, many
adults are seeking private long-term care insurance
(LTCI) to help pay for these costs. LTCI helps pay
for the cost of care in both private homes and private
facilities to preserve the retirement nest egg, protect
income streams and promote greater choices in care.
Unfortunately, many major insurers have
stopped offering traditional LTCI to consumers
due to many factors, including low return on in-
vestment in the current economy and miscalculated
underwriting with more and longer claims than
originally anticipated. In addition, some compa-
nies have increased premium rates substantially on
existing policies, and companies still offering new
policies have increased rates and tightened under-
writing guidelines. e premium increases on exist-
ing polices, while bad news for older adults on fixed
incomes, often come offered with what are known
in the industry as “landing spots.” ese are options
allowing the policyholder to pay the same premium
but reduce policy benefits, such as the daily amount
paid or the length of time the policy will pay. Sev-
eral bills have been filed in the Massachusetts Legis-
lature in the last few years seeking to impose limits
on premium increases. As of December 2022, none
have been passed into law. Unfortunately, the rate
increases on Massachusetts LTCI policies have re-
sulted in consumers seeking out-of-state group poli-
cies in an effort to obtain the protection, but at a
lower cost. e problem there is that the Massachu-
setts Division of Insurance, which regulates Mas-
sachusetts LTCI policies, has no basis to regulate
out-of-state policies. ere is increasing pressure on
policymakers to find a way to regulate policies for
Massachusetts consumers buying LTCI products
out of state, and to also find a way to limit premium
increases on existing LTCI policies. In these difficult
times, it is important to discuss options with trusted
advisers (attorneys and financial planners) to review
the situation. Also, please consider bringing family
members into the conversation, as the children may
be able to step up and pay the premiums to protect
the parents’ life savings and legacy. Be sure that a
trusted person is named on the application as a per-
son to be notified in the event of a failure to make a
premium payment. Together, the older adults, chil-
dren and advisers may well be able to find a creative
and sustainable way to preserve the policy after an
in-depth review of the family finances and available
capital.
at said, as the industry has changed and poli-
cies have become more expensive, it may be advis-
able to give greater consideration to hybrid life/LTCI
contracts and fixed annuities with LTCI provisions
(see Section E of this chapter). ese can provide an
alternative to traditional LTCI. is chapter will
discuss both options in detail.
PAGE 50 LONG-TERM CARE INSURANCE
NOTE: In a MassHealth Fair Hearing decision from
2020, a hearing officer concluded that MassHealth’s
position that LTCI benefits constituted countable in-
come in determining eligibility for community benefits
under the Frail Elder Waiver was incorrect. The decision
was not appealed by MassHealth and stands for the
proposition that benefits paid from an LTCI policy that
constitute repayment for incurred medical expenses
are not countable income for Frail Elder Waiver eligibil-
ity purposes.
A. What Are the Benefits of Long-Term Care
Insurance?
Modern long-term care policies can offer cover-
age for long-term care expenses not otherwise cov-
ered by medical insurance. Policies may provide a
cash benefit or offer reimbursement for the cost of
care up to the policy limits. Many policies today
will cover care in the home and in facilities, provid-
ing flexibility for the insured older adult. As custo-
dial care can be quite expensive, the insurance pol-
icy can provide the funds necessary to pay for care
without exhausting assets or liquidating retirement
plans. Oftentimes, liquidating retirement plans can
create income tax issues, further accelerating the
degradation of the older adult’s nest egg. Further-
more, if care expenses exceed interest earned on the
retirement assets, the older adult can rapidly reduce
principal, leaving fewer assets available to generate
future income or leave to loved ones.
A significant benefit to a traditional LTCI policy
(in contrast to hybrid policies, described in Section
E) is that Massachusetts law and MassHealth regu-
lations allow for an exemption against a post-death
claim by MassHealth for recovery of MassHealth
benefits paid during the life of the policyholder.
is exemption protects the primary residence (the
“home”) provided that the policy meets certain
minimum requirements. e minimum policy ben-
efits must be in place at the time the policy is pur-
chased (the policy could certainly exceed these and
still qualify), and must, under current regulations:
• Include coverage for nursing home care for at
least 730 days;
• Pay at least $125 per day for nursing home care;
and
• Begin paying benefits within one year, or have a
substantial deductible.
If the policy did not have the minimum ben-
efits in place when purchased, but due to inflation
riders, the policy did have the minimum benefits
in place when the person was institutionalized, an
amendment to the exemption law passed with the
state budget for 2020 allows the exemption to ap-
ply if, at any time after purchase, the policy has the
minimum benefits in place (provided that the ac-
tions noted below are taken).
Note that having the exemption in place will
not prevent a lien being placed on the home
while the MassHealth applicant is alive and on
benefits. is lien is intended to keep the home
from being sold during the applicant’s lifetime.
If the home is sold during the applicant’s life-
time, MassHealth will be entitled to recover any
benefits paid for the applicant from the proceeds
of the sale. However, upon the applicant’s death,
the exemption will prevent MassHealth from re-
covering those benefits when the home is then
inherited by the applicant’s heirs or other ben-
eficiaries.
In addition to these basic provisions in the policy, the
following actions must be taken to take advantage of
the exemption:
1. An application for MassHealth long-term care
must provide that the applicant does NOT intend
to return home.
2. The policy must still be in place at the time of
institutionalization, and some minimum policy
benefits must still be in place. Be mindful that
exhausting the benefits of a policy too soon could
jeopardize the protection of the primary residence.
The exemption only covers long-term care costs,
such as nursing home or hospice costs. MassHealth
payments for medical bills, such as hospitalization
during life, are not protected. The exemption only
applies to the person(s) who is, or are, the named
insured(s) under the LTCI policy. For instance, if only
one spouse has an LTCI policy, unless the policy cov-
ers both spouses, the exemption will not protect the
house against the MassHealth costs of the spouse
who does not have the policy.
3. The home must not be sold during the time the
applicant is alive. The home can be rented or
otherwise occupied or not occupied, but if it is
sold while the applicant is alive, MassHealth can
recover benefits paid for the applicant from the
sale proceeds.
LONG-TERM CARE INSURANCE PAGE 51
Because current hybrid LTCI policies allow for
a return of premium paid by the policyholder dur-
ing the term of the policy (you can get your cash
paid for the policy back), they do not qualify for the
exemption.
B. Potential Tax Advantages
For individuals who do not itemize deductions,
no income tax deduction is available for LTCI.
Under IRC Section 7702B (a)(1), LTCI is treat-
ed as an accident and health insurance benefit. For
those who itemize deductions, premiums may be
deductible up to the eligible LTCI premium limit.
For example, the individual who turns 71 before the
beginning of 2021 can claim a deduction for up to
$5,640 in long-term care premiums on their 2022
return, but the deduction, combined with other de-
ductible medical expenses, may be deducted only to
the extent it exceeds 7.5% of adjusted gross income.
Please note, policyholders who own a business
may well have the ability to deduct a greater portion
of the premium depending upon how the business
is structured. Consult your tax adviser for more in-
formation.
When benefits are received, the reimbursement
for care under a policy bought by an individual is
not included in income (IRC Section 104(a)(3),
7702B(a)(2)), but if the contract provides for a per
diem reimbursement, the exclusion is limited to
$370 per diem in 2023. Different provisions apply
to LTCI provided through an individual’s employ-
er. If the premiums paid are not includable in the
employee’s income currently, benefits will be taxed
when received. If LTCI is provided through an indi-
vidual’s employer, and the premiums are includable
in the employee’s income when paid, benefits will
not be taxed when received.
C. When to Purchase Long-Term Care
Insurance
As with any other type of insurance, it is neces-
sary for consumers to purchase LTCI before they
need it. e main advantage of purchasing LTCI
earlier in life is the reduced cost of premiums. For
example, the premiums for a typical policy pur-
chased for a female, non-smoker, age 55, would be
approximately $5,466 per year. e same policy for
the same person at age 75 would be approximately
$14,928. Purchasing LTCI earlier in life, however,
carries its own risks. First, LTCI is generally an un-
wise investment for those who cannot afford to pay
the policy premiums for the remainder of their lives
because policyholders often pay premiums for many
years before receiving services. When retired and on
a fixed income, managing premium payments may
become difficult.
In addition, LTCI premiums can and do in-
crease over time. Significantly, a prominent insur-
ance company raised rates an average of 83% for
federal employees on the plan. Most policies are
guaranteed renewable, not non-cancelable, allowing
the insurance company flexibility to raise premiums
on a class basis. In fact, over the last decade, many
carriers have had rate increases and, in many cases,
increased rates by more than 40%. Such increas-
es can make keeping the policy in place for older
adults on fixed incomes very difficult. As was com-
mon throughout the last decade, states continue to
approve rate increases. Companies are looking at
ways to provide so-called “landing spots,” amending
policies so that benefits are reduced but premiums
remain affordable.
D. What to Consider When Comparing
Policies
• Limits on Benefits
LTCI policies generally feature both daily (ex-
pressed in dollars) and lifetime maximum ben-
efits (expressed in days). Daily maximum benefits
vary in terms of the amount of money the insur-
ance company pays for each day or month a poli-
cyholder is covered by an LTCI policy. If the cost
of care is more than the policyholder’s daily or
monthly benefit, the policyholder will need to pay
the balance out of their own pocket. Please note,
some insurance companies offer monthly benefit
options rather than daily.
• Length of Benefit Period
LTCI policies cover different periods that mea-
sure the length of time policyholders can receive
benefits from their policy. In Massachusetts, LTCI
benefit periods may last as little as two years or as
long as a lifetime. While lifetime policies offer the
greatest security, many consumers cannot afford
the premiums. For most individuals, four years
of coverage is more than sufficient, as the average
nursing home stay is approximately 2.5 years.
PAGE 52 LONG-TERM CARE INSURANCE
• Length of Elimination Period
LTCI elimination periods are waiting periods
before benefits begin. Just as health insurance
beneficiaries usually pay for a portion of their
treatment out of pocket before they are eligible
for benefits, LTCI beneficiaries must pay their
long-term care expenses out of pocket during
the elimination period. Policies may have
no elimination period at all, or may have an
elimination policy lasting a full year; typically,
the longer the elimination period, the lower the
premium.
• Eligibility to Begin Receiving Benefits
Insurers determine whether a policyholder
is eligible to begin receiving policy benefits in
different ways. e more common methods center
on the policyholder’s ability to perform various
activities of daily living (ADLs). Insurers typically
consider a policyholder’s ability to eat, walk, move
from a bed to a chair, dress themselves, bathe
and use the bathroom. Ordinarily, a physician
or licensed health care practitioner chosen by the
insurer evaluates these skills, and a policyholder
becomes eligible to begin receiving benefits when
they cannot perform two or more ADLs. When
comparing LTCI policies, the consumer should
evaluate which ADLs a prospective insurer will
consider. Consumers are prudent to consider only
those policies that mention bathing specifically,
since most older adults with long-term care needs
require assistance with this task.
E. LTCI/Life Insurance Policy (Hybrids)
Contrasted with Traditional LTCI
In recent years, many of the major insurers have
exited the individual LTCI industry. With fewer
providers and less competition, pricing has become
less favorable. Because many older adults have con-
cerns about long-term care issues, planners in the
industry are developing alternatives. One such al-
ternative is hybrid life insurance/LTCI combina-
tion policies. With life insurance/LTCI hybrids,
insureds can accelerate access to the death benefit
if they need long-term care. e named life insur-
ance beneficiaries receive either the full death ben-
efit if the long-term care benefits are not used, or
what remains of the death benefit if the policy has
been tapped for long-term care (less any service fee
assessed per the insurance contract). ese types of
policies often offer guaranteed level premiums for
life (providing stable costs), while traditional LTCI
premiums are subject to change. Also, certain older
adults with morbidity issues may be able to qualify
for coverage in cases in which they are declined for
LTCI, as many of the hybrid products are under-
written on life insurance (mortality standards), not
long-term care (morbidity criteria).
Some contracts offer amounts greater than the
death benefit to pay for long-term care, and even
if the death benefit is exhausted by long-term care
expenses, some policies offer a residual death ben-
efit payable to beneficiaries. In most cases, however,
with an accelerated death benefit, one cannot expect
substantial insurance payouts for both an expensive
long-term care episode and death. e consumer
must continue to pay the life insurance premiums
while receiving the accelerated benefit.
ese policies do not offer joint benefits for
spouses (as some so-called joint and survivor tradi-
tional LTCI contracts do), since each spouse would
have their own individual policy.
Hybrid policy premiums generally are not tax-
deductible, though benefits are usually received tax-
free. Generally, standalone LTCI policies provide a
wider range of benefit options than a combination
policy. Also, hybrid policies may not have inflation
protection, which would significantly erode the pur-
chasing power of the benefits in the future. Con-
sumers are encouraged to purchase a benefit that is
sufficient to cover needs after accounting for poten-
tial increased costs of care later.
Insurance companies are also offering fixed an-
nuities with embedded LTCI-like protections and
whole life policies, which are funded by a one-time
lump sum and provide LTCI benefits. Please note
that these annuity-based options often come with
less stringent underwriting requirements. With the
recent, rapid increase in interest rates, these annui-
ty-based policies are currently offering competitive
rates and terms. ese new contracts allow for poli-
cies with inflation options that may prove benefi-
cial, as well as reports from the insurer outlining for
the client the portion of the premium that may be
LONG-TERM CARE INSURANCE PAGE 53
tax-deductible. e policies are customarily funded
with non-IRA assets. As these options evolve, and
to determine which option to use, please be sure
to discuss their applicability to your situation with
your experienced and trusted adviser. Remember, as
noted in Section A, that if a hybrid LTCI policy
allows for a return of premium paid by the policy-
holder during the term of the policy (you can get
your cash paid for the policy back), it would not
qualify for the “home” exemption to MassHealth
estate recovery.
CONCLUSION
Currently, LTCI plays only a small part in the
overall long-term care financing system, covering
only about 10% of all long-term care costs.
However, as individuals live longer, the applicability
of insurance options as an estate planning tool
is likely to grow. Remember that it may not be
affordable to purchase a policy large enough to
cover the entire cost of care. In such cases, one may
do well to employ a co-insurance principle in which
the consumer purchases a policy that covers some
of the risk, and commits to cover the difference (if
care is needed) from assets or income. is way, the
premium is more manageable, but the risk is still
addressed.
As LTCI is a complex insurance product,
consumers should gather information and begin
discussing these options for payment of their long-
term care costs with family members and experienced
advisers well in advance of when they might need
long-term care. One resource for general information
that is very useful is “A Shopper’s Guide to Long-
Term Care Insurance,” 2021 edition, put out by the
National Association of Insurance Commissioners.
is publication can be found at https://content.naic.
org/publications?name=guide+to+long-term&field_
publication_category_target_id=All.
PAGE 54 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
CHAPTER 7
LONG-TERM CARE
Residents’ Legal Rights
CONTINUUM OF CARE
Long-term care services are provided along a spectrum of care. Service might be provided in a private
home, a continuing care retirement community, an assisted living residence or a nursing facility. It is im-
portant for consumers to understand the differences between the settings and the different rules that apply
within each context.
A. What Is Nursing Home Care?
Nursing homes provide around-the-clock nursing care and assistance with activities of daily living
(ADLs). Nursing homes, technically “long-term care facilities,” are subject to state and federal law, as well as
regulations issued by the Massachusetts Department of Public Health (DPH), the state Medicaid program
(MassHealth), the Office of the Attorney General and the federal Center for Medicare and Medicaid Ser-
vices (CMS). Many of the regulations will be discussed below.
COVID-19
Public Health Emergency. The earlier COVID-19-related state of emergency was rescinded effective June 15, 2021.
However, the governor issued an executive order on May 28, 2021, finding that a public health emergency still existed,
allowing DPH to continue to mandate certain measures to respond to the virus outbreak.
Waivers and Guidance to Nursing Homes and Assisted Living Residences. CMS and DPH have responded to the
COVID-19 pandemic by issuing waivers of certain regulations as well as ongoing memoranda of guidance regard-
ing many of the nursing home and assisted living residence provisions described in this chapter. The guidance from
these organizations is updated frequently, as outbreak conditions change. Detailed information can be found on the
CMS website,
www.cms.gov, as well as the DPH website: www.mass.gov/info-details/covid-19-public-health-
guidance-and-directives#health-care-organizations-
.
Other Provisions. Nursing facilities should not be allowed to make decisions about admission or return to the facility
based on COVID-19 status, although facilities may be required to undertake certain measures. If a facility refuses to
readmit a resident after a hospitalization, a Medicaid appeal may be filed whether or not the resident is Medicaid-
eligible. Visitation should be allowed under the procedures outlined in both the CMS and DPH publications, subject to
change depending upon the state of the pandemic.
Closures. Due to a variety of factors, including the public health emergency, staffing shortages and aging buildings,
an increasing number of nursing homes and assisted living facilities have recently closed. It appears that this trend
is likely to continue. DPH regulates and, in coordination with the Long-Term Care Ombuds Program, monitors nurs-
ing home closures. The Executive Office of Elder Affairs has recently amended its regulations to require a 120-day
advance notice prior to the closure or sale of an assisted living facility.
DPH Website. The DPH website maintains an updated list of nursing facilities that have an admissions freeze based
on infection control surveys or the number of new cases. The website also contains a list of pending nursing home
closures.
Moving a Loved One Home During COVID-19 Pandemic. See the Appendix on page 63 for DPH guidance on moving
residents from nursing homes, rest homes and assisted living facilities.
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 55
B. What Is Assisted Living?
Assisted living is a residential arrangement pro-
viding room and board for eligible older adults who
need some minimal aid, support or supervision with
activities of daily living, such as meal preparation,
medication regimen, housekeeping, clothes laun-
dering, dressing or bathing, grocery shopping and
transportation needs.
1
However, except as has been
allowed under COVID exceptions, assisted living
residents should not require the level of care pro-
vided in a nursing home.
2
Typically, assisted living
residences offer a “menu” of services, for which a
resident must pay extra. Assisted living is intended
to encourage the maintenance of older adults’ au-
tonomy and privacy.
3
C. What Is a Continuing Care Retirement
Community?
A continuing care retirement community
(CCRC) is an option that offers single and married
older adults a continuum of housing, services and
nursing care that is intended to allow them to remain
housed in the same community as their services are
adjusted and altered depending upon their needs.
4
It
is a comprehensive and individualized plan offering
such services as nursing and health care, housekeep-
ing, transportation, meals and special diets, recre-
ational activities and emergency help.
5
NURSING HOME CARE
A. Choosing a Nursing Home
Once a health care practitioner has determined
the level of care you need, you are able to make
choices on which nursing home to use. CMS has
a website tool that allows you to compare nursing
homes and select the most appropriate ones. (See
www.medicare.gov/care-compare/?providerType=N
ursingHome&redirect=true.) is website provides
a wealth of information, including data on health
inspections, staffing, quality measures and quality
ratings. e nursing home reports this information
to CMS, so it is important to visit the nursing home
in person before you make a final decision.
Additionally, although most nursing homes in
Massachusetts are Medicaid-certified, not all are, so
a resident may only be able to stay in a private facil-
ity as long as they are able to pay for the required
care. In order to use a Medicaid benefit to pay for
nursing home care, the nursing home must be Med-
icaid-certified.
6
Although the attorney general’s reg-
ulations and Massachusetts law prohibit discrimi-
nation based on eligibility for MassHealth benefits,
these provisions are often difficult to enforce. See
940 C.M.R. 4.03 and MASS G.L. 151B, § 4.
When choosing a nursing home, it is important
to speak with others, such as the long-term care
ombudsman, care managers, residents, and family
members of residents. e Massachusetts Advocates
for Nursing Home Reform and the National Con-
sumer Voice websites contain information on how
to select a nursing home and what questions to ask.
e following are quotes from the Massachu-
setts Advocates for Nursing Home Reform website:
• Surveys measure whether the nursing home
meets certain “minimum” standards. If a nursing
home has no deficiencies, it means that it met the
minimum standards at the time of the survey. It
is important to realize that surveys and rat-
ings do not identify nursing homes that give
outstanding care.
• While reading the Massachusetts and federal re-
ports, keep in mind that the quality of a nurs-
ing home may get much better or much worse in
a short period of time. ese changes can occur
when a nursing home’s administrator or owner-
ship changes or when a nursing home’s finances
suddenly change.
• Survey inspectors are only in the nursing home
for a few days, which means surveys only provide
a “snapshot” of what the facility is like — and
the “snapshot” is usually taken when the facility
administration and staff know they are being ob-
served. In addition, inspectors do not look at the
care of all residents; they only look at a sample of
residents.
• And remember, government agency reports rep-
resent “one piece of the puzzle” in searching for
a nursing home. Low ratings can tell more of a
story than high ratings. Consider ratings with
your personal perceptions and other research to
help make an informed decision.
B. Dementia Care Standard for Nursing
Homes
Massachusetts law provides further safeguards
for dementia patients in nursing homes in the form
PAGE 56 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
of regulations that require all direct care workers to
have eight hours of initial training and an addition-
al four hours of training annually.
In addition, Dementia Special Care Units
(DSCUs) provide specialized care to nursing home
residents with dementia through a combination of
additional and ongoing dementia care training, ex-
panded activities, and a safe and comfortable physi-
cal environment (e.g., special lighting and floor cov-
erings to minimize confusion, safe/supervised access
to the outdoors, etc.). Not every nursing home in
Massachusetts has a DSCU, since compliance with
DSCU law is not mandatory. DSCUs must be certi-
fied every year by DPH, and finding out if a nursing
home has one is as simple as just asking. DSCUs
must have at least one “therapeutic activities direc-
tor” who is responsible for developing and imple-
menting activities for residents. ese regulations
ensure that dementia units are staffed with appro-
priately trained workers.
7
Additionally, the regulations mandate that a
fence or barrier surround the facility to prevent in-
jury and elopement of dementia care residents. An-
other significant change to the laws that aims to pro-
tect those living in dementia units is the prohibition
against overhead paging systems, which often scare
residents. Facilities can now use such systems only
for emergencies.
8
DPH has promulgated guidance
with respect to the administration of antipsychotic
medications that requires the written consent of the
resident, the resident’s health care proxy agent or a
duly authorized guardian.
C. Nursing Home Resident Rights
Under state and federal law, nursing home resi-
dents are entitled to certain rights with regard to
quality of care, treatment, safety and quality of life.
9
Nursing home residents have the right:
• To obtain, upon admittance to the facility, writ-
ten notice of their rights as residents;
10
• To freedom of choice of a physician, facility and
health care mode;
11
• To obtain, upon request, an itemized bill for
nursing home services;
12
• To have all medical records and communications
kept confidential to the extent provided by law;
13
• To have all reasonable requests responded to
promptly within the capacity of the facility;
14
• To access all of their medical records upon re-
quest;
15
• To refuse to be examined, observed or treated
without jeopardizing access to other medical
care;
16
• To have privacy during medical exams or treat-
ment;
17
and
• To have informed consent to the extent provided
by law.
18
A nursing home resident is also entitled to certain
rights relating directly to their personal freedoms.
A nursing home resident is entitled:
• To communicate with persons of one’s choice,
privately and without restriction;
19
• To make a complaint or express a grievance free
from reprisal, restraint, coercion or discrimina-
tion;
20
• To be free from any requirement to perform any
service for the facility not in the resident’s indi-
vidual care plan, unless one volunteers or is paid
for such service;
21
• To participate in social, religious and community
groups;
22
• To manage one’s own financial affairs;
23
• To keep and use personal possessions and cloth-
ing as space permits, and to have personal posses-
sions reasonably safeguarded and secured;
24
• To be permitted to share a room with one’s
spouse;
25
and
• To receive at least 48 hours’ notice of a roommate
change, barring any emergency.
26
See “Arbitration” on the next page for in-
formation on mechanisms to enforce residents’
rights. Effective September 2019, federal regula-
tion provides that residents cannot be required
to agree to arbitration as a condition of admis-
sion to, or continued stay in, a nursing home.
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 57
ARBITRATION
Long-term care providers — nursing homes, assisted
living residences and CCRCs — frequently include ar-
bitration requirements in their admission agreements.
By agreeing to arbitration, consumers are giving up im-
portant rights, including the constitutional right to a jury
trial, in case they are harmed by the provider. Although
the long-term care industry has argued that arbitration
helps reduce legal costs, there is no good reason for
residents to voluntarily agree in advance to waive their
rights to a jury trial; alternative dispute resolution is al-
ways an option once a dispute has arisen if the parties
agree. The practice of forced arbitration has had the
effect of denying residents and their family members
access to justice. Because arbitrations are confiden-
tial and there is no record of the outcomes, the use of
forced arbitration has also operated to keep issues of
abuse and neglect out of the public eye. Residents and
their families should be aware of the prevalence and
risks of arbitration, and should exercise their right to
“just say no” to arbitration clauses in admission agree-
ments. See an important and helpful brochure regard-
ing this issue in the Appendix at the end of this chapter.
D. Nursing Home Transfers and Discharges
in Medicaid- and Medicare-Certified
Facilities
Nursing home residents should not be trans-
ferred or discharged from their rooms (their homes)
without cause. Under federal law, residents in Med-
icaid- and Medicare-certified facilities must be given
adequate notice prior to a transfer or discharge, and
be informed of their right to a hearing to contest
the proposed transfer or discharge.
27
Most nursing
homes in Massachusetts are certified to participate
in the Medicaid and Medicare programs. e fed-
eral transfer and discharge requirements apply to
transfers or discharges to a hospital, other institu-
tional setting or community setting (return home),
as well as to transfers between differently certified
parts of a nursing facility. Intra-facility transfers are
not subject to these requirements; the different re-
quirements applicable to them are discussed later in
this section.
Before a nursing home can transfer or discharge
a resident, there must be a permissible reason for
the discharge properly documented in the resident’s
record. A resident can be moved only:
• If necessary for the resident’s welfare and the resi-
dent’s needs cannot be met in the facility.
• If the resident’s health has improved sufficiently
so that the resident no longer needs nursing home
care.
• Due to the clinical or behavioral status of the resi-
dent.
• If the health of individuals in the facility would
otherwise be endangered.
• For nonpayment or if the resident does not submit
the necessary paperwork for third-party payment.
• If the nursing home closes.
28
However, a resident cannot be transferred or dis-
charged for nonpayment pending an administrative
appeal of a denial of eligibility.
29
Discharge Planning: As part of the discharge
process, a facility must provide sufficient prepara-
tion and orientation to ensure a safe and orderly
transfer or discharge from the facility, in a form and
manner that the resident can understand, and the
plan must be documented.
30
e resident may not
be transferred if the resident files a timely appeal,
whether the transfer is between different certified
units, to another nursing home, to a hospital or to
another setting.
Notice Requirements: Notice of a transfer to
another facility or a discharge must be given to the
resident, or the resident’s designated representative
and to the Office of the Ombudsman, at least 30
days in advance, except in an emergency. Notice
may be given fewer than 30 days in advance but
must be given as soon as possible when the health
and safety of individuals in the facility would be en-
dangered, a resident’s health improves sufficiently to
not require care in the facility, the resident has ur-
gent medical needs (e.g., a need for hospitalization),
or if the resident has resided in the facility for fewer
than 30 days.
31
e notice must specify the action to be taken,
the specific reason(s) for the action, the effective
date of the transfer or discharge, and the location to
which the resident is to be discharged or transferred,
and must inform the resident of appeal rights.
32
Any resident wishing to appeal a transfer or dis-
charge has the right to request a fair hearing through
the Office of Medicaid Board of Hearings. A resi-
dent has the right to refuse hospitalization, and an
PAGE 58 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
appeal can be a useful mechanism to ensure that a
resident’s directives are followed. For a transfer to be
approved, a hearing officer must find that the facil-
ity complied with all of the legal requirements. e
assistance of an attorney or a care manager can be
very useful in the appeal process.
If a timely appeal is filed (30 days from the date
of the notice for non-emergency situations), the
transfer or discharge may not occur until 30 days
after a hearing decision is rendered. For emergency
situations, the appeal period is 14 days. If the trans-
fer or discharge has not taken place, the resident
cannot be moved until five days after the decision.
If the resident has been moved, the facility must re-
admit the resident to the next available bed in the
event of a favorable decision.
33
Intra-facility Transfers: Massachusetts law
governs transfers within the same certified facility.
Transfers are permitted to different living quarters
or to a different room based on a change in the resi-
dent’s needs, e.g., the resident requires, or no longer
requires, specialized accommodations, care, servic-
es, technologies or staffing not customarily provided
in connection with the resident’s living quarters.
34
e reason for an intra-facility transfer must be doc-
umented in the resident’s clinical record by a physi-
cian. A resident should not be transferred based on
a change in the payment status, such as termination
of Medicare coverage or establishing eligibility for
MassHealth. A nursing home may not discrimi-
nate against a resident based on source of payment.
However, upon termination of Medicare coverage, a
resident might wish to move to a different bed with
a lower daily rate.
e resident must be notified of the proposed
intra-facility transfer and the right to appeal to the
facility’s medical director.
35
e state law does not
contain any provisions regarding the content of the
notice or the appeal process. However, prior to a
change of room, the resident must be given advance
notice in writing with a reason for the change, and
48 hours’ advance notice must be given for a change
of roommate, except in an emergency.
36
Bed Hold: Under Massachusetts law, a nurs-
ing home resident has the right to return to their
bed following a medical or non-medical leave of ab-
sence, and the nursing home must notify the resi-
dent of this right. e bed of a MassHealth recipient
must be held during this bed hold period.
37
Private
pay residents may pay to hold their beds during such
leaves. If a medical leave exceeds the bed hold pe-
riod, the facility must admit the resident to the first
available bed in a semi-private room.
38
e bed hold
period is currently 20 days but subject to change on
a yearly basis.
Readmission After Hospitalization: A nursing
home resident has the right to be readmitted to the
resident’s nursing home following a hospitalization.
e failure of a nursing home to readmit a resident
following a hospitalization is a discharge, which re-
quires notice and appeal rights.
39
e resident has a
right to file an appeal, even if a nursing home has
failed to give the required notice.
E. Department of Public Health Regulations
DPH monitors and licenses nursing home facili-
ties throughout the commonwealth.
40
To determine
whether an applicant for a nursing home license is
responsible and suitable for licensing, DPH will look
to the applicant’s criminal history, if any; financial
capacity to operate a long-term care facility; and the
applicant’s history and experience in providing long-
term care.
41
DPH sets out rules and regulations govern-
ing medical and nursing care, the maintenance of
medical records, the handling of patient funds, the
prevention of loss or damage to residents’ personal
possessions, and standards of facility sanitation.
42
DPH surveyors have the right to visit and inspect
any nursing home institution at any time to monitor
compliance with regulations.
43
Such inspections are
unannounced, and occur at least twice per year.
44
If violations are found, the nursing home facility
may be subject to a monetary fine, and will be ex-
pected to submit a plan of correction to DPH with-
in a certain time period. At the expiration of such
time period, the violation will be made public if
no correction plan has been submitted.
45
DPH also
fields complaints by or on behalf of nursing home
residents through its website and telephone hot-
line. DPH requires nursing homes to obtain writ-
ten informed consent to treat with any psychotro-
pic medications. e consent must be signed by the
resident, the resident’s health care agent or a duly
authorized guardian. e written informed consent
must be documented on a form approved by DPH,
kept in the resident’s medical record, and must in-
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 59
clude, at a minimum, the purpose for administering
the psychotropic drug, the prescribed dosage and
any known side effect of the medication. Note that
guardians of protected persons must obtain court
approval to consent to the administration of anti-
psychotic medication.
INFORMED CONSENT FOR
PSYCHOTROPIC MEDICATION
M
ass. G.L. ch. 111 § 72BB (effective 7/1/14)
requires documentation of informed consent prior
to the administration of psychotropic medications
in long-term care facilities.
See DPH Circular Letter: DHCQ 17-2-699, dated
2/1/17:
• Summarizes the law.
• Lists psychotropic and antipsychotic medications.
• Requires an informed consent form:
º Prior to administration of medication.
º Anytime dosage range has changed beyond what
resident or authorized person has consented.
º At least yearly.
• Provides a good summary of when an agent under
a health care proxy can consent to administration
of antipsychotics without court approval.
F. Medicaid Regulations
To be certified for participation in MassHealth
and Medicare programs, a nursing home facility
must also follow regulations promulgated by the
Office of Medicaid.
46
Among other things, these
regulations include transfer and discharge provi-
sions, bed hold rights and the right to request a fair
hearing in certain circumstances. Otherwise, the
nursing home will not be reimbursed for any ser-
vices the nursing home provides to MassHealth- or
Medicare-eligible residents.
47
G. Attorney General’s Regulations
Nursing home facilities must also follow the At-
torney General’s Office regulations, which state that
it will be considered an “unfair and deceptive” act,
in violation of Mass. G.L. ch. 93A, for a nursing
home to fail to comply with any federal or state stat-
ute or regulation protective of resident rights, or for
a nursing home to fail to disclose the policies of the
facility to a resident or prospective resident.
48
Fur-
ther, a nursing home will be in violation of Chapter
93A if it discriminates against a Medicaid-eligible
resident on the basis of that resident’s source of pay-
ment for nursing home services.
49
e attorney general’s regulations also prohibit
nursing homes from requiring residents to have a
third-party guarantor, or requiring residents to
waive the facility’s liability for personal injury or loss
of personal property.
50
Nursing homes may not limit a resident’s choice
of physician or, for that matter, a resident’s choice of
pharmacy. See Chapter 5.
51
Nursing home facilities cannot require residents
to pay a non-refundable deposit.
52
Other Chapter 93A violations include a nursing
home’s refusal to permit a resident to have privacy
during medical treatment or other activities of daily
living, or refusal to allow a resident to live in the
same unit with their spouse, if both consent.
53
While this is hardly an exhaustive list of the
regulations as set out by the Attorney General’s Of-
fice, it provides an overview of standards by which
nursing homes must operate in order to prevent li-
ability. e consumer protection statute enables an
aggrieved consumer to seek a non-judicial remedy
by writing a consumer demand letter and provides a
mechanism for suing a facility and collecting dam-
ages and possibly attorney’s fees should that be nec-
essary.
H. Consumer Resources for Nursing Home
Residents
If you are facing neglect, abuse, an illegal dis-
charge or any other consumer issue in long-term
care, it is important to protect your rights and build
a record with the public agencies charged with long-
term care oversight. See list of consumer resources at
end of chapter.
I. Long-Term Care Ombudsman Program
e Long-Term Care Ombudsman Program has
been moved from the Executive Office of Elder Af-
fairs (EOEA) to the Executive Office of Health and
Human Services. e State LTC Ombudsman over-
sees a network of staff and volunteer visiting om-
budsmen whose job it is to help resolve problems re-
lated to the health, welfare and rights of individuals
living in nursing facilities, rest homes and assisted
living residences. Visiting facilities on a regular ba-
sis, ombudsmen offer a way for residents to voice
PAGE 60 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
their complaints and work toward resolution with
staff. Each facility is required to post, in a conspicu-
ous location, the name and contact information of
the visiting ombudsman assigned to that facility.
ASSISTED LIVING
A. Assisted Living Regulations
e EOEA certifies all assisted living residences
(ALRs) in Massachusetts.
54
ALRs are not licensed
facilities and are not subject to the same type of
government oversight as nursing homes or other
licensed health care facilities. An ALR must pro-
vide only single or double living units with lockable
doors and a kitchenette within the unit or access
to cooking facilities.
55
Any newly constructed ALR
must provide a full bathroom for each unit, while
existing ALRs must provide, at minimum, a pri-
vate half-bathroom.
56
After evaluation of eligibility
and assessment of appropriateness of assisted living
services for an older adult, the older adult should
receive an individualized service plan that sets out
the services provided, who will provide them, how
often and for how long the services will be provided,
the payment terms and reimbursement source for
such services, the way the residence will provide for
the presence of 24-hour on-site staff capability, and
information regarding self-administered medica-
tion management.
57
In addition to a service plan,
each resident and sponsor of the ALR must execute
a written agreement setting out the responsibilities
and rights of the resident and sponsor with regard to
the charges for services, a grievance procedure and
termination conditions.
58
Effective Jan. 1, 2019, all
assisted living residency agreements must include a
cover sheet summarizing the important provisions
of the agreement, and the resident or legal represen-
tative must sign the form, which must be retained
in the resident’s record.
59
See cover sheet attached in
Appendix.
Skilled Care in Assisted Living. During the COVID-19
emergency, ALRs were allowed to provide skilled care
in certain circumstances. Proposed legislation could
extend or permanently change some of the rules re-
garding certain skilled care services that ALRs can
provide.
B. Assisted Living Resident Rights
Massachusetts law specifies that a resident of an
assisted living residence has the right:
• To live in a decent, safe and habitable environ-
ment;
60
• To be treated with consideration and respect;
61
• To have one’s personal dignity and privacy ob-
served;
62
• To retain and use personal property in one’s
unit;
63
• To communicate privately and without restric-
tion;
64
• To contract or engage with health care profes-
sionals in one’s unit as needed;
65
• To engage in community services and activi-
ties as one chooses;
66
• To manage one’s own financial affairs;
67
• To present grievances and recommendations
without reprisal;
68
• To have all of one’s records kept confidential;
69
• To have privacy during medical treatment or
other services;
70
• To have reasonable requests responded to
promptly and adequately;
and
71
• To be free from involuntary discharge or evic-
tion without judicial process (summary pro
cess eviction proceedings).
It is important to note that assisted living is a
residential model and residents do not have to move
unless ordered to do so by a court following notice
and a court hearing.
C. Assisted Living Ombudsman Program
e Assisted Living Ombudsman Program has
been expanded and combined with the Long-Term
Care Ombudsman Program, now housed under the
Executive Office of Health and Human Services.
In the case of a complaint or violation, a resident,
the family member of a resident, or the representa-
tive of a resident may contact a statewide ombuds-
man. e ombudsman will enter the ALR to review
and examine the situation.
72
In order to maintain
certification, each assisted living facility must com-
ply with the Ombudsman Program and facilitate
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 61
CONSUMER RESOURCES FOR ASSISTED LIVING RESIDENTS
Residents in assisted living may not be “discharged” or evicted without written notice and due process of law
(i.e., summary process).
File a Complaint with the State Ombudsman Program
The Executive Office of Health and Human Services has a separate Ombudsman Program for assisted living facilities.
Phone: (617) 727-7750 or 1-800-243-4636
Send a Consumer Complaint
A demand letter is likely to get the facility’s attention and may yield a resolution. Send copies of the demand letter to:
Mary Freeley, Esq., Consumer Protection Division
Office of the Attorney General, One Ashburton Place, Boston, MA 02108
Phone: (617) 727-8400
Email:
ago@state.ma.us
Fax: (855) 237-5130
Assisted Living Ombudsman Program
One Ashburton Place, Boston, MA 02108
Phone: (617) 727-7750
Valuable advocacy resources can also be found at Massachusetts Advocates for Nursing Home Reform:
www.manhr.org.
The Executive Office of Elder Affairs 2019 Consumer Guide to Assisted Living can be found online at:
www.mass.gov/files/documents/2019/09/11/ALR%20Consumer%20Guide_09.2019.pdf.
the ombudsman’s right to enter and investigate the
residence.
73
e assisted living ombudsman acts as
a mediator and attempts to resolve problems or con-
flicts that arise between an ALR and one or more of
its residents. To contact an assisted living ombuds-
man, you may call (617) 727-7750 or (800) AGE-
INFO (1-800-243-4636).
D. Enforcement
In addition to contacting the Ombudsman Pro-
gram or an attorney, residents can file a complaint
with the EOEA or the Attorney General’s Office.
e attorney general’s regulations provide a mecha-
nism for consumers to pursue complaints based on
unfair or deceptive practices, which include disputes
regarding the provision of services. See 940 CMR
3.01 -3.03, 3:05, 3.16 and 3.17.
CONTINUING CARE RETIREMENT
COMMUNITIES
A. Continuing Care Retirement Community
Oversight
EOEA compiles information about CCRCs in
Massachusetts pursuant to Mass. G.L. ch. 93, § 76.
e statute sets out disclosure requirements regard-
ing the contractual rights of the parties. ere are no
regulations governing CCRCs. However, any part
of the CCRC that is licensed by DPH as a skilled
nursing facility is subject to the same laws, rules and
regulations as any long-term care facility.
PAGE 62 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
CONSUMER RESOURCES
If you are facing neglect, abuse, an illegal discharge or any other consumer issue in long-term care or assisted living,
it is important to protect your rights and build a record with the public agencies charged with long-term care over-
sight.
Consumer Organizations
Valuable advocacy resources can also be found at the following organizations:
Massachusetts Advocates for Nursing Home Reform (MANHR):
www.manhr.org
National Consumer Voice for Quality Long-Term Care: theconsumervoice.org/home
Justice In Aging: https://justiceinaging.org/our-work/healthcare/long-term-services-and-supports/nursing-
facilities/
Long Term Care Community Coalition (New York based): https://nursinghome411.org/
Contact a local legal services program, elder law attorney or care manager.
To find a local legal services program:
https://masslrf.org/en/home/
To find a local elder law attorney:
https://massnaela.com/
To find a care manager:
www.aginglifecare.org/ALCA/Regional_Chapters/New_England_Chapter/New_Eng-
land_Chapter_HOME.aspx/
File a Complaint with the Department of Public Health (DPH)
DPH website:
www.mass.gov/nursing-home-consumer-information
DPH complaint form: www.mass.gov/how-to/file-a-complaint-regarding-a-nursing-home-or-other-health-
care-facility
. The complaint form is on the website, but it can’t be filed online — it must be faxed or mailed in.
Consumers or their authorized representatives (as outlined below) should send the complaint form (with HIPAA
release form if applicable) by:
Mail: Division of Health Care Facility Licensure and Certification Complaint Intake Unit
67 Forest St., Marlborough, MA 01752
Fax: (617) 753-8165
Phone: 1-800-462-5540 (24-hour complaint line for those unable to file a written complaint)
Contact the State Ombudsman Program: (617) 727-7750
The LTC Ombudsman Program assigns an ombudsman to every nursing home in the state, and every area has an as-
sisted living ombudsman program. They can be helpful in resolving consumer complaints.
A list of local long-term care ombudsman programs is at:
www.mass.gov/doc/nursing-rest-home-ombudsman-
local-contact-information/download
.
A list of assisted living ombuds programs is at:
www.mass.gov/doc/assisted-living-ombudsman-local-contact-
information/download
.
Send a Consumer Complaint
The Attorney General’s regulations provide that any violation of nursing home residents’ rights is a per se violation of
the state consumer protection statute, known as Chapter 93A. Send the demand letter to the facility, with copies to:
Mary Freeley, Esq., Consumer Protection Division
Office of the Attorney General
One Ashburton Place, Boston, MA 02108
Phone: (617) 727-8400
Email: ago@state.ma.us
Fax: (855) 237-5130
Carolyn Fenn, State Long-Term Care Ombudsman
One Ashburton Place, Fifth Floor, Boston, MA 02108
Division of Health Care Facility Licensure and Certification, Complaint Intake Unit
67 Forest St., Marlborough, MA 01752
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 63
APPENDIX — DPH GUIDELINES
Considerations for Moving a Loved One Home from a Nursing Facility,
Rest Home or Assisted Living Residence
During the declared state of emergency in response to the COVID-19 pandemic, families may be con-
sidering whether their loved one should move from a nursing facility, rest home or assisted living residence.
Outlined below are some steps to evaluate and a list of resources that are available to assist families in assess-
ing this complex decision, as it important to fully understand the care needs and other supports that your
loved one may need.
Step 1: What type of facility does my loved one reside in?
e processes and implications are different depending on where your loved one resides. Read below to
learn more.
If a loved one lives in an assisted
living residence (ALR):
If a loved one lives in a nursing
facility or rest home:
There is no uniform process to move out, as the tenancy
is governed by landlord-tenant law; however,
• If the move is permanent, it is important to check
the resident agreement to understand any applicable
terms or penalties for terminating residency.
• If the move is temporary, it is important to inform
the residence (preferably in writing) that the family
member will be spending time away from the ALR and
continue to make required payments to preserve your
family member’s tenancy so that they can return to
their unit at a later date.
• It is also important to coordinate the date, time and
process for the move or subsequent return with the
ALR and ensure access to any necessary medications,
supplies and assistive equipment.
If you have decided on a discharge home, you can begin
the process by:
• Contacting the social worker at the nursing home
to begin to facilitate the discharge process outlined
below.
• The resident may initiate this contact on their own,
or if a resident does not have decisional capacity, the
authorized contact or guardian can make this request.
• It is important to note that if a family chooses to
discharge a loved one from a nursing facility or rest
home, their loved one is not guaranteed readmittance
to that facility.
Step 2: Primary considerations for moving a loved one
Here are some key questions to consider in moving a loved one from their facility to home:
• Does my loved one have a safe and accessible place to live?
• Is there consistent support and a backup plan should that support not be available?
• What specific services and supports are needed?
PAGE 64 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
Step 3: What are your loved one’s needs? Who will provide assistance?
is chart below can assist with evaluating your loved one’s needs, help you gauge the level of assistance
they may require, and allow you to determine who within the family/social support network can provide the
in-home assistance. is chart can be shared with the social worker to help determine how much assistance
is required and if an outside service is needed.
Needs
Independent/
able to do for
themselves
Family/friend/in-home
support will provide
needed assistance
Will need
outside
assistance
Bathing/personal hygiene
Getting dressed/undressed
Toileting
Walking (ambulating)
Getting into and out of chair or bed (transferring)
Taking or reminding to take medication
Meal preparation
Shopping
Laundry
Transportation to medical appointments
Supervision (due to cognition/memory loss)
Other
Step 4: If outside services are needed:
Now that you have a sense of what your loved one’s needs are and which of these needs requires outside
assistance, there are resources in your community to assist you with these decisions.
Aging Services Access Points (ASAPs) are available in every region in the state and can help evaluate the
following questions regarding the long-term care needs of a loved one:
• What services or care are available to support community living?
• What assistive devices or home modifications are available to support my loved one living in the com-
munity?
• Does insurance cover any services, care and/or home modifications? If not, what funding, loans or dona-
tions may be available?
Additionally, if your loved one was previously receiving in-home services from their local ASAP, the
ASAP can assist with reinstating services upon their return home.
Step 5: Call your local Aging Services Access Point (ASAP):
Utilize your local ASAP to help navigate these decisions and ask which option is best for your loved one.
Go to www.MassOptions.org to identify your local ASAP and their contact information.
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 65
EOEA issued: Effective 1-1-19
EXECUTIVE OFFICE OF ELDER AFFAIRS
Assisted Living Certification Unit
www.mass.gov/elder
Assisted Living Residence (ALR): ____________________________________
Residency Agreement Cover Sheet: (651 CMR 12.08(4))
Initialing the box next to each section header confirms that the Resident or legal
representative has read each statement listed on this form and has been given the
opportunity to ask questions.
CARE:
__ An Assisted Living Residence (ALR) is not a nursing home.
__ Nurses are not required to be on duty and in the building 24 hours per day/7
days per week. Inquire with the ALR how often and when nurses are in the
building.
__ Resident’s cannot receive skilled nursing care from ALR employees.
__ You may be required to provide and pay for additional private care if the ALR
determines that your care needs exceed the level of care available at the ALR.
RESIDENCY:
__ A signed residency agreement is a contract between you and the ALR; read it
carefully before signing. Note: If additional services are subsequently required,
your monthly costs may increase.
__ Eviction from an ALR must comply with the provisions of landlord/tenant law,
M.G.L. c. 186 or c. 239, and include all notices required by law.
__ The ALR cannot prevent you from returning to the ALR after a hospital or rehab
stay; however, if your care needs exceed the ALR’s capacity fo
r services you may
be required to hire private care staff to meet your care needs.
__ Your resident agreement may allow the ALR to terminate your residency if it
determines that you are no longer suitable to live there; if this is the case, the
Residence must provide a ___ day notice prior to requiring you to leave.
__ Signing a residency agreement that includes an arbitration clause or signing a
separate arbitration agreement may prohibit use of the court system to resolve
disputes and instead require you to present your case to an mediator.
PAGE 66 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
COST:
__ You should assess your finances to determine how long you can afford to
stay at the ALR before making a commitment.
__ If you deplete your assets (run out of money) and are unable to afford the cost
of the ALR in the future, the ALR may require you to move.
__ The ALR can change your monthly fees with ___ days’ notice.
__ Your service plan can change based on the ALR’s reassessment of your
needs. Changes to your service plan may change your monthly costs.
__ If you fail to provide notice of termination of Residency in accordance with the
terms of the Residency Agreement, you may incur additional charges.
RESIDENT RIGHT
__ Residents may file a complaint at any time with the Assisted Living Residence
Ombudsman or the Assisted Living Residence Certification Unit at Executive
Office of Elder Affairs by calling (617) 727-7750 or 1-800-AGE-INFO (1-800-
243-4636).
Required Signatures
________________________________________________ Date: _____________
Resident or Legal Representative
________________________________________________ Date: _____________
ALR Witness: Name and Position
A copy of this form should be provided to both parties after signing.
The ALR's copy should be maintained in the resident record.
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 67
Just Say
“NO” to
Arbitration!
E
LDER
A
DVOCATES
S
PREAD THE
W
ORD
:
www.MassNAELA.com
P.O. Box 600046
Newtonville, MA 02460
Phone: (617) 566-5640
Fax: (781) 207-9027
The Massachusetts Chapter of the Nation-
al Academy of Elder Law Attorneys
(MassNAELA) is a non-profit organiza-
tion that was incorporated in 1992, to
serve the legal profession and the public
with the following mission:
To provide information, education,
networking, and assistance to
Massachusetts attorneys, bar
organizations, and other individuals or
groups advising elderly clients, clients
with special needs and their families;
To promote high standards of
technical expertise and ethical
awareness among attorneys, bar
organizations and other individuals or
groups engaged in the practice of
advising elderly clients, clients with
special needs and their families;
To develop public awareness and
advocate for the benefit of the elderly,
those with special needs and their
families, by promoting public policies
that support our mission; and
To encourage involvement and
enhance membership in, and to
promote networking among members
of the National Academy of Elder
Law Attorneys.
MassNAELA is a voluntary association
whose members consist of a dedicated
group of elder law and special needs
attorneys across the Commonwealth of
M
a
ssachusetts.
C
ONTACT
I
NFORMATION FOR
MASSNAELA
PAGE 68 LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS
Frail nursing home residents and their
frazzled family members are routinely
asked to sign a stack of densely-
printed documents at the time of
admission, without adequate time to
review them or to consult with
counsel, and without realizing that the
agreements may include forced
arbitration provisions. Arbitration
requires residents to waive their
fundamental constitutional right to a
jury trial, even if they later suffer
serious injury, medical malpractice,
or wrongful death. Because
arbitration is secret and there is no
public record of the outcome, it keeps
cases of malpractice, abuse and
neglect out of the public eye,
effectively denying residents and their
families access to justice.
A new federal rule from Centers for
Medicare and Medicaid Services,
effective September 16, 2019,
provides that:
Although the new rule does not
impose an outright ban on
arbitration agreements in nursing
homes, it does affirm the right of
residents to “just say no” to
arbitration clauses in admission
agreements. Elder advocates should
seize this opportunity to educate
residents, their families and
representatives, and the public
about these critical rights.
Residents may not be required
to agree to arbitration as a
condition of admission to a
nursing home.
Residents may not be required
to agree to arbitration as a
condition of continued stay in
a nursing home.
Residents and their represent-
atives have a 30-day right to
rescind the arbitration
agreement.
Nursing homes must explicitly
inform residents or their
representatives of the right
not to sign an arbitration
agreement as a condition of
admission to, or right to remain
in, the facility.
The arbitration agreement
itself must explicitly state that
the agreement is not a
condition of admission to, or
right to remain in, the facility.
Facilities must ensure that the
agreement is explained to
residents and their represent-
atives in a “form and manner”
that they understand, including
in a language they understand.
LONG-TERM CARE: RESIDENTS’ LEGAL RIGHTS PAGE 69
1. MASS. G.L. ch. 19D, § 1 (2012).
2. Id.
3. Id.
4. MASS. G.L. ch. 93, § 76 (2012).
5. Id.
6. www.medicaid.gov/medicaid/ltss/institutional/nursing/index.
html
.
7. 105 CMR 150.000: STANDARDS FOR LONG-TERM CARE FACILITIES 150.022 –
150.029 Dementia Special Care Units.
8. Id.
9. MASS. G.L. ch. 111, § 70E (2010).
10. Id.
11. Id.
12. Id.
13. Id.
14. MASS. G.L. ch. 111, § 70E (2010).
15. Id.
16. Id.
17. Id.
18. Id.
19. 940 C.M.R. § 4.06.
20. Id.
21. Id.
22. Id.
23. 940 C.M.R. § 4.07.
24. Id.
25. 940 C.M.R. § 4.06.
26. Id.
27. Nursing Home Reform Law, 42 U.S.C. §§ 1395i-3(a)-(h) and 1396r(a)-(h).
28. 42 C.F.R. § 483.15(c)(1).
29. 940 C.M.R. § 4.09(2).
30. 42 C.F.R. § 483.15(c)(1).
31. 42 C.F.R. § 483.15(c)(3).
32. 42 C.F.R. § 483.15(c)(3).
33. 42 C.F.R. § 483.15(e)(1)(i).
34. Id.
35. Id.
36. 42 C.F.R. § 483.10(e)(6), 940 C.M.R. § 4.06(11).
37. 42 C.F.R. § 483.15(c)(1) and (2).
38. 42 C.F.R. § 483.15(e)(1)(i).
39. 42 C.F.R. § 483.15(e)(1), See 130 C.M.R. § 456.429, 130 C.M.R. § 610.028(D);
and Brunelle v. DMA (Mass. Superior Ct.).
40. MASS. G.L. ch. 111, § 71 (2010).
41. Id.
42. Id. § 72.
43. MASS. G.L. ch. 111, § 72 (2010).
44. Id.
45. Id.
46. 130 C.M.R. § 456.406.
47. Id.
48. Id.
49. 940 C.M.R. § 4.03.
50. 940 C.M.R. § 4.04.
51. Id.
52. Id.
53. 940 C.M.R. § 4.06.
54. 651 C.M.R. § 12.03.
55. 651 C.M.R. § 12.04.
56. Id.
57. Id.
58. 651 C.M.R. § 12.08.
59. 651 C.M.R. §12.08(4).
60. 651 C.M.R. § 12.08.
61. Id.
62. Id.
63. Id.
64. 651 C.M.R. § 12.08.
65. Id.
66. Id.
67. Id.
68. Id.
69. 651 C.M.R. § 12.08.
70. Id.
71. Id.
72. 651 C.M.R. § 13.00.
73. Id. § 13.03.
PAGE 70 HOMESTEADS AND LIFE ESTATES
CHAPTER 8
HOMESTEADS AND LIFE ESTATES
INTRODUCTION
For most Americans, their home is their larg-
est single asset. As we age, we become increasing-
ly concerned about how its value can be protected
and passed on to future generations. It is important
for homeowners to educate themselves about how
to protect their homes from creditors (by placing a
homestead declaration on the home), how to reduce
property taxes (discussed in Chapter 9), how to bor-
row prudently on equity that has built up during
their lifetimes (discussed in Chapter 10 and how to
efficiently transfer property to family and loved ones.
Consulting with a knowledgeable elder law attorney
is critical to determine what planning steps may be
appropriate. See the sample forms at the end of this
chapter that are available online at www.mass.gov for
Homes Owned by Natural Persons and Homes Owned
by Trustee(s).
A. Homestead Declaration
1. What Is a Homestead Declaration?
A homestead declaration is a document recorded
with the Registry of Deeds that protects equity in
one’s principal residence from certain creditors and
their claims.
Massachusetts revised its homestead laws in 2011
and again in 2022 to provide homeowners with add-
ed protection against creditors. e 2022 amend-
ment to the homestead laws provided clarification
to the 2011 law, expanded the class of individuals
who could benefit from a homestead declaration, and
expanded the ways in which a homestead could be
terminated. e law provides homeowners with an
automatic $125,000 homestead exemption. Home-
owners may record a declared homestead exemption
to extend the exemption amount to $500,000. is
protection extends to the homeowner’s spouse and
family. Further, multi-family homes and homes in
trust are eligible for the homestead protection.
Homesteads filed prior to March 2011 are grand-
fathered into the law and, therefore, homeowners do
not have to refile. Caveat: A homestead filed prior to
March 2011 may not be grandfathered if a mortgage
(or equity line of credit) was subsequently filed be-
fore March 2011. If that is the case, it would be wise
to file a new homestead now. Older adults (persons
62 years of age or older) have an increased home-
stead exemption of $500,000 for single owners and
$1,000,000 for a married couple. Lastly, homeown-
ers do not have to refile homesteads when a home is
refinanced (after March 2011), which had long been
an issue with Massachusetts residents.
2. What Should I Know About a Homestead
Declaration?
a. It is important to be aware that the homestead
declaration cannot protect the homeowner
from certain claims, such as:
• Federal, state and local taxes,
assessments, claims and liens;
• Liens on the home recorded prior to the
filing of the declaration of homestead;
• First and second mortgages;
• A court order that the homeowner pay
support to a former spouse or minor
children; or
• A Medicaid (MassHealth) lien if the
owner requires nursing home care.
b. If an individual recorded a homestead decla-
ration before attaining age 62, the individu-
al must file a new declaration to gain added
protections for older homeowners.
c. Individuals who gift the remainder interest
in the property to one or more individuals
and reserve a life estate may lose the home-
stead protection over the entire property. To
be safe, the life estate holder should file a
new homestead with respect to the life es-
tate.
d. A remainderman may file a declaration of
homestead if they use the property as their
primary residence.
e. When transferring a home to or from a trust,
a new homestead declaration must be filed.
HOMESTEADS AND LIFE ESTATES PAGE 71
B. What Is a Deed with a Life Estate?
(i) An individual may give a future interest in
a home to another person by deed, while at
the same time reserving the exclusive right to
live in the home for life. is transfer is ac-
complished by executing and recording a deed
transferring this property interest. e indi-
vidual retaining the right to live in the proper-
ty is the “life tenant,” and the person receiving
the future interest in the property is the “re-
mainderman.” In many situations, individuals
will give their children or other relatives the
remainder interest in their homes.
(ii) e life tenant has the sole right to live in and
operate the property. If the life tenant rents
the property, the life tenant has the right to
any income generated from the property. e
life tenant has the duty to maintain the prop-
erty.
(iii) Upon the death of the life tenant, the life es-
tate terminates and the remainderman will
then own the property in its entirety, avoid-
ing probate.
(iv) If a property is owned in this format, then the
property cannot be sold or mortgaged with-
out the consent of both the life tenant and the
remainderman. e life tenant may still be
eligible for a reverse mortgage provided that
the remainderman consents.
(v) If the property is sold during the life ten-
ant’s life, the life tenant will not receive the
full sales proceeds since they do not entirely
own the property. e life tenant will receive
a portion of the sales proceeds (the actuarial
value of the life estate), and the remainder-
man will receive the balance. e remainder-
man may be subject to and have to pay capital
gains taxes when the property is sold if they
do not qualify for the IRC Sec. 121 capital
gains tax exclusion by not using the property
as their primary residence. If the property is
sold after the life tenant’s death, the remain-
derman would benefit from a stepped up in
basis for capital gains tax purposes.
(vi) Under current MassHealth (the term used for
Medicaid in Massachusetts) law, certain indi-
viduals who receive MassHealth benefits will
have a lien placed on any property in which
they have an ownership interest, including a
life estate. If a MassHealth recipient owns a
life estate in a property that has a lien and the
property is sold during the life tenant’s life,
then MassHealth can collect on the lien from
the proceeds of the sale that are attributable to
the life estate’s actuarial value, but not the re-
mainderman’s actuarial value. If the property
is sold after the life tenant’s death, MassHealth
cannot enforce the lien because, under current
law, that life estate is extinguished upon the
death of the life tenant.
(vii) A transfer of a remainder interest is a disqual-
ifying transfer under MassHealth regulations
and creates a “five-year look-back period”
on that transfer. If the transferor applies for
MassHealth benefits within five years af-
ter making the transfer, then the transferor
would be subject to a disqualification period
for MassHealth benefits. e disqualification
period is a period of time determined under
a formula that MassHealth utilizes. (See the
section on Transfer Rules in Chapter 3.)
(viii) A transfer of a remainder interest is a taxable
gift that needs to be reported on a federal gift
tax return.
(ix) e remainderman’s interest in the property
is subject to their creditors, including a di-
vorce judgment, and the future sale of the
property may be further complicated if the
remainderman predeceases the life tenant.
EXAMPLE 1
Larry retains a life estate and gifts the remainder inter-
est in his home to his son, Robert. Larry needs to file a
gift tax return reporting the gift of the remainder inter-
est. Later, Larry decides he wants to sell his home to a
third party. Not only does Larry need Robert to agree to
sell the home, since Larry does not have full ownership
of the property (he only has a life estate), Larry will only
receive the actuarial value of his life estate and Robert
would receive the balance of the sales proceeds. Larry
can use his Section 121 capital gains tax exemption on
his portion of the sales proceeds, but Robert, presum-
ing he did not use the property as his primary residence
two out of the last five years, would have to pay capital
gains taxes on his portion of the amount realized less
his portion of the basis.
PAGE 72 HOMESTEADS AND LIFE ESTATES
The Commonwealth of Massachusetts
William Francis Galvin, Secretary of the Commonwealth
Declaration of Homestead for Homes Owned
by Natural Persons (General Laws Chapter 188)
In situations where the home is owned by multiple owners, each owner may
be best served to complete a separate declaration of homestead.
1. I, _______________________________________________________________,
(insert name of owner)
We, ______________________________________________________________,
(insert name of owners)
_________________________________________________________________,
_________________________________________________________________,
hereby declare homestead pursuant to M.G.L. c.188 and state that I/we own the home
described below and occupy or intend to occupy the home as my/our principal residence.
Owner Information
2. Check all that apply:
I/we, _____________________________________________________________________ am elderly (62 years of age or older).
(insert name (s))
I/we, _________________________________________________________________________________________________
(insert name (s))
am/are disabled (have a physical or mental impairment that meets the disability requirements for Supplemental Security Income
under 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C). One of the following must be attached: 1) an original or certied
copy of a disability award letter issued to the person by the United States Social Security Administration, or 2) a letter signed by a
physician registered with the board of registration in medicine certifying that each person meets the disability requirements stated
in 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C).
I am married to _________________________________________________________________________________________ ,
who is not a co-owner of the home but who occupies or intends to occupy the home as his/her principal residence.
I/we, _________________________________________________________________________________________________
(insert name (s))
am/are servicemember(s) who may be subject to protection under the servicemember(s) Civil Relief Act, 50 U.S.C. App 533, should
I/we be called to active duty.
Home Information
3. Address: ______________________________________________________________________________________ , Massachusetts.
(street number and name, city/town)
4. Select ONE of the following:
Deed is recorded in __________________________________ Registry of Deeds in ______________ and _______________
(district/county) (book) (page)
Certicate of Title _________________ registered in the Land Registration Oce _________________________________
(number) (document #)
Inheritance from _________________________________________________________________________ , Docket number
(name of previous owner)
_______________________________________________ in ________________________________________________.
(number) (county)
For manufactured homes, license number __________________________________________________________________ .
(number)
Filing Fee $35
(over)
Declaration of Homestead for Homes Owned by Natural Persons - Page 1 of 2
HOMESTEADS AND LIFE ESTATES PAGE 73
5. I/we, whose names are signed on this document, acknowledge that I/we sign it voluntarily for its stated purpose.
To be signed by Applicant(s) in front of Notary Public.
Signed under pains and penalties of perjury this
_______________________________________________day of _____________________________________________ , 20 ______.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
For Use by Notary Public Only:
COMMONWEALTH OF MASSACHUSETTS
_______________________________________________, ss.
________________________________________, 20 ______ , before me, the undersigned notary public, personally appeared
____________________________________________________________________________________________________ ,
(name(s) of the document signer(s))
proved to me through satisfactory evidence of identication, which were ___________________________________________ ,
(drivers license, passport, etc.)
to be the person(s) who signed the preceding or attached document in my presence, and who swore or armed to me that the contents of
the document are truthful and accurate to the best of (his) (her) (their) knowledge and belief.
Notary Public: ____________________________________________________________________________________________
My commission expires: _____________________________________________________________________________________
Declaration of Homestead for Homes Owned by Natural Persons - Page 2 of 2
(Updated 5/29/20)
PAGE 74 HOMESTEADS AND LIFE ESTATES
The Commonwealth of Massachusetts
William Francis Galvin, Secretary of the Commonwealth
Declaration of Homestead for Homes Owned
by Trustee(s) (General Laws Chapter 188)
1. I, ________________________________________________________ , Trustee
(insert name of owner)
We, ______________________________________________________________,
(insert name of owners)
__________________________________________________________, Trustees
of certain trust _____________________________________________________
(trust name)
_________________________________________________________________,
dated _______________ and recorded ________________and________________
(date) (book) (page)
hereby declare homestead pursuant to M.G.L. c.188 and state that I/we own the home
described below and which the beneciaries listed herein occupy or intend to occupy
as his/her/their principal residence:
Beneciary Information
2. Enter beneciary name(s): _____________________________________________________________________________________
(insert beneciary name(s))
3. Check all that apply and enter beneciary name(s):
________________________________________________________________________is/are elderly (62 years of age or older).
(insert beneciary name(s))
_____________________________________________________________________________________________________
(insert beneciary name(s))
is/are disabled (have a physical or mental impairment that meets the disability requirements for Supplemental Security Income
under 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C). One of the following must be attached: 1) an original or certied
copy of a disability award letter issued to the person by the United States Social Security Administration, or 2) a letter signed by a
physician registered with the board of registration in medicine certifying that each person meets the disability requirements stated
in 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C).
I/we, _________________________________________________________________________________________________
(insert name (s))
am/are servicemember(s) who may be subject to protection under the servicemember(s) Civil Relief Act, 50 U.S.C. App 533, should
I/we be called to active duty.
4. For each applicable beneciary, complete one statement. Attach additional page(s) as necessary.
__________________________________________ is married to ________________________________________________
who is not a co-owner of the home but who occupies or intends to occupy the home as his/her principal residence.
__________________________________________ is married to ________________________________________________
who is not a co-owner of the home but who occupies or intends to occupy the home as his/her principal residence.
Home Information
5. Address: ______________________________________________________________________________________ , Massachusetts.
(street number and name, city/town)
Filing Fee $35
(over)
Declaration of Homestead for Homes Owned by Trustee(s) - Page 1 of 2
HOMESTEADS AND LIFE ESTATES PAGE 75
6. Select ONE of the following:
Deed is recorded in __________________________________ Registry of Deeds in ______________ and _______________
(district/county) (book) (page)
Certicate of Title _________________ registered in the Land Registration Oce _________________________________
(number) (document #)
Inheritance from _________________________________________________________________________ , Docket number
(name of previous owner)
_______________________________________________ in ________________________________________________.
(number) (county)
For manufactured homes, license number __________________________________________________________________ .
(number)
7. I/we, the trustee(s) whose name(s) are signed on this document, acknowledge that I/we sign it voluntarily for its stated purpose.
To be signed by Applicant(s) in front of Notary Public.
Signed under pains and penalties of perjury this
_______________________________________________day of _____________________________________________ , 20 ______.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
For Use by Notary Public Only:
COMMONWEALTH OF MASSACHUSETTS
_______________________________________________, ss.
________________________________________, 20 ______ , before me, the undersigned notary public, personally appeared
____________________________________________________________________________________________________ ,
(name(s) of the document signer(s))
proved to me through satisfactory evidence of identication, which were ___________________________________________ ,
(drivers license, passport, etc.)
to be the person(s) who signed the preceding or attached document in my presence, and who swore or armed to me that the contents of
the document are truthful and accurate to the best of (his) (her) (their) knowledge and belief.
Notary Public: ____________________________________________________________________________________________
My commission expires: _____________________________________________________________________________________
Declaration of Homestead for Homes Owned by Trustee(s) - Page 2 of 2
(Updated 5/29/20)
PAGE 76 TAX ABATEMENTS
CHAPTER 9
TAX ABATEMENTS
A. How Exemptions and Deferrals Work
Each property tax exemption, deferral and credit
has eligibility requirements that may include age, as-
set or income limitations. e applicant must be a
resident of Massachusetts. Most exemptions require
that the resident occupy their home for a minimum
number of years (usually five or 10 years). An ap-
plicant may either own their home individually, or
co-own the home with another person. Even a trust
beneficiary can obtain the exemption if the benefi-
ciary has a sufficient beneficial interest in the house
held in trust, and the beneficiary is a trustee. Each
exemption should be read carefully to determine its
specific eligibility requirements.
Homeowners must file an application for an ex-
emption or deferral at their local Board of Asses-
sors’ Office on or before April 1 of the year to which
the tax relates, or three months after the tax bill
is mailed, whichever is later. Applicants must pay
their property taxes while their application is pend-
ing. Approved applications will result in a reduced
real estate tax bill to the taxpayer/applicant. Since
an individual typically can qualify for only one ex-
emption each year, it is important to review all ex-
emptions annually in order to select the exemption
that will result in the greatest tax reduction. If one
is still having trouble paying their property taxes,
they may receive additional relief through a hard-
ship exemption, the Elderly and Disabled Taxation
Fund, the Senior Work-Off Program or the Senior
Circuit Breaker Tax Credit, discussed in Section D
of this chapter.
EXAMPLE 1
Mary lives in a two-family home. Mary occupies the
first floor, and her son occupies the second floor. If she
otherwise qualifies for a tax exemption of $1,000, her
tax reduction would be $500 because Mary occupies
50% of the property.
B. Exemptions
Exemption discharges a taxpayer from the legal
obligation to pay all or part of the tax, and examples
can be found in the various clauses of Mass. G.L.
ch. 59, § 5. Since an individual can only apply for
one exemption, and the exemptions vary from town
to town, applicants should contact their local tax au-
thorities for particular details on programs.
1. Elderly Persons
e standard Elderly Persons exemption pro-
vides $500 (or $1,000 in some communities) for
homeowners who are at least 70 years of age or 65
years of age in some communities. e applicant
must have occupied the property as their primary
residence for at least five years, and the applicant
must have lived in Massachusetts for 10 years
preceding the application. e Elderly Persons
exemption is only granted to one person for the
same parcel of property. If two older individuals
own the property jointly, the exemption amount
will only benefit one owner.
An applicant must also meet income and asset
limitations to be eligible for this exemption. e
standard exemption is available to single applicants
who earn less than $13,000 per year and have as-
sets less than $28,000. A married applicant cannot
earn more than $15,000 per year and cannot own
assets that exceed $30,000. e income limita-
tions do not include Social Security benefits, and
the asset limitations do not include the value of
the home. As with other exemptions, the value of
the applicant’s cemetery plots, registered vehicles,
clothing and household furniture is also excluded
when calculating the applicant’s assets.
Cities and towns may adopt more liberal re-
strictions, and therefore, older adults should con-
tact their local assessor to see if they qualify under
the town’s Elderly Persons exemption.
Applicants who do not qualify for this exemp-
tion because they exceed the income restriction
should apply for the Older Citizens exemption
(discussed in Section B, no. 4 of this chapter), as
there is no income restriction for that particular
exemption.
2. Veterans
e Veterans exemption is available to certain
veterans, as well as their spouses, surviving spous-
es and/or surviving parents. Although the resi-
dency requirement may vary from town to town,
TAX ABATEMENTS PAGE 77
applicants seeking this exemption must have been
a Massachusetts resident for at least six months
prior to entering the service, or the veteran must
have lived in Massachusetts for at least two years
prior to filing for this exemption.
Disabled veterans, honored veterans, and their
spouses or parents are eligible for one of several
real estate tax exemptions. Exemption amounts
vary depending on the severity of the veteran’s dis-
ability or their medal awarded. A list of available
veteran exemptions relating to real estate includes:
• $400 to veterans who received at least a 10%
disability rating from wartime service, veter-
ans who have been awarded the Purple Heart,
and mothers and fathers of veterans who have
been awarded the Gold Star;
• $750 to veterans who suffered the loss of one
foot, one hand or one eye; veterans who re-
ceived the Congressional Medal of Honor,
Navy Cross or Air Force Cross; and their
spouses or surviving spouses;
• $1,000 to veterans who suffered total disability
in the line of duty and are incapable of work-
ing, and their spouses or surviving spouses;
• $1,250 to veterans who suffered in the line of
duty the loss of use of both feet, both hands
or both eyes, and their spouses or surviving
spouses;
• $1,500 to veterans who suffered total disability
in the line of duty and to veterans who received
assistance in acquiring “specially adapted
housing,” as well as their spouses or surviving
spouses;
• A full exemption, with a cap of $2,500 after
five years, is available to surviving spouses of
soldiers, sailors and guardsmen who died from
being in a combat zone; and
• A total exemption is available to paraplegic vet-
erans and their surviving spouses.
ere are no income or asset restrictions for the
qualified Veterans exemption, but the applicant
must occupy the property as their primary
residence. Applicants who co-own the property
must have an ownership interest in the property
valued at $2,000 to $10,000, depending on the
exemption. If the property is greater than a single-
family home, the exemption amount is calculated
and is prorated based on the value of the property
that is occupied by the applicant.
A motor vehicle of a disabled veteran operated
for personal use is exempt from automobile excise
taxes. In addition, a motor vehicle of a veteran or
their surviving spouse is exempt from automobile
excise taxes if the veteran was a prisoner of war and
the city or town allows this exemption provision.
3. Blind
e property tax exemption for the blind is ei-
ther $437.50 or $500, depending on the city or
town’s discretion. An individual applying for this
exemption will need to provide proof that they
are legally blind. Most assessors will accept a cer-
tificate showing that the applicant is registered as
legally blind with the Massachusetts Commission
for the Blind or a letter from the applicant’s physi-
cian stating that the applicant is legally blind.
While there are no income or asset restrictions,
the blind applicant must own and occupy the
property as their primary residence. Applicants
who co-own the property must have an owner-
ship interest worth at least $5,000 in order to sat-
isfy the requirement of this exemption. ere is no
apportionment of this exemption if the blind per-
son co-owns the property (owns as a joint tenant
or tenant in common, for example). A co-owning
blind person will receive the entire exemption.
EXAMPLE 2
Sally and her sister are both legally blind, registered
with the Massachusetts Commission for the Blind,
and are joint owners of the property. Even though both
women qualify for the exemption, the first person to
apply for the exemption will receive the abatement
because only one exemption is granted on the same
parcel of land.
4. Older Citizens, Surviving Spouses and
Minors
is exemption provides relief to three catego-
ries of persons: 1) widows and widowers; 2) minor
children with one parent deceased; and 3) persons
70 years of age and older. e state statute com-
pels cities and towns to provide a $175 property tax
exemption to applicants meeting the eligibility re-
quirements. Some cities and towns, however, have
voluntarily adopted a higher exemption amount.
ere are no income limitations for these exemp-
tions. As a result, this exemption is a good alterna-
PAGE 78 TAX ABATEMENTS
tive for older adults who do not qualify under the
Elderly Persons exemption discussed in Section B,
N o. 1 of this chapter. A surviving spouse or a mi-
nor with a deceased parent does not have to own
and occupy the property for any period of time
to receive this exemption. On the other hand, an
older adult applying for this exemption must have
owned and occupied the property as their primary
residence for at least five or 10 years, depending on
the town’s discretion.
e dollar amounts in the original eligibility
requirements under this exemption established by
the commonwealth have become somewhat out-
dated with increasing property values. e com-
monwealth, therefore, now gives cities and towns
the option of electing from several alternatives that
vary in asset limitations and residency require-
ments. For example, under the original standard
exemption, an individual cannot exceed $20,000
in total assets, excluding any unpaid mortgage on
the property.
Conversely, under the most flexible alternative,
an individual cannot own more than $20,000 un-
der clause 17, or $40,000 under the other clauses,
excluding the total value of the subject property.
EXAMPLE 3
Ethel is 70 years old and has lived in her home for
the past seven years. Ethel has $30,000 in the bank
and a home valued at $200,000 with an outstanding
mortgage of $170,000. Ethel would not qualify for this
exemption if she lives in a town that adopted the stan-
dard exemption because she exceeds the asset limita-
tion ($30,000 cash + $30,000 in equity) and she does
not meet the residency requirement of 10 years. Ethel
does, however, qualify for the exemption if she lives
in a town that adopted the least restrictive alternative
because she does not exceed the asset limitation and
she does meet the residency requirement of five years.
Practice note: Check with the local assessor
to determine which clause the city or town has
adopted. Also check if the exemption amount is
$175 or if the city or town adopted a higher ex-
emption amount.
An applicant’s personal belongings, household
furniture, car and prepaid funeral expenses are
not counted in determining the applicant’s maxi-
mum total asset value amount.
EXAMPLE 4
George is 70 years old and has lived in his home for
the past 10 years. In addition to $13,000 in the bank,
George owns a car worth $15,000 and has household
furniture valued at $20,000. George also prepaid his
funeral expenses. George would qualify for all clause
17 exemptions and would receive a reduction of taxes
on his home of $175.
5. Hardship
Individuals who do not qualify for any of the
above exemptions may apply for a hardship exemp-
tion. A hardship exemption can be obtained by
individuals who also received one of the above ex-
emptions. is exemption grants relief to a home-
owner in their tax bill due to medical hardship,
financial hardship, or extenuating circumstances
and expenses.
ere are no expressed restrictions, and eligibil-
ity is determined on a case-by-case basis. is ex-
emption is typically available to individuals who
are unable to fulfill their tax obligation because of
age, infirmity, poverty or financial hardship result-
ing from a change to active military status.
C. Deferring Taxes
e Elderly Tax Deferral, available under Mass.
G.L. ch. 59, § 5,(41)(A), allows an older homeowner
to defer payment on their property taxes. In contrast
to tax exemptions, deferred taxes must eventually be
paid. Under the deferral, all or part of the property
taxes due on the property are deferred until the de-
ferred tax amount reaches 50% of the then-assessed
property value. A single older homeowner must be
at least 65 years old to be eligible for the deferral. An
older adult may own the property jointly or as a ten-
ant in common. For older adults owning property
jointly with a spouse, at least one spouse must be 65
years or older.
A qualified applicant must enter into a written
tax deferral and recovery agreement with the city
or town. is agreement is recorded at the Registry
of Deeds. During the deferral period, the deferred
tax amount incurs a maximum 8% interest annu-
ally, although the statute permits cities and towns to
elect a lower interest rate. Some towns have elected
an interest rate of zero. Deferred taxes must be re-
paid within six months after the death of the older
TAX ABATEMENTS PAGE 79
homeowner or sale of the property. If the property
is sold or the older homeowner is deceased and the
taxes are not repaid, the tax deferral becomes a lien
on the property.
e applicant must have owned and occupied
any real property in Massachusetts (including the
current property) for five years and must have been a
resident of Massachusetts for the previous 10 years.
While there are no asset limitations, the older adult’s
income may not exceed $20,000 per year. Cities and
towns may adopt higher income limitations, but no
city or town may adopt an annual income limitation
higher than $40,000. e deferral can be used in
conjunction with one of the available real estate tax
exemptions, as long as the applicants meet eligibility
requirements for both.
EXAMPLE 5
Frankie has a yearly real estate tax bill of $1,200 on his
home. He is 73 years old and receives a $500 reduc-
tion in his real estate tax under the Elderly Persons ex-
emption. Frankie’s remaining tax amount due of $700
can be deferred.
D. Other Tax Exemptions and Credits for
Older Adults
1. Elderly and Disabled Tax Fund (Mass. G.L.
ch. 60, §3D)
Pursuant to Mass. G.L. ch. 60, § 3D, the com-
monwealth authorized cities and towns to create
an Elderly and Disabled Taxation Fund “... for the
purpose of defraying the real estate taxes of el-
derly and disabled persons of low income.”
Each city or town may adopt the program. If
adopted, the community will establish a five-
person Taxation Aid Committee, which identi-
fies the recipients of the aid and determines how
much of their tax bills will be defrayed. e com-
munity’s taxpayers may donate any amount to the
fund through their tax bills. Donated funds are
deposited into a special account until adminis-
tered by the committee.
An individual meeting the eligibility criteria
must submit an application to the Taxation Aid
Committee. e applicant must be elderly or
disabled in accordance with their community’s
eligibility guidelines. Since the statute does not
provide specific standards to define elderly or dis-
abled, the committee has some flexibility in ad-
ministering the funds.
Whether elderly or disabled, the applicant must
have some degree of financial hardship, and must
disclose their financial information on the appli-
cation. Certain communities consider other fac-
tors, such as marital status, employment status,
work qualifications, public assistance received by
the applicant or the value of the applicant’s home.
Each community may establish its own unique
standards to better meet its local needs.
Communities will frequently award aid to all
qualified applicants because few residents apply
for aid. is high acceptance rate is ordinarily due
to a lack of knowledge of the program. Because
an individual’s entire property tax burden can be
covered by the tax fund, it is essential for potential
applicants who meet the minimum qualifications
to be made aware of the program and submit an
application.
2. Senior Work-Off Abatement (Mass. G.L.
ch. 59, § 5K)
e Senior Work-Off Abatement program en-
ables tax-paying older adults to volunteer their
services to the community in exchange for a re-
duction in their property tax bill.
An eligible older adult may save up to $1,500 on
their taxes, depending on the community’s elec-
tion. e older adult will work at an hourly rate
that may not exceed the state minimum wage; in
exchange for such work, the city or town will is-
sue a voucher to the older adult that will be ap-
plied against their property tax bill. By applying
these vouchers, the older adults are not earning
income, and therefore, the voucher is tax-free.
e state statute provides that the taxpayer
must be more than 60 years of age and own prop-
erty within the community. e applicant may
be a trustee if the property is owned by a trust.
More than one qualifying owner may earn the
abatement on the same property, unless local pro-
visions express otherwise. Older adults may earn
the work-off abatement on top of any other ex-
emptions and credits that may be available un-
der any other statutes. Older adults may work in
schools, libraries, senior centers, or other public
departments and offices in the community.
Not every applicant is guaranteed work through
PAGE 80 TAX ABATEMENTS
the program. Generally, older adults must dem-
onstrate a financial hardship in order to receive
jobs with the community, and the hours an older
adult may work are limited since they can only
earn up to $1,500 per year. In most towns, there
is no automatic reenrollment, and as a result, in-
terested workers need to apply each year.
e program has been well received in the
communities that have adopted the senior work-
off, because it: (a) decreases property taxes for the
working older adult; (b) increases the involvement
of older adults in local government; and (c) gives
communities a skilled pool of potential older em-
ployees.
3. Senior Circuit Breaker Tax Credit (Mass.
G.L. ch. 62, § 6(k))
e Senior Circuit Breaker Tax Credit differs
from the other exemptions and deferrals dis-
cussed earlier because this program credits the
older adult’s state income tax as opposed to their
property tax. e circuit breaker credit allows
property owners or renters 65 years of age or older
to claim a credit of up to $1,200 (for 2022) for
rent or real estate taxes paid on their principal res-
idence to the extent the taxes exceed 10% of their
total income. e state pays the credit as opposed
to the local cities and towns.
Older homeowners who paid more than 10%
of their income for real estate taxes and water and
sewer charges are eligible for the credit. Older
renters can count 25% of their rent as real estate
taxes. In order to receive the credit, an older adult
must file a state income tax return, even if they
are not otherwise required to do so. e taxpayer
will receive a refund if the credit due exceeds the
amount of the income tax paid that year.
To be eligible for the credit for 2022, single
older adults cannot earn more than $64,000. For
heads of household, and married couples filing
a joint return, the annual 2022 income limita-
tions are $80,000 and $96,000, respectively. In
all cases, the value of the home after abatements
cannot exceed $912,000 for 2022. In order for a
renter to receive the credit, they cannot be receiv-
ing a rent subsidy, and they cannot pay rent to
a landlord who is not required to pay real estate
taxes. A taxpayer may add 50% of their water and
sewer bill to their property tax assessment when
calculating the credit, so long as the water and
sewer bill is not already included in the municipal
property tax bill. For example, delinquent water
and sewer bills are generally added to the property
tax, whereas the provisions of the circuit breaker
credit only apply to current water and sewer bills.
Any property tax reductions or exemptions,
such as the ones described in this guide, earned
or received by the taxpayer must be taken into
account before determining the total real estate
tax paid.
EXAMPLE 6
Nancy is 81 years old and lives alone. Nancy’s home is
valued at $350,000, and she earned $20,000 in 2022.
She had an unadjusted real estate tax bill of $5,000
and a $500 water and sewer bill. She can therefore
add $250 (50% of $500) to her tax bill in calculat-
ing the circuit breaker credit, bringing it up to $5,250.
Nancy also received the Elderly Persons exemption of
$175 and earned $500 through the Senior Work-Off
Abatement. Nancy’s adjusted property tax is $4,575
($5,250 - $175 - $500). Ten percent of Nancy’s income
is $2,000. Because Nancy’s adjusted real estate tax
exceeds 10% of her total income by at least $1,200,
Nancy is eligible for the full $1,200 income tax credit
for 2022.
ADDITIONAL RESOURCES AND CONCLUSION
Additional information and applications for
exemptions can be obtained at the assessors’ office
in each city or town. Several assessors’ offices have
websites that provide local exemption information,
downloadable applications, and links to other web-
sites. e following are additional resources that
may be useful:
• Commonwealth of Massachusetts Citizen
Information Service
www.sec.state.ma.us/cis, (617) 727-7030
• Department of Revenue, Division of Local
Services, Property Tax Bureau
51 Sleeper St., Boston, MA 02210
(617) 626-2300
is chapter should provide you with infor-
mation needed to determine whether you may be
eligible for a real estate tax exemption or deferral.
Because several cities and towns have adopted al-
ternatives for many exemptions, you should contact
your local assessors’ office for specific eligibility re-
quirements and exemption amounts.
REVERSE MORTGAGES PAGE 81
CHAPTER 10
REVERSE MORTGAGES
Basic Information About a Potentially Helpful Retirement Tool
INTRODUCTION
Reverse mortgages are one of the most misun-
derstood financial products on the market today.
For many older homeowners, their homes are their
most valuable, if not their only, asset. Some may
need funds to help pay for health care bills, prop-
erty-related expenses or even subsistence needs. On
the other side of the financial spectrum, many af-
fluent baby boomers and their financial advisers are
searching for creative ways to incorporate home eq-
uity into their comprehensive retirement plans. One
tool available to homeowners who reach a certain
age is a reverse mortgage.
Reverse mortgages allow older homeowners to
borrow against their home equity and convert it into
spendable cash in order to accomplish their personal
financial goals. ere are many myths and miscon-
ceptions about reverse mortgages, and they are not
the answer for everyone. Homeowners should do
their research, weigh their options, connect with
U.S. Department of Housing and Urban Develop-
ment (HUD) counselors, and speak to an elder law
attorney or other trusted professional adviser before
entering into one of these transactions.
WHAT IS A REVERSE MORTGAGE?
A reverse mortgage is a type of loan that enables
an age-qualified homeowner to release or “cash out”
some of the equity in their home without incurring
a new monthly mortgage payment. e purpose of a
reverse mortgage is to increase a homeowner’s access
to spendable cash in their later years. e tradeoff
is that the reverse mortgage is eating into the bor-
rower’s home equity as the loan repayment balance
increases steadily over time.
HOW DOES A REVERSE MORTGAGE COMPARE
WITH THE OTHER MORTGAGES?
In a “standard” mortgage, you pay principal to
build equity in your home. In a home equity line of
credit (HELOC), you can take out “loans” secured
by the value of your home, but you must make inter-
est payments on the outstanding loan balance. For
all mortgages, there are eligibility rules and costs.
e Loan Comparison Chart (see page 84) com-
pares a reverse mortgage with a standard mortgage
and a HELOC.
A. Types of Reverse Mortgages
In 2023, Massachusetts homeowners can choose
among a few types of reverse mortgages. By far the
most common is the Federal Housing Adminis-
tration (FHA)-insured Home Equity Conversion
Mortgage (HECM). HECMs are offered through
mortgage lenders, mortgage brokers, banks and
credit unions. FHA made several program changes
between 2014 and 2018 in an effort to improve con-
sumer protections and stabilize the FHA Mutual
Mortgage Insurance Fund.
From time to time, there may be additional
proprietary reverse mortgage products available for
high-value properties. While many of these loans
are set up to run similarly to a HECM, they often
have different closing costs and interest rates and
other unique features. An individual contemplating
one of these loans should consult with an elder law
attorney or a real estate attorney to have the loan
terms reviewed and explained. As with a HECM,
homeowners obtaining these loans are required to
have reverse mortgage counseling with a HUD-cer-
tified reverse mortgage counselor prior to obtaining
the loan.
As the HECM program is the most prolific
reverse mortgage program in Massachusetts, the
remaining chapter is devoted to explaining the
HECM.
B. How Does an HECM Reverse Mortgage
Work?
Unlike a conventional “forward” mortgage, a
HECM has no required monthly repayment obliga-
tion. It is a deferred payment loan. e repayment of
the loan is deferred until the home is sold or the last
borrower (or qualified non-borrowing spouse) has
PAGE 82 REVERSE MORTGAGES
passed away, left the home permanently or defaulted
on the terms of the mortgage. As with any mort-
gage, the borrower must keep current with property
taxes, homeowners insurance, maintenance, and
municipal utility charges.
e loan amount available under a reverse mort-
gage varies based upon a number of factors, but
primarily upon the borrower’s age, the value of the
home and the expected interest rate. erefore, older
borrowers with more valuable homes (up to the cur-
rent limit) can access greater loan amounts.
Borrowers can access loan proceeds in one of the
following ways or any combination of them.
• Immediate Lump Sum.
• Tenure Payment. A monthly amount sent to
the homeowner that is guaranteed to continue
as long as the homeowner occupies the home
as their primary residence, even if for life. e
older the homeowner at the start of the loan,
the larger the tenure payment. For instance, a
62-year-old living in a $400,000 house might
have a tenure payment of $724 per month,
whereas a 75-year-old living in the same house
might have a tenure payment of $1,060 per
month.
1
• Term Payment. A monthly payment that lasts
for a finite number of months and then ends.
ese payments are usually for a larger amount
than is available under the tenure payment op-
tion and may deplete the available loan bal-
ance quickly.
• Line of Credit. e homeowner can pull out
loan funds at times and in amounts of their
choosing. In that way, it is similar to a HE-
LOC. However, that is where the similarities
end. As long as the borrower meets their loan
obligations, a HECM line of credit cannot be
“called” or arbitrarily terminated by the lender
the way a HELOC can. Also, the unused por-
tion of a HECM line of credit grows larger at
a guaranteed, compounding growth rate (the
same interest rate at which the loan balance
grows). So, a 62-year-old living in a home
worth $600,000 may start out today with a
line of credit of $174,973. But if the individual
leaves the line of credit alone and allows it to
grow, it will grow to $357,454 in 10 years and
$730,241 in 20 years, even if the home de-
creases in value.
2
e importance of understanding how com-
pounding interest impacts any reverse mortgage is
significant. e impact on the balance due at the
time of payoff may cause some confusion among
homeowners and their families. See Example 1 on
page 83).
C. Repaying an HECM Reverse Mortgage
Any of the following six circumstances will trig-
ger repayment of a HECM:
1. Most common — the last borrower (or eligible
non-borrowing spouse) passes away.
2. e borrower sells the property or otherwise
conveys title without retaining a life estate in-
terest or beneficial interest in a trust.
3. e borrower ceases to occupy the real estate
as their principal residence.
4. Failure to maintain the property such that the
home falls into disrepair.
5. Failure to maintain the homeowners insurance
on the property.
6. Failure to pay the property taxes and, in some
cases, municipal utility charges, which, if un-
paid, become liens, such as water and sewer
bills.
e outstanding repayment balance will be
made up of any loan funds disbursed to the home-
owner over the life of the loan plus interest, FHA
mortgage insurance and servicing fees that have ac-
cumulated over time. Unless the homeowner makes
voluntary prepayments, the charges will compound
over time, so it is important to draw down only
the loan funds that one needs to pay one’s bills and
live comfortably. For instance, a homeowner who
withdraws $20,000 initially for a home repair and
to eliminate credit card debt may owe $48,305 in
five years and $69,042 in 10 years.
3
Compare that
to a homeowner who withdraws $100,000 initially
and deposits most of it in the bank. e homeowner
could owe $169,124 in five years and $241,728 in
10 years because of the compounding effect of the
loan charges.
4
A HECM can be repaid, in part or in whole,
without any prepayment penalty. Prepaying an ad-
justable-rate HECM down to a zero balance will
close out the loan, whereas leaving a small outstand-
REVERSE MORTGAGES PAGE 83
ing balance will leave the loan open and accessible
in the future.
Usually, a HECM is repaid by selling the home,
refinancing into a regular mortgage, or utilizing the
cash or life insurance death benefit of a deceased
borrower. Typically, the home is sold for a price that
exceeds the HECM outstanding balance. In that
case, the excess sale proceeds revert to the borrower
or their estate.
A HECM is a “non-recourse” loan, meaning
that, if the outstanding loan balance exceeds the
home’s fair market value at the time of repayment,
the borrower or their estate is only responsible for
repaying 95% of the home’s value. FHA’s mortgage
insurance fund covers the repayment of any short-
fall between the outstanding loan balance and the
home’s value. Neither the borrower nor the borrow-
er’s estate is personally responsible for repaying the
shortfall. Lenders will allow the estate up to one year
from the last borrower’s date of death to repay the
reverse mortgage. is one-year period includes an
initial six-month repayment period plus additional,
allowable extensions. Interest and FHA mortgage
insurance will continue to accrue during this time,
which can reduce the amount of any remaining
equity in the home.
D. Reasons to Use an HECM Reverse
Mortgage
e HECM can be used for any purpose and,
when used responsibly, can provide additional, long-
term financial security during a homeowner’s retire-
ment. at being said, it is recommended that bor-
rowers carefully consider how they want to use the
money. Here are some common examples of how
HECMs are used today:
1. Paying off existing mortgage debt to eliminate
monthly principal and interest payments;
2. Eliminating credit card debt and other unse-
cured debts;
3. In-home care services;
4. Home renovations and repairs, including ac-
cessibility modifications;
5. Dental work, hearing aids and other medical
expenses not covered by Medicare or health
insurance;
6. Deferring the date that one begins drawing
EXAMPLE 1
First, understand compound interest. Compound interest is the addition of interest to the principal sum of a loan or
deposit, or in other words, interest on interest. For example, borrowing $50,000, at a 2% interest rate, compounded
monthly. In January, the interest is $83.33 ($50,000 times .02, then divided by 12). In February, the interest is calcu-
lated on $50,083.33, so the February interest is $83.47.
Let’s assume a 70-year-old couple in a $500,000 home sets up an HECM line of credit with $283,000 in it. First, their
$19,543 in closing costs are automatically subtracted, and then the couple withdraws $125,000 immediately. Their
beginning loan balance is $144,543. Lender interest and FHA mortgage insurance begin accruing on that amount and
compound over time. If the couple sells their home or dies 15 years later when they are 85, their outstanding loan bal-
ance could be $255,627. Over that 15-year period, $111,084 in lender interest and FHA mortgage insurance has built
up and is added into their outstanding loan balance.
The difference between the home’s value and the $255,627 loan balance is their remaining home equity that they will
receive as cash from the sale. The same $500,000 home could either appreciate or depreciate over time, and that
will impact how much equity, if any, the homeowners or their estate will receive upon sale. For instance, if the home
appreciates at 4% per year over that 15-year period, it will be worth $900,472. If it appreciates at 2% per year, then
the home will be worth $672,934. The difference between those figures and the $255,627 loan payoff is the equity
returning to the homeowners or their estate. Finally, if the home depreciates over the 15 years down to $240,000, then
the non-recourse protections built into the HECM program will protect the homeowners and their estate.
At the same time this couple’s loan balance is growing due to the compounding interest and FHA mortgage insurance,
their available line of credit is also growing larger. After our couple withdrew their initial $125,000, their remaining
available line of credit was $138,457. Over the next 15 years, the available line of credit grows, and that growth, like
their interest, compounds over time. By year 15, their available unused line of credit grows from $138,457 to $244,866.
That’s $106,409 in additional line of credit growth that the couple had the opportunity to access if they wanted to.
PAGE 84 REVERSE MORTGAGES
Social Security retirement benefits in order to
receive a larger monthly benefit;
7. Replacing lost income sources like a deceased
spouse’s Social Security or pension, or a deplet-
ed 401K, IRA or annuity;
8. As a funding source for older adults caring for
grandchildren or adult disabled children;
9. Supplementing income to help pay for every-
day living expenses;
10. As a “safety net” for emergencies or large ex-
penditures;
11. Extending the longevity of one’s other retire-
ment savings and investments.
An HECM should never be used as a means
to purchase any other type of financial product,
investment or annuity.
E. Determining Eligibility for an HECM
Reverse Mortgage
ere are a few requirements to be eligible for a
HECM.
Age. e minimum qualifying age for the
FHA-insured HECM program is 62. New rules
extend eligibility to a married applicant who has a
spouse under age 62 as long as certain procedures
are followed. ese new rules create new protec-
tions, responsibilities and consequences for the
“non-borrowing spouse,” which the couple should
review with their attorney, a HUD-certified reverse
mortgage counselor and their lender.
Property Value. ere is no minimum property
value requirement, though a homeowner must have
enough equity in their home to pay off any existing
LOAN COMPARISON
Loan Type Due Date Interest Rate
Non-
Recourse
Expenses
Income/Credit/
Asset in
Underwriting
Mortgage
Payment and
Balance
(Reverse
mortgage)
HECM (federally
insured Home
Equity Conver-
sion Mortgage)
Death of borrower(s); Sale
of home; Borrower(s)’s
absence from property for
six or more months in a
year; Borrower(s) in hos-
pital and/or nursing home
care for 12 consecutive
months; Foreclosure for
nonpayment of property
charges. See no. 1 refer-
ence below.
Adjustable or
Fixed Rate
(smaller sum
available under
fixed rate “lump
sum” option).
Yes Mortgage insur-
ance premium =
2% of home value;
negotiable loan
origination fee of
$2,500 to $6,000
based on home
value; Standard
loan closing costs
(see no. 2 refer-
ence below);
annual MIP
(see no. 3 refer-
ence below).
Only for
purposes of
confirming
borrower's
ability to
pay property
charges
(potential
proceeds from
HECM loan are
included in the
calculation).
No mortgage
payments are
required. Loan
balance increases
at compounding
interest. In these
loans, the interest
is added to the
loan amount and
becomes interest
on interest.
Standard
Mortgage
End of term of loan; Sale
of home; Refinance of
loan; Foreclosure for non-
payment.
Adjustable or
Fixed Rate
No Standard loan
closing costs;
Origination fee(s)/
points (if appli-
cable).
Yes Principal and
interest payments
are required,
reducing loan
balance over life
of loan.
HELOC (Home
Equity Line of
Credit)
End of term of loan; Sale
of home; Refinance of
loan; Foreclosure for non-
payment.
Adjustable or
Fixed Rate
No Standard loan
closing costs;
Origination fee(s)/
points (if appli-
cable).
Yes Interest payments
are required; Prin-
cipal payments
will reduce loan
balance over the
life of loan.
1. Property charges are real estate taxes, homeowners insurance, condominium or homeowners association (HOA) fees, and certain
municipal fees, which, if unpaid, become liens.
2. Standard loan closing costs are lender attorney’s fee, lender’s title insurance premium and recording fees at Registry of Deeds.
3. A mortgage insurance premium equal to 0.5% of the outstanding loan balance added on an annual basis.
REVERSE MORTGAGES PAGE 85
mortgages or liens, and the home must meet FHA
guidelines. In 2023, lenders may consider up to the
first $1,089,300 when determining an applicant’s
eligibility and loan amount.
Residency. e property securing the loan must
be the borrower’s primary residence.
Ownership. While home ownership is ordinar-
ily a prerequisite, life tenants and beneficiaries of
certain types of trusts may obtain a HECM, subject
to some restrictions. Applicants should make sure
that they or their attorney communicates with the
lender early in the process to make sure their owner-
ship interest meets HUD and lender guidelines.
Home Type and Condition. Single-family
residences are eligible, but lenders will also extend
credit on owner-occupied, multi-family homes (up
to four units) and FHA-approved condominiums
(individual condominiums can now be approved
rather than entire condominium complexes/build-
ings). For homes requiring structural repairs, lend-
ers will either set aside a portion of the loan funds
into a “repair set-aside account” and give the home-
owner one year to complete the repairs post-closing
or, in cases when repairs are deemed a serious safety
or structural hazard, lenders will require a home-
owner to complete those repairs prior to closing.
Homeowners who installed leased solar panels on
their homes should note that a portion of their solar
panel lease agreement will have to be changed. e
lender should discuss this matter directly with the
solar energy company.
Income and Credit. “Financial Assessment”
is a term describing credit and income underwrit-
ing rules that assess the suitability of a HECM for
each applicant’s financial situation and reduce the
number of technical mortgage defaults caused by
nonpayment of property taxes and homeowners in-
surance. Lenders must now analyze each applicant’s
credit history, property charge payment history and
income to determine the homeowner’s ability (in-
come) and willingness (credit) to meet their ongoing
property expenses. ose who don’t meet certain
HUD thresholds will encounter “Life Expectancy
Set Asides” that require setting aside what can be
a substantial percentage of their available HECM
funds for future property tax and insurance pay-
ments, or in some cases (where the borrower is 62 or
a few years older and the property charges are large),
their HECM application may be denied.
F. Fees Associated with Obtaining a Reverse
Mortgage
Fees vary based upon the lender offering the pro-
gram. Initial loan costs include those for FHA mort-
gage insurance, usual and customary third-party
closing costs, and loan origination fees. Homeown-
ers should shop around to see what different lenders
offer for closing costs and lender credits.
e FHA Initial Mortgage Insurance Premium
is equal to either 2% of the home’s value or $21,786,
whichever is less. More often than not, this insur-
ance premium makes up the largest percentage of
the total financed closing costs.
An origination fee is another closing cost, and
depending on the home’s value, it can be as high as
$6,000 for a home valued at $400,000 or more. In
some cases, lenders will agree to reduce their origi-
nation fee or offer “lender credits” to offset some
of the closing costs. However, this may cause the
lenders to increase the interest rate margin, allowing
them to recapture these fees over time.
Although borrowers need not pay most closing
costs out of pocket, they should be aware that if they
finance the loan costs by adding them to their loan
balance, they (or their estate on their death) will
still pay them back (plus interest) when the loan be-
comes due and payable.
In terms of ongoing costs, there is interest, an
FHA mortgage insurance premium of .50% per
year and possibly servicing fees of $30 or $35 per
month. As Section C illustrates, interest and the
FHA annual insurance premium compound over
time, thereby causing the outstanding loan balance
to grow faster over time.
Most reverse mortgage lenders offer both fixed
and adjustable interest rates. Keep in mind that
borrowers who select a fixed interest rate must take
all of their loan funds in one single disbursement
lump sum at closing in a much lower amount than
is available with an adjustable rate. A line of credit,
tenure payment and term payment are not available
with a fixed interest rate.
PAGE 86 REVERSE MORTGAGES
REVERSE MORTGAGE COUNSELING
TIP: Calculate the amount you will need immediately,
and then calculate what you will need going forward.
Ask for the calculations over different periods of time
— the first year, the fifth year, etc. If you expect to live
in the home indefinitely, what are the calculations 15 or
20 years out? Is the interest rate variable or fixed? How
do these calculations fit into your overall plan? Know
that both the lender and the reverse mortgage counsel-
or are required to show each borrower an amortization
schedule forecasting the loan’s outstanding balance
each year until the youngest borrower’s 100
th
birthday.
In an effort to protect older homeowners from
undue influence and to ensure that they make the
most educated decision possible, HECM applicants
must complete a reverse mortgage counseling ses-
sion with an independent, HUD-certified reverse
mortgage counselor. All reverse mortgage counsel-
ing sessions within Massachusetts must take place
face-to-face with a HUD-approved counselor.
NOTE: Telephonic or virtual “Zoom” counseling is
allowed through March 31, 2023, per state legislation
passed in July 2022. One can find an agency
approved in Massachusetts at the Executive Office
of Elder Affairs website:
www.mass.gov/service-
details/reverse-mortgage-counselors
.
APPROVED HUD HOUSING COUNSELING
AGENCIES
e following is the currently approved list of
HUD Housing Counseling agencies providing
HECM counseling within the commonwealth as of
January 2023:
American Consumer Credit Counseling
130 Rumford Ave., Ste. 202
Auburndale, MA 02466
Tel: (617) 559-5700 • Toll-free (866) 826-7180
Cambridge Credit Counseling Corp.
67 Hunt St.
Agawam, MA 01001-1920
Tel: (800) 757-1788
Community Service Network Inc.
52 Broadway
Stoneham, MA 02180
Tel: (781) 438-1977
Housing Assistance Corp.
460 West Main St.
Hyannis, MA 02601
Tel: (508) 771-5400, ext. 287
Neighborworks Housing Solutions
68 Legion Parkway
Brockton, MA 02301
Tel: (617) 770-2227, ext. 344
1. Calculated 02/22/2023 assuming $400,000 home value, 6.665% expected rate,
7.835% initial rate adjusting monthly, $17,296 financed closing costs.
2. Calculated 02/22/2023 assuming $600,000 home value, 6.665% expected rate,
7.835% initial rate adjusting monthly, $21,826 financed closing costs.
3. Calculated 02/22/2023 assuming $400,000 home value, 6.665% expected rate,
7.835% initial rate adjusting monthly, 0.50% MIP, $17,296 financed closing costs.
4. Calculated 02/22/2023 assuming $600,000 home value, 6.665% expected rate,
7.835% initial rate adjusting monthly, $21,826 financed closing costs.
ELDER ABUSE, NEGLECT AND FINANCIAL EXPLOITATION PAGE 87
CHAPTER 11
ELDER ABUSE, NEGLECT AND FINANCIAL EXPLOITATION
** In this chapter, the term “elder” will be used due to statutory references.
Otherwise, “older adult” is now the commonly accepted term.
INTRODUCTION
Elder abuse encompasses classic physical and
emotional abuse, as well as neglect, self-neglect and
financial exploitation. Numerous studies have found
that elder abuse is far underreported, with roughly
only one in five incidents being reported. is low
figure is due partly to the common familial or close
relationship between the victim and perpetrator.
Some studies have shown that when abuse occurs,
family members and caregivers may account for as
much as 90% of the abuse. To stop the abuse and
help victims, elder abuse, neglect, self-neglect and
financial exploitation must be on the forefront of
educational efforts for those caring for older adults.
A. What Is Elder Abuse?
Elder abuse has a broad definition because of the
many ways in which older adults are vulnerable. In
Massachusetts, elder abuse includes actions by al-
most anyone, including a caretaker,
1
conservator
2
or
guardian,
3
causing: (1) physical or emotional injury,
including sexual abuse; (2) financial exploitation;
or (3) denial of life necessities essential for physi-
cal and emotional well-being (neglect). Elder abuse
also includes self-neglect, which is when older adults
are unable to care for themselves. Some often-over-
looked warning signs of neglect include bed sores,
poor hygiene, malnutrition, mood changes and un-
accounted-for changes to the older adult’s finances.
B. What Should I Know About Financial
Exploitation of Older Adults?
1. Definition
Financial exploitation is an act or omission that
causes a substantial monetary or property loss to
an older adult, or causes a substantial monetary
or property gain to another person, which gain
would otherwise benefit the older adult but for the
act or omission of such other person.
4
e consent
of an older adult to the harmful act or omission is
not valid if the older adult lacked capacity or if it
was the consequence of misrepresentation, undue
influence, coercion or threat of force.
5
Some common examples of financial abuse
include: misuse of durable powers of attorney and
bank accounts; misuse or neglect of the authority
by a guardian or conservator; failure to provide
reasonable consideration for the transfer of real
estate; excessive charges for goods or services;
or the use of fraud or undue influence to gain
control of or obtain money or property. Predatory
lending, telemarketing fraud, sweepstakes fraud
and other scams that are targeted toward older
adults also may be considered to be financial
exploitation. For the more traditional forms of
financial abuse by persons that the older adult
trusts, it can be hard to identify the abuse because
it happens over time, and in many cases, the
abuser is also a person who might ordinarily be
expected to receive gifts from the older adult,
such as a child or a sibling. Often, the older adult
does not know it is happening because the older
adult depends on and trusts the abuser. Financial
abuse is sometimes accompanied by physical or
emotional abuse, which silences the older adult.
2. Warning Signs
ere are some warning signs that can help
you identify whether financial abuse may be
occurring, such as unusual bank withdrawals;
failure to meet financial obligations; withdrawals
from investments in spite of penalties for early
withdrawal; abrupt changes in wills, trusts,
contracts, powers of attorney, property titles,
deeds or mortgages; changes in beneficiaries on
insurance policies; or financial activity that is
inconsistent with the older adult’s abilities (such
as ATM withdrawals when the older adult has
difficulty leaving the house) or previous spending
patterns (such as online shopping). Another
potential warning sign of financial exploitation
is a new, and many times significantly younger,
“friend” of the older adult, who has been
PAGE 88 ELDER ABUSE, NEGLECT AND FINANCIAL EXPLOITATION
receiving substantial “gifts” from the older
adult. Sometimes, the “friendship” is couched in
romantic terms, which perhaps fills a void in the
older adult’s life. Oftentimes, older adults refuse
to believe that they have been a victim of the
scam and, if they do believe it, are too ashamed
to admit that they were victimized.
3. Role of Banks
Financial exploitation can be devastating to an
older adult, and bank tellers are an evolving first
line of defense. Often, financial exploitation can
be hard to detect because the person exploiting the
older adult has been trusted with the older adult’s
money, but a bank may be able to notice sudden
changes in accounts and other suspicious activity.
To address financial exploitation, Massachusetts
has implemented a program, the Massachusetts
Bank Reporting Project: An Edge Against Elder
Financial Exploitation, that provides training to
bank personnel in how to identify and report
financial exploitation.
6
e project has been
successfully replicated in numerous communities.
If you would like more information on the
Bank Reporting Project, call (617) 523-7595
or visit www.massbankers.org/MBRD/MB_
TechnologyFraud/Bank_Reporting_Project.
7
4. Power of Attorney
A power of attorney (see Chapter 1) gives another
individual the power to make decisions about the
older adult’s property. In order for the power of
attorney document to be valid, the older adult
granting the power must be mentally competent
at the time of execution and execute it knowingly
and voluntarily, without fraud, coercion or undue
influence. Such powerful instruments can easily
be misused to exploit older adults. erefore,
the grant of power to an attorney-in-fact should
be carefully and thoughtfully considered and
drafted, and the actions of the attorney-in-fact
should be monitored.
C. I Am Worried About Older Adults Who
Cannot Care for Themselves. Is Help
Available?
Elder abuse encompasses “self-neglect,” meaning
when older adults can no longer provide for their
own essential life needs, cannot make informed
decisions understanding the consequences of their
actions, and/or their mental and physical condition
declines without it being addressed.
8
One of the rea-
sons that the law includes this self-neglect is so that
these individuals can receive services from Protec-
tive Services. Protective Services must always use
the least restrictive measures to alleviate the neglect,
and try to keep a self-neglecting older adult in the
community safely.
9
Even in cases of self-neglect, an
older adult who has capacity has the right to refuse
services. If the older adult lacks decisional capac-
ity, or there is reasonable cause to believe the older
adult lacks decisional capacity, the court may be pe-
titioned for a protective order under M.G.L. ch. 19A
and/or for guardianship and/or conservatorship.
D. What Should I Know About Abuse in a
Nursing Home?
Abuse in a long-term care facility is separately
defined as, “ ... the willful infliction of injury, unrea-
sonable confinement, intimidation, including verbal
or mental abuse or punishment with resulting physi-
cal harm, pain or mental anguish or assault and bat-
tery … ”
10
Regulations require that reports of abuse
be made to the Department of Public Health rather
than Protective Services.
11
Note: Protective Services
are discussed later in this chapter, and the rights of a
nursing home resident are fully discussed in Chapter 7.
E. Who Can Report Elder Physical or
Emotional Abuse, Neglect or Financial
Exploitation?
Elder abuse should be reported when the re-
porter has reasonable cause to believe that abuse
has occurred or is about to occur. Every day of the
year, the Massachusetts Elder Abuse Hotline can be
reached at (800) 922-2275 or online at www.mass.
gov/how-to/report-elder-abuse. Certain people, such
as doctors, nurses, police and elder outreach work-
ers, are considered to be mandated reporters, and are
required by law to report suspected elder abuse; all
other individuals, while not required to report elder
abuse, may and should do so if the older adult is at
risk of harm. Mandated reporters who have reason-
able cause to believe abuse has occurred but fail to
report may be subject to a $1,000 fine.
12
e identity
of the person who makes a report of elder abuse may
not be disclosed to anyone, except to the district at-
torney or in compliance with a court order.
ELDER ABUSE, NEGLECT AND FINANCIAL EXPLOITATION PAGE 89
F. Is There a Statewide Agency That Helps
Older Adult Victims?
Yes. e Executive Office of Elder Affairs, by law,
maintains 22 Protective Services agencies through-
out Massachusetts.
13
e role of Protective Services
is to investigate reports of abuse and, where appro-
priate, offer services, make referrals and connect
older adults to community resources. All reports
are received through a statewide centralized intake
system. Reports can be made by calling the Massa-
chusetts Elder Abuse Hotline at (800) 922-2275 or
online at www.mass.gov/how-to/report-elder-abuse.
G. What Happens When Abuse Is Reported?
If an allegation of abuse is made, then a case-
worker from Protective Services will investigate the
allegation. Due care is taken to balance the rights
of privacy and self-determination of the older adult
and the need to protect the older adult from harm.
If, as a result of the ensuing investigation, one or
more types of abuse are found, then the Protective
Services social worker will intervene to protect the
older adult’s safety. Often, this intervention means
that a care plan will be drafted with the older adult,
if they have capacity. e care plan may include
counseling, legal aid, home health care, transporta-
tion, housing aid or safety planning. If the abuse
is very serious, Protective Services will report it to
the prosecuting authority, which may elect to bring
criminal charges against the alleged abuser. In addi-
tion to criminal charges, in some cases, there may be
referrals to attorneys to take legal actions, including
civil lawsuits to address the wrongdoing and restore
the wrongfully removed property to the older adult.
It is important to note that elder abuse victims
who have capacity can choose whether or not to
take advantage of any of the services offered by Pro-
tective Services.
14
If the older adult lacks capacity,
and Protective Services believes the older adult is in
need of protection, Protective Services can petition
the court for the appointment of a guardian and/
or conservator, or for a protective order pursuant
to M.G.L. ch. 19A, Section 20.
15
In such petitions,
Protective Services must prove by a preponderance
of the evidence that the older adult is being abused,
is in need of services and lacks the capacity to con-
sent.
16
Protective Services may only seek a protective
order or the appointment of a guardian or conserva-
tor if that is the least restrictive and least intrusive
means available for protecting the older adult.
17
H. Will Older Adults Lose Their Rights Once
Protective Services Are Involved?
An older adult should not lose rights once Pro-
tective Services has been contacted because, as not-
ed previously, Protective Services can only provide
services if the older adult consents, or through a
protective order issued by the court, or if a guardian
or conservator consents on their behalf. Due to the
doctrine of self-determination, an older adult who
has capacity has the right to refuse services. In ad-
dition, the Department of Protective Services for an
elder services agency may not serve in a fiduciary
capacity for an abused older adult. is means that
Protective Services may not act as a conservator,
making financial or property decisions for an abused
older adult,
18
or as a guardian, making personal or
medical decisions for older adults.
19
If Protective
Services seeks a protective order or appointment of
a guardian and/or a conservator, the older adult has
numerous rights with regard to those proceedings,
including possibly the right to counsel.
ere are cases in which it might be helpful for
the court to appoint a guardian ad litem (GAL) for
the older adult, either for the purpose of conducting
a neutral investigation and informing the court of
their recommendations, or, in the case of an older
adult who lacks capacity, for the purpose of repre-
senting the best interests of the older adult. In the
latter situation, the difference between the GAL and
an attorney appointed to represent the older adult is
that the attorney would be required to advocate for
whatever it is that the older adult wants, while the
GAL would be required to advocate for what they
believe is in the best interest of the incapacitated
older adult.
I. What Protections Are Available to LGBTQ
Older Adults?
Everyone has the absolute right to age with dig-
nity. In Massachusetts, discrimination based on
sexual orientation and gender identity is illegal.
Laws are in place to protect against discrimination
in medical care, housing and other services. Many
PAGE 90 ELDER ABUSE, NEGLECT AND FINANCIAL EXPLOITATION
people who provide elder services are required by
law to have special training to care for LGBTQ old-
er adults. Furthermore, long-term residential care
providers must intervene to stop discrimination and
harassment by staff or other residents. You should
report discrimination and harassment immediately.
Contact an attorney, call the GLAD Answers legal
hotline at (800) 455-GLAD or visit www.glad.org/
know-your-rights/resources-from-glad-answers.
1. Mass. G.L. ch. 19A, § 14 (2012). A caretaker is defined as “a person responsible
for the care of an elderly person, which responsibility may arise as the result of a
family relationship, or by a voluntary or contractual duty undertaken on behalf of
an elderly person, or may arise by a fiduciary duty imposed by law.” Id.
2. Id. A conservator is a person who is appointed to manage the estate of a person
pursuant to Mass. G.L. ch. 190B, § 5-409 (2013).
3. Id. A guardian is a person who has qualified as a guardian of an older adult
pursuant to Mass. G.L. ch. 190B, § 5-305 (2013).
4. § 14.
5. Id.
6. Office of Attorney General, www.mass.gov/service-details/the-massachusetts-
bank-reporting-project.
7. Id.
8. Mass. G.L. ch. 19A, § 14 (2012).
9. 651 C.M.R. § 5.02.
10. Mass. G.L. ch. 111, § 72F (2012).
11. Id. § 72G.
12. Mass. G.L. ch. 19A, § 15(A) (2012).
13. Executive Office of Elder Affairs, www.mass.gov/report-elder-abuse.
14. Id.
15. Id.
16. 651 C.M.R. § 5.17.
17. Id.
18. 651 C.M.R. § 5.02.
19. Id.
SPECIAL CONSIDERATIONS FOR DISABLED DEPENDENT ADULT CHILDREN PAGE 91
CHAPTER 12
SPECIAL CONSIDERATIONS FOR DISABLED
DEPENDENT ADULT CHILDREN
INTRODUCTION
Families with disabled dependents face special
considerations. e disability community is the
only minority group that anyone can unexpect-
edly join at any time. In recent years, e Arc of
the United States identified the issue of aging fam-
ily caregivers as an important concern for disabled
dependents. Families need to plan carefully for the
eventual transition to the next generation of caregiv-
ers. is topic is a complex web of long-term services
and supports to navigate, further compounded in its
difficulty by the impact of dealing with the caregiv-
er’s own health care and long-term care needs. Early
planning is essential for success and it involves more
factors than can be addressed in this brief chapter,
such as: housing, public benefits, caregiver choices,
guardianship and legal authority, advocacy, trustees
and more.
A. Government Benefits: SSI, SSDI and
MassHealth
1. Supplemental Security Income (SSI)
Supplemental Security Income (SSI) is a means-
tested benefits program that pays monthly ben-
efits to low-income older adults (ages 65 or older),
disabled adults, and disabled or blind children.
Disability for adults is defined as the inability to
work (“to engage in substantial gainful activity”
in Social Security terms) due to medical condi-
tions that are expected to last at least one year or
result in death. e program bases financial eligi-
bility on income and assets. In order to be eligible
for the benefit, an individual cannot have more
than $2,000 in countable resources.
SSI benefits are funded by the federal govern-
ment and provide monthly cash assistance. Some
states, including Massachusetts, supplement the
amount of the SSI stipend with additional funds.
Although the living situation of the SSI recipi-
ent initially determines the amount the recipient
will receive from SSI, other factors, principally
what other income, earned or unearned, the re-
cipient receives, can reduce the monthly payment.
Generally, the more income an individual has, the
lower the SSI monthly payment. It is important
to note that the SSI rules greatly favor income
from work (“earned income”), and the reduction
to the SSI benefit from earned income is lower
than from other income.
An individual eligible for SSI in most states,
including Massachusetts, will be automatical-
ly eligible for Medicaid benefits (MassHealth
in Massachusetts) not including nursing home
Medicaid and certain MassHealth Home- and
Community-Based Waiver Services.
If an individual receiving SSI or Medicaid ben-
efits inherits a large sum of money directly rather
than in a properly drafted trust, then that person
may be disqualified from the program.
2. Social Security Disability Insurance (SSDI)
Social Security Disability Insurance (SSDI) is
an earned benefit available to individuals over the
age of 18 who are unable to work because of a
medical condition that is expected to last at least
one year or result in death. is definition is the
same disability standard as in the SSI program
described on this page. e benefit is based on
the person’s work record and how much they have
contributed to Social Security rather than on as-
sets or income. SSDI benefits are administered
by the Social Security Administration, and the
program is largely funded by a participant’s pay-
ments into Social Security during their working
years. Since SSDI benefits are based on an indi-
vidual’s work record and not on their assets, an
inheritance will not disqualify a recipient from
receiving benefits.
SSDI also provides cash benefits for eligible
family members. For example, a disabled adult
child may also be eligible for SSDI on a parent’s
record if the disability began before the age of
22 and has been continuous, and if the parent is
PAGE 92 SPECIAL CONSIDERATIONS FOR DISABLED DEPENDANT ADULT CHILDREN
drawing their own Social Security benefits, or is
deceased, and paid into the Social Security sys-
tem. ese benefits are sometimes referred to as
Disabled Adult Child (DAC) benefits. A child
may also start receiving a monthly private pen-
sion or other income upon a parent’s death.
One of the consequences of SSDI or other
non-working income, however, may be the loss of
MassHealth benefits or the need to pay a premi-
um for those benefits. (Note that income for pub-
lic benefits programs differs from taxable income,
and what is considered income varies from pro-
gram to program. Additionally, income limits for
MassHealth Standard are lower than the income
limits for MassHealth Home- and Community-
Based Waiver Services.) If a disabled adult child
receives a higher SSDI payment than the monthly
SSI payment, then the adult child will be ineligi-
ble for SSI payments and may lose their automatic
eligibility for MassHealth.
is loss of SSI may require a separate
MassHealth application and special planning for
continued MassHealth eligibility. Many times,
this problem can be fixed by seeking a court order
to assign pension payments or other income to a
d4A trust (discussed on this page); however, some
pensions and Social Security payments are non-
assignable. Fortunately, there is a MassHealth
regulation in place that protects individuals
whose DAC benefits cause them to be over the
income limits for MassHealth Standard. An older
adult with a dependent adult child who receives
SSI benefits must be mindful of the eligibility re-
quirements and should
3. Differences Between SSI and SSDI
ere are many significant differences between
the SSI and SSDI programs. Among them are: a)
how work income is treated, b) how distributions
from trusts are treated, and c) the impact of sup-
ported housing. ese differences go beyond the
scope of this chapter. Suffice it to say that one
needs to have a thorough knowledge of these pro-
grams and their differences.
B. Special Needs Trusts
A special needs trust (or supplemental needs
trust) is a planning technique an attorney can uti-
lize as part of an estate plan to offer a family flex-
ibility and control over assets as well as protection
for the dependent child’s government benefits. e
assets held in a properly drafted special needs trust
are for the dependent child and are generally used to
supplement the dependent child’s needs that are not
paid for with government benefits. A trustee uses
their discretion to manage and distribute assets on
behalf of the child.
1. Types of Special Needs Trusts
ere are two basic types of special needs
trusts: third-party settled trusts and first-party
self-settled trusts.
ird-party settled trusts are created and fund-
ed by a third party. For example, a parent or other
individual can establish a special needs trust and
direct assets to the trust established for the benefit
of a dependent child. e assets did not originate
from the beneficiary. ese types of trusts can be
established at death by an individual’s will (testa-
mentary trusts) or during an individual’s life by a
separate trust. e provisions of the special needs
trusts can include the ultimate disposition of the
assets once the beneficiary child passes away (e.g.,
the remaining assets can go to other family mem-
bers).
First-party or self-settled trusts hold the assets
of the beneficiary. If properly established, the as-
sets in a self-settled trust do not disqualify the
beneficiary from SSI or Medicaid benefits. For
example, if the beneficiary is injured and receives
a settlement or award, those proceeds can be de-
posited into the special needs trust and not be
considered a countable resource. In order to be
properly established, this special needs trust must:
1) be established by the disabled individual, a par-
ent, grandparent, legal guardian or the court; 2)
be funded prior to the disabled beneficiary attain-
ing age 65; and 3) provide a payback provision
that states the Commonwealth of Massachusetts
and other states will receive payment to the extent
the beneficiary received Medicaid benefits during
the beneficiary’s entire lifetime (not just since the
funding of the trust) upon the beneficiary’s death.
ese types of trusts are usually referred to as
“d4A trusts” in reference to their statutory title.
In addition to d4A trusts, d4C trusts are an-
other type of self-settled trust. d4C trusts are
pooled trusts that have all the same requirements
SPECIAL CONSIDERATIONS FOR DISABLED DEPENDENT ADULT CHILDREN PAGE 93
as d4A trusts, but differ in that they are adminis-
tered by a nonprofit organization and not an indi-
vidual trustee. Having a nonprofit administer the
d4C trust makes it possible for the pooled trust to
take smaller trust deposits while being economi-
cal with fees. It also allows for individuals who
cannot identify an appropriate trustee to manage
their funds. Currently, pooled trusts are avail-
able to persons of any age. However, MassHealth
proposed regulations in 2016 that would penal-
ize funding these trusts for individuals over age
64. ese regulations are still pending. erefore,
individuals should consult with knowledgeable
elder law attorneys before considering this option.
ese trusts must be reported to both Social
Security and MassHealth when created or upon
application for certain benefits by the disabled
individual. (Note that Social Security recently
stopped requiring reporting of unfunded third-
party trusts.) Both agencies will review how the
trusts were established, the trusts’ terms, and how
the trusts are administered to determine whether
the trust assets are countable or whether a transfer
penalty period will apply.
2. Special Needs Trusts and Long-Term Care
Planning
Special needs trusts can also be used during
the legal spend-down process for an individual to
qualify for long-term MassHealth benefits. e
transfer of assets to a special needs trust estab-
lished for the sole benefit of a totally and perma-
nently disabled person under the age of 65 is not
a disqualifying transfer for an older adult seeking
MassHealth long-term care benefits. Under the
terms of the trust, the trustee must use the funds
in a manner that is actuarially sound based upon
the beneficiary’s life expectancy, or the trust must
contain the same pay-back provision as a self-set-
tled trust (as discussed in Section 1).
3. Third-Party Special Needs Trusts as
Beneficiaries of Retirement Plans
When individuals attain a certain age, they are
required to withdraw mandatory required mini-
mum distributions (RMDs) from their retirement
accounts. Individuals may designate certain ben-
eficiaries to inherit the balance of their accounts
after their death. e SECURE Act, signed into
law on Dec. 20, 2019, created a number of chang-
es for retirees (e.g., delaying the age to begin to
take RMDs from 70.5 years to 72) and beneficia-
ries (e.g., limiting the amount of time over which
a beneficiary may withdraw from the inherited
account).
e SECURE Act, however, provides an excep-
tion for certain beneficiaries, including disabled
or chronically ill beneficiaries. In these situations,
a disabled or chronically ill beneficiary (or special
needs trust for their benefit) may qualify as an
eligible designated beneficiary and benefit from a
prolonged distribution over the life expectancy of
the beneficiary.
Special needs trust and account beneficiary
designations should be carefully drafted by quali-
fied estate and tax planning professionals to en-
sure that the special needs trust is an eligible des-
ignated beneficiary. Moreover, the special needs
trust should only permit the beneficiary who is
disabled or chronically ill during their lifetime to
receive distributions so that the trust will qualify
to use the life expectancy of that individual for
RMDs.
e Secure 2.0 Act was enacted on Dec. 29,
2022, and provided greater clarity for special
needs trusts to be eligible designated beneficiaries
and to benefit from the prolonged lifetime distri-
bution periods.
4. ABLE Accounts
ABLE Accounts can be a useful addition to
special needs planning. ese accounts are owned
by the disabled person and can be managed by
the disabled person or someone else on their be-
half. Contributions to the account from all sourc-
es per year cannot exceed $17,000 in 2023, except
that some working disabled persons may be able
to contribute more. Additionally, ABLE Account
balances over $100,000 count toward the $2,000
asset limit for SSI. Similar to a d4A trust, there is
a Medicaid payback at the death of the account
owner. Final regulations were issued in October
2020. e uses, restrictions, and differences be-
tween ABLE Accounts and d4A trusts are com-
plex and beyond the scope of this brief chapter.
For more information, you should consult with
PAGE 94 WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY
C H A P T E R 1 3
WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY
INTRODUCTION
It is important for workers and their families
to understand how Social Security benefits fit into
the overall plan for financing retirement years. e
Social Security Administration (SSA) generally pro-
vides workers and their spouses certain basic retire-
ment benefits, payable monthly for life. A worker’s
retirement benefit at full retirement age is based on
their average indexed wages over a work history of
up to 35 years. Spousal benefits are calculated based
on the worker’s Social Security benefits. e follow-
ing is an overview of the basic Social Security retire-
ment program.
A. Timing Retirement
e chart below outlines when workers reach
full retirement age under Social Security.
Year of Birth Full Retirement Age
1943–1954 66
1955 66 + 2 months
1956 66 + 4 months
1957 66 + 6 months
1958 66 + 8 months
1959 66 + 10 months
1960 and later 67
*If you were born on Jan. 1 of any year, you should
refer to the previous year. If you were born on the
first of the month, your full retirement age will be
determined as of the immediate previous month.
1
Individuals do not have to wait until their full
Social Security retirement age before they can be-
gin taking benefits. Instead, an individual may elect
to begin taking Social Security benefits as early as
age 62, but the monthly amount will be reduced
to reflect the longer period over an individual’s life-
time during which payments will be made. Alterna-
tively, an individual can delay receiving retirement
benefits until after reaching the Social Security re-
tirement age, up to age 70. By delaying the start of
payments, each monthly amount will be increased
above the monthly amount otherwise due at early or
full retirement age to account for the shorter period
of an individual’s lifetime during which monthly
payments will be made. Delaying Social Security
payments past age 70 will not further increase the
monthly Social Security payment.
Social Security benefits are eligible for cost-of-
living (COLA) adjustments.
2
e COLA adjust-
ment for 2023 is an 8.7% increase from the previous
year.
• Early Retirement: An individual may begin col-
lecting Social Security benefits before full retire-
ment age, and as early as age 62, but the monthly
payments are reduced to account for the longer
period of one’s life that benefits will be paid. If an
individual’s health status is precarious, choosing
early retirement benefits may be prudent if one
is not expected to live to one’s life expectancy.
3
If an individual continues working past age 62,
the amount of Social Security payments may be
reduced further to account for that work (see D,
How Working Affects Benefits).
• Full Retirement: Once an individual reaches full
retirement age (see chart on this page), they may
elect to begin receiving the primary insurance
amount based on their highest average indexed
earnings during a work history of up to 35 years.
Working past full retirement age at lower wages
will not result in a reduction of Social Security
payments (see D, How Working Affects Benefits).
• Delayed Retirement: Between full retirement
age and age 70, monthly payment amounts will
be increased to reflect the shorter period over
which they will be paid. Benefit payments de-
layed to age 70 will not be reduced if the individ-
ual continues working past age 70 at lower pay.
Helpful Tip: Individuals are advised to contact the
SSA for a personal calculation and not to rely on the
general calculators. Merely requesting the informa-
tion does not trigger the benefit.
WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY PAGE 95
B. Factors Affecting the Calculations
Average earnings over a work history of up to
35 years based on Social Security records for Fed-
eral Insurance Contributions Act (FICA) and Self-
Employment Contributions Act (SECA) taxes paid
by the individual are used to calculate the amount
of the retirement benefit.
4
at amount is called the
primary insurance amount (PIA), and it is used as
the basis for any retirement, dependents’ or survi-
vors’ benefits paid on that person’s record. e calcu-
lation also pays a higher percentage benefit amount
for replacement of pre-retirement earnings to indi-
viduals with lower lifetime earnings.
5
Working past
retirement age, whether or not an individual’s Social
Security payments have begun, can increase the 35-
year average if those wages are significantly higher.
Stopping working early may limit the 35-year av-
erage to a lower amount if one would have earned
substantially higher wages after reaching the earliest
retirement age at 62.
One hundred percent of benefits are paid if re-
tiring at full retirement age in 2023, which is age
66 and six months. is is the age at which ben-
efits will not be reduced due to “early retirement.”
After the worker’s primary insurance amount at
full retirement age is determined, it is adjusted to
reflect when an individual’s payments actually be-
gin before or after full retirement age. For example,
if an individual elects to begin retirement benefits
in 2023 at age 62, the monthly amount will be re-
duced by 30% compared to what would have been
paid if the individual had started receiving benefits
at full retirement age.
6
If the individual waits until
age 70 before starting benefits, the benefits will be
increased by 8% for each full year of delay. For ex-
ample, if an individual reaches full retirement age at
66 and six months in 2023, but waits until age 70 or
later to begin payments, then the monthly amount
will be about 25% higher than what the individual
would have received at full retirement age.
7
An individual who begins receiving monthly
Social Security payments at age 62 receives a higher
lifetime benefit total than an individual who begins
payments at age 70 only until a crossover point at
about age 78. After the crossover point, the person
who delays payments to age 70 will collect more
lifetime benefits than the person who begins Social
Security payments at age 62. However, the cross-
over point also depends on an individual’s particu-
lar situation, including working status, taxes and
rate of inflation. Many advisers suggest that the best
guide is to wait until benefits are necessary to sus-
tain the individual’s, dependents’ and survivors’ life-
time needs rather than base the decision solely on
expected total lifetime benefits by starting benefits
at a particular age.
e calculation for early or late retirement ben-
efits can be confusing, but the SSA has a nifty cal-
culator on its website, www.ssa.gov/oact/quickcalc/
early_late.html.
C. Taxes and Other Factors to Consider
A portion of Social Security benefits is taxable
if a recipient’s income is over certain thresholds. If
an individual’s combined income (adjusted gross
income, nontaxable interest and half of their So-
cial Security benefits) falls between $25,000 and
$34,000 (or $32,000 and $44,000 if filing jointly),
then half of the Social Security benefits are subject
to income tax. If an individual’s combined income
is above $34,000 (or $44,000 if filing jointly), then
85% of their Social Security benefits are subject to
income tax.
8
Some financial planners recommend that indi-
viduals begin Social Security payments at age 62 if
they believe that they can invest those payments and
receive a higher rate of return than what would oth-
erwise accrue by delaying payments. is strategy
assumes that the individual does not need the So-
cial Security payments, and that future investment
returns, net of investment fees and income taxes, are
greater than the increased monthly payments of de-
laying Social Security payments. For each year that
Social Security is delayed after full retirement age
to age 70, there is an 8% increase in the amount of
benefits paid.
If an individual has limited savings and other
retirement benefits, then beginning Social Security
payments early may be financially necessary.
If an individual is in poor or precarious health,
then beginning payments early will result in that
individual’s greater overall receipt of benefits if they
do not live to an average life expectancy.
D. How Working Affects Benefits
Social Security monthly payments begun before
full retirement age can be reduced if an individual
PAGE 96 WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY
is continuing to work. For every $2 earned above
the annual limit, the individual’s early Social Se-
curity payments will be reduced by $1. For 2023,
the annual limit is $21,240 ($1,770 per month).
9
In
the year in which an individual attains full retire-
ment age, Social Security will deduct $1 for every $3
earned above a separate limit until the month before
the month in which full retirement age is reached.
For 2023, that annual limit is $56,520 ($4,710 per
month).
10
Working past full retirement age will not result
in a reduction of the monthly amount otherwise
payable. An individual working past full retirement
age may be able to increase their Social Security ben-
efit if the wages paid increase the individual’s prior
career average upon which benefits were otherwise
calculated. See B, Factors Affecting the Calculations.
E. How Disability Affects Benefits
e Social Security Disability Insurance (SSDI)
benefit, which arises due to a medical condition, is
the same as the full retirement benefit. Once the dis-
abled worker reaches full retirement age, the benefit
switches to a retirement benefit instead of a disabil-
ity benefit. SSDI recipients who are still able and
willing to work can earn up to $1,470 per month
(2023) without being found to be not disabled and
losing the benefit, but in practice, this amount is
more of a guide rather than a set limit. Benefits are
not reduced by earnings, but if the recipient works,
the continuing disability analysis by the SSA is
made on total work capacity and verifiable medical
condition rather than actual earnings exceeding this
limit. e SSA offers support and incentives for dis-
abled workers to return to the workforce in the form
of “trial periods,” job training for new careers, and
continuation of benefits for an extended period of
time. Check out Ticket to Work programs on the
SSA website, www.ssa.gov/work, to learn how the
SSA is supporting the disabled worker.
Disabled workers (and certain family members
eligible for SSDI on the record of a worker) who
have been approved for SSDI benefits are eligible to
apply for Medicare benefits after 24 months of pay-
ments, even if they have not reached age 65. ere
are exceptions for waivers of the waiting period for
certain catastrophic illnesses. Please refer to Chapter
5 for an excellent review of the Medicare program.
F. Family Benefits
Spouse. Social Security benefits provide some
protection to a worker’s family. For example, a
spouse with a limited or no work history is entitled
to receive Social Security retirement benefits based
on the working spouse’s record. If the spouse be-
gins receiving the spousal benefit at full retirement
age, the maximum amount of that benefit is half
the amount that the working spouse receives at full
retirement age. If the spousal benefit begins when
the spouse is between age 62 and full retirement
age, however, it will be reduced to reflect the longer
period of payment. If the spouse is working when
receiving the benefit, the spouse’s Social Security
benefits may be reduced. (See D, How Working Af-
fects Benefits.) e spousal benefit is not increased
for delayed payment of Social Security benefits that
the working spouse receives after full retirement age.
If a spouse has worked, they would generally receive
an amount equal to the higher of their own Social
Security benefit or the spousal benefit. A spousal
benefit does not reduce the working spouse’s Social
Security payment. If the working spouse’s birthday
is Jan. 2, 1954, or later, it is no longer possible to
take only one spouse’s benefit at full retirement age
and delay the other. Rather, if the working spouse
files for a benefit, it is automatically treated as filing
for the spousal benefit at the same time.
11
Divorced Spouse. A divorced spouse of a mar-
riage that lasted at least 10 years can collect a spousal
benefit based on the other spouse’s work history if
that benefit is higher than what the divorced spouse
could collect based on their own work history. To
collect the spousal benefit, the divorced person must
be at least age 62 and unmarried, and the working
ex-spouse must be entitled to Social Security ben-
efits. If the working spouse qualifies for, but has
not applied for, Social Security benefits, the spouses
must have been divorced at least two years before
the other spouse qualifies for the divorced spouse
benefit. e maximum spousal benefit for a di-
vorced person is equal to half of the former spouse’s
Social Security retirement benefit at full retirement
age, and can be subject to reduction if the divorced
spouse is working. See D, How Working Affects Ben-
efits.
12
WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY PAGE 97
Children. e children or dependent grandchil-
dren of a worker who qualifies for Social Security
retirement benefits may also qualify for Social Secu-
rity benefits based on the worker’s record. To receive
benefits, the child must be unmarried and:
• under age 18; or
• 18–19 years old and a full-time student (no
higher than grade 12); or
• 18 or older and disabled since before age 22.
Normally, benefits stop when a child reaches age
18 unless the child is disabled. If a child is still a full-
time student at a secondary (or elementary) school
at age 18, however, benefits will continue until the
child graduates or until two months after the child
becomes age 19, whichever is first.
13
Adult Disabled Child. e adult disabled child
of an individual collecting Social Security retire-
ment benefits is eligible for Social Security benefits
based on the worker’s (or retiree’s) work history.
If the child is working when receiving the ben-
efit, their Social Security benefits may be reduced.
See D, How Working Affects Benefits.
Widow or Widower. e widow or widower
of a worker may receive a survivor benefit based on
the worker’s earnings history. e survivor benefit
can begin as early as age 60, at a reduced rate, or
when the widow or widower reaches full retirement
age or older, at a higher monthly amount. e re-
duction for taking benefits early is 19/40 of 1% for
each month under full retirement age. For example,
if a widow or widower begins receiving a survivor
benefit at age 60, that benefit will equal 71.5% of
the deceased spouse’s primary insurance amount at
full retirement age. If a widow or widower qualifies
for higher retirement benefits on their own record,
they can switch to that benefit as early as age 62.
If a widow or widower is disabled before the death
of the worker, or within seven years thereafter, they
can begin receiving survivor benefits as early as age
50. Remarriage of the surviving spouse does not re-
duce or eliminate the survivor benefit.
14
Dependent Parent. If a worker who was sup-
porting a parent dies, the dependent parent, who
is at least age 62, may be eligible to receive Social
Security survivor benefits. To be eligible, the de-
pendent parent must be unmarried, and must have
been receiving at least half of their support from
the working child. e dependent parent must not
have a work history of their own that would yield a
higher benefit.
15
Family Cap. Total family benefits payable under
a worker’s record are capped. e total cap varies but
is equal to about 150% to 180% of what the worker
would otherwise receive at full retirement age.
16
G. Contacting Social Security and
Representation by a Third Party
An appointment can be made to speak with a
representative at a local Social Security office, but
many persons now apply for benefits through the
Social Security website, www.SSA.gov. Known as
“my Social Security,” this online tool allows the
participant to check their earnings record, apply for
benefits, and estimate future earnings and benefits
to help make decisions about when to retire. e in-
dividual is also able to add or change direct deposit
instructions, obtain benefit verification letters, and
notify Social Security of any changes.
Other than the eligible individual or the par-
ent of a minor child making the contact, the SSA
will not provide information to or take instructions
from a third party. e SSA will not recognize the
authority of a person under a power of attorney or
a court-appointed guardian or conservator without
the person being appointed as the individual’s rep-
resentative payee or being appointed a representa-
tive by completion of the proper SSA form signed
by the individual. A representative can be appointed
on Form SSA 1696, Claimant’s Appointment of a
Representative, which allows the representative to
take any actions on behalf of the individual that the
individual could take themselves. A representative
payee can be appointed by filing Form SSA-11, Re-
quest to Be Selected as a Payee, which allows a third
party, typically a relative or care organization, to
receive and manage an individual’s Social Security
payment, but which also allows the payee to take ac-
tions on behalf of the individual with the SSA.
H. Coordinating Social Security with Private
Retirement Benefits
In budgeting for retirement years and deciding
when to begin taking Social Security payments, it
is important to consider other retirement benefits
besides Social Security. Many employees earn tax-
qualified retirement benefits through their work
PAGE 98 WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY
— for example, under 401(k), profit sharing or de-
fined benefit pension plans. An individual may also
own an individual retirement account (IRA), with
a balance sheltered from tax until distributed. e
payment of retirement benefits from these sources
should be considered in overall retirement planning.
Employees typically receive their retirement ben-
efits from private plans when they leave employment
or retire. By law, employers must generally begin
paying an employee’s qualified retirement benefits
in the calendar year in which the employee reaches
a certain age. Owners of IRAs who reach age 73
after Jan. 1, 2023, must begin taking a minimum
distribution at age 73 whether or not they are still
working (for individuals who reached age 72 before
Jan. 1, 2023, such age was formerly 72, and prior
to Jan. 1, 2020, such age was 70 ½). For employees
reaching age 73 in 2023, the first RMD must be
taken by April 1, 2024. For all subsequent years, the
RMD must be taken by Dec. 31 of that year. e
minimum distribution age will increase to age 75
in 2033. Failure to take RMDs in a timely manner
can subject an individual to a 25% penalty for the
amount not withdrawn.
RMDs from private retirement plans are gener-
ally spread over the life expectancy of the individual
(or the individual and a beneficiary) and are taxed
to the individual recipient at ordinary rates. Failing
to take RMDs in a timely manner can subject an
individual to excise tax.
Individuals who got married or divorced before
receiving retirement payments from an employer
should be particularly careful to verify that all bene-
ficiary designations for retirement benefits are prop-
erly updated. Employees who have been divorced
should also take into account any applicable quali-
fied domestic relations order (QDRO) requiring the
private plan to pay some portion of a worker’s re-
tirement benefits to an ex-spouse. Anyone who was
married to an individual who died before receiv-
ing retirement benefits from their employer should
contact that employer for information regarding
any death benefit that may be due to the surviving
spouse.
Financial and/or tax advisers can often help an
individual evaluate their retirement options, con-
sidering available Social Security benefits, private
retirement benefits and an individual’s needs to be
able to “afford to retire.”
I. Social Security Benefits and Government
Pensions
Social Security retirement, spousal, and widow’s
or widower’s benefits can be reduced if a worker
earned a pension from “noncovered” work that
was not subject to Social Security withholding
taxes (FICA). e Windfall Elimination Provision
(WEP) reduces the Social Security retirement bene-
fits that a worker might otherwise receive because of
noncovered work.
17
e Government Pension Off-
set (GPO) reduces the Social Security benefits of a
spouse, widow or widower who worked for a federal,
state or local government and earned a pension.
18
e WEP reduces Social Security retirement
benefits of workers with fewer than 30 years of earn-
ings at jobs subject to FICA. e reduction cannot
exceed 50% of the amount of the pension received
from public sector employment.
19
If the worker paid
FICA at jobs for more than 20, but fewer than 30,
years of work, the reduction will gradually be elimi-
nated. To calculate WEP reductions, please see the
WEP Online Calculator or Detailed Calculator.
20
A
worker with 30 or more years of work where earn-
ings were “substantial” (See Social Security Substan-
tial Earnings Table at www.ssa.gov/planners/retire/
wep-chart.html)
21
and covered by FICA taxes is not
subject to WEP reductions.
Social Security spousal and widow’s or widower’s
benefits are reduced under the GPO by two-thirds
of the amount of the individual’s government pen-
sion. For example, if a government employee is enti-
tled to a government pension of $600 a month and a
Social Security spouse’s, widow’s or widower’s ben-
efit of $500 a month, the Social Security payment
($500) will be reduced by two-thirds of the govern-
mental pension ($400), and the spouse, widow or
widower will be entitled to $100 of Social Security
plus $600 of the government pension. If two-thirds
of the government pension is more than the indi-
vidual’s Social Security monthly amount, the Social
Security benefit is reduced to zero.
ere are some very narrow exceptions to the
offset. For example, if an individual’s government
pension is not based on earnings, the offset does not
apply.
WHAT YOU NEED TO KNOW ABOUT SOCIAL SECURITY PAGE 99
For more information on any of the material
presented in this chapter, please go to the Social Se-
curity website, www.ssa.gov, or call the SSA at (800)
772-1213 for specific information about your own
benefit calculation.
1. www.ssa.gov/planners/retire/retirechart.html.
2. https://www.ssa.gov/oact/cola/latestCOLA.html.
3. www.ssa.gov/oact/STATS/table4c6.html.
4. www.ssa.gov/oact/cola/Benefits.html.
5. www.ssa.gov/oact/cola/piaformula.html.
6. www.ssa.gov/oact/quickcalc/early_late.html. The reduction formula is 5/9 of 1%
for each month before normal retirement age, up to 36 months, and if the number
of months exceeds 36, then an additional reduction of 5/12 of 1% per month.
For example, if the number of reduction months is 60 (the maximum number for
retirement at 62 when normal retirement age is 67), then the benefit is reduced by
30%.
7. www.ssa.gov/planners/retire/1943-delay.html.
8. www.ssa.gov/planners/taxes.html. This tax requirement has applied since 1993.
9. www.ssa.gov/planners/retire/whileworking.html.
10. Id.
11. www.ssa.gov/planners/retire/applying6.html.
12. www.ssa.gov/planners/retire/divspouse.html.
13. www.ssa.gov/planners/retire/applying7.html.
14. www.ssa.gov/planners/survivors/onyourown.html#h1.
15. www.ssa.gov/planners/survivors/ifyou.html#h2.
16. www.ssa.gov/pubs/EN-05-10085.pdf.
17. www.ssa.gov/pubs/EN-05-10045.pdf.
18. www.ssa.gov/pubs/EN-05-10007.pdf.
19. www.ssa.gov/policy/docs/ssb/v74n3/v74n3p55.html.
20. www.ssa.gov/planners/retire/wep-chart.html.
21. www.ssa.gov/planners/retire/wep-chart.html.
PAGE 100 OLDER ADULT DRIVING
CHAPTER 14
OLDER ADULT DRIVING
INTRODUCTION
As the older adult population of the United
States continues to grow, and the average life ex-
pectancy increases, more individuals are continuing
to drive later in life than ever before. Older drivers,
their family members, practitioners, and society as
a whole have an interest in both assessing an old-
er adult’s ability to continue to safely drive and in
the transportation alternatives that may be utilized
when a driver must eventually hang up the keys.
ere is no set age at which one loses the ability
to drive safely. Rather, physical and cognitive im-
pairments, which often accompany the aging pro-
cess, will gradually begin to diminish and affect an
older adult’s ability to drive. erefore, older adults,
families, physicians, police officers and lawmakers
are growing increasingly aware of the indications
that it may no longer be safe for an older adult to
drive, in an effort to minimize the risks to the older
driver, other drivers, passengers and pedestrians.
THE AGING PROCESS
e aging process is generally accompanied by
physical and cognitive impairments, both of which
may require medication. Drowsiness, dizziness,
fatigue and blurred vision may result from taking
medications, and such symptoms may make safe
driving increasingly difficult.
1
Drivers who take
medications should be aware of the side effects of
each medication and how exactly those side effects
may impact driving abilities.
2
Among the various
physical limitations that challenge safe driving are
diminished vision, slower reflexes and arthritis.
Cognitive impairment, such as memory loss or de-
mentia, may also greatly challenge an older adult’s
ability to safely drive. While those with mild symp-
toms of dementia may be able to safely drive with
limitations, eventually, as dementia-related symp-
toms progress, the older adult will no longer be able
to adequately evaluate their own driving.
3
Safe driving habits should be implemented by
older adults who are able to, and who choose to,
continue driving as they age. ey may take proac-
tive measures to ensure their own safety and that
of others by maintaining good health, enrolling in
driver safety classes tailored to older adults, and ad-
justing driving patterns to avoid driving when traffic
is heavy or when visibility is limited. However, some
older drivers may have difficulty recognizing when
they have reached the point that they are no longer
able to drive safely. For others, they may realize the
time has come to hang up the keys, but may resist,
as their ability to drive provides continued indepen-
dence.
It is crucial that family members and physicians
support older drivers in hanging up the keys when it
becomes necessary by engaging in candid conversa-
tions. Family members may struggle to determine
when it becomes necessary to have this conversa-
tion. A pattern of clear and open dialogue must be
established with the older driver in order to rein-
force driving safety issues. While this conversation
should be ongoing, family members should also be
observing the older adult’s ability to drive regularly
by riding in the car with the older adult and observ-
ing the older adult’s vehicle. Close calls while driv-
ing, getting lost and damage to the older adult’s car
are strong indicators that the older adult’s driving
abilities are diminishing. Family members do have
the option to have the older adult’s driving clinically
evaluated at several area hospitals or by an occupa-
tional therapist.
is conversation must be structured so that
the older adult feels listened to and respected, and
is aware of the transportation alternatives that are
available. Careful attention should be given to de-
termine who should initiate the conversation. It may
be best to have one person conduct a private conver-
sation so that the older adult does not feel ganged-
up on. Other interested parties should then form a
united front about the decisions reached during the
conversation and help the older adult to make safe
decisions.
4
It is important to determine who might
be the best person to communicate with the indi-
vidual about driving concerns.
5
e conversation
may be best received from a spouse, family member,
OLDER ADULT DRIVING PAGE 101
friend or trusted professional.
6
In planning such con-
versations with older adults, family members should
take into consideration the driver’s personality, level
of cognitive impairment, driving record, family re-
lationships, available resources and the geographic
proximity of those resources.
7
Unfortunately, in
some cases, the older adult’s diminished insight,
judgment and mood, as well as personality changes,
may render the older adult unable to meaningfully
participate in a conversation about driving. In these
circumstances, with evidence of serious risk to self
or others by continued driving, family members
may need to take steps to remove the older adult’s
access to keys and the vehicle. See www.alz.org/help-
support/caregiving/safety/dementia-driving.
Even if an older adult does readily agree that it
is no longer safe for them to drive, family members
must still be sensitive to the notion that relinquish-
ing one’s driving privileges may be both overwhelm-
ing and depressing for the older adult.
8
Nearly one
in four older drivers reported experiencing depres-
sion as a result of this conversation.
9
is is to be
expected, as surrendering driving privileges often
results in fewer trips outside of the home, increased
isolation, often permanent dependency on others for
transportation and other basic needs, and fewer so-
cial opportunities.
10
MASS. REGISTRY OF MOTOR VEHICLES
Although the Massachusetts Registry of Motor
Vehicles (RMV) does not require drivers to renew
their licenses more frequently when they attain a
certain age, the RMV does require that drivers age
75 and older renew their driver’s licenses in person.
11
At the time of renewal, the licensee must either pass
a vision screening or present a completed vision-
screening certificate.
12
e Medical Affairs Branch
of the RMV has developed policies and procedures
that set minimum physical qualifications for all mo-
tor vehicle operators in Massachusetts, regardless
of age.
13
As such, drivers must meet the minimum
standards for vision, loss of consciousness and sei-
zure conditions, as well as cardiovascular and respi-
ratory conditions.
It is important to note that Massachusetts is a
self-reporting state, and thus, “… [a] person is legally
responsible for their actions behind the wheel. ere
are no mandatory reporting laws for physicians to
report persons who may be unsafe to the RMV … .
at means it is [the driver’s] responsibility to report
any medical condition that may affect [their] ability
to drive.”
14
However, though not required to report
a potentially unfit driver, physicians may choose to
report. When a report is received, the RMV will
conduct an individualized assessment, which may
include a road test, to determine whether the driver
is, in fact, qualified to safely operate a motor vehi-
cle.
15
RESOURCES
Resources are available to aid older adults and
interested parties in dealing with the issues and
challenges pertaining to older adult driving. Below
is a list of several resources:
• e Massachusetts RMV has dedicated a part of
its website to addressing the needs of, and provid-
ing resources concerning, older adult driving.
• Community senior centers are also typically a
great source of information.
• e U.S. Administration on Aging has developed
“Eldercare Locator,” a search tool that connects
older adults and their families with various ser-
vices, including transportation.
• e American Automobile Association, the
American Association of Retired Persons (AARP)
and the Alzheimer’s Association, on both the state
and national levels, are also helpful resources, as
they have published brochures and feature web-
sites that offer tips, guides and worksheets for ad-
dressing older adult driving issues and challenges.
• e Alzheimer’s Association’s website includes
several helpful videos about different approaches
to engaging in a conversation about driving and
dementia, available at www.alz.org/help-support/
caregiving/safety/dementia-driving.
Its 24/7 Helpline also has experienced counselors
who can provide expert advice on how to address
the unique challenges each family may face. To
speak to a 24/7 Helpline counselor about your
individual situation, call 1-800-272-3900.
• AARP helps drivers stay safe, educated and con-
fident behind the wheel with the AARP Smart
Driver™ Course. ese courses are designed to
help drivers age 50-plus familiarize themselves
with the current rules of the road, defensive driv-
ing techniques, and how to operate vehicles more
PAGE 102 OLDER ADULT DRIVING
safely in today’s increasingly challenging driving
environment. For more information or to register
for classes, visit www.aarpdriversafety.org or call
1-888-AARP-NOW (1-888-227-7669).
All of these organizations have excellent resourc-
es that may be of help in addressing the sensitive
issue of when an older adult should no longer be
driving.
1. “Dangers of Driving After Taking Prescription Drugs or Over-the-Counter Medicines,”
National Highway Traffic Safety Administration, www.nhtsa.gov/drug-impaired-
driving/dangers-driving-after-taking-prescription-drugs-or-over-counter-medicines.
2. Id.
3. “We Need to Talk: Family Conversations with Older Drivers,” AARP, www.aarp.org/
auto/driver-safety/info-2016/when-to-stop-driving-in-older-age.html.
4. Id.
5. Id.
6. Id.
7. Id.
8. “We Need to Talk: Family Conversations with Older Drivers,” AARP, www.aarp.org/
auto/driver-safety/info-2016/when-to-stop-driving-in-older-age.html.
9. Id.
10. Id.
11. “Older Driver Overview,” Mass. Registry of Motor Vehicles, www.mass.gov/info-
details/older-drivers.
12. Id.
13. Id.
14. Id.
15. “Report a medically impaired driver,” Mass. Registry of Motor Vehicles,
www.mass.gov/how-to/report-a-medically-impaired-driver.
OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT PAGE 103
INTRODUCTION
A catastrophic medical event, unemployment, or
some other unforeseen event, such as the death of a
spouse, could result in the creation of debt that is
beyond an individual’s ability to repay. While the
prospect of bankruptcy is unthinkable to most, it
may be an appropriate solution in some circum-
stances. If you are experiencing the stress of your
own overwhelming debt, or confusion as to which
bills you are legally obligated to pay upon the death
of a spouse, it is important to seek professional
guidance to assess your individual situation and to
compare the pros and cons of bankruptcy and non-
bankruptcy options to determine what the best solu-
tion is for you. Also, you must consider whether you
are legally responsible to pay the debts of a spouse or
family member upon death, due to their failure to
make payment during their lifetime.
A. What Is Bankruptcy?
Bankrupt is a term that describes the legal status
of a person or other entity (such as a business) that
cannot repay some or all of their debts to creditors.
Bankruptcy is imposed by a court order, and is often
initiated by the debtor. e Merriam-Webster Dic-
tionary defines bankruptcy, in part, as the adminis-
tration of an insolvent debtor’s property by the court
for the benefit of creditors.
Depending on the type, or “chapter,” of bank-
ruptcy, debts are treated differently. ere are five
types of bankruptcy filings, but only four of them
are available to individuals:
• Chapter 7: Liquidation
• Chapter 11: Reorganization (or Rehabilitation
bankruptcy)
• Chapter 12: Adjustment of Debts of a Family
Farmer with Regular Annual Income
• Chapter 13: Adjustment of Debts of an Indi-
vidual with Regular Income
• Chapter 9: For municipalities (including cit-
ies, towns, townships and school districts) [not
available to individuals]
Here we will focus only on Chapters 7 and 13,
since these are the forms of bankruptcy that are typ-
ically appropriate for older adults.
Chapter 7 bankruptcy is often referred to as a
“straight” or “liquidation” bankruptcy. Chapter 7 is
typically considered when a debtor has no hope of
repaying debts. Under a Chapter 7 bankruptcy fil-
ing, some or all of the debtor’s non-exempt assets
are sold (liquidated) to pay the lenders (creditors).
It is a quick way for a debtor to get a fresh financial
start. Additionally, in many Chapter 7 cases, all of a
debtor’s assets are retained by the debtor.
Chapter 13 bankruptcy is a reorganization
bankruptcy designed for debtors with regular in-
come who can pay back at least a portion of debts
through a three- to five-year repayment plan. Chap-
ter 13 allows debtors to keep their property while
they are completing the repayment plan. Once the
payment plan is complete, unsecured creditors can-
not force the debtor to pay additional monies, and
the obligations owed to creditors will be discharged
and uncollectable.
Most people would prefer to voluntarily settle
their debts instead of filing bankruptcy. ere is a
perceived stigma attached to bankruptcy, so many
people avoid it for as long as they can.
Persons considering bankruptcy incorrectly be-
lieve that everyone will find out, but the reality is
that usually the only people who may learn that
you filed for bankruptcy are your creditors and the
people you tell.
Also, if you file bankruptcy, although that fact
stays on your credit report for seven to 10 years, you
can begin to improve your credit score immediately
after your bankruptcy petition is filed. ere is a
big difference between a bankruptcy notation on
your credit report and your credit score. If you be-
gin to pay your bills on time after your bankruptcy
is filed, you will begin to improve your credit score
immediately. Your credit score is the number lend-
ers and credit extenders, including banks, use when
deciding to loan you money. e point is, although
you may have a bankruptcy notation on your credit
CHAPTER 15
OVERVIEW OF COMMON BANKRUPTCY AND
DEBT ISSUES FOR THE OLDER ADULT
PAGE 104 OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT
report, if your credit score is within an acceptable
range for a lender by the time you seek credit, you
may be able to qualify for extensions of credit, in-
cluding car loans, and even mortgages.
B. Some General Considerations
1. Pros of Bankruptcy
Before we discuss the specifics of Chapter 7
and Chapter 13 bankruptcy, the following are
some general considerations to keep in mind as
you weigh your options.
• Stress Minimization: When creditors call you
nonstop, it can be very stressful and demeaning.
Bankruptcy stops all contact by creditors, includ-
ing phone calls, visits, bills and threatening let-
ters.
• Elimination of Medical Bills: Bankruptcy can
eliminate medical bills. Keep in mind, if you are
continuing to incur medical debt, the bankrupt-
cy will only discharge the bills you have incurred
as of the day your case is filed. (You will be re-
sponsible for all bills incurred after filing. So, if
you need ongoing medical care, you may want to
plan ahead to determine the best time to file for
bankruptcy.)
• Social Security Income is Protected: Social Se-
curity income is not considered in the means test,
which determines whether or not you are eligible
to file in Chapter 7. It is also excluded from con-
sideration in determining the amount that you
can afford to pay a creditor, such as credit card
debt, if you decide not to file bankruptcy. ere
are many other exemptions that may be claimed
in order to protect assets, which are immune from
the reach of creditors, whether or not bankruptcy
is filed. (See Section C-3 regarding exemptions.)
• e Credit Card Cycle is Stopped: A bankrupt-
cy discharge can free up funds in your monthly
budget so you can better provide for yourself and
your dependents. If you find yourself spending
most of your monthly income on credit card
minimums, and then relying on those same credit
cards to afford food and other necessities, bank-
ruptcy may be appropriate. Bankruptcy can stop
the credit card cycle and give you a fresh financial
start.
2. Protected Assets
In bankruptcy proceedings, many assets can
be protected, which means that you will be able
to keep those protected assets and avoid having
them sold by court order to pay all or some of
your creditors.
If your life insurance policy has accrued cash
value, there may be a limit to the amount that
can be fully protected from your creditors. Term
life insurance policies with no cash value present
are fully protected and generally may be retained
by you. In most cases, the value of your pension,
401(k) or other retirement plan can be fully
protected in a bankruptcy case.
3. Secured Creditors
(i) House and Vehicles
If you have a loan on your house or car and
your loan balance is greater than the value of your
house or car, you can keep those assets as long as
you continue to pay for them.
If that is the case, then your house and car
are “upside-down,” which means that if you sold
them, there would be no money left for you or
your creditors because there is no equity in excess
of the debt owed. If there is no equity, then there
is nothing of value to be protected. However, if
you file bankruptcy and fail to make payments on
an “upside-down asset,” the secured creditor may
seek relief from the stay and ask the court for an
order allowing foreclosure and sale of the “upside-
down asset.”
Note that in a Chapter 7 bankruptcy, you may
be able to “redeem” your vehicle. e bankruptcy
court can reduce your car loan to the actual val-
ue of your car. So, if you owed $15,000 on a car
worth $10,000, you would only owe $10,000 on
your car after the redemption procedure is com-
pleted.
(ii) Repossession
If you fail to pay secured creditors, they are
allowed to take back or repossess the property
that you purchased and was used as security for
the money they loaned to you. Secured creditors
always have at least two avenues to collect the
amount owed from you, namely collecting based
on the promissory note or contract you signed, or
seizing and selling the asset for which they loaned
OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT PAGE 105
you the purchase money. Secured creditors that
have properly filed their documents in the right
place and in correct form have a lien upon your
asset, whether it be a house, car, dining room set,
or washer and dryer.
Bankruptcy only gets rid of your legal obliga-
tion to pay your secured creditor money under the
contract you signed; it does not get rid of the lien
or right your secured creditor has to take back the
property. So, in order to keep your house, car or
other secured property, you need to keep paying
as promised. On the other hand, you can “sur-
render” it or give it back to the creditor, and you
will not owe them any additional amount based
on your bankruptcy discharge.
(iii) Exemptions
In bankruptcy, certain assets are exempt and
cannot be used to satisfy your debts in the bank-
ruptcy proceeding, although a secured lien can
survive bankruptcy. Some states allow you to
choose between your state law exemptions and
federal bankruptcy exemptions. In Massachu-
setts, the state’s homestead law can protect the
equity in your primary residence up to $500,000.
(See Chapter 8 for a discussion of this law.)
4. Debts Related to Deaths of Spouses and
Estates of Decedents
(i) Be aware that you may not be responsible to
pay the unsecured debts standing only in the
name of a deceased person, or spouse, except
in limited circumstances.
(ii) Generally, for an unsecured creditor to be
able to collect a debt of a decedent, such un-
secured creditor must, within one year of an
individual’s date of death, file a formal claim
against the estate of the decedent with the
probate court where the decedent’s estate is
subject to probate (except Medicaid, which
has three years). Such unsecured creditors
must also take certain additional steps to
“perfect” their claims against an estate in
order for the decedent’s estate to be legally
bound to pay the debt. Accordingly, it is im-
portant to consult with an attorney prior to
paying any debts of a decedent.
C. How Chapter 7 Liquidation Bankruptcy
Works
When you file a Chapter 7 bankruptcy case,
a federal court order goes into effect immediately,
making it illegal for your creditors to contact you
in any way, or commence or continue any actions
to collect from you or repossess your property. is
provides breathing room and alleviates pressure.
ere are some types of creditors who can still col-
lect from you. If you are under court orders to pay
for child support, alimony or other domestic sup-
port obligations, these obligations, along with most
income taxes and student loans, are generally not
discharged in a bankruptcy filing. However, there
are times when income taxes and student loans may
be eligible for discharge.
A Chapter 7 case with no distributable assets
stays open for about four months, at the conclusion
of which the judge will issue an order discharging
all of the dischargeable debts that you have listed
in your petition. Generally, any debts that you have
failed to list will not be discharged and you will still
be obligated to pay them. To confirm that you are
aware of all of your creditors, you should obtain
copies of your credit reports from the three major
credit reporting agencies: TransUnion, Experian
and Equifax. ese reports can be obtained online,
and in some states, including Massachusetts, you
are entitled to one free report per year from these
reporting agencies. Certain websites and lenders
provide unlimited free credit reports.
1. What Documentation Is Needed?
Generally, you will be required to produce two
years of tax returns, proof of your income, bank
statements, your driver’s license or other govern-
mentissued photo identification card, and proof of
your Social Security number, as well as a host of
other documents that may apply to your case, such
as deeds and evidence of the value of your house,
vehicles, personal belongings, retirement plans and
life insurance.
2. Time Frame
About a month after your case is filed, you
will have to attend a “meeting of creditors” where
you will answer questions about your case from
a court-appointed trustee in a conference room
PAGE 106 OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT
setting. Most people filing bankruptcy never see
the inside of a courtroom. And these days, the
meetings of creditors are held telephonically or
by Zoom or other videoconferencing platforms
so that debtors do not even have to leave their
homes.
3. Which Exemptions Can You Use?
Most people in a Chapter 7 case get the best
of both worlds because they are allowed to keep
most, if not all, of what they own, but they get rid
of their debts forever. e bankruptcy laws have a
long and generous list of exemptions that let peo-
ple keep much of their real and personal property,
so long as they fit within the allowed exemptions.
If you have a mortgage on your house or a loan
on your vehicle, you will generally be allowed to
keep them, provided that you continue to pay the
lender. If you miss payments on your house or
car, the lender can foreclose on your house and
repossess your vehicle, but they usually need to
obtain the prior permission of the bankruptcy
court. Bankruptcy rarely terminates the secured
status of a lender, so it is important to understand
that you can still lose your house or car (or other
secured property) after your bankruptcy case is
resolved if you fail to make payments to a secured
lender as agreed.
D. How Chapter 13 Reorganization
Bankruptcy Works
For most people, Chapter 13 bankruptcy will
only work for you if you have regular monthly in-
come. Upon filing your case, you will be required
to begin making regular payments to your lender,
plus an extra payment to catch up on the past-due
amounts. is extra monthly payment will be paid
to the court-appointed Chapter 13 trustee, who will
keep track of your payments and pay off your credi-
tors over a three- to five-year timetable.
Filing a Chapter 13 bankruptcy can be an ef-
fective way to save your home from foreclosure and
get three to five years to catch up on the past-due
mortgage payments. Chapter 13 also works if you
are behind on car payments, or any other secured
item that you want to keep. e bankruptcy court
generally has no authority to lower your monthly
mortgage payment or to change the terms of your
loan or mortgage.
EXAMPLE 1
Let’s assume that your regular mortgage payment is
$1,000 per month and that you are six months behind.
Also, by this time, your bank has usually hired attor-
neys, whom you will have to pay because you agreed to
do so when you signed your mortgage and promissory
note. Let’s estimate $3,000 as a minimum legal fee,
depending on how much work the bank’s lawyers have
done. If an auction of your home has been scheduled,
you will also likely have to pay additional auctioneer
fees and advertising fees. So now you owe the bank
$6,000 for past-due mortgage payments plus $3,000
in legal fees, for a total past-due amount of $9,000.
The plan payment would also include a 10% fee to the
trustee, whom you pay each month, bringing the total
payment to about $10,000. In most cases, the repay-
ment plan would require you to repay that $10,000 by
dividing the payments over three to five years. So, for
a three-year plan, that means that each month you will
pay your $1,000 mortgage payment to the bank, plus
you will have to make an additional payment of $278
each month for the next three years in order to catch up
on your mortgage arrears. If you miss more than two
or three payments, the court may dismiss your case,
which means you are no longer protected by the bank-
ruptcy court and the bank may seek to reschedule the
foreclosure auction of your home.
1. What Documentation Is Needed?
Substantial documentation is required to pro-
vide an accurate picture of your finances as of the
date of filing your case. You will be required to
produce and be up to date on filing tax returns
and provide paystubs or other evidence of income,
a binder for your homeowners and vehicle insur-
ance (if applicable), and evidence of the value of
your home (which can be provided by a local real-
tor). You will also need to disclose any domestic
support obligations you owe, such as alimony or
child support.
2. Reverse Mortgages in Bankruptcy
An older adult who has taken out a reverse
mortgage may be uncertain about the circum-
stances under which a lender can foreclose. It is
important for the homeowner to understand that,
while there is no monthly mortgage payment
due on a reverse mortgage, payment must still
OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT PAGE 107
be made for real estate taxes, homeowners insur-
ance and basic maintenance on the property. If
the homeowner fails to pay real estate taxes, the
reverse mortgage company, or the municipality,
can foreclose on the property. In such a situation,
Chapter 13 bankruptcy can provide the means for
the homeowner with a reverse mortgage to keep
their home, provided that the past-due real estate
taxes are paid through the Chapter 13 plan. e
homeowner will need to have sufficient income to
pay the past-due real estate taxes over three to five
years, plus pay the real estate taxes on time in the
future. It is important to note that the homeown-
er cannot draw additional funds from the reverse
mortgage while the bankruptcy or payment plan
is pending. (See Chapter 10 on Reverse Mortgages
as to other situations where a lender can take action
on your home.)
3. Other Debts
If you have other debts, such as credit card bills
or other unsecured debts, you may also have to
pay a portion of those back. After you complete
the three- to five-year repayment plan, any
remaining balances on your credit card debts or
other unsecured debts are discharged.
EXAMPLE 2
If you are behind $2,000 on your car payment, and also
have $20,000 of credit card bills, your Chapter 13 plan
will require you to pay the full $2,000 to fully catch up
on your car loan, and you will typically have to pay back
a percentage of the $20,000 on your credit cards. The
amount depends on how much of your monthly income
is left over after all your necessary expenses are paid.
The formula is based on your income, and each case
must be independently analyzed to determine the ad-
ditional amount that must be paid to the Chapter 13
trustee. The amount paid also must provide at least as
much as the creditors could have received in a Chapter
7 case. The Chapter 13 trustee earns a 10% commis-
sion on the total amount to be paid to your creditors
through the plan, and the trustee’s fee is paid by you
and added to your plan payment.
4. Chapter 13 Payment Plans
e monthly payment you make will be deter-
mined according to your Chapter 13 plan. e
plan is a document that has all of your debts, both
secured and unsecured, as well as the amount of
your regular monthly income. A calculation of
how much your monthly payment will be is then
required. As soon as your plan is agreed upon by
the Chapter 13 trustee and the bankruptcy judge,
your plan will be confirmed. You will be ordered
to make the monthly payment to the Chapter 13
trustee, who will pay each of your creditors. e
plan payment is in addition to your regular pay-
ments to secured lenders.
5. Benefits of Chapter 13
One of the most helpful benefits is that, in
some cases, a Chapter 13 determination order can
discharge a second mortgage on your home. is
is called a “strip off.” Whether you can take ad-
vantage of it or not depends on several factors,
including the fair market value of your house and
how much you owe the first mortgage holder. If
you have student loans or income taxes owed, a
Chapter 13 can stop collection enforcement and
the accumulation of interest on past-due amounts
for tax liabilities, as well as give you protection
from your creditors because any payments made
to them will be subject to court oversight.
Another benefit of a Chapter 13 is that it pro-
tects co-signers on your accounts because co-
signers receive the same bankruptcy court protec-
tion that you do, even though they are not filing
bankruptcy. is is true when only one spouse
files bankruptcy and the other spouse, who is a
co-signer, is also granted bankruptcy court pro-
tection, even though the non-filing spouse did not
file bankruptcy.
E. Alternatives to Bankruptcy
Explaining and documenting your financial
hardship with your creditor will assist them in
evaluating your settlement offer. Hardships that are
ongoing, such as chronic medical conditions, loss
of income from a business closure, the death of a
bread-winning partner, or situations that have had a
permanent impact on your finances, are among the
most persuasive. It may be more helpful to demon-
strate to your creditor that your financial situation is
unlikely to improve, and that your offer to settle is
often the proverbial “bird in hand” for your creditor.
If you have multiple creditors, you can explain to
PAGE 108 OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT
them that your settlement offers are on a first-come,
first-served basis, and that once the money is gone,
then no further offers will be forthcoming. is may
motivate a creditor to take your offer, because they
are usually able to obtain your credit report to con-
firm how many other creditors you have and how
much you owe them.
1. Debt Settlement
For clients who wish to settle their debts, the
key is timely paying the creditor the settlement
amount you have agreed to. ere are two general
types of settlements, namely: payment plans over
time and lump-sum settlements.
(i) Payment Plan
For example, if you have a $10,000 balance on a
credit card and you want to set up a payment plan
to pay it off, the credit card company will usually
let you make smaller monthly payments over time,
so long as you agree to pay off the full $10,000.
Some creditors may allow periodic payments on
a lesser amount than the full balance owed, but
that must be negotiated and reduced to writing
for your protection. Whether the creditor will
agree to waive interest and late fees that are still
accumulating depends on how well you negotiate
an agreement with your credit card company.
is type of settlement can be long and drawn
out, and may not save you very much money in
the long run.
Also, the longer a settlement agreement is in
place, generally the worse it is for you because the
credit card companies often have a clause that
says if you miss an agreed payment, the deal is
canceled and they can pursue you immediately
for the full past-due balance. ese payment
plans usually fall by the wayside for one reason
or another, often after people have made many
monthly payments that they would not have had
to make if they filed for bankruptcy earlier.
(ii) Lump-Sum Settlements
e more beneficial type of settlement is a
“lump-sum” settlement. With that same $10,000
balance in the previous example, if you offer the
credit card company an immediate payment of
$8,000 to settle this account in full and final set-
tlement, the chances are that they will take it. If
you are current with your payments, the credit
card company is unlikely to agree to this, and
that is because they are getting your payment
every month and they have no incentive to offer
you a deal. e longer you are unable to make
your monthly payment, and the further behind
you fall month after month, tells the credit card
company that you are having financial difficulty.
Typically, the more you fall behind, the better
your chances are for a lump-sum settlement for a
lower amount.
Before you agree to any type of settlement, it
is best to get the terms of the agreement in writ-
ing. Also, you should insist that, upon receipt of
your final payment, the credit card company will
report to the credit bureaus that your account is
“paid off” or “settled in full.”
ere are other important consequences to
consider before attempting to settle your credit
card or other debts without the assistance of an
experienced attorney. As you fall further behind
on your monthly payments, your credit score will
be negatively affected. You may be called twice
weekly by your creditors. Creditor calls to your
place of employment are permitted, unless you
inform the creditor in writing not to do so. Oral
requests to creditors asking them not to commu-
nicate with you at your place of employment are
valid for 10 days. Written requests are valid until
you remove the restriction. You also run the risk
that they will sue you in court if you do not pay
your balance. However, if you have an attorney,
they cannot contact you by law. Further, typically
your creditors will not file suit against you while
you are represented by an attorney and are trying
in good faith to negotiate a settlement.
Note that settlements can cost you income
taxes. If the credit card company agrees to accept
$2,000 to settle your $10,000 balance, that may
sound wonderful — a savings of $8,000. But the
IRS requires that any amounts of debt in excess
of $600 that are forgiven by your creditors be in-
cluded in your gross income in the year that the
debt was forgiven, and that income may be tax-
able. e credit card company will issue an IRS
1099-C form to you for the amount of forgiven
debt. You should check with your tax preparer to
see how much tax, if any, you will have to pay as
a result of the debt forgiveness.
OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT PAGE 109
Withdrawals from your retirement accounts to
pay off credit card or other debts can have adverse
consequences. Making such a withdrawal is gen-
erally a poor decision because you are using funds
that were set aside for your future and will usually
create income tax liability when withdrawn. Fur-
thermore, depending on your age, you could suf-
fer penalties and the tax consequences for using
the retirement funds to pay the debts. Consult an
experienced financial adviser to assess your situa-
tion.
2. Mortgage/Loan Modification
A loan modification is typically a request by
a borrower for a lender to change the terms of
the borrower’s loan. is may involve changing
all or some of the following: interest rate, princi-
pal balance, past-due amounts, collection costs,
late fees, legal fees and/or auctioneer fees. A loan
modification can also change your loan from an
adjustable rate to a fixed rate in some instances.
e decision to grant or not grant a loan modifi-
cation is entirely the lender’s decision. In the case
of real estate, the mortgage and promissory note
that you originally signed when you bought your
real estate or refinanced are the legally binding
documents that control your relationship with
your lender. us, the lender may simply refuse
any change you request.
(i) Modification Application
Your lender may have a website where you can
fill out their specific loan modification applica-
tion. Your lender may use a formula to determine
your ability to participate in a loan modifica-
tion, and if, for example, you are currently past
due on your home mortgage, being in arrears can
actually be a benefit when asking your lender to
modify your loan. e reality is that most people
who request a loan modification are behind on
their mortgage and need the lender to make some
changes to their loan in order to make the house
more affordable. You will need to gather your fi-
nancial documents, such as tax returns, paystubs
and other evidence of income and expenses, to
show your lender that you have money left over at
the end of each month.
Also, it may be helpful for you to write a “hard-
ship letter” to explain to the lender what caused
you to fall behind with your mortgage payments,
how you have resolved those problems, and why
you anticipate being able to make your monthly
payments if the lender gives you a loan modifica-
tion.
(ii) Dealing with the Lender
While the process of submitting a loan modi-
fication request is relatively straightforward, one
difficulty usually lies in the constant follow-up
that will be required from you to make sure that
the bank has your completed package. Lenders
often lose paperwork, and requests from them for
you to resubmit your loan modification package
are quite common, frequently due to the lender’s
processing delays, so be sure to make legible cop-
ies of everything that you send to your lender in
case you need to send the paperwork again. It may
take between three months to well over a year to
get an answer from your lender on whether your
modification has been granted.
Even though your lender is reviewing your loan
modification application, the lender can still pur-
sue its legal right to foreclose on your real estate.
at is why some people are confused when they
receive notice of a foreclosure proceeding from
their lender’s attorneys at the same time a loan
modification is being processed. Remember that
the lender is going to take the necessary steps to
protect what is best for the lender, and you should
take the necessary steps to protect what is best
for you. You should consult with an experienced
attorney to fully explain your rights and legal op-
tions.
(iii) Dealing with Debt Collection Correspon-
dence — Sample Letter
(Name and address of Debt Collector)
RE: Your Name; Creditor’s Name,
Account #: 1234567
Dear Sir or Madam,
I am writing to your company regarding its
collection efforts on the above-referenced account
and my ability to pay this debt.
I am unable to make any further payment be-
cause (state reasons for inability to pay, such as
no ownership of or interest in any real estate or
other assets that would not be exempt from pro-
PAGE 110 OVERVIEW OF COMMON BANKRUPTCY AND DEBT ISSUES FOR THE OLDER ADULT
cess under Massachusetts law; or monthly income
consisting of Social Security, public assistance,
unemployment compensation, workers’ com-
pensation, veterans benefits, railroad retirement
benefits, a pension or wages that are exempt from
garnishment).
I clearly cannot afford to make even a mini-
mum monthly payment on the balance. Further,
my monthly income is entirely exempt from this
process, and it is extremely unlikely that any
judgment obtained against me would ever be col-
lectible.
In light of the above, I will not make any fur-
ther payments on your accounts and will not use
the accounts anymore. My credit cards have been
destroyed and the accounts are closed.
is letter is to request that you cease all contact
with me regarding the collection of the above-ref-
erenced account, pursuant to the Fair Debt Col-
lections Practices Act (15 U.S.C. section 1692).
is letter is also to request that the creditor write
off the balance owed by me as uncollectible and
notify me in writing of this disposition.
ank you for your attention to this matter.
Very truly yours,
(name of debtor)
3. Do Nothing
Another option for someone in debt is simply
to do nothing. Waiting for a summons and
complaint to arrive may be the best alternative. It
may never arrive, and the creditor may close the
case as uncollectible. But you could wait and see
what the creditor does to collect. If all of your assets
are either exempt or without value, disclosing that
to the creditor may lead the creditor to close the
case against you. You may draw from the letter
on this page and send such a letter, certified mail,
to the creditor or the creditor’s representative. If a
lawsuit is filed and the debt is admitted, and if you
are insolvent, handling the matter yourself may
be a reasonable choice. On the other hand, if you
have attachable assets, such as a bank account or
motor vehicle, and you earn enough wages so that
it is worthwhile for a creditor to attach your pay,
then you would be wise to seek an attorney who
can explain the wage or bank account attachment
process to you and teach you how to avoid a wage
attachment or defend the lawsuit.
In the meantime, attending education courses
and learning about money management,
financial affairs, budgeting skills and payment
plans would be extremely helpful in dealing with
communications by creditors and their aggressive
representatives.
Of course, if a debt is denied either as to
liability or as to the amount of the claim, then
doing nothing would not be the best course of
action. An attorney is needed to defend you in
court if none of the alternatives suggested above
apply. However, keep in mind that if you ignore
a creditor, it is possible that your creditor will
contact your family members, neighbors, people
you live with, and others who they believe can
assist them in locating you. ey are allowed to
do this, but they are not allowed to inform others
about your debt.
CONCLUSION
All options are complex to consider at such a
vulnerable time in your life, and the best decision
for you depends on your personal situation. Each
option has positive and negative consequences, and
each has highly technical requirements. It is always
recommended that you consult with an experienced
bankruptcy or collection attorney to help you as-
sess your specific situation and determine your best
strategy.
e death of a spouse or a family member may
cause creditors to communicate with you to pay a
debt that you believe is not your responsibility. An
attorney can advise you as to your rights, insofar as
your legal obligation to pay these bills.
e Resource Directory on page 130 lists some
agencies to contact for further information.
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 111
WHAT TO CONSIDER WHEN PLANNING FOR RETIREMENT
PAGE 111
CHAPTER 16
WHAT TO CONSIDER WHEN PLANNING FOR RETIREMENT
Retirement is a major life transition. e ques-
tions below are meant as a starting point and are
followed by both relevant information and helpful
resources. While not a comprehensive list of topics,
the questions provide a guide to additional informa-
tion on retirement planning.
Retirement decisions are made more complicated
by the COVID-19 pandemic. e Wall Street Journal
(WSJ) predicts that the pandemic “is going to make
people rethink retirement, and result in so much un-
certainty about financing retirement that most peo-
ple will work as long as possible.” is report sets out
in detail how leaders in aging-related fields expect
the pandemic to reshape retirement and aging. See
WSJ Encore Report, Monday, Nov. 16, 2020.
CAN I AFFORD TO RETIRE?
e first question many of us have is, “Can I afford
to retire?” In considering this question, you should
initially estimate your future income and expenses.
First, list your current expenses and income.
Make a note of which income is guaranteed and
which is not. Next, consider the changes to income
and expenses that may occur with retirement. Ex-
penses that may change in retirement might include
an increase in health insurance costs, additional
travel and vacation expenditures, and perhaps a
decrease in income taxes. Other costs may stay the
same, such as the cost of your mortgages, utilities
and property insurance. Also consider potential in-
heritances as part of your financial picture.
For married couples, it is critical to look at the
changes in expenses and income that will occur
upon the death of the first spouse. is is especially
important to consider in planning for future Social
Security benefits or pensions, and the impact the
death of a spouse will have on that income.
Expenses can be grouped into three categories:
1) Fixed monthly expenses (such as your mortgage
payment), 2) Variable monthly expenses (such as
your basic needs and wants), and 3) Discretionary
expenses (such as your optional expenses and those
things or services you would “love to have”).
Once you have those lists in place, consider us-
ing online retirement calculators. ese are tools de-
signed to help you develop a well-formulated budget
and help make some reasonable financial projections.
e calculations frighten many people because the
planners often suggest that much more money is
needed in retirement than the average person has
saved. e median amount of retirement savings for
Americans in their 60s is $172,000. See www.nas-
daq.com/articles/average-retirement-savings-by-age.
What are the reasons for the large difference?
One is that some calculators are based on your cur-
rent lifestyle, rather than your retirement lifestyle.
Also, there may be some motivation on the part
of investment firms to market their services. Your
own calculations may be considerably different from
those obtained from web calculators, but it is impor-
tant to understand and evaluate all the data.
UNDERSTANDING TIMING FOR CLAIMING
SOCIAL SECURITY BENEFITS AND TAKING
DISTRIBUTIONS FROM RETIREMENT BENEFITS
While there are, of course, other sources of in-
come available to retirees, three of the most common
sources of income for retiring individuals are Social
Security benefits, pension plans and retirement ac-
counts, such as 401(k)s, IRAs, 403(b) accounts, etc.
Part of your planning for retirement should entail
considering the timing of when you will need to
start relying on this income. If you have other assets
upon which you can rely, you will need to consider
whether it would be advantageous to delay taking
funds from these particular sources.
If you will be eligible for Social Security ben-
efits, you may claim benefits as early as age 62. If
you are financially able to do so, however, it can
be advantageous to wait until your full retirement
age, which is described in further detail in Chapter
13. At full retirement age or later, you will receive
a larger monthly benefit. Depending on your other
income (including retirement benefits, pensions and
investment income), up to 85% of your Social Secu-
rity benefit may be considered taxable income.
e timing of when to begin withdrawing from
your pensions or retirement accounts should also
be considered. With respect to retirement accounts,
PAGE 112
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 112
WHAT TO CONSIDER WHEN PLANNING FOR RETIREMENT
Congress passed what is known as the SECURE 2.0
Act in December 2022. While its full implications
are beyond the scope of this chapter, it is important
to note that the mandatory date by which you must
begin taking “required minimum distributions”
from your retirement accounts has been raised to
age 73 beginning in 2023 (and age 75 in 2033). is
can be important, because it can allow for further
savings without prematurely drawing down on your
accounts. Keep in mind that for many retirement
accounts, such as 401(k)s and traditional IRAs, the
amounts of the entire distributions are taxable in-
come. You may want to consider developing a tax
efficient plan for the timing of withdrawing from
such assets versus withdrawing from assets with dif-
ferent tax implications, such as Roth IRAs and non-
qualified assets.
WILL I BE ABLE TO AFFORD TO STAY IN MY
HOME?
One of the primary concerns for individuals con-
templating retirement is whether they will be able to
afford to maintain their home. For many, the home
represents security and a lifetime investment that is
difficult to give up. Special consideration should be
given to the expenses required to maintain the home
and whether it will be realistic to afford the bills af-
ter retirement. ere are potential resources that can
help you. You may consider refinancing your mort-
gage, obtaining an equity loan or applying for a re-
verse mortgage if you need liquidity (see Chapter 10
for further discussion regarding reverse mortgages).
Your city or town may have abatement programs for
seniors relative to real estate taxes (see Chapter 9 for
further discussion regarding tax abatements). If you
are considering selling your property as part of re-
tirement planning, you should be sure to consider
any potential capital gains taxes upon sale in evalu-
ating the decision to sell.
DO I NEED A FINANCIAL PLANNER?
A financial planner is a professional who works
with clients to help them manage their money and
reach their long-term financial goals. Financial
planning includes help with budgeting, investing,
saving for retirement, tax planning, insurance cov-
erage and more. Some financial planners may hold a
“CFP” or other professional designation to establish
their professional qualifications.
If you have been successfully managing your
money, you may not need a financial planner for
your investments. But, as you get older, you may
want a relationship with a financial professional or
trusted (perhaps younger) family member, as your
ability or desire to continue managing your finances
in the same way may change. A financial planner
can also be valuable in the continuity of financial
management over time as you age and for your fam-
ily members, as they may become involved in assist-
ing with your financial affairs.
If you would like a personalized or second opin-
ion regarding your financial plan and situation, you
should consider a consultation with a financial plan-
ner. Many financial planners offer free/complimen-
tary consultations and analyses/proposed plans.
What should you consider in selecting a financial
planner? ere are numerous financial professionals
competing for the attention of older adults to assist
in retirement planning. e fees charged are often
confusing. Conflicts of interest can be hard to detect.
In some instances, vulnerable and/or unaware older
adults are financially exploited. If you ever have any
concerns about this, you should immediately contact
the Massachusetts Division of Securities.
How do you locate a trustworthy financial pro-
fessional? Word-of-mouth recommendations from
friends and relatives are one starting point. You may
also receive sound recommendations from your at-
torney and tax professional.
Due to the large number of titles and designations
of those who specialize in providing financial advice
and guidance, space limitations prevent listing them
here. However, the American Association of Retired
Persons (AARP) has a comprehensive guide available
online. See www.aarp.org/money/investing/info-2021/
complete-guide-to-financial-advisors.h tml.
UNDERSTANDING FEES AND EXPENSES
If you choose to have a professional assist you
with your financial planning, one of the most impor-
tant discussions with prospective financial advisors
is regarding their fees. You should feel comfortable
understanding how an advisor charges for their ser-
vices and how such fees will affect the total return of
your investments. You should expect full disclosure
and complete transparency. Fees may be structured
based on a fee for services, based on a percentage of
assets managed, by the trade, or some combination
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 113
WHAT TO CONSIDER WHEN PLANNING FOR RETIREMENT
PAGE 113
thereof. If your advisor is investing your funds in in-
dividual stocks, you should ask what fee you would
pay for each trade (purchase or sale) of a stock. Ex-
cessive trading of stocks can be costly and reduce
your total return. e practice is known as “churn-
ing” an account to benefit the advisor.
Fees may not be directly stated as charges to you
and instead may be built in to the financial prod-
ucts a planner is recommending (such as commis-
sions for sales of annuities or so-called 12b-1 fees
for mutual funds), so you should also inquire about
such considerations in determining the overall cost
of employing a financial planner. Such fees can sub-
stantially impact your savings over time. For exam-
ple, if you were to invest $500,000 over a 20-year
span, with average annual growth of 5%, with a
1.5% investment advisory fee, your portfolio would
grow to $994,898 (assuming you made no deduc-
tions during the term). However, if the fess amount-
ed to 2.5%, that same $500,000 would only grow to
$810,309. It is often helpful to get several opinions
at the outset to understand the various potential in-
vestment options and their relative costs.
You should also ask an advisor for the “ADV”
brochure and “Relationship Summary” that list the
firm’s and advisor’s disciplinary events. Also, ask
about potential conflicts of interest and compensa-
tion arrangements (regulatory requirements); these
should be readily available. It’s a good idea to go to
the Financial Industry Regulatory Authority (FIN-
RA) BrokerCheck site to see the disciplinary history
and licenses held for any potential advisor. e site
is https://brokercheck.finra.org.
If the advisor seems reluctant to discuss any of
these matters to your satisfaction, that should raise
a red flag.
USING BINDERS AND ORGANIZERS
It is important to make sure that all your essen-
tial documents and papers, whether they are stored
electronically or organized on paper, are in one
place. A large, three-ring binder with tabs listing
legal, financial, home and personal may work best.
Your original documents, including your health care
proxy, power of attorney, will, and any trusts and
deeds to your home, as well as all insurance policies
and a list of your assets and important passwords,
should be in the binder. e binder should also in-
clude important documents that your personal rep-
resentative or named agent, fiduciary or loved one
will need to know about upon your death. You also
should tell that person where this binder is located
so it can be found in an emergency or upon death.
Since this contains sensitive financial information,
the binder should be kept in a secure location. Buying
a fireproof security file box would be a good idea.
ADDITIONAL RESOURCES
ese SEC websites are easy to understand and
have many embedded links with additional, unbi-
ased information.
• Status of investment advisers and related
professionals at www.sec.gov/investor/seniors/
guideforseniors.pdf.
• See also for excellent information on this
topic: www.investor.gov/additional-resources/
information/seniors.
• “Brokers and Investors Face a Crazy Quilt of
State Regulations,” by Barley McCann, Wall
Street Journal, May 7, 2021.
NOTE: Four states — Massachusetts, New York,
New Jersey and Nevada — now have their own
state regulations that must be followed by financial
advisors. The 2019 SEC rule on “Best Interests”
of the client states that financial advisors’ actions
“must align with client interest and clear disclosure
of fees and conflicts.”
• “A Simple Framework for Financial Advice,” by
Eugene Scalia and Jay Clayton, Wall Street Jour-
nal, Dec. 15, 2020 (note former secretary of labor
and SEC director, respectively).
• “Seven Questions to Ask When Picking a Finan-
cial Advisor,” by Shelly Banjo, Wall Street Jour-
nal, April 13, 2009.
• “SEC focuses attention on conflicts of interest in
financial advice for seniors, retirement savers,”
See https://www.cnbc.com/2021/03/03/sec-sets-
focus-on-conflicts-of-interest-in-advice-for-seniors.
html.
Note that the focus is on sales practices, exchange
funds, real estate trusts, annuities, digital assets,
municipal and other bonds, as well as accounts
that carry commission vs. annual fees.
• Another site that sets out key questions, advisor
background and disciplinary history is https://ad-
viserinfo.sec.gov/.
PAGE 114
PENSION CONCERNS FOR RETIREES
CHAPTER 17 PENSION CONCERNS FOR RETIREES
is chapter focuses on pensions and retirement plans that are subject to the Employee Retirement In-
come Security Act of 1974 (ERISA). is includes most pensions and retirement plans that are sponsored
by private employers or unions. Except as indicated,
the material in this chapter does not pertain to plans
that are sponsored by state or federal government
employers, nor does it include so-called “church
plans,” which are sponsored by religious entities.
Please review the resources included in the “Seek
Outside Help” portion of this chapter for advice re-
garding these non-ERISA plans.
DIFFERENT TYPES OF PENSIONS
Private pensions weren’t always protected by fed-
eral law as they are today. Before ERISA took effect
in 1976, pensions were largely subject to the em-
ployer’s rules, with few federal legal requirements.
After ERISA, plan participants received a number
of significant protections under federal law.
Most workers today will earn some kind of re-
tirement benefit during their working lives. e
most common types of benefits are defined benefit
plans and defined contribution plans. Defined ben-
efit plans (often called “pensions”) provide a fixed,
monthly benefit payment upon retirement, with the
amount determined based on a formula that typi-
cally considers the retiree’s earnings and years of ser-
vice. Defined contribution plans provide individual
accounts for each worker who chooses to participate
that are funded by worker contributions and may
also include employer contributions. At retirement,
the worker has access to the full balance in the ac-
count. e most common defined contribution
plans are 401(k) and 403(b) plans.
is chapter focuses primarily on defined ben-
efit pension plans (“pensions”). Many people who
are reaching retirement age now earned a pension
during their working years. Current private sec-
tor workers are much less likely to have access to
a defined benefit pension. Nowadays, private sector
employers are more likely to offer a 401(k) or other
defined contribution plan.
EARNING A PENSION
Not every worker has access to a pension. You
will only have access to a pension if your employer
has decided to include a pension in the benefits that
it offers its employees. e number of private em-
ployers that offer a defined benefit pension has fallen
dramatically since the 1970s. Most public employ-
ers, however, continue to offer pensions to their em-
ployees.
In order to earn a pension benefit, plan partici-
pants must vest in a pension. Generally, workers vest
in a pension by working for their employer for a re-
quired number of years. e specific requirements
to vest in a pension are determined by law, but some
pension plans may be more generous than the law
requires. It is important to review your Summary
Plan Description or Plan Document to determine
how much service you need to complete in order
to vest. After you have earned a vested benefit, that
pension becomes yours even if you leave the compa-
ny and work somewhere else. e pension then be-
comes a deferred vested benefit that you will be able
to collect when you reach retirement age, regardless
of where you work for the rest of your career.
e age at which a worker can retire and collect
their benefit differs between plans, but most plans
set Normal Retirement Age at 65. A few months
before you plan to retire, you should contact your
plan to start your benefit. It typically takes at least
a few months from applying to receive your benefits
to receiving your first check.
FORMS OF BENEFITS
Your pension will likely have different options
for how you may receive your benefit. e most
common types of benefit payments are a single life
annuity, a joint and survivor annuity, a year certain
and life annuity, and a lump sum payment.
If you are married, then the default form of ben-
efit is a joint and survivor annuity (J&S). A J&S an-
nuity pays a fixed monthly benefit to the participant
during the participant’s lifetime. If the participant’s
spouse lives longer than the participant, then the
spouse will continue to receive a monthly benefit
— a “survivor benefit” — after the spouse dies. e
survivor benefit must be at least 50% of the amount
PENSION CONCERNS FOR RETIREES
PAGE 115
that the participant received while alive.
A single life annuity typically pays the partici-
pant a larger amount each month than the J&S an-
nuity. However, if the participant is married, the
single life annuity will not provide a survivor benefit
for the spouse. In order for a married participant to
elect a single life annuity, the participant’s spouse
must sign a waiver before a notary, consenting to the
form of benefit.
Many plans offer other annuity options in ad-
dition to the J&S annuity and the single life annu-
ity. It is very important to carefully read and under-
stand the benefit options. For example, some benefit
options may not provide a benefit that continues
throughout the participant or beneficiary’s lifetime,
or the benefit may not continue at the same level.
Once you have elected a form of benefit, the choice
usually cannot be changed.
TAKING YOUR DEFINED BENEFIT PENSION AS A
LUMP SUM
1
Some plans give their participants the option to
receive all or part of their defined benefit pension as
a single lump sum. Plans are not required to offer
benefits in a lump sum, and a participant cannot
force a plan to offer a lump sum. If a plan does of-
fer a lump sum, the amount will be calculated ac-
cording to a plan formula, and will often represent
the present value of the amount that a participant
would receive as a single life annuity during their
life expectancy. Once a plan pays out a lump sum,
there are no additional benefits due a participant.
Sometimes, pension plans will offer deferred
vested retirees a “lump sum buyout” or “lump sum
window.” For a limited period of time, deferred vest-
ed participants and/or retirees who wish to take ad-
vantage of the offer may receive a lump sum, gener-
ally instead of receiving a monthly annuity. Often,
these lump sum windows are limited-time offers.
Participants may only take advantage of the offer
by submitting their lump sum paperwork within a
limited window of time.
e decision of whether to take a lump sum
should be considered carefully, ideally with assis-
tance from a financial advisor or tax planner. Some
factors that you may want to consider include:
• Guaranteed income: Choosing a life annu-
ity means guaranteed income each month that
will not vary as a result of market performance.
Coupled with Social Security benefits, lifetime
pension payments generally ensure that you will
have a fixed amount of monthly income for the
remainder of your life. Taking a one-time lump
sum cash payment leaves it up to you to ensure
that the money lasts as long as you need it.
• Longevity: Your health and expected longevity
should play an important role in determining
which form of payment is right for you. Monthly
annuity payments may be a prudent choice if you
are in good health and expect to have an above
average life span. You cannot outlive lifetime an-
nuity payments; as long as you are alive, you will
have the comfort of knowing you will receive a
monthly pension. You can also elect a joint and
survivor annuity with your spouse, which means
your spouse will continue to receive monthly
benefits after your death. Most experts would
agree that, for most retirees, a guaranteed stream
of income for life is a better option than a lump
sum. However, a few factors that might weigh in
favor of taking a lump sum option include: if you
are in poor health or do not expect to have a long
lifespan, and you will not have a surviving spouse
who will need lifetime income; or if you already
have a substantial nest egg or other secure source
of adequate income, such as a spouse’s pension.
• Investment risk: If you choose to invest your
lump sum payment, the value of your investments
will be subject to market fluctuations. is means
that while the value of your investments may in-
crease, it also may decrease. If you elect annuity
payments, the investment risk remains with your
company and the pension plan. If the market
struggles, your annuity payments will remain the
same, and your company will likely be required
to make greater contributions to the pension plan
to compensate for lower-than-expected invest-
ment returns. If you take a lump sum, no one is
responsible for taking care of your money other
than you.
• Taxation of benefits: Taking a lump sum pay-
ment will result in being taxed on the entire
amount all at once unless the payment is rolled
over into an IRA or another employer-sponsored
retirement plan. Depending on the size of the
lump sum, you may be pushed into a higher tax
bracket. Also, if you take a lump sum distribu-
PAGE 116
PENSION CONCERNS FOR RETIREES
tion before age 59½, you may be subject to a 10%
early withdrawal penalty in addition to the taxes
owed. In the case of annuity payments, you will
also be taxed each year on the value of monthly
payments you receive, though given their smaller
size, they are less likely to impact your tax brack-
et.
• Financial health of your company and your
pension plan: If your company is struggling fi-
nancially and is no longer able to meet its required
contributions to the pension plan, the plan may
be turned over to the Pension Benefit Guaranty
Corporation (PBGC). e PBGC has limits on
the benefits that it can pay, so your monthly ben-
efit might be reduced (see here for current limits:
https://www.pbgc.gov/wr/benefits/guaranteed-
benefits/maximum-guarantee). It is important
to understand that the vast majority of retirees
who get their benefits from the PBGC receive the
same amount that they would have received if the
plan had not terminated.
THIRD-PARTY INTERESTS
In addition to participants, there are other peo-
ple who may have rights under a pension plan. is
includes surviving spouses, surviving beneficiaries,
and people who receive all or part of their former
spouse’s pension post-divorce (often called “alter-
nate payees”).
Spousal survivor benefits for married partici-
pants are protected by law, and the spouse of a par-
ticipant is guaranteed to receive at least 50% of a
J&S annuity. In order to receive this benefit, how-
ever, in most instances, the participant must have
been married to the spouse for at least one year pri-
or to retirement. Pension plans are not required to
provide benefits for non-spousal beneficiaries (such
as children or domestic partners). However, some
pension plans do provide options to leave a survivor
benefit to a non-spousal beneficiary.
Pensions and 401(k) plans must be handled very
specifically during divorce proceedings in order for
the non-participant spouse to receive benefits under
the participant’s plan. If you are getting divorced
and there is a pension benefit at issue, it is important
to speak with an attorney who has experience in this
area of the law.
LOST PENSIONS
Sometimes, pension plans can be hard to track
down when the participant reaches retirement age.
Sometimes it’s because a company goes out of busi-
ness, changes its name or merges into another com-
pany. Sometimes the pension plan has mistakes in
its employment records, and no longer has a record
that a former employee is entitled to a pension.
While ERISA protects participants and their vested
status, a participant is sometimes required to prove
their employment, years of service or entitlement to
a benefit prior to receiving their benefits.
e protections under ERISA are very strong,
and you will not lose your right to a pension sim-
ply because your company has gone out of business,
merged with another company, or lost your employ-
ment or pension records. ere are steps that you
can take to protect your rights.
Sometimes plans are terminated or frozen. Of-
ten, when a plan is frozen, benefits earned are locked
in place, and workers no longer are able to earn ad-
ditional benefits. When a plan is frozen, the freeze
is either a soft freeze (meaning the plan is discon-
tinued for newer employees joining the company
and employees who have not yet vested in the plan,
but the plan continues for current vested employ-
ees) or a hard freeze (meaning the plan is frozen for
all employees, and vested employees no longer ac-
crue benefits). If your employer does elect to freeze
its pension plan, it may only freeze benefits going
forward. Under no circumstances may an employer
retroactively freeze a pension plan or reduce pension
benefits that have already been earned. In the event
of a plan freeze, it is strongly recommended that you
request and obtain a statement from your company
that details your frozen accrued benefit calculation.
Keep this statement in a safe place until you are
ready to commence your retirement benefits.
Many defined benefit pension plans have been
terminated by the employers that sponsor their
plans. A terminated plan, often the next step after
a plan is frozen, is the complete shutting down of a
pension plan. Terminating a plan is a complicated
process that requires the involvement of the PBGC,
which is an agency of the U.S. government. Once a
plan is properly terminated, either all benefits will be
paid out to participants as a lump sum, or a group
annuity contract at an insurance company will be
PENSION CONCERNS FOR RETIREES
PAGE 117
purchased for the remaining participants, and an-
nuity certificates will be mailed to them.
2
COMPILE YOUR DOCUMENTS
ere are many important documents that you
receive during employment concerning your pen-
sion. One of the most important documents you
may receive is called a vesting letter. is is usually a
document or certificate that your employer sends to
you to acknowledge your vested status. is docu-
ment will usually show the date you are eligible to
receive your pension, the amount you will receive,
and confirmation that you have vested in the pen-
sion. It is very important to keep this document in a
safe place. Other important documents include W-2
forms, which can be used to prove employment and
years worked, and 1099-R forms from your tax re-
turns. is part of your tax return will show what,
if any, retirement distributions you received during
the year.
Tax returns are incredibly important and help-
ful to hold onto. If you have a pension, you should
try to maintain copies of all tax returns during your
working years, and keep the documents in a safe
place.
e Social Security Administration can be a
helpful resource to get additional information to
help prove your years of employment or to help de-
termine if you may have a potential pension. You
can request an Itemized Statement of Earnings to
prove years of employment with the employer you
worked for and the total earnings for each year of
employment. As of the publication of this chapter,
Social Security charges $92 for this record. is
document can be completed at any Social Security
field office, or can be printed and mailed online at:
www.ssa.gov/forms/ssa-7050.pdf. e other docu-
ment is a Statement of Potential Private Retirement
Benefit, which is a helpful first step in determining
if you or a spouse has earned a pension. It is free to
request, and you will receive a document in return
that explains your potential benefit and the amount
recorded. A form letter that you can use to ask for
this statement is included in the appendix to this
chapter.
Share your documents with your pension plan
or former employer
Once you’ve collected your documentation, con-
tact your pension plan or former employer to share
the information and explain why you are entitled to
a benefit. If your company has merged with another
company, you may need to contact the successor
company. Keep copies of any written communica-
tions in your files.
If your initial attempts to obtain your pension
are not successful, you may want to file a formal
claim pursuant to ERISA. A claim for benefits is an
official argument to persuade the plan to pay ben-
efits. e plan must answer the claim with either
an award of benefits or a denial of benefits. After
the claim is denied, there is a right to appeal the
plan’s denial, and the argument is reconsidered, of-
ten with input from the plan’s Board of Trustees or
legal advisors. e claims and appeals process is pro-
tected by ERISA and found in the Code of Federal
Regulations (29 CFR § 2560.503-1). Every pension
plan has a claims and appeals process, which you
can request and which the plan must give to you
upon request.
SEEK OUTSIDE HELP
ere are several government agencies and other
organizations that may be able to help you locate
your pension. Please review the agencies and orga-
nizations below for further information.
• Pension Benefit Guaranty Corporation
(PBGC)
o e PBGC is a government agency in Wash-
ington, D.C., that insures private defined ben-
efit pensions. In some cases, they are respon-
sible for paying benefits, usually when a plan
sponsor has declared bankruptcy.
o If the PBGC is responsible for your pension
benefit, or you are the beneficiary to a pension
benefit administered by the PBGC, then call
their Customer Contact Center. Its hours are
between 8 a.m. and 7 p.m. Monday through
Friday, and the number is 1-800-400-7242.
Please have your Social Security number and
pension plan’s name or number ready to share
when you call.
o Email: CustomerService@pbgc.gov
o PBGC
P.O. Box 151750
Alexandria, VA 22315-1750
Include your full name, customer ID, or the
last four digits of your Social Security num-
PAGE 118
PENSION CONCERNS FOR RETIREES
ber at the top of each document, along with
your request. Please allow four to six weeks for
PBGC to respond to your request.
• U.S. Department of Labor, Employee Benefits
Security Administration (DOL-EBSA)
o DOL-EBSA is available to answer questions if
you believe that you have been inappropriately
denied a retirement, health, disability or other
ERISA employee benefit.
o 1-866-444-3272
Assistance is available in over 105 languages. If
you are deaf, hard of hearing or have a speech
disability, please dial 7-1-1.
o Ask a question online:
https://www.askebsa.dol.gov/WebIntake/?_
ga=2.163257278.323340782.1670360177-
1857761670.1669841835
• e Pension Action Center
o e Pension Action Center provides free legal
counseling for workers and retirees who live
or worked in Connecticut, Maine, Massachu-
setts, New Hampshire, Rhode Island, Ver-
mont and Illinois.
o To request assistance, call 1-888-425-6067, or
submit an online request for assistance through
their website: www.umb.edu/pensionaction.
• Massachusetts State Retirement Board
o e Massachusetts State Employees’ Retire-
ment System (MSERS) administers the Mas-
sachusetts State Employee Retirement System
(MERS) for all municipal and state employees,
as well as employees of the state judiciary.
o (617) 367-7770 (8 a.m.–5 p.m.)
o Email: srb@tre.state.ma.us
o Members of the MSERS may visit the MSRB
offices to drop off completed retirement ap-
plications, forms and other documents at:
the MSRB’s Boston office at One Winter St.,
Downtown Crossing; or the MSRB’s Spring-
field office: 436 Dwight St., Room 109A.
Drop-off hours at both offices are Monday
through Friday from 10 a.m. –3 p.m., except
on state holidays.
1. The following information on lump sum payments was previously published in
the Pension Action Center Fact Sheet, “Lump Sum vs Annuity Payments: Which Is
Right for Me?” (2017), which is available on the Pension Action Center website,
www.umb.edu/pensionaction.
PENSION CONCERNS FOR RETIREES
PAGE 119
SAMPLE PENSION BENEFIT REQUEST LETTER
Name: __________________________________________
Street Address: ___________________________________
City, State and Zip: ________________________________
Today’s Date: ____________________________________
OCO
Office of Earnings Operation
ATTN: ERISA Correspondence Group
P.O. Box 33007
Baltimore, MD 21290-3007
Dear Sir or Madam:
Please provide me with a copy of the SSA Notice SSA-L99-C1 regarding my potential pension benefits
from in .
(name of employer) (city and state where employer was located)
In support of my request, I am submitting the following facts:
Name: _________________________________________________________
Social Security Number: ___________________________________________
Date of Birth: ___________________________________________________
Parents’ Names: _________________________________________________
I certify that I am the person to whom the record pertains, or that person’s legal guardian, or a person
who is authorized to sign on behalf of that individual. I know that the knowing and willful request or
acquisition of records under false pretenses is a criminal offense subject to a fine of up to $5,000.
Please send the information to me at the address noted above. I am enclosing a copy of
my as proof of my identity. ank you.
(government-issued photo ID, such as driver’s license)
Sincerely,
Signature:
REMEMBER TO ATTACH A COPY OF YOUR PHOTO ID TO THIS FORM BEFORE MAIlING.
PAGE 120
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
CHAPTER 18
HEALTH CARE DECISIONS, MEDICAL INFORMATION
AND END-OF-LIFE CHOICES
INTRODUCTION
As people age, a major area of concern for older
adults is addressing health care decisions and end-
of-life considerations. In Massachusetts, there are a
number of documents that older adults should im-
plement as part of their health care decision plan-
ning.
TIP: For those who have just learned they have cancer,
there is a booklet from the American Bar Association
which details steps in determining the right type of
care for an individual at: https://linkprotect.cudasvc.
com/url?a=https%3a%2f%2fwww.americanbar.
org%2fgroups%2fhealth_law%2finterest_
groups%2feducational_outreach%2fhlcancer%2f
&c=E,1,VjDaKt78V-Lu8o-GVFQr5xAnOl06w-3-g1U
9G1qE3dnqq4coo2c9sQWfJeE3F0guRiqnmIBp0F6
0uzHx92LBTVXwclvgFU1hFg0LiBsx3j1w&typo=1.
THE HEALTH CARE PROXY
e key document governing the delegation of
health care decisions in Massachusetts is a Health
Care Proxy. Using a Health Care Proxy, you (the
principal) can appoint a trusted individual (the
health care agent) in a health care proxy to make
health care decisions for you should you become in-
capacitated or unable to communicate your wishes.
Massachusetts recognizes the health care proxy by
statute and provides a form, which must be appro-
priately witnessed and signed. A sample Health Care
Proxy is included as an exhibit to this chapter.
e Health Care Proxy is activated upon your
incapacity. Your lack of capacity must be determined
by an attending physician in consultation with oth-
ers. If you have not executed a Health Care Proxy
prior to incapacity, a court-appointed guardian may
be required to make your medical decisions.
e agent you select must be 18 years of age or
older. You can also appoint an alternate agent if the
first person becomes unavailable to act. You may
only select one agent to act a time to serve as your
health care agent. e agent will be permitted to
make a wide range of medical decisions on your be-
half. You are free to limit in your proxy the decisions
your agent is authorized to make. Your agent makes
decisions for you only when and for as long as you
cannot do that for yourself. If and when you regain
the capacity to make medical decisions, the author-
ity over such decisions shifts from your agent back
to you individually.
You can also indicate other wishes in a Health
Care Proxy, such as whether or not you wish to have
your organs donated upon your passing (but should
also ensure that if you wish to be an organ donor,
that your wishes are reflected with the Massachu-
setts Registry of Motor Vehicles.) To be an organ
donor, you can register at any time through the
Registry of Motor Vehicles (RMV). Many people
register when they apply for or renew their Massa-
chusetts driver's license or ID. You can also register
online at RegisterMe.org/MA.
You may want to express your wishes as to end-
of-life care in writing within the Health Care Proxy
itself, or by way of an advance medical directive,
sometimes referred to as a “living will” (see below).
An agent under a Health Care Proxy will gen-
erally have access to your medical records in con-
nection with their authority to make medical deci-
sions on your behalf. If you wish, you may restrict
the scope of this authority within your Health Care
Proxy.
If you wish for additional individuals beyond
your Health Care Proxy to have access to your
medical Information, you may consider executing
a HIPPA release form to authorize such release of
information. A sample release form is included as an
exhibit to this chapter. See page 121 regarding per-
sonal and health care professional access to medical
records.
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 121
NOTE: Medicare now gives you the option on
its website to identify a contact in the event of
a medical emergency. This does not replace a
Health Care Proxy. (See www.Medicare.gov/Medi-
careOnlineForms/PublicForms/CMS10106.pdf.)
WHAT ARE THE DIFFERENCES BETWEEN A
HEALTH CARE PROXY AND AN ADVANCE
DIRECTIVE? DO I NEED A LIVING WILL ALSO?
ere are other ways for you to provide a state-
ment of your preferences regarding medical-related
decisions, such as life-sustaining or do-not-resusci-
tate measures, to a health care agent or medical pro-
vider in case you cannot communicate your wishes.
If you wish to refuse the use of feeding tubes, res-
pirators and/or cardiac resuscitation, these deci-
sions can be expressed not only in your Health Care
Proxy, but also in an advance directive or living will.
An advance directive makes an incapacitated indi-
vidual’s treatment preferences known to the health
care agent in a set of limited and specific circum-
stances and provides written evidence of the princi-
pal’s wishes, values, beliefs and specific instructions.
Whether to include provisions regarding these mat-
ters in a Health Care Proxy or in a separate living
will or advance directive is a matter, to be discussed
with an elder law attorney. A living will can be help-
ful if you anticipate a potential dispute among fam-
ily members regarding your health care treatment.
MEDICAL ORDERS FOR LIFE-SUSTAINING
TREATMENT ("MOLST")
MOLST is the acronym used for medical orders
for life-sustaining treatment. It is a standardized
form that provides for a process for discussing, doc-
umenting and communicating end-of-life treatment
options and preferences between doctor and patient.
In order for the MOLST to be effective, it must
be signed by both the patient and the clinician only
after an in-depth conversation between the patient
and the clinician.
In addition to having a Health Care Proxy, any-
one with a serious medical condition should speak
to their physician about a MOLST.
Your physician may ask you to complete a
MOLST. If you are uncomfortable in doing so, you
should decline but ensure that your physician is
aware that you have a Health Care Proxy and that a
copy is in your file.
If you become unable to make or communicate
treatment decisions to health care providers, and
you have not executed a valid Health Care Proxy or
applicable MOLST, then decisions must be made
by a court-appointed guardian. Guardianship can
be a costly and time-consuming process and can be
avoided by having the proper health care documents
in place.
Accessing Medical Information
(i) Every physician who treats you keeps a record
of your visit; when this record is entered on
a computer, it is called an Electronic Medi-
cal Record (EMR). e record belongs to the
medical professional who wrote it, but you
can inspect the record and get a copy of it,
usually upon a request in writing. Under the
Health Insurance Portability and Account-
ability Act (HIPAA), the doctor has 30 days
to provide you with a copy of the medical re-
cord; if the records are older and no longer in
the office, the process can take up to 60 days.
You are charged a reasonable fee to copy the
records, but you do not pay for the time it
takes to find them.
(ii) You may be asked for permission for your
medical record to be shared with your other
providers. Some hospitals and physicians use
the Mass HIway (the Massachusetts Health
Information Highway) where your personal
Electronic Health Record (EHR) is shared
with other providers who treat you. is is
especially useful if you have specialists who
treat you at different hospitals, since all of
your doctors will be able to share their re-
ports.
(iii) Your medical records are not shared automat-
ically; you have to agree or “opt in” to have
your records shared among your providers.
Your spouse, family members or other per-
sons cannot get your medical records without
your permission. You generally have the right
to see your records made by a psychologist or
psychiatrist unless the provider feels that the
inspection would “lead you to serious harm.”
PAGE 122
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
(iv) ere are situations where your medical pro-
vider must report certain conditions, such as
injuries due to guns, burns on more than 5%
of a person’s body, rape, sexual assault or opi-
oid overdose. Results of HIV/AIDs tests can-
not be disclosed without first obtaining your
written permission.
DOCUMENTS, LISTS AND OTHER ITEMS
TO BRING WITH YOU IF YOU ARE TO BE
HOSPITALIZED:
1. Your Health Care Proxy, living will (if any) and/
or other advance medical directives. A sample
Health Care Proxy is included at the end of this
chapter.
2. A document with your name, age, address and
phone number, as well as the names of close rela-
tives or friends and their phone numbers; your
Medicare or MassHealth insurance numbers;
and any other health insurance cards.
3. e list of current medications you are on, in-
cluding all ones for heart and blood-thinning, as
well as any chronic illnesses you have.
4. Your cell phone, tablet and/or computer with ap-
plicable chargers, because visitors are not allowed
to see you in the hospital or recovery rooms.
COMMUNICATING WITH YOUR HEALTH CARE
PROVIDERS, HEALTH CARE AGENT, AND
FAMILY AND FRIENDS
It is very important to communicate with your
health care agent as to what decisions you want
them to make on your behalf in the event you can-
not make or communicate the decision for your-
self. ey cannot respect your wishes if you have
not made choices for them to follow and told them
clearly. You should also consider sharing your medi-
cal wishes and directives with your family, friends
and caregivers so that they will be aware of and re-
spect your wishes. ere are several resources avail-
able to help you do this. One is the Conversation
Project — whose website is https://theconversation-
project.org/, which specifically records your wishes.
A copy of that form is included at the end of this
section, along with a sample health care proxy with
instructions and a Medical Orders for Life-Sustain-
ing Treatment (MOLST) form, which, if presented
to you, should be reviewed with your physician.
Choices when faced with Cancer: For those who have
just learned they have cancer, there is a booklet from the
American Bar Association which details steps in determin-
ing the right type of care for an individual at https://link-
protect.cudasvc.com/url?a=https%3a%2f%2fwww.
americanbar.org%2fgroups%2fhealth_law%2finterest_
groups%2feducational_outreach%2fhlcancer%2f&c=E
,1,VjDaKt78V-Lu8o-GVFQr5xAnOl06w-3-g1U9G1qE3d-
nqq4coo2c9sQWfJeE3F0guRiqnmIBp0F60uzHx92LBT-
VXwclvgFU1hFg0LiBsx3j1w&typo=1.
Choices at the End of Life
Learning that you have a serious or terminal
illness is life-changing. We all avoid talking about
death, especially with our spouse, children and
those closest to us. However, it is most important
to have these conversations about our wishes, in fact
our responsibility to initiate and have them.
While a person cannot live forever, there are
quality-of-life decisions a person can make when
faced with poor outcomes. Your family, care givers,
physicians and medical teams have limited power to
change outcomes, but each and all can honor your
wishes and instructions.
You must decide on the path you wish to take,
given this news. Is there any specific event, activity,
person you wish to see, or plan you want to finalize?
Identify them and make a list. Discuss this list, and
its time-frame with your providers. Most likely, they
will be hopeful that you can achieve it all, but you
should ask about their experience with others and
the offered treatment alternatives. Be specific. For
example, how will you be affected by the progres-
sion of the disease? Will you be able to read, walk or
feed yourself? ese questions seem harsh, but they
are necessary to establish what you value as quality
of life. Where will you receive this care? Can you
return home? Is your family unit able to care for
you, or will you need assistance beyond what they
can provide?
Our focus here is on heroic measures/aggres-
sive care, clinical trials, palliative care, and hospice.
Quality-of-life decisions do not include physician-
assisted suicide in Massachusetts.
Consider these four alternatives:
1. Heroic Care — is is aggressive care, which of-
ten has side effects. Ask your providers what are
the side effects of this care, and how many people
taking this care have survived for 6 months, a
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 123
year or more. What were they able to do – if you
were to do this, would you enjoy your quality of
life after enduring the side effects? Ask if this ag-
gressive care would disqualify you from a clinical
trial.
2. Clinical Trials — Ask if the care being discussed
is an approved experimental treatment of the Food
and Drug Administration. Will you be receiving
the experimental treatment or a different treat-
ment? What percentage of patients are alive six
months/one year after receiving this treatment?
What are the side effects? What happens if you
discontinue this? Note that you may not qualify
for a clinical trial or you may decide against it.
3. Palliative Care — is care is primarily intend-
ed to reduce pain. You can continue on your plan
of treatment, but the main emphasis is to make
you comfortable. Palliative care can begin at any
time that you and your physician decide.
4. Hospice Care — is care ends any treatment
for the disease, and emphasizes pain management
and quality of life. For example, a patient who
has terminal cancer will not receive chemother-
apy, but will receive their standard medications,
including anti-depressants, insulin, etc. Hospice
requires a Do Not Resuscitate (DNR) order.
Hospice care supports terminally ill patients and
their families. In order to qualify for hospice, a
physician must certify that the patient has a life-
limiting condition and is unlikely to live beyond
six months. If the patient continues to live be-
yond six months, the patient is reevaluated. Hos-
pice does not end automatically at the end of six
months. Hospice is covered by Medicare, most
Medicare Advantage plans, and if the patient is
qualified, by MassHealth. https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/
Hospice.
Please refer to other sections of this guide re-
garding documents and forms which will be need-
ed. Most importantly, be clear with your family and
providers about your wishes. Following your wishes
will be a comfort for those who love and care for
you.
HELPFUL RESOURCES:
How to start the conversation about end of life:
https://hospicefoundation.org/Hospice-Care/Starting-
the-Conversation
https://samaritannj.org/resources/end-of-life-
conversation-starters/
https://lifecare.org/news-events/hospice-end-of-life-
discussion-guide/
Five Wishes: Asks you to answer questions — such
as how do you want people to treat you, what you
want them to know, etc. (paid site)
https://www.fivewishes.org/for-myself/
Further information on the difference between
palliative care and hospice:
https://www.vitas.com/hospice-and-palliative-care-
basics/about-palliative-care/hospice-vs-palliative-
care-whats-the-difference
VNA hospice care: https://vnacare.org/
PAGE 124
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
COVID-19 CHECKLIST AND KEY RESOURCES PAGE xi
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 125
PAGE xii COVID-19 CHECKLIST AND KEY RESOURCES
PAGE 126
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
COVID-19 CHECKLIST AND KEY RESOURCES PAGE xv
MASSACHUSETTS MEDICAL ORDERS
for LIFE-SUSTAINING TREATMENT
(MOLST) www.molst-ma.org
Patient’s Name: __________________________
Date of Birth: ____________________________
Medical Record Number if applicable: _________
INSTRUCTIONS: Every patient should receive full attention to comfort.
This form should be signed based on goals of care discussions between the patient (or patient's representative signing below)
and the signing clinician.
Sections A–C are valid orders only if Sections D and E are complete. Section F is valid only if Sections G and H are complete.
If any section is not completed, there is no limitation on the treatment indicated in that section.
The form is effective immediately upon signature. Photocopy, fax or electronic copies of properly signed MOLST forms are valid.
A
Mark one circle
CARDIOPULMONARY RESUSCITATION: for a patient in cardiac or respiratory arrest
Do Not Resuscitate Attempt Resuscitation
B
Mark one circle
Mark one circle
VENTILATION: for a patient in respiratory distress
Do Not Intubate and Ventilate Intubate and Ventilate
Do Not Use Non-invasive Ventilation (e.g., CPAP) Use Non-invasive Ventilation (e.g., CPAP)
C
Mark one circle
TRANSFER TO HOSPITAL:
Do Not Transfer to Hospital (unless needed for comfort) Transfer to Hospital
PATIENT
or patient’s
representative
signature
D
Required
Mark one circle and
fill in every line for
valid Page 1.
Mark one circle below to indicate who is signing Section D:
Patient Health Care Agent Guardian* Parent/Guardian* of minor
Signature of patient conrms this form was signed of patient’s own free will and reects their wishes and goals of
care as expressed to the Section E signer. Signature by the patient’s representative (indicated above) conrms
that this form reects their assessment of the patient’s wishes and goals of care, or if those wishes are unknown,
their assessment of the patient’s best interests. *A guardian can sign only to the extent permitted by MA law.
Consult legal counsel with questions about a guardian’s authority.
CLINICIAN
signature
E
Required
Fill in every line for
valid Page 1.
Signature of physician, nurse practitioner or physician assistant conrms that this form accurately reects their
discussion(s) with the signer in Section D.
Optional
Expiration date (if
any) and other
infornation.
This form does not expire unless expressly stated. Expiration date (if any) of this form:
SEND THIS FORM WITH THE PATIENT AT ALL TIMES.
HIPAA permits disclosure of MOLST to health care providers as necessary for treatment.
X
Signature of Patient (or Person Representing the Patient)
X
Legible Printed Name of Signer
X
Signature of Physician, Nurse Practitioner or Physician Assistant
X
Legible Printed Name of Signer
Date of Signature
Telephone Number of Signer
Date and Time of Signature
Telephone Number of Signer
Telephone Number
Telephone Number
Health Care Agent Printed Name
Primary Care Provider Printed Name
Approved by DPH August 10, 2013 MOLST Form Page 1 of 2
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 127
PAGE xvi COVID-19 CHECKLIST AND KEY RESOURCES
Patient’s Name: Patient’s DOB: Medical Record # if Applicable:
PATIENT
or patient’s
representative
signature
G
Required
Mark one circle and
fill in every line for
valid Page 2.
Mark one circle below to indicate who is signing Section G:
Patient Health Care Agent Guardian* Parent/Guardian* of minor
Signature of patient conrms this form was signed of patient’s own free will and reects their wishes and goals of
care as expressed to the Section H signer. Signature by the patient’s representative (indicated above) conrms
that this form reects their assessment of the patient’s wishes and goals of care, or if those wishes are unknown,
their assessment of the patient’s best interests. *A guardian can sign only to the extent permitted by MA law.
Consult legal counsel with questions about a guardian’s authority.
CLINICIAN
signature
H
Required
Fill in every line for
valid Page 2.
Signature of physician, nurse practitioner or physician assistant conrms that this form accurately reects their
discussion(s) with the signer in Section G.
ADDITIONAL INSTRUCTIONS FOR HEALTH CARE PROFESSIONALS
Follow orders listed in A, B and C and honor preferences listed in F until there is an opportunity for a clinician to review as described below.
Any change to this form requires the form to be voided and a new form to be signed. To void the form, write VOID in large letters across
both sides of the form. If no new form is completed, no limitations on treatment are documented and full treatment may be provided.
Re-discuss the patient’s goals for care and treatment preferences as clinically appropriate to disease progression, at transfer to a new
care setting or level of care, or if preferences change. Revise the form when needed to accurately reflect treatment preferences.
The patient or health care agent (if the patient lacks capacity), guardian*, or parent/guardian* of a minor can revoke the MOLST form
at any time and/or request and receive previously refused medically indicated treatment. *A guardian can sign only to the extent
permitted by MA law. Consult legal counsel with questions about a guardian’s authority.
X
Signature of Patient (or Person Representing the Patient)
X
Legible Printed Name of Signer
Date of Signature
Telephone Number of Signer
X
Signature of Physician, Nurse Practitioner or Physician Assistant
X
Legible Printed Name of Signer
Date and Time of Signature
Telephone Number of Signer
F
Mark one circle
Mark one circle
Mark one circle
Mark one circle
Mark one circle
STATEMENT OF PATIENT PREFERENCES FOR OTHER MEDICALLY INDICATED TREATMENTS
INTUBATION AND VENTILATION
Refer to Section B on Page 1
Use intubation and ventilation as marked in
Section B, but short term only
Undecided
Did not discuss
NON-INVASIVE VENTILATION (e.g., Continuous Positive Airway Pressure — CPAP)
Refer to Section B on Page 1
Use non-invasive ventilation as marked in
Section B, but short term only
Undecided
Did not discuss
DIALYSIS
No dialysis
Use dialysis
Use dialysis, but short term only
Undecided
Did not discuss
ARTIFICIAL NUTRITION
No artificial nutrition
Use artificial nutrition
Use artificial nutrition, but short term only
Undecided
Did not discuss
ARTIFICIAL HYDRATION
No artificial hydration
Use artificial hydration
Use artificial hydration, but short term only
Undecided
Did not discuss
Other treatment preferences specific to the patient's medical condition and care:
Approved by DPH August 10, 2013 MOLST Form Page 2 of 2
PAGE 128
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
Massachusetts Department of Public Health
Authorization for Release of Information
Permission to Share Information
If you want the ________________________to share information about you with another person or
(Fill in name of person or organization)
organization, please make sure that you fill out all of the sections below (Sections I-VI). This will tell us what
information you want us to share and who to share it with. If you leave any sections blank, with the exception of
Section II (B), your permission will not be valid, and we will not be able to share your information with the person(s)
or organization you listed on this form.
SECTION I
I, ,
give my permission for _______________________
(print your name) (Fill in name of person or
organization)
to share the information about me that I list in Section II with the person(s) or organization that I list in Section V.
SECTION II
A. Health and Personal Information
Please describe the information you want the _______________________ to share about you.
(Fill in name of person or organization)
Please include any dates and details you want to share.
B. Permission about Specific Health Information. Only if you choose to share any of the following
information, please write your initials on the line:
_____I specifically give permission, as required by M.G.L. c. 111, § 70F, to share information in my record about HIV
antibody and antigen testing, and HIV/AIDS diagnosis or HIV/AIDS treatment.
____I specifically give permission, as required by M.G.L. c. 111, §70G, to share information in my record about my
genetic information.
____I specifically give permission to share information in my record about alcohol or drug treatment. If this
information is shared, I understand that a specific notice required by 42 CFR, Part 2 shall be included prohibiting the
redisclosure of this confidential information.
SECTION III – Reason for Sharing this Information
Please describe the reason(s) for sharing this information. If you do not want to list reasons, you may simply write:
“at my request,” if you are initiating the request.
SECTION IV – Who May Share This Information
I give permission to the person or organization listed below to share the information I listed in Section II:
Name
Organization
Address
HIPAA-compliant Authorization 9/08 Form 5-A
1
HEALTH CARE DECISIONS, MEDICAL INFORMATION AND END OF LIFE CHOICES
PAGE 129
Massachusetts Department of Public Health
Authorization for Release of Information
Permission to Share Information
If you want the ________________________to share information about you with another person or
(Fill in name of person or organization)
organization, please make sure that you fill out all of the sections below (Sections I-VI). This will tell us what
information you want us to share and who to share it with. If you leave any sections blank, with the exception of
Section II (B), your permission will not be valid, and we will not be able to share your information with the person(s)
or organization you listed on this form.
SECTION I
I, ,
give my permission for _______________________
(print your name) (Fill in name of person or
organization)
to share the information about me that I list in Section II with the person(s) or organization that I list in Section V.
SECTION II
A. Health and Personal Information
Please describe the information you want the _______________________ to share about you.
(Fill in name of person or organization)
Please include any dates and details you want to share.
B. Permission about Specific Health Information. Only if you choose to share any of the following
information, please write your initials on the line:
_____I specifically give permission, as required by M.G.L. c. 111, § 70F, to share information in my record about HIV
antibody and antigen testing, and HIV/AIDS diagnosis or HIV/AIDS treatment.
____I specifically give permission, as required by M.G.L. c. 111, §70G, to share information in my record about my
genetic information.
____I specifically give permission to share information in my record about alcohol or drug treatment. If this
information is shared, I understand that a specific notice required by 42 CFR, Part 2 shall be included prohibiting the
redisclosure of this confidential information.
SECTION III – Reason for Sharing this Information
Please describe the reason(s) for sharing this information. If you do not want to list reasons, you may simply write:
“at my request,” if you are initiating the request.
SECTION IV – Who May Share This Information
I give permission to the person or organization listed below to share the information I listed in Section II:
Name
Organization
Address
HIPAA-compliant Authorization 9/08 Form 5-A
1
Massachusetts Department of Public Health
Authorization for Release of Information
SECTION V – Who May Receive My Information
The person or organization listed in Section IV may share the information I listed in Section II with this person(s) or
organization:
Name
Organization
Address
I understand that the person(s) or organization listed in this section may not be covered by federal or state privacy
laws, and that they may be able to further share the information that is given to them.
SECTION VI – How Long This Permission Lasts
This permission to share my information is good until
.
Indicate date or event
If I do not list a date or event, this permission will last for one year from the date it is signed.
• I understand that I can change my mind and cancel this permission at any time. To do this, I need to write a
letter to ____________________, and send it or bring it to the place where I am now giving
(Fill in name of person or organization)
this permission (or fill in specific location) If the information has already been given out by, I understand that it is
too late for me to change my mind and cancel the permission.
• I understand that I do not have to give permission to share my information with the person(s) or organization I
listed in Section V.
• I understand that if I choose not to give this permission or if I cancel my permission, I will still be able to receive
any treatment or benefits that I am entitled to, as long as this information is not needed to determine if I am
eligible for services or to pay for the services that I receive.
SECTION V – Signature
Please sign and date this form, and print your name.
Your Signature Date
Print Your Name
If this form is being filled out by someone who has the legal authority to act for you (such as the parent of a
minor child, a court appointed guardian or executor, a custodial parent, or a health care agent), please:
Print the name of the person filling out this form:
Signature of the person filling out this form:
Describe how this person has legal authority for this individual:
HIPAA-compliant Authorization 9/08 Form 5-A
2
PAGE 130 RESOURCE DIRECTORY
CHAPTER 19
RESOURCE DIRECTORY
GENERAL INFORMATION
MassOptions: For Mass. Older Adults and eir
Families
www.MassOptions.org
Alzheimer’s Association
(800) 272-3900, (617) 868-6718 (Waltham),
(508)799-2386 (Central & Western MA),
(603) 635-3026 (New Hampshire)
www.ALZ.org
Executive Office of Elder Affairs in Mass.
(617) 727-7750 • (800) 243-4636
www.Mass.Gov/Elders
National Council on Aging
(571) 527-3900
www.NCOA.org
National Multiple Sclerosis Society
(800) 344-4867
www.NationalMSSociety.org
www.NationalMSSociety.org/Chapters/MAM
LEGAL INFORMATION
Justice in Aging
www.JusticeInAging.org
LGBTQ Resources
GLBTQ Legal Advocates & Defenders
GLAD Answers
(800) 455-GLAD
617-426-1350
www.glad.org
Legal Assistance: Massachusetts Bar
Association Lawyer Referral Service
(617) 654-0400
Toll-free: (866) 627-7577
www.MassLawHelp.com
Massachusetts Bar Association Dial-A-Lawyer
(held on the first Wednesday of each month)
5:30–7:30 p.m.
(617) 338-0610
Toll-free: (877) 686-0711
www.MassLawHelp.com
Mass. Chapter of the National Academy of Elder
Law Attorneys (MassNAELA)
(617) 566-5640
www.MassNAELA.com
National Academy of Elder Law Attorneys
www.NAELA.org
ELDER ABUSE PREVENTION AND REPORTING
INFORMATION
Attorney General Elder Hotline
(888) 243-5337
www.mass.gov/service-details/the-attorney-
generals-elder-hotline
Executive Office of Elder Affairs/Elder Abuse
and Protective Services
(800) 922-2275
www.Mass.gov/Reporting-elder-abuse-neglect
Long-Term Care Ombudsman
(617) 727-7750
www.mass.gov/service-details/ombudsman-
programs
Massachusetts Bank Reporting Project
www.mass.gov/service-details/the-massachusetts-
bank-reporting-project
RESOURCE DIRECTORY PAGE 131
SOCIAL SECURITY INFORMATION
Martin on Social Security
www.Law.Cornell.edu/socsec_treatise
Social Security Prescription Help
www.SSA.gov/benefits/medicare/prescriptionhelp/
U.S. Social Security Administration
(800) 772-1213
www.SSA.gov
MEDICAL INSURANCE INFORMATION
MassHealth: Customer Service Center
(800) 841-2900
Massachusetts Health Care for All
Health Care Resources
(800) 272-4232
(617) 350-7279
www.HCFAMA.org
MEDICARE AND MEDICAID SERVICES
Centers for Medicare and Medicaid Services
www.cms.gov/
Prescription Drug Coverage: General
Information
www.CMS.gov/PrescriptionDrugCovGenIn
Medicare HelpLine: Official U.S. Government
Site for People with Medicare
(800) 633-4227
www.Medicare.gov
MCPHS Pharmacy Outreach Program
(866) 633-1617
www.MCPHS.edu/Patient-centers/Pharmacy-
outreach-program
Medicare Rights Center: Prescription Drug Plan
National Helpline: (800) 333-4114
www.MedicareRights.org
SHINE (Serving Health Insurance Needs of
Everyone)
(800) 243-4636
www.Mass.gov/Health-insurance-counseling
VETERANS INFORMATION
City of Boston Veterans’ Services
(617) 635-3026
www.Boston.gov/Departments/Veterans-services
Mass. Department of Veterans’ Services
(617) 210-5480
www.Mass.gov/Orgs/Massachusetts-department-of-
veterans-services
In each of the chapters, you may find additional resources that are not listed on these pages.
