By Jeanne Sahadi via CNN Money

It’s always good to inherit money, whatever the tax consequences. But for the lucky few, it will be especially lucrative and tax free over the next eight years.

That’s because the new federal tax law doubles the amount of money that’s automatically exempt from the federal estate tax — to roughly $11 million of an estate for someone who was unmarried, or $22 million if they were married.

The provision remains in effect through the end of 2025, unless Congress extends it.

As it is, it’s not like many estates have been hit with the federal estate tax over the past several years.

Even if the old exemption levels remained in place — at $5.5 million per person ($11 million if married) — fewer than 11,500 estates would have to file an estate tax return, and of those only 5,500 or so would end up owing any tax at all, according to estimates from the Tax Policy Center.

Those numbers drop sharply under the new law. Less than 4,000 estates will have to file every year, and 1,800 or fewer will end up owing any money, the TPC estimates.

There’s even more profitable news for those who stand to inherit a serious batch.

Despite the doubling of exemption levels, the new tax law does not curtail what has been one of the most generous tax-free provisions for heirs: The step-up-in-basis rule.

The step-up rule basically lets you inherit a valuable asset without ever having to pay a capital gains tax on all the appreciation in the value of that asset that occurred before it became yours.

That’s because your capital gains basis is the value of the asset the day the person bequeathing it to you dies, rather than its value the day it was first acquired.

Effectively that means that those years of gains prior to your inheritance will remain untaxed forever.

No need to die to take full advantage of new rules

Should the new estate tax provisions expire as scheduled after 2025, the exemption levels will revert to where they would have been if the federal tax overhaul never passed. So, after accounting for inflation, that likely means they’ll be somewhere around $6 million for individuals and $12 million for married couples.

But if you’re wealthy and have no intention of dying in the next eight years, there’s still good news for your heirs.

“One does not need to die before 2026 to take advantage of this increased exemption since it can be used for lifetime gifts,” said Beth Kaufman, an estate tax lawyer at Caplin & Drysdale and former associate tax legislative counsel at the Treasury Department.

That’s because you’re allowed to give away money while you’re alive, tax free, up to the amount of the estate tax exemption. But what you give in life will reduce your exemption at death.

Until last year, you could only give away $5.5 million (or $11 million as a couple) in your lifetime. But under the new law, you may give away up to twice those amounts without owing taxes.

Even if you die after 2025, the legislation makes clear that the gifts you make under today’s higher exemption levels will retain their benefit even if the estate tax exemption level falls in the future, Kaufman said.

Here’s a simple example: Say you’re a wealthy widower who expects to live a long time. Today you have an $11 million exemption level. After 2025, it’s likely to fall to $6 million.

By giving your kids an $11 million gift today, you effectively get to give them $5 million more tax free than you would otherwise if you waited until you die after 2025 to bequeath it to them.

By Jordan Rau via NPR.org

As the federal government penalizes 751 hospitals for having too many infections and patient injuries, some states are feeling the cuts in Medicare payments more than others.

This year’s punishments landed the hardest in Connecticut and Delaware, where Medicare penalized half of the evaluated hospitals, federal records show. In New York and Nevada, 4 in 10 hospitals were penalized. A third were punished in Rhode Island and Georgia. (These figures do not include specialty hospitals automatically exempted from penalties: those serving veterans, children and psychiatric patients, and “critical access” hospitals that are the only institutions in their area.)

While every state except Maryland — which is excluded because it has a different Medicare payment system — had at least one hospital punished, some got off comparatively lightly. Of hospitals in Alabama, Kansas, Massachusetts, Missouri, Ohio, Texas and nine other states, 16 percent or fewer of the institutions were punished. (State summaries can be found at the bottom of this post; a searchable list of individual hospitals penalized is here.)

The penalties — now in their fourth year — were created by the Affordable Care Act to drive hospitals to improve the quality of their care. Each year, hundreds of hospitals lose 1 percent of their Medicare payments through the Hospital-Acquired Conditions Reduction Program.

The program’s design is stern: Out of the roughly 3,300 general hospitals that are evaluated each year, Medicare must punish the worst-performing quarter of them — even if they have reduced their number of potentially avoidable mishaps from the previous evaluation period.

“I have seen with my own eyes the improvement,” says Dr. Amy Boutwell, a quality-improvement consultant in Massachusetts. “I hear hospitals say straight up, ‘We don’t want to be in the lowest quartile; we want to get out of the penalty zone.’ “

The conditions Medicare considers include rates of infections from colon surgeries, hysterectomies, urinary tract catheters and central line tubes inserted into veins. Medicare also examines rates of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C-diff. The frequency of 10 types of in-hospital injuries — including bedsores, hip fractures, blood clots, sepsis and post-surgical wound ruptures — are also assessed. All these types of potentially avoidable events are known as hospital-acquired conditions, or HACs.

A mix of factors contributes to why more hospitals are punished in certain states. The penalties fall more frequently on teaching hospitals and on facilities with large portions of low-income patients. There are more of those in some states than in others. Some penalty recipients say Medicare isn’t adequately taking into account differences in patients, since those who are frailer are more susceptible to HACs.

There is also some element of statistical chance, since the number of reported conditions in one hospital on the edge of the bottom quartile might just have one or two more incidents than a hospital that narrowly escapes that designation.

“It’s a ‘HACidental’ payment policy,” says Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Some repeatedly penalized hospitals, such as Northwestern Memorial Hospital in Chicago, say the program is flawed by what researchers call surveillance bias: The hospitals that are most diligent in testing and treating infections and injuries are going to appear to have more such incidents than relatively lackadaisical institutions. The hospitals are responsible for reporting incidents to the federal government.

Medicare says it performs spot checks, but Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at the Northwestern University Feinberg School of Medicine, says more policing is needed for the rates to be credible.

“In no other industry would this pass, where a program without an audit and [with] voluntary data reporting would be considered valid,” Bilimoria says. “We know guys are gaming.”

Still, many hospitals that have large numbers of sicker and low-income patients, or that handle more complex cases, have avoided the penalties. Medicare issued no punishments this year to Cedars-Sinai Medical Center in Los Angeles; the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Massachusetts General Hospital in Boston or New York-Presbyterian Hospital in Manhattan.

While safety-net hospitals and teaching hospitals were penalized at a higher rate than other institutions, two-thirds of each group escaped penalties this year.

Dr. Kevin Kavanagh, board chairman of Health Watch USA, a patient advocacy group, says that most hospitals are reducing their HACs each year, in part because of the penalties.

“That’s really the bottom line that everyone should support,” he says. “No system is perfect.”

By Richard Eisenberg via Forbes.com

Survey after survey shows that people want to continue living in their homes as they age, rather than moving to a nursing home or an assisted living facility. (In a recent Nationwide Insurance survey of Americans 50 and older, 61% said they’d rather die than live in a nursing home.) But whether you or your parents will be able to receive long-term care benefits at home through Medicaid — assuming Medicaid-eligibility — is an open question.

That’s because state rules vary enormously regarding whether Medicaid — the leading payer of long-term care in America — will pay for a person’s long-term care at home. But a new report from the Center for Health Care Strategies (a nonprofit health policy resource center focused on low-income Americans) and Manatt Health (a health policy and business strategy advisory subsidiary of the Manatt, Phelps & Phillips law firm) aims to broaden the availability of Medicaid at home and in community-based settings.

A Toolkit for Medicaid at Home

Strengthening Medicaid Long-Term Services and Supports in an Evolving Policy Environment: A Toolkit for States describes innovative state programs that other states might replicate to serve their older residents. It was funded by The SCAN Foundation (a funder of Next Avenue, too) and the Milbank Memorial Fund.

“There’s a lot of innovation going on, but it can be a little dizzying in some respects,” said Cindy Mann, a partner at Manatt Health who worked on the report. “We wanted to present options that states might consider.”

Currently — and this may surprise you — more Medicaid money for long-term care services and supports is spent on home- and community-based services than in nursing facilities. That’s a welcome change. In 1995, only 18% of Medicaid long-term care spending supported home- and community-based services; today, 55% does.

Why not even more? “It’s hard, for a number of reasons,” says Dr. Bruce Chernof, president and CEO of The SCAN Foundation. “States want to make changes cautiously. They don’t want to start a program they might have to pull back on.”

The Medicaid Toolkit report featured three strategies states can adopt, and how certain states have already have done so. The strategies:

1. Developing the infrastructure to promote greater access to home- and community-based services.

“When someone is in need of long-term care services, figuring out where to go and how to get the services can be difficult,” said Alexandra Kruse, senior program officer at the Center for Health Care Strategies.

But Massachusetts, the report notes, has a nifty, free, one-stop information and referral network (a website and call center called MassOptions) to help residents understand how, or whether, they can get Medicaid reimbursement at home.

Even allowing people to provide long-term care at home through Medicaid is critically important. California, the report says, has implemented paid family leave to support family members providing long-term care for loved ones. “It’s hard to take time for caregiving without getting paid,” said Mann. “Paid family leave is a really terrific advance.”

2. Helping nursing facility residents return to, and remain in, communities.

“A lot of people in nursing homes could be getting care and services in the community and outside of the nursing home,” said Mann.

Problem is: Medicaid doesn’t pay for housing. “But there are opportunities for states to pull down funding from other programs to help reestablish somebody in the community,” said Mann. Arizona and Texas, the report said, are already providing housing supports to help nursing facility residents remain in their communities.

“And some health plans help families secure housing because it’s likely to be less expensive supporting them in the community than in a nursing home,” noted Mann.

In fact, a June 2017 report from the U.S. Department of Health and Human Services (HHS) said a program to bring nursing home residents back to their communities has shown significant cost savings to Medicaid.

On average, per-beneficiary, per-month expenditures declined by $1,840 (23%) among older adults transitioning from nursing homes through state pilots of the Money Follows the Person Rebalancing Demonstration program. Translation: average cost savings for Medicaid and Medicare programs of $22,080 per beneficiary during the first year after the transition. By the end of 2015, states had transitioned 63,337 Medicaid beneficiaries from long-term institutional care to community-based care.

Texas’ pilot Money Follows the Person program resulted in 68% of participants remaining in the community, saving $24.5 million in Medicaid funds.

The overall Money Follows the Person program, the HHS report added, “provides strong evidence of success at improving the quality of life of participants.” These people experienced “the highest levels of satisfaction with their living arrangements” and nearly all liked where they lived one year after community living — a 32 percentage point increase compared to when they were in institutional care. Their care didn’t suffer, either, after leaving the nursing homes, the HHS report noted.

3. Expanding access to home- and community-based services for “pre-Medicaid” individuals to prevent or delay nursing facility use.

Few older people suddenly need long-term care; typically, their health gradually devolves. That’s why it’s useful for states to offer access to home- and community-based services before someone will apply for full Medicaid.

“Washington and Vermont are looking to invest in some services for people who may not need a very significant amount of long-term care supports and services but may need moderate or light help,” said Mann. “If they’re provided that help, they may be able to avoid or postpone needing long-term services.”

In Vermont’s Choices for Care program, people are divided into three groups, including those who could benefit from in-home care, but aren’t infirm enough for Medicaid. Satisfaction with this pre-Medicaid program, the toolkit report said, “is very high.” Washington offers support to caregivers assisting state residents who don’t yet qualify for full Medicaid benefits.

An obvious question: If Congress cuts Medicaid, as seems increasingly likely, will that inhibit these types of state initiatives?

“It’s a serious concern,” said Chernof, who chaired the federal Commission on Long-Term Care in 2013. “You can’t take enormous bites out of Medicaid and Medicare and serve the same number of people with the same needs. Substantial cuts to either program will put people at risk.”

That said, Chernof added, “what’s interesting is there is bipartisan agreement that there ought to be better care at lower cost.” He’s hopeful the new toolkit “will help states make well-informed decisions.”

By Naseem S. Miller via The Orlando Sentinel

The future of American health care may be vague, but for 2018, here’s what we know about Medicare: premiums aren’t expected to change drastically and there are more Medicare Advantage plans to choose from.

“My best advice is that if you’ve turned 65, celebrate that you have options, and they’re some good options,” said Laura Feldman, who became a public speaker on aging issues after retiring from the National Committee to Preserve Social Security and Medicare. “But also remember that nothing is perfect, and nothing is free.”

Medicare open enrollment began Oct. 15 and will end on Dec. 7. During this time recipients can choose and change plans. You can decide if you want a Medicare Advantage plan with or without a prescription benefit; a stand-alone drug coverage plan; or traditional Medicare. Your selected coverage starts Jan. 1.

As a quick primer, traditional Medicare refers to Medicare Part A and B, for which the federal government sets reimbursement rates. Part A covers hospitals and Part B covers doctors visits and medical tests.

Then there are plans that are offered by private insurers with Medicare’s approval. These plans include stand-alone prescription drug, or Part D, plans, and Medicare Advantage plans. Many of these plans offer prescription coverage, but some don’t. The plans also are specific to each county, so make sure the plan you pick is for your county.

The new premium for Medicare Part B has not been announced yet, but according to the 2017 Medicare Trustees Report, the premium is not expected to increase next year.

Most seniors and disabled adults paid $109 a month this year. New Medicare enrollees, people not collecting Social Security and those with higher incomes paid $134 or more.

As for Medicare Advantage plans, overall, the average monthly premiums are projected to decrease by $1.91 — about 6 percent — in 2018, from an average of $31.91 in 2017 to $30, according to Centers for Medicare and Medicaid Services. Also, more Medicare Advantage enrollees are projected to have access to supplemental benefits such as dental, vision, and hearing, according to the agency.

The average premium for the Part D prescription drug plans also is projected to decline next year to an estimated $33.50 per month, which is about $1.20 below the average basic premium this year, according to CMS.

This year, you’ll have more Advantage plans to choose from.

Nationwide, the number of Advantage plans has grown from 2,700 to more than 3,100. The majority of beneficiaries will have access to 10 or more Medicare Advantage plans, according to CMS. That holds true for Florida, which with 295 plans will have the second-highest number of options behind California with 266 offerings.

In Central Florida, options have also increased from last year. You can choose from 20 plans in Lake County; 27 in Orange; 28 in Osceola; 29 in Seminole; and 24 plans in Volusia County.

There also are more prescription drug plans in Florida this year, with 21 offerings, three more than last year. More than 80 percent of Floridians with a Medicare prescription drug plan have access to a plan with a lower premium than what they paid in 2017. The lowest premium in 2018 is $17.70, according to CMS.

All this means “there are more choices, but there’s a lot more research and comparison shopping you have to do,” said Sue Greeno , the Center for Medicare Advocacy, a nonprofit based in Connecticut and Washington, D.C. “Medicare’s [online] Plan Finder tool is excellent, but without knowing how to use it, it could be daunting. So we always advise people to go their local [SHINE] office and get unbiased, individualized counseling.”

SHINE, or Serving the Health Insurance Needs of Elders, has volunteer counselors highly trained about Medicare. It’s the best source of advice and information, experts say. [See info box for contact information.]

Meanwhile, the worst thing you can do to yourself is taking no action, even if you’re very happy with your current plan, experts said. Plans change their networks and drug formularies each year and if you haven’t read the information they’ve been mailing you in recent months, you may be in for a surprise come January.

“Your primary care physician or specialist, or even your local hospital, may no longer be in network,” Greeno said.

When Margaret Lynn Duggar, executive director of Florida Council on Aging, was picking a plan for her husband, the first thing she did was call the Mayo Clinic, where he receives care, to find out if the plan was accepted there.

“Make that extra call. Call you specialist and providers before signing up,” Duggar advised.

And read your mail.

If you’re turning 65, your insurance company may automatically switch you from your work or marketplace policy to its Medicare Advantage plan — as long as the insurer has received the federal government’s approval and mailed you a notice 60 days in advance.

If you have Medicare and receive a low-income subsidy, you should also watch for documents that require you to recertify your eligibility.

And here’s one last piece of advice: watch out for scams and marketing violations.

“Medicare Advantage plans are allowed to advertise by direct mail, radio, TV and print, but they can’t call you or email you without your permission,” Greeno said. “They can’t come after you at a marketing event. They’re only allowed to discuss what you ask them.”

If you think someone representing a plan is violating the marketing rules, call the insurance company or your local SHINE office.

“The important thing is that people should take action,” Greeno saud. “That’s why it’s important to pay attention to open enrollment right now. It could really help or hinder your health care for the next year.”

nmiller@orlandosentinel.com, 407-420-5158, @naseemmiller

By Kimberly Marselas via McKnights.com

A new Centers for Medicare & Medicaid Services initiative will attempt to reverse a controversial trend of evicting residents who can no longer pay from the nation’s skilled nursing facilities.

In a memo dated Dec. 22, the agency reminds surveyors that federal regulations only allow facilities to discharge residents in specific circumstances, such as improving health or needs that cannot be met within the current facility. Though residents can be discharged for non-payment, some have criticized the process. They claim certain nursing homes operators sometimes begin the process before residents are given time to complete third-party or Medicare/Medicaid arrangements.

In 2015, CMS reported, “discharge/eviction” was the most frequent nursing home complaint category with national Long-Term Care Ombudsman programs.

“Discharges which violate federal programs…can be unsafe and/or traumatic for residents and their families,” the memo said. “In some cases, residents have become homeless or remain in hospitals for months.”

CMS is considering reinvestment proposals to prevent improper facility-initiated discharges, potentially through better resident and family education; better care plan design; or formation of a collaborative group focusing on resident placement and transitional care.