Legal Issues and Parkinson’s: Medicaid
for Long-Term Care
By planning
ahead, you also
can help ensure
that your assets
are protected.
“
”
Janna Dutton, J.D.
PA R K I N S O N ’ S D I S E AS E F OU N DAT I O N
5
N E W S & R E V I E W
S P R I N G 2 011
Medicaid for a specified period.
Some financial transfers are allow-
able; for instance, you can transfer un-
limited assets to or for the benefit of
any disabled person (that is, a person
who meets the Social Security Adminis-
tration definitions for being disabled
and is receiving benefits). This person
can be, but does not have to be, a child.
Such a transfer would need to be part
of a trust document or a power of at-
torney (see previous installments of this
series for further information).
Additional allowable financial
transfers that will not affect your eligi-
bility for Medicaid include:
•
Transfer to or for the benefit of an
adult disabled child (SSA definitions
of disabled)
•
Transfers to a trust for the benefit of
a disabled person
•
Transfers made exclusively for rea-
sons other than to become eligible
for Medicaid
•
Transfers for fair market value (you
can sell assets for fair value, but can-
not give them away and then apply
for Medicaid)
•
In cases where the imposition of a
penalty period will cause a hardship
(e.g., it would impact a person’s
health or basic necessities such as
food, clothing or shelter)
•
Certain transfers of homestead
property (for example, to a spouse,
to a disabled child, or to a caregiver
child who has been living in the
home for at least two years)
Exempt Trusts
You can also plan for the future
without losing eligibility by putting
your assets into a trust — that is, a
legal arrangement in which one person,
the trustee, holds property for the bene-
fit of another, the beneficiary. The
funds held in one of these trusts can be
used for your benefit while you con-
tinue to receive Medicaid. There are
certain requirements, e.g., the trusts
must be irrevocable, meaning they can-
not be reversed and under certain cir-
cumstances (for example, if the
beneficiary passes away), the trust must
pay back Medicaid.
There are two kinds of exempt
“OBRA Trusts” — named for the Om-
nibus Budget Reconciliation Act of
1993 — that are authorized under fed-
eral law to help people with disabilities
to plan for Medicaid. One of the ap-
proved uses of such a trust — in states
where Medicaid would not pay for a
private room in a nursing facility —
would be to pay for the difference in
rates between a private room and a
shared room. Another would be to
pay for additional services or facilities
not typically paid for by Medicaid,
such as recreation or a computer.
OBRA Trusts are good planning
devices, and can be set up at the last
minute. If you are sure that you want
to use this option in the future, be cer-
tain that you have provisions in your
power of attorney or finances docu-
ment allowing your agent to set up
the trust if you are not fully capable.
Applying for Medicaid
How can you get started? You can
apply for Medicaid by contacting your
local department of social services or
human services and asking for a Medi-
Coming Up:
Understanding Pain in Parkinson's
Tuesday, May 24
|
1:00 PM – 2:00 PM ET
Faculty:
Jeffrey Wertheimer, Ph.D.
Cedars-Sinai Medical Center, Los Angeles, CA
caid application (this may be adminis-
tered by your county, and may have a
different name, such as “Department of
Children and Families”). To fill out the
application, you will need, among
other things, your birth certificate, so-
cial security number, proof of address,
and information about your finances
and any insurance you have.
But before you do this, remember
that there are planning options that
you can use in order to make the most
of your assets. For help, you should
consult a knowledgeable elder law at-
torney in your state. You can find
one through the National Academy of
Elder Law Attorneys. If possible,
work with someone who is a certified
elder law attorney (CELA). Remem-
ber, it still is important to get a refer-
ral to make sure you find an at torney
with whom you are comfortable.
As with other legal issues and
Parkinson’s, if you think that it is likely
you will need some sort of chronic
long-term care, and you have no source
of paying for it other than Medicaid,
start right now to do your planning.
This can put you and your loved one’s
minds at ease and ensure your quality
of care for the future.
Ms. Dutton is an Eldercare Attor-
ney with Dutton & Casey. She recently
presented this topic at one of PDF’s PD
ExpertBriefings.
Pre-registration is recommended: (800) 457-6676
|
www.pdf.org/parkinsononline
|
info@pdf.org
Join PDF online or by phone for our upcoming PD ExpertBriefings
To learn more about Medicaid, call
(800) 633-4227 or go to:
www.cms.hhs.gov.
To find an elder law attorney, go to:
www.naela.org.
What's in the PD Pipeline?
Tuesday, April 12
|
1:00 PM – 2:00 PM ET
Faculty:
Michael Schlossmacher, M.D.,
University of Ottawa, Ottawa, Canada
6
PA R K I N S O N ’ S D I S E AS E F OU N DAT I O N
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Age.
About one percent of people over age 60 have Parkinson's disease, compared
with just 0.001 percent of people 45 or younger.
Gender.
Parkinson’s is more common in men than in women. It is not known
whether this is due to genetic factors, hormones or differences in behavior.
Head Injury.
Traumatic brain injury — injury that results in amnesia or loss of con-
sciousness — has been associated with an increased risk of developing Parkinson’s
years after the injury. Laboratory studies suggest that such injury may provoke in-
flammation in the brain, which could lead to the development of PD.
Area of Residence.
There are differences in the geographic distribution of PD.
These could be due to differences in environmental factors, some of which are refer-
enced below, and differences in genetic risk factors. Alternatively, they could be
traced to differences in the methods that are used to count people with PD. While
studies are too few to provide definitive patterns, some have been suggested. For ex-
ample, Parkinson’s prevalence is higher in the Inuit population in Denmark than it is
among other Danes, possibly reflecting a greater dietary intake among the Inuits of
persistent organic pollutants such as polychlorinated biphenyls, or PCBs (see page 7).
In the agricultural California central valley, living in a home near to fields where the
pesticides paraquat and maneb were used was associated with PD in one report. An-
other study reported greater incidence of PD in urban areas with high levels of indus-
trial emissions of the metal manganese, and possibly copper (see more on page 7).
Occupation.
Certain occupational categories or job titles have been associated with
a higher incidence of PD, but results have been inconsistent. The relationship be-
tween welding (the process of fusing substances, usually metals) and PD has been a
recent focus of controversy. In some reports for example, studies of people who are
referred for medicolegal evaluation (an examination to determine the legal aspects of
a workplace) welding has been suggested to cause Parkinson’s symptoms or earlier
onset of PD. However, in most other studies, including several in large national occu-
pational and disease registries, welding has not been associated with PD risk.
A higher frequency of PD has been associated with many other occupations, but only
a few occupations have been associated with PD in multiple studies, including agri-
cultural and industrial workers. By contrast, lower rates of Parkinson’s are associ-
ated with shift work and jobs involving vigorous physical work. While we can
hypothesize that the agricultural or industrial jobs may involve greater exposure to
toxicant chemicals, further study in other populations is needed to understand if cer-
tain occupations are actually associated with a higher risk of PD. Some of the studies
investigating specific toxicant exposures are described in the next sections.
Pesticide Exposure.
Of all the chemical exposures that have been linked to Parkin-
son’s, pesticides have been reported the most consistently. Recent research has shown
higher rates of Parkinson’s among people who were exposed to pesticides over a long
period of time as part of their work. Investigating other types of pesticide exposure,
such as home use, is more challenging. However, hobby gardening and home pesti-
cide use have each been associated with PD in one report. Although few studies have
identified specific pesticides as leading to PD, those that have been so identified in-
clude the insecticides rotenone and permethrin (used in clothing and mosquito netting
to kill mosquitos); organochlorines such as beta-hexachlorocyclohexane (beta-HCH
— used in the United States from the 1950s to the 1970s); and the herbicides
paraquat and 2,4- dichlorophenoxyacetic acid (2,4-D). It is important to note that
Environmental Factors and Parkinson’s
Continued from page 1
Coffee and tea.
Drinking coffee or
tea has been associated with a
lower risk of Parkinson’s, most
markedly so in men. Caffeine has di-
rect effects on the brain, and some
of these effects may help to cause a
lower risk of PD.
Uric acid or urate.
This chemical
occurs naturally in blood. High lev-
els, associated with diets high in cer-
tain foods, such as meats, can cause
gout and kidney stones. However,
researchers have found that men
with uric acid levels in the high end
of the normal range have a lower in-
cidence of Parkinson’s. Men with
PD who have uric acid in the high
normal range have a slower rate of
PD progression. In women, who
typically have lower urate levels, the
same effects are not established. A
drug that increases blood urate is
being studied in a clinical trial in PD.
Anti-inflammatory drugs.
Sev-
eral studies have shown that people
who regularly take anti-inflamma-
tory drugs such as ibuprofen have a
lower risk of Parkinson’s. Inflamma-
tion is thought to play a role in caus-
ing Parkinson’s, and reducing
in flammation may explain the re-
duced PD risk.
Potential Protective
Factors
Scientists have also found certain
factors that may actually reduce the
risk of developing Parkinson’s.
As with risk factors, not enough is
known about these and they should
not be tried without the counsel
of a doctor.
Dr. Tanner is the Director of Clinical Research at the
Parkinson's Institute and Clinical Center.
For a list of references used in this article, please contact PDF at info@pdf.org.
PA R K I N S O N ’ S D I S E AS E F OU N DAT I O N
7
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most people who are exposed to these pesticides do not go on to develop Parkinson’s.
The herbicide 2,4-D is one of the chemicals making up Agent Orange, used as a defo-
liant during the Vietnam war era. Although Agent Orange has not been proven to
cause PD, the US Department of Veterans Affairs has ruled that veterans with PD
who served in Vietnam between January 9, 1962 and May 7, 1975 are eligible to re-
ceive disability compensation from the Veterans Administration.
Exposure to Metals.
Occupational exposures to various metals have been sug-
gested to be related to the development of PD. But long-term exposure to metals is
not easily measured, and the results of studies measuring PD risk and specific metals
have been inconsistent. For example, high dose manganese exposure, a metal men-
tioned earlier, is known to cause a form of parkinsonism called manganism. Whether
there is a relationship between manganese exposure and PD has been a point of inter-
est, with focus on welders who may be exposed to it. A recent review concluded that
manganese is an unlikely cause of Parkinsonism in the US population of welders. Di-
rect measurement of lead levels in bone and blood serum suggests a link between PD
and lead exposure, with greater risk associated with greater lifetime exposure.
Solvents and Polychlorinated Biphenyls (PCBs).
Trichloroethylene (TCE) is a
solvent used in many industries and is the most common organic contaminant in
groundwater. Occupational exposure to TCE was found to be associated with
Parkinson’s among workers whose factory jobs resulted in long-term (eight to 33
years) exposure to the solvent. In a study of discordant twins (that is, twin pairs in
which just one of the members had PD), the twin who had been occupationally ex-
posed to TCE was more likely to develop Parkinson’s than the one who had not.
This link has also been observed in experiments in the laboratory.
Polychlorinated biphenyls (PCBs), mentioned earlier, are persistent organic pollutants
that were used in industrial processes until the late 1970s. PCBs have been found in
relatively high concentrations in the brains of people who had PD. Occupational ex-
posure to PCBs has been associated with greater risk of Parkinson’s in women, but
not in men, and those women who were exposed have shown evidence of injury to
their dopamine systems (the systems disrupted in PD).
Genetic Predisposition.
Often, a person’s genetic makeup will help to determine
the effect of an environmental exposure. For example, agricultural workers exposed
to pesticides were at an increased risk of PD only if they also had inherited a reduced
ability to metabolize toxicants. In another study, head injury was associated with a
higher risk of Parkinson’s only in people with one form of a particular gene; in peo-
ple without this particular gene variant, head injury was not associated with a higher
risk of PD. Increasingly, epidemiologists and geneticists are working together to iden-
tify combinations of genes and environmental exposures that are related to PD.
The Search for Proof
Observational studies cannot prove that an association is truly a cause of PD. This
is because the kinds of studies that could pin down exact answers cannot be carried
out on people. Instead, we must conduct experiments in the laboratory and then
project the results of these tests as best we can to what happens in people. However,
laboratory experiments can never give us the full picture of PD risk in humans. The
final test can only be done through an iterative process, taking the clues gained from
observations of human populations into the laboratory, and then bringing the labo-
ratory results back again to the human population. Plausibility in the human frame-
work provides the ultimate test for results from laboratory research. Our hope is
that understanding environmental risk factors will lead to a better understanding
not only of the causes of PD, but of other neurodegenerative disorders as well.
Smoking.
Many studies have asso-
ciated cigarette smoking with a de-
creased risk of PD. Researchers
hypothesize that nicotine may block
the damaging processes causing PD,
but the exact effects are not known.
A clinical trial to study nicotine in PD
is planned.
Cholesterol levels.
Some studies
have suggested that the use of statins
— drugs that are used to lower cho-
lesterol levels — is associated with re-
duced PD risk. However, in other
studies an association was also found
between low blood cholesterol levels
and increased PD risk. Understanding
cholesterol metabolism may provide
clues to the molecular mechanisms
that cause PD.
Body mass.
People with higher vi-
tamin D levels were at lower risk of
PD in one study. Vitamin D has
many beneficial effects that, theoret-
ically, could help to prevent PD, and
Vitamin D receptors (recognition
sites) are found in the brain areas
damaged in PD.
Exercise.
Greater physical activity
has been associated with lower risk of
Parkinson’s. Studies in animals also
support this.
Dr. Tanner is the Director of Clinical Research at the
Parkinson's Institute and Clinical Center.
For a list of references used in this article, please contact PDF at info@pdf.org.
8
PA R K I N S O N ’ S D I S E AS E F OU N DAT I O N
News In Brief
Continued from page 2
Q: Can DaTscan diagnose Parkinson’s?
Dr. Beck:
DaTscans cannot diagnose
Parkinson’s disease. These scans are
used to help a doctor confirm a diagnosis.
In Europe more than 300,000 people have
undergone the procedure. A DaTscan can
be used to help rule out other diseases
that may have clinical symptoms similar
to those seen in Parkinson’s — such as
essential tremor — that do not show the
deficiency in dopamine that marks Parkin-
son’s disease. However, it will not differ-
entiate PD from those diseases that —
like Parkinson’s — are marked by a
dopamine deficiency, such as multiple
system atrophy (MSA) or progressive
supranuclear palsy (PSP).
Q: What is the role of the DaTscan for
people living with Parkinson’s?
Dr. Beck:
Currently, there is no objective
test for Parkinson's disease. While the
specificity and sensitivity of DaTscans are
not 100 percent, the test can help doctors
to confirm or refute the diagnosis they
have made based on a clinical examina-
tion. DaTscans will therefore be helpful in
people whose symptoms present an in-
conclusive or confusing diagnosis.
Q: Are there any risks associated
with DaTscan?
Dr. Beck:
Among some individuals, there
have been reports of headache, nausea,
vertigo, dry mouth, and mild to moderate
dizziness. There have also been cases of
hypersensitivity reaction and pain at the
site of the injection. No other major side-
effects have been reported.
Q: I have Parkinson’s. Should I get a
DaTscan?
Dr. Beck:
Likely, no — especially if you are
someone who has been diagnosed with
Parkinson’s for several years and who re-
sponds well to standard Parkinson’s med-
ications. A DaTscan is most useful for
people whose diagnosis is clinically uncer-
tain or who have failed to respond well to
common Parkinson’s medication ther-
apy. If a person is unable to see a Parkin-
son’s specialist or his or her clinical signs
are not clearly those of PD, this is when a
DaTscan may be deemed helpful.
Q: How can I get a DaTscan?
Dr. Beck:
PDF recommends that you
speak with your doctor to see if a DaTscan
is right for you. If you are interested in
learning more, we suggest you visit
http://us.datscan.com/.
Q: Is the DaTscan test covered by insur-
ance, Medicare and Medicaid?
Dr. Beck:
DaTscan will be covered by
Medicare and Medicaid. Insurers are likely
to cover DaTscan but will policies vary, so
contact your insurer for more information.
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