Medicaid

Read this article from NAMI with a thorough and straightforward explanation of a Pooled Income Trust. 

Why do people want to qualify for Medicaid in the first place? Because, even though this knowledge may come as a shocking surprise, neither Medicare nor any supplemental insurance coverage policies pay for long term care. Long term care includes home care services and nursing home services. When paid for privately, the cost of long term care runs to approximately $150K-$200K in New York.

But can one qualify for Medicaid without being poor? In New York, the answer is surprisingly yes. When determining one's eligibility, for a person over 65 years of age, Medicaid evaluates both assets and income.

If you spend some time in New York and some time in Florida, you may wish to consult your accountant about determining your domicile (as, depending on the answer, you will owe very different taxes). You may also think about consulting with two different local attorneys regarding your estate planning, as both New York and Florida have real differences in Will execution formalities, asset and homestead protection, Health Care and Power of Attorney languages, Medicaid eligibility rules and estate taxes. Consider this non-exclusive list of differences:

Recently someone asked me a question: if an co-op apt. is owned jointly by spouses with right of survivorship, can Medicaid enforce a lien against the estate or the decedent's interest in the co-op when the joint owner who was a Medicaid recipient dies?

One in three people who turn 65 end up in a nursing home. No one ever wants to go there, yet most of the time the family has no choice about this issue (it becomes dangerous to keep the person at home, the daily care required is too much for a home care aide, etc). 

In New York and in New Jersey nursing home now costs $15-$20K a month! The vast majority of people cannot pay this bill on their own, especially after years of retirement spending. Even if the person wants to stay at home, an average home care bill is $10-$12K a month, which, for most people is also unaffordable based on Social Security pensions and retirement savings.

Currently, Medicaid pays for home care and nursing home care.
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Even though some seniors may be entitled to home care through their Medicare benefits, it may be impossible for them to receive this needed care.

And that is why most people plan for Medicaid - not because they are trying to cheat the system, but because they have no other real choice. 

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Medicaid imposes a transfer penalty that can last for up to 5 years for all uncompensated transfers made prior to the application for nursing home Medicaid. This provision makes crisis planning for nursing home not efficient. Yet many people are reluctant to transfer their assets ahead of time and impoverish themselves, because, of course, no one knows when nursing home will be needed.

One way of avoiding the nursing home penalty is to prove to Medicaid that the transfer was made not for the purpose of Medicaid giving. For example, grandmother has a history of gifting large amounts of money to grandchildren, and continues doing so for several years while being in good health. If, at some point, she has a stroke and has to go to a nursing home, Medicaid will deny her application, claiming that the money gifted was an uncompensated transfer. The family can then appeal and try to prove to an administrative judge that the transfers were done while she was in good health and not as part of Medicaid planning.

This is an affirmative defense, meaning that the burden is on the family to prove their point, not on Medicaid to prove the opposite. If there is no evidence that grandmother was in good health while gifting the money, and if there is no pattern of gifting the money, the petition will likely be denied.

Disclaimer: This article only offers general information.  Each situation is unique. It is always helpful to talk to a specialized attorney, to figure out your various options and ramifications of actions.  As every case has subtle differences, please do not use this article for legal advice. Only a signed engagement letter will create an attorney-client relationship. ATTORNEY ADVERTISING

Many seniors are not aware that Medicare does not pay for custodial long term care. An individual suffering from Alzheimer’s disease or dementia, which requires assistance with feeding, bathing, and taking oral medications will not be covered by Medicare not by a Medigap insurance. The only way of paying for custodial long term care are: private payments, Medicaid, or Long Term Care Insurance.

Long term care: this is care that can be provided in the home, in a nursing home or in an assisted living facility. Eligibility for benefits is based on medical necessity as evidenced by an individual’s inability to perform a specified number of personal functions (activities of daily living): bathing, toileting, dressing, self-feeding, lack of mobility or loss of cognitive capacity.

Home Care: Most long term care insurance policies have a home care component. It is usually beneficial for an elderly person to continue to reside at home: familiar surroundings, familiar people and familiar foods provide comfort and control. The long term care insurance policy can pay for the number of hours required by the patient. This is a large improvement over Medicaid: individuals relying on public programs (Medicaid) frequently find that the number of hours authorized may be significantly less than what is required for the individual’s health and safety.

Coverage Provisions: These vary, depending on the need and the willingness to pay. In New York, a policy must offer at least 24 consecutive months of coverage. Each policy generally provides for a specified payment level, based on whether care is received at home, in an assisted living facility or in a nursing home. If the cost of care exceeds the policy benefit, the full benefit will be paid. If the cost of care is lower than policy benefit, the actual cost will be paid. Most policies contain a deductible, usually measured in days. The benefit period can be as short as two years, and as long as the life of the insured, with everything in between.

Exclusions: certain conditions are excluded by long term care insurance policies. These are, among others: alcoholism and drug additions, attempted suicide or intentionally self-inflicted injuries, mental and nervous disorders (except Alzheimer’s disease or demonstrable organic brain disease).

New York State Partnership for Long Term Care

These are specific long term care insurance policies approved by the New York Partnership policy.

Under a Total Asset Protection plan, the insurance policy will pay for the first three years nursing home care or six years of home care or a combination of the above (where two home care days are equal to one nursing home day). Individuals who have received these specified Partnership long term insurance benefits may apply for Medicaid and be eligible without regard to the value of their assets. Individuals may sell, transfer spend or retain assets, before during and after applying for Medicaid nursing home care – the penalty period does not apply. However, the Medicaid income levels will still be applied.

The policy premiums depend on age and coverage chosen. The Partnership policies are generally slightly more expensive than other policies. Annual premiums for a basic policy can range from $2,800 for a 40 year old to $13,000 for an 80 year old. However, the benefit is the ability to apply for Medicaid without transferring assets. All aspects must be considered and analyzed before a decision is made.

Disclaimer: This article only offers general information.  Each situation is unique. It is always helpful to talk to a specialized attorney, to figure out your various options and ramifications of actions.  As every case has subtle differences, please do not use this article for legal advice. Only a signed engagement letter will create an attorney-client relationship. ATTORNEY ADVERTISING.

Even though this concept appears reasonable (after all, most nursing homes are short on staff and rooms are semi-private at best), Medicaid does not permit it.

Medicaid is a payor of last resort: if there are any available sources of payment then these sources must be used first. If a resident, or anyone else on resident’s behalf pays for private nursing services, then it is considered a payment for a service for which Medicaid is already paying. As a result, Medicaid would then have to reduce its payment to the nursing home by the amount being private paid for the nursing services. This reduction would be unacceptable to the nursing home.

Similarly, Medicaid and Medicare pay a fixed fee to the nursing home for any room in the facility. As a result, Medicaid rate for a private room would be the same as the rate for a semi-private room. Therefore, most nursing homes reserve private rooms for private paying residents. Some relatives want to supplement the nursing home by giving additional payment for a private room. However, Medicaid would look to the private payment and reduce its payment to the nursing home by the amount of this private payment. The end result would be a nursing home receiving a similar rate for a private room and a semi-private room, which is not an acceptable business model. 

If a nursing home would accept a privately paid supplement on behalf of a Medicaid resident, either for a private room or for a private nurse, and if this payment was not reported to Medicaid, the nursing home would be committing Medicaid fraud. The consequences, both civil and criminal, are such that nursing homes are usually unwilling to discuss these supplements.

The one method that is available to supplement the nursing home care is to hire a “companion” to a Medicaid resident. Companion services are not considered medical, as a result they are not provided in the Medicaid nursing home rate. Placing a companion with a Medicaid resident will not have an effect on Medicaid payments. A skilled companion may provide various services to the resident, including bathing, toileting and feeding the resident.

Disclaimer: This article only offers general information.  Each situation is unique. It is always helpful to talk to a specialized attorney, to figure out your various options and ramifications of actions.  As every case has subtle differences, please do not use this article for legal advice. Only a signed engagement letter will create an attorney-client relationship.

It may come as an unwelcome shock to many personal injury plaintiffs, but Medicaid is entitled to recover medical expenses paid on behalf of an individual, from the proceeds of a personal injury or a malpractice action.

The entire award is subject to Medicaid recovery: there is no distinction between pain and suffering and medical expenses, both portions of the award are subject to Medicaid liens. Unlike estate claims, there is no limitation on the age of the recipient for Medicaid to impose its lien.

Limitations

The lien is limited to Medicaid payments made after the date the injuries were sustained. The lien is also limited to those Medicaid payments made for the treatment of injuries sustained. The rationale is that Medicaid is not entitled to recover for Medicaid properly paid (other than from estate claims).

One final limitation is that Medicaid is not entitled to a recovery when the claim is against a nursing home based on negligence or abuse of a Medicaid patient.

Legal Fees

Medicaid lien has the priority over all other liens, with the exception of the attorney fee for representing the injured party in an action to recover for the injuries in the accident. However, the attorney is not entitled to a fee from the proceeds being paid to Medicaid.

Disclaimer: This article only offers general information.  Each situation is unique. It is always helpful to talk to a specialized attorney, to figure out your various options and ramifications of actions.  As every case has subtle differences, please do not use this article for legal advice. Only a signed engagement letter will create an attorney-client relationship.