Sustainable Bliss

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Long Term Care Insurance

As we experience the aging of our parents and older friends, it is clear that it is important to think about how we will manage a good quality of life when we cannot do everything ourselves. Some statistics:

  • Average age needing Long Term Health Insurance: 81
  • Average duration of stay over 1 year: 3.5 years
  • San Diego County Average for care: $270/day => $99,000/yr (California Averages)

Kinds of Long Term Care:

  1. custodial care - non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in/out of a bed/chair, using the bathroom (source)
  2. skilled nursing care - Nursing care such as help with medications and caring for wounds, and therapies such as occupational, speech, respiratory, and physical therapy
  3. long-term care - Services that include medical and non-medical (custodial) care for people with a chronic illness or disability.
  4. hospice care - Short-term, supportive care for individuals who are have a life expectancy of six months or less. Focuses on pain management and emotional, physical, and spiritual support for the patient and family. It can be provided at home or in a hospital, nursing home, or hospice facility.

Custodial care is the focus of this post.

Medicare does not include custodial care, and you can only get custodial assistance from your state's Medicaid program if you have less than $2000 in assets, and $600 in income (see below for details).

So if you have assets you want to protect, and sufficient income, long term care insurance often makes sense.

Some considerations when choosing a Long Term Care Insurance plan:

  • individual or group plan
    • group plan may be canceled
  • daily or monthly benefit
    • should cover 70% minimum daily benefit
    • you want monthly for home care
  • payment processing
    • reimbursement, indemnity, cash
  • waiting period before benefits start
    • normally 90 days - you pay out of pocket for this amount of time
  • inflation protection
    • important - want compound; typically 3%
  • facility-only or comprehensive that includes in-home care
    • for in-home, you must have a primary caregiver already
  • waiver of premiums while you receive care
  • benefit limits: period/total amount
    • average duration of stay over 1 year is 3.5 years, <15% more than 4 years

Long Term Care Partnership Policy

** not really viable anymore, as premiums have gone up **

California sample insurance rates

finding an agent: Agent Review * LTC Financial Solutions

FYI, if you fill out Schedule A when doing your annual taxes, you can enter long term care premiums, between $700 (less than 50 yrs old) up to $4,660 (over 70 yrs old).

Medicare / Medicaid

You are eligible for Medicare at age 65.  Medicare only covers medically necessary care and does not cover custodial care. Medicare does cover long-term care in a long-term care hospital or skilled nursing facility up to 100 days, some medical in-home care and hospice care. There are a limited number of facilities that are Medicare-certified. Even on Medicare, you are still responsible for copays.

Medicaid pays more of your bills, but you must be eligible.

Financial Eligibility for Medicaid

Assets whose value is counted in determining financial eligibility for Medicaid (max total of $2000):

  •  Checking and savings accounts
  • Stocks and bonds
  • Certificates of deposit
  • Real property other than your primary residence
  • Additional motor vehicles if you have more than one.
  • Cash surrender value of whole life insurance
  • Jewelry over $100
  • Your home if its equity value is greater than $500,000 ($750,000 in some states) and your spouse or child does not live there

Assets that do not get counted for eligibility:

  • Your primary residence
  • Personal property and household belongings, including all jewelry of spouse
  • One motor vehicle used for transportation
  • Whole Life insurance with a face value under $1,500; all Term Life insurance
  • Burial plots
  • IRA of applicant/beneficiary, if it is being distributed via periodic payments of interest and principal
  • IRA of spouse
  • Annuities if it is being distributed via periodic payments of interest and principal computed to be exhausted at the end of annuitant's life expectancy.
  • $2000 in cash

Income included these sources (max $600/mo to fully qualify) :

  • Regular benefit payments such as Social Security retirement or disability payments
  • Veterans benefits
  • Pensions
  • Salaries
  • Wages
  • Interest from bank accounts and certificates of deposit
  • Dividends from stocks and bonds

Spousal Impoverishment

If one person in a married couple needs long term care, the assets of both of them will be drawn down until all copays, etc are paid. So if one person needs long term care and then passes away, the survivor could be left destitute, as they are responsible for any outstanding bills. There is a Spousal Impoverishment Standard, that states that the spouse can have $119,220 in liquid assets and $2981 in monthly income, except if income is in spouse's name, then they can keep it all.

If you have limited assets and income, and will rely primarily on social security, it might not make sense to pay for long term care insurance, as the medical care

Insurance Policy Sources:

California Partnership for Long-Term Care The ABCs of Long Term Care Insurance California Department of Insurance Suze Orman

Government Program Sources: California Advocates for Nursing Home Reform

Weight Loss Checklist

I put this list together to help keep me on track with my challenge to lose some weight, and re-establish good habits that I will continue after I lose my target weight.


  • Stretch/Abs of Steel
  • Green tea
  • Breakfast (by 9am)
  • Walk (60 min)
  • Healthy snack
  • Healthy snack
  • Dinner (by 8pm)
  • Water (min 64 oz)
  • PT exercises
  • Class - yoga, piyo, etc
  • Cardio - rower, swim, etc
  • Meditate
  • Sleep (8 hrs)

Weight Loss Program

I have been struggling with my weight for a while - mostly up and down some during my 20s (started with the 'freshman 15') and 30s, and the past few years the change in my body due to my age (40s) and medical issues (back surgery, thyroid, hip and shoulder issues, etc) contributed to blocking me from achieving a good level of success in getting fit, though I had some streaks that went in the right direction. A few years ago I was at a good weight, and had good habits. Then I developed chronic and debilitating back issues, and had surgery so my exercise program went out the window, as well as motivation to spend time in the kitchen cooking. I gained some weight even though I would say that my eating habits were not terrible: vegetarian for 20+ years, organic produce (not enough fresh tho), 'healthy' frozen meals, not overwhelming amount of bread/carbs and cheese/dairy, occasional ice cream or fast food (maybe once a week). I recovered and went back to the good, stricter habits.  The small amount of weight loss was  slow, and it was hard to build momentum due to setbacks from all sorts of outside (and inside) influences.

I never really wanted to do a 'shake' diet. My thought was that ok, you lose some weight. But once you achieve your goal, come off the meal replacement shakes and stop being super strict, what's going to prevent you from boomeranging into unhealthy behavior? Well, I changed my mind. I believe that my body is different now, which makes it harder to take the weight off initially, and am confident that once I get down to a healthy weight I (and my hubby) will be able to consistently establish my prior healthy program and stay where I want to be.

I start ViSalus tomorrow... but first I need to come up with a daily checklist to keep me on track and motivated!

post script - it was not the right fit for me. I felt very ill (not the way you feel when you do cleanses, my body was rejecting the shakes, etc) for 3 days, and felt very shaky before I stopped. 


I had some little weird things happen to me last summer (light headedness, lack of energy, etc) that I thought were unconnected. I was already on thyroid medicine (had been since I was around 30), and had been tested 6 or 8 months before. My doc had me take a stress test to make sure there was nothing wrong with my heart. Ended up being my thyroid! Come to find out, if your thyroid is acting up there are lots of other things in your body that can act up, or shut down, too.

image from

Here are just the things that I experienced - there are actually even more effects of hypothyroidism:

  • Nails brittle
  • Hair brittle
  • Light headedness
  • High cholesterol
  • Iron saturation deficiency (super low)
  • Weight gain
  • Mood swings
  • Feeling out of balance
  • Difficulty sleeping
  • Fatigue
  • Frozen shoulder (happened a few months after my levels got to the correct spot)

Luckily, after feeling like my primary care doc wasn't getting it, I went to an endocrinologist who evaluated the right things and got me on the right path - some iron supplements until my iron saturation got back to normal (I use Floradix + Emergen-C packets to help with absorption), ashwagandha, higher levels of synthroid, more greek yogurt, more yoga. I also found out that my thyroid is a virtual moonscape - lots of striations, scar and nodules. Nothing to do about it, just need to keep an eye on it to make sure no nodules get too big or cancerous. Good news is that I was able to get my life back, and wake up feeling like I wanted to get out of bed!!

Frozen Shoulder (adhesive capulitis)

I have been diagnosed with a frozen shoulder, and honestly I think the pain is worse than when I herniated a disc and had to get a microdiscectomy. Full disclosure - I am not a medical professional and all info on this page is personal experience and research and if you think you have one you should see a doctor!

I didn't realize the shoulder is so complex, but basically it is made up of 2 bones (humerus=arm and scapula=shoulder blade), 4 major rotator cuff muscles (esubscapularis, supraspinatus, infraspinatus, teres minor) other muscles that attach to the skull/spine or humerus, a number of ligaments, cartilage (labrum) and a capsule that surrounds the joint.  Here's a picture I picked up from which is a great article.

In a nutshell, the capsule that is basically in your armpit contracts and sticks to itself. This is bad because the bones in the shoulder rely on the capsule to be nice and fluffy and keep space tolerances correct that allow the humerus to spin under the scapula which enables you to lift your arm over your head and behind you. Otherwise, the bones just move in one direction and pinch the area on your outer shoulder, causing inflammation. Not sure if this is clear. As I said before, I'm not a medical professional!

What happens

First your shoulder starts to bother you, followed by increasingly limited mobility and pain, climbing the mountain as the shoulder freezes more and more. The next step is when it is considered 'frozen', the pinnacle when the capsule contracts so much that it limits the movement of your shoulder since without a functioning capsule, the bones cannot move normally, ending up pinching the tendons in the outer shoulder. After you crest the frozen part, thawing can occur. Lots of documentation I've read said it will go away on its own eventually, possibly up to a year later. I'm not willing to deal with this pain for that long, if I can help it!


My doc did some range of motion tests to determine that he thought I had a frozen shoulder. I got an xray to be sure it wasn't structural, he gave me a cortisone shot, some exercise to do at home, and sent me on my merry way. A month later, some ranges of motion were improved but not all. So he had me get an MRI with arthrogam. Talk about paiiiiiiin!!!! They injected dye into the shoulder joint, but since the capsule is so contracted and stuck together it couldn't take much liquid and the pressure on the joint was literally unbearable. The normal hands-at-sides MRI was fine, but they wanted me to put the arm over my head... fuggetaboutit!!

The MRI seemed to show that I had a torn rotator cuff. Oh yay. But when I talked to the specialist, he said in the case where there is a frozen shoulder, the MRI can be inconclusive. And besides, he said that we would first need to treat the frozen shoulder anyway and then deal with the rotator cuff injury. In case I do have a torn rotator cuff, I just need to avoid hoisting more than 5 pounds over my head. Prescription: cortisone shot right into the joint coupled with very painful physical therapy. Start with 1 month and it should be 80% better, else get another shot and do therapy another month, possibly up to 16 weeks. Assuming I have crested the frozen pinnacle. If not, it might be longer.

How do you get it? Unfortunately that's unknown, but there are some factors that seem to contribute:

  • a woman between 40 and 60 (check)
  • thyroid problems (check)
  • diabetes (no thank you)
  • naturally 'loose' shoulder joint - can go back/side more than 90 degrees (check)
  • no daily full range of movement for some reason, may be disease or injury, may be lifestyle

Some initial therapy that I'm doing:

note: some of the stretches require a stick. I use an expandable trekking stick, but a broom or unscrewed handle of a Swiffer does nicely.

It's very important to relax the shoulder and the arm in the stretches. And breathe through the pain.

  • Stretch: lay on the bed and using a stick, bring your arms, shoulder width apart, straight up toward the ceiling and over your head. Hold for 5, back down
  • Stretch: lay on the bed, arms by side. bring them up  at your sides, keeping them in the plane with your body like a snow angel and shoulders not scrunching together. Hold for 5, back down
  • Stretch: lay on the bed and using a stick grab with both hands, elbows at 90 degrees.  Push the offending side down, keeping the elbow at 90 degrees.
  • Stretch: standing, grab a sick or towel behind your back with both hands. Pull your good arm over your head, stretching the back one against your body starting at your hips, eventually fingertips reaching your shoulderblade
  • Stretch: stand with offending arm at 90 degrees holding door jamb, twist body away from the arm. Be careful to keep arm at 90 degrees, shoulders relaxed and feel the stretch under your armpit and not in the top of the shoulder
  • Don't do anything weight-bearing with your arms (pushing up, downward dog)
  • Don't push yoga poses where your hands are over your head
  • Even when better, be careful not to twist in the shoulder joint too much. My shoulder is super loose/flexible so I have to be careful not to take it to the point of stopping, but just to the point of reasonable movement
  • Possible torn rotator cuff consideration: don't hoist anything over 5 lbs above your head

What to do When Recovering

I might have shoulder surgery in a bit, and was looking into what I could do while I'm recovering. I've had back surgery and mouth surgery and mostly watched a ton of TV with those, which gets boring and feels like a waste.  I'm sure I will do some of that, but this time I'm looking for things that can give me a bit of satisfaction,  only involve the use of one arm, and can be stopped and started as I transition in and out of the haze of painkillers and naps. Here are some ideas:

  1. learn a language - Duolingo is free has short daily exercises
  2. Watch TED Talks
  3. Take free self paced classes by MIT
  4. Join online classes by Coursera
  5. Watch photography webinars
  6. In November, write a book in coordination with NaNoWriMo
  7. Learn how to meditate
  8. Read some free books in Google Books
  9. Research a topic in Google Scholar
  10. Blog about the injury -> surgery -> recovery process
  11. Do a daily photo challenge
  12. Watch movies and TV shows on Hulu and Netflix
  13. Take up a craft... but not sure how much I could do with one arm immobile

Any other good ideas out there?