Presenting a live 90-minute webinar with interactive Q&A Medicaid Eligibility Strategies in Long-Term Care Planning for the Elderly Navigating the Complex Requirements for Medicaid Qualification in a Climate of Services Cutbacks THURSDAY, JUNE 14, 2012 1pm Eastern 12pm Central 11am Mountain 10am Pacific Today s faculty features: David Goldfarb, Managing Partner, Goldfarb Abrandt Salzman & Kutzin, New York Michael J. Keenan, Attorney, Keenan Law, Glastonbury, Conn. Yale S. Hauptman, Attorney, Hauptman & Hauptman, Livingston, N.J. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10.
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Strafford June 14, 2012 Medicaid Eligibility Strategies in Long-Term Care Planning for the Elderly David Goldfarb Goldfarb Abrandt Salzman & Kutzin LLP 350 Fifth Ave. Suite 4310 New York, NY 10118 212-387-8400 www.seniorlaw.com
6 I. Medicare v. Medicaid Medicare is a federal program available to persons who are sixty-five years of age and older and certain disabled persons. Medicaid is a joint federal, state and city program which provides medical assistance for persons with low incomes and limited assets.
7 Medicare Parts A & B Basically Medicare is the health insurance component of Social Security. There is a Medicare Part A which covers hospital care and a limited amount of "skilled" nursing care and home health care. There is an optional Medicare Part B which covers part of physicians' costs and other medical services and supplies.
8 Medicare Parts C & D There is Medicare Part C or Medicare + Choice, which is an option for Medicare Managed Care. There is a Medicare Part D which is prescription drug coverage.
9 Medicare Gaps Medicare is far from perfect; it is in fact a safety net with many holes. Medicare has certain deductibles, limited payment periods, and restrictions on the types of services covered. Two of the most severe restrictions are: It only covers nursing home care if it is "skilled" care rather than "custodial," and it covers only 100 days of nursing home care per spell of illness. A spell of illness begins with the first day of inpatient care in a hospital or nursing home and ends when the beneficiary has been hospital and nursing home free for 60 consecutive days.
10 Medicare Supplemental Insurance (Medigap) Fill-in some of the gaps in Medicare coverage. For example most Medigap policies cover the 20% of physician's charges not covered under Medicare. However, most policies do not cover the part of the physician charges above the Medicare approved level. Medigap policies which cover nursing home care (Plan C or better) only cover 80 days of coinsurance and care which is "skilled" under the Medicare definition. There are some guaranteed renewable policies which predate the federal regulation of Medigap which cover up to 365 days of nursing home care (for example, AARP policies M or N)
11 Medicaid Medicaid is available to persons who are eligible for public assistance or SSI (Supplementary Security Income). Medicaid is also available in some states for persons with higher incomes. Spendown or Surplus Income Program: In states like New York the Medicaid Surplus Income Program is available for persons over sixty-five or who are blind or disabled whose incomes are too high to qualify for public assistance or SSI, but who spend down any excess income on medical costs until they reach the Medicaid income level.
Glastonbury, CT www.keenan-law.com (860) 657-2683 Medicaid: Medical Necessity Michael J. Keenan, Esq. Michael@Keenan-Law.com
Medicaid: Medical Necessity Criteria Used to determine level of care for Medicaid reimbursement for NH care or participation in long-term supportive services via a Medicaid waiver varies widely from state to state. Such criteria can include: Medical conditions, or A combination of medical conditions and functional impairments, or Functional impairments alone, or A particular score through an assessment instrument. www.keenan-law.com 13
Medicaid: Medical Necessity Medical Some states allow for admission to a nursing facility when nursing care is needed on a daily basis. Some states allow for admission when the resident requires intermittent skilled nursing care, daily skilled nursing assessment and 24/7 supervision by an RN or LPN. www.keenan-law.com 14
Medicaid: Medical Necessity Medical/Functional Some states require that residents need skilled care on a daily basis, which may include nursing or rehabilitation therapies, or Full assistance with at least 3 ADL s which may include transferring, ambulating, toileting, or eating; or One of several specified combinations of nursing and functional needs. www.keenan-law.com 15
Medicaid: Medical Necessity Functional States may use ADL s to establish its minimum criteria for admission. In such states, individuals need assistance with 2 or more ADL s, or they may need 24/7 care for medical monitoring and nursing care, restorative nursing or rehabilitative care or medication administration. www.keenan-law.com 16
Medicaid: Medical Necessity Scores Eligibility in states may be based upon determination of need scoring. May be derived from a mini-mental state examination (MMSE), identified minimum number of needs for assistance with ADL s, ability to recognize and respond to danger when left alone. This process is designed to target services for individuals with higher level of impairments who may have informal supports, and to individuals with lower level of impairments without informal supports. www.keenan-law.com 17
Medicaid: Medical Necessity Federal regulations require that states limit eligibility for such services to individuals who meet the state s criteria for institutionalization. Although states may apply stricter criteria limiting eligibility for admission to an institutional placement, the consequence is that such states would also be limiting participation for those why may be functionally or clinically eligible to participate in waiver programs. States must provide satisfactory assurances to the Centers for Medicare and Medicaid Services that necessary safeguards have been taken to protect the health and welfare of Medicaid recipients. www.keenan-law.com 18
Medicaid: Medical Necessity Adequate standards for all types of providers of services under the waiver; That standards of any state licensure, or certification requirements are met for service providers or individuals furnishing services under the waiver; That all facilities in which home and community based services are provided are in compliance with state standards that meet requirements for board and care facilities; Include periodic re-evaluations of level of care to determine if the recipient continues to require the level of care provided and absent the availability of waivered services, the individual would require institutionalization in either a hospital, nursing facility, or ICF/MR. www.keenan-law.com 19
Medicaid: Medical Necessity States can and do change LOC in response to budget constraints. The state of Georgia in particular revised it s LOC criteria and screening procedures for children s participation in the TEFRA/Deeming Waiver, resulting in the denial of LOC for hundreds of children who were previously participating, state-wide. Anticipate that current economic conditions will continue to result in states making LOC criteria more stringent. www.keenan-law.com 20
Medicaid Eligibility Requirements Yale S. Hauptman (973) 994-2287 contact@hauptmanlaw.com 21
II. Medicaid Eligibility Requirements B. Financial Eligibility Aged, Blind and Disabled (ABD) Classes of Medicaid have varying financial eligibility criteria including, income and asset limits 22
2012 SSI Financial Eligibility Supplemental Security Income (SSI) SSI Individual Benefit Rate: $698 SSI Individual Resource Standard: $2000 SSI Couple Benefit Rate: $1047 SSI Couple Resource Standard: $3000 23
Nursing Home Income Cap 2012 Nursing Home Income Cap $2094/month (gross) or 300% of the federal benefit rate Only income of the Medicaid spouse is counted Spend down Medicaid states permit eligibility if the resident s income is less than the incurred nursing home and medical expenses Income Cap Medicaid states must allow the use of a Miller Trust or Qualified Income Trust (QIT) to enable an individual whose income exceeds the income cap to meet income eligibility requirements 24
2012 Spousal Impoverishment (Nursing Home Financial Criteria) Minimum Monthly Maintenance Needs Allowance (MMMNA): $1838.75/month (All States except Alaska and Hawaii)* Maximum Monthly Maintenance Needs Allowance: $2841.00/month All states * Alaska - $2297.50; Hawaii - $2116.25 25
2012 Community Spouse Resource Allowance Minimum resource standard: $ 22,728 Maximum resource standard: $113,640 Home equity limits (not applicable to spouse) Minimum: $525,000 Maximum: $786,000 Exempt or non-countable assets Primary residence and contiguous land Retirement funds Personal property One car Life estate interest in real property if serving as primary residence Qualifying Promissory Notes Qualifying Annuities Qualifying Personal Services contracts Limited Business Interest Term Life Insurance Qualifying Pre-need Funeral Contracts 26
27 II. Medicaid Eligibilty Requirements C. Transfer of Assets Medicaid Transfer of Asset rules were originally in the Omnibus Reconciliation Act of 1993 (OBRA 93) The "Foster Care Independence Act of 1999" included important provisions affecting SSI recipients. Transfer of assets now effect eligibility for SSI (as had been the rule prior to 1988). There is only a 36-month look-back (unlike Medicaid s current 60 months) And a penalty period calculated by dividing the amount transferred by the SSI rate (including the state supplement).
28 II. Medicaid Eligibilty Requirements C. Transfer of Assets Deficit Reduction Act of 2005 (DRA) enacted Feb. 8, 2006, created major changes in the Medicaid Transfer of Asset rules: (1) created a five year look back; (2) calculate a penalty or waiting period from when a person is receiving institutional care and would be otherwise eligible; (3) created limits on home equity; and (4) required the state be a beneficiary on annuities.
29 Transfer of Assets: Institutional vs. Community Based Care States must imposes a penalty period of ineligibility for nonexempt transfers made by persons applying for "nursing facility services," typically a nursing home. States have an option as to whether to impose a penalty for transfers made by a person who is applying for community-based (noninstitutionalized) Medicaid (e.g., home care, hospital services). States vary as to whether they impose a transfer of asset penalty to care, services, and supplies provided as part of a waivered program under Section 1915(c) of the Social Security Act.
Transfer of Assets: Exceptions 30 No penalty period is imposed on transfers made for full and adequate consideration (e.g., sale of an asset for fair market value)
31 Transfers for Value: Personal Service Contracts Funds paid to a care provider, including a friend or relative, may be considered "a transfer for fair market value or other valuable consideration" if the compensation is reasonable and in accord with the fair market value of the services. a lump sum payment for an actuarially sound lifetime contract based on the life expectancy of the person receiving the care, may also be considered "for fair market value or other valuable consideration."
32 Transfer of Assets: Annuities Under DRA '05, the purchase of an annuity is treated as a transfer for less than fair market value, unless the annuity meets the following criteria: (1) it names the State as the first remainder beneficiary for at least the total amount of medical assistance paid on behalf of the institutionalized individual or the second remainder beneficiary after a community spouse or minor or disabled child; (2) it is irrevocable and nonassignable; (3) is actuarially sound; (4) it provides for equal payments during the term with no deferral or balloon payment. The provisions (2) through (4) above do not apply to annuitizing certain qualified retirement plans, an IRA or a Roth IRA.
33 Transfer of Assets: Promissory Notes The transfer of assets under DRA '05 includes funds used to purchase a promissory note, loan or mortgage unless the note, loan or mortgage: (1) has a repayment term that is actuarially sound; (2) has equal repayments during the term of the loan, with no deferral or balloon payments; (3) prohibits cancellation upon death of the lender. However, a promissory note may not be considered to be for fair market value where there is no reasonable expectation that it will be paid back.
34 Exempt Transfers: Purchase of a life estate The purchase of a life estate interest in another person's home is a transfer of assets under DRA '05 unless the purchaser resides in the home for at least one year after the purchase.
35 Exempt Transfer of Homestead A person will be eligible for Medicaid including, if the house is transferred to that person's: spouse; child who is blind, disabled or under age 21; sibling who has an equity interest in the home and who resided in the home for at least one year before the person was institutionalized; or child who resided in the home for at least two years before the person was institutionalized and provided care to maintain the person at home ("caretaker child").
36 Exempt Transfers (other than a home ) Transfers of assets other than a home are exempt from penalty if the asset transferred was a disregarded or exempt resource: A burial fund; property which is "contiguous" to the homestead; Life insurance policies with an aggregate face value of $1,500 or less; Reparation payments; and Retroactive SSI and Social Security benefits for nine months after the month received.
37 Exempt Transfers (other than homestead) Transfers of assets are exempt from penalty if the transfer is to: the spouse, or to another for the sole benefit of the spouse (including, but not limited to, transfer to a trust for the sole benefit of the spouse); a third party, by the spouse, for the sole benefit of the spouse; a blind or disabled child or a trust established for the sole benefit of the child (including, but not necessarily limited to, an OBRA '93 supplemental needs trust); or a trust established for the sole benefit of a disabled person under the age of 65.
38 Self Settled Exception Trusts Trusts that are established for the sole benefit of a disabled person, and funded with the assets of the disabled person, are exceptions to the general rule that the principal and income of discretionary self-settled trusts are considered available to the Medicaid applicant or recipient. There are two forms of exception trusts which contain the assets of a person with a disability: an individual OBRA '93 "payback" trust established for a disabled person under the age of 65; and an OBRA '93 pooled trust established for a disabled person of any age.
39 Self Settled Exception Trusts To qualify as an individual OBRA '93 payback trust: The trust is established for the benefit of a disabled person under the age of 65 by a parent, grandparent, guardian of the disabled person, or a court. The trust is funded with the assets of the disabled beneficiary. The state Medicaid agency must be reimbursed, up to the total value of medical assistance provided to the beneficiary, from the remaining balance in the trust upon the death of the beneficiary.
Glastonbury, CT www.keenan-law.com (860) 657-2683 Medicaid: Scope of Services Michael J. Keenan, Esq.
Medicaid: Scope of Services Mandatory coverage requirements dictated by federal statute, but states can expand on these minimum requirements. Medicaid covers medically necessary services. Coverage for some services is mandatory while coverage for others is optional. www.keenan-law.com 41
Medicaid: Scope of Services Home health care services. Coverage outlined in the state plan. Plan must spell out amount, duration and scope of benefits. SSI States & Section 209(b) States. Waiver programs. www.keenan-law.com 42
43 III. Medicaid Scope of Services B. Cutbacks in Home care Home Care is an optional service provided by some states under there Medicaid State Plan. Some States provide various amounts of home care under Medicaid Waivers. States are expanding Medicaid Managed Care to include their home care programs. New York is mandating Managed Long Term Care.
44 Cutbacks in Home care Personal care services (home attendant services) means assistance with the activities of daily living such as dressing and feeding; nutritional and environmental support functions; and health-related tasks. Continuous personal care services (for more than 16 hours per day) can include up to continuous 24-hour personal care services provided in shifts for persons who require total assistance with toileting, walking, transferring or feeding at times that cannot be predicted.
45 Cutbacks in Home care Personal care services shall not be authorized if the patient's need for assistance can be met by (a) voluntary assistance available from informal caregivers including, family, friends or other responsible adult; or formal services provided by an entity or agency; or (b) adaptive or specialized equipment or supplies including bedside commodes, urinals, walkers and wheelchairs. New York has refused to include safety monitoring in its task-based assessment and it has been upheld in federal court. Rodriguez v. DeBuono (City of New York), 197 F.3d 611 (2d Cir. 1999).
46 Home Care: Consumer Directed Personal Assistance Program NY has a Consumer Directed Personal Assistance Program (CDPAP) program provides for the applicant-recipient, or a family member, to manage all aspects of the employment of the home care worker, including hiring, training, and supervising the worker. A vendor agency authorized by the local Department of Social Services oversees the administrative aspects of the program such as timesheets and paychecks. To be eligible, the applicant-recipient must be able to direct the home care workers or have a guardian, relative or other adult who is able to direct the home care workers.
IV. Best Practices for Meeting Medicaid Eligibility and Application Requirements A. Healthy Spouse Strategies Snapshot of Assets As of the first day of the first month of continuous institutionalization 47
Healthy Spouse Strategies (cont) Convert Countable assets to Non-Countable Buy a new home No equity limit for healthy spouse 48
Healthy Spouse Strategies (cont) Purchase Medicaid qualifying annuity Irrevocable Nontransferable and non-cancellable Can only take out monthly payments Actuarially sound 49
Healthy Spouse Strategies (cont) Purchase life estate Must live there 1 year to avoid transfer penalty 50
Healthy Spouse Strategies (cont) Pay down debt Expand CSRA Fix up home 51
Healthy Spouse Strategies (cont) Change the will to disinherit the Medicaid spouse Be aware of the elective share which could trigger Medicaid transfer penalty 52
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Glastonbury, CT www.keenan-law.com (860) 657-2683 Pro s & Con s of Medicaid Michael J. Keenan, Esq.
Pro s If long term care insurance and/or private payment is not an option, Medicaid qualification can address staggering long-term care costs. Medicaid qualification can preserve some assets and income for a community spouse and/or dependents. www.keenan-law.com 55
Con s A significant spend-down of assets is often required. Medicaid beneficiary status can often make entry into a high-quality nursing home. Risk that gifts during the 5-year look-back, done without asset protection in mind, can ultimately be a significant eligibility problem. www.keenan-law.com 56
Con s Onerous application process; volumes of documentation, lengthy process. Shared room at nursing facility is likely. Ongoing re-determination process. Risk of estate recovery. www.keenan-law.com 57
Alternatives Private pay Long term care insurance www.keenan-law.com 58
59 IV. Best Practices C. Estate Recovery There are strict limitations on the right of the State to recover against the estates of decedents who were Medicaid recipients and the estates of their spouses. There is no right of recovery against an estate for Medicaid benefits correctly paid, except from the estate of a person who was permanently institutionalized and who owned real property that was subject to a valid Medicaid lien, or the estate of a person who received Medicaid benefits when he was over the age of 55.
60 Estate Recovery Any adjustment or recovery shall be made "only after the death of the surviving spouse" and "only at a time" when there is no surviving child who is under 21, blind, or disabled.
61 Estate Recovery: Limited or Expanded Federal law gives states the option to define the term "estate" broadly or narrowly. Notably, some states limit the definition of estate to "all real and personal property and other assets included within the individual's estate and passing under a valid will or intestacy."
62 Estate Recovery: Limited or Expanded Enhanced Medicaid estate recovery: an individual's "estate" includes all of the individual's real and personal property and other assets passing under the terms of a valid will or by intestacy and also includes any other property in which the individual has any legal title or interest at the time of death, including jointly held property, retained life estates, and interests in trusts, to the extent of such interests.
63 Estate Recovery: Estate of a Spouse If a Medicaid recipient is survived by a spouse, no recovery against the recipient's estate may be made until after the death of the surviving spouse In cases involving efforts to recover from the estate of a surviving spouse, some courts have denied recovery unless the surviving spouse could be considered a "responsible relative," who had the means to support the Medicaid recipient during the time benefits were received.