Medicaid Spend Down Strategies

Medicaid is not just for the indigent.  Medicaid is a government program which offers a variety of benefits to those in need, which includes elderly individuals who need assistance with paying for long term care costs. With the right planning, assets can be protected for the next generation, while helping a person become eligible for help with long term care costs.

Medicaid was to help with insurance coverage and protect seniors from the costs of medical care, regardless of their income, health status or past medical history, reports Kiplinger in a recent article “How to Restructure Your Assets to Qualify for Medicaid.” Medicaid was a state-managed, means-based program, with broad federal parameters that is run by the individual states. Eligibility criteria, coverage groups, services covered, administration and operating procedures are all managed by each state.

With the increasing cost and need for long term care, Medicaid has become a life-saver for people who need long term nursing home care costs and home health care costs not covered by Medicare.  So, this article will discuss various techniques and ideas on how to become eligible for Medicaid when appropriate.  However, this article is for ideas only, and I cannot stress this enough, but you should never undertake a Medicaid spend down without the advice and direction of an attorney.

If the household income exceeds your state’s Medicaid eligibility threshold, two commonly used trusts may be used to divert excess income to maintain program eligibility and thereby spend down income.

QITs, or Qualified Income Trusts. Also known as a “Miller Trust,” income is deposited into this irrevocable trust, which is controlled by a trustee. Restrictions on what the income in the trust may be used for are strict, and include things such as medical care costs and the cost of private health insurance premiums. However, the funds are owned by the trust, not the individual, so they do not count against Medicaid eligibility.  This tool is extremely effective, which facilities eligibility despite the amount of income.

If you qualify as disabled, you may be able to use a Pooled Income Trust. This is another irrevocable trust where your “surplus income” is deposited. Income is pooled together with the income of others. The trust is managed by a non-profit charitable organization, which acts as a trustee and makes monthly disbursements to pay expenses for the individuals participating in the trust. When you die, any remaining funds in the trust are used to help other disabled persons.

Meeting eligibility requirements are complicated and vary from state to state. An estate planning attorney in your state of residence will help guide you through the process, using his or her extensive knowledge of your state’s laws. Mistakes can be costly, and permanent, and often appear in Medicaid spend down.

For instance, your home’s value (up to a maximum amount) is exempt, as long as you still live there or intend to return. Several other exemptions may apply depending on the assets.  Otherwise, the amount of countable assets for an individual is $2,000, more for a married couple.

Transferring assets to other people, typically family members, is a risky strategy. There is a five-year look back period and if you’ve transferred asset without getting adequate value in return during that period your eligibility could be affected. So, gifting strategies could be risky.  If the person you transfer assets to has any personal financial issues, like creditors or divorce, they could lose your property.

Asset Protection Trusts, also known as Medicaid Trusts. You may transfer most or all of your assets into this trust, especially if they are otherwise countable. Upon your death, assets are transferred to beneficiaries, according to the trust documents.  This needs to be done in advance of the 5 year look-back, which is why this works best in anticipation of long term care need in the future, not when its imminent.

Right of Spousal Transfers and Refusals. Assets transferred between spouses are not subject to the five-year look back period or any penalties. Some states allow Spousal Refusal, where one spouse can legally refuse to provide support for a spouse, making them immediately eligible for Medicaid. The only hitch? Medicaid has the right to request the healthy spouse to contribute to a spouse who is receiving care but does not always take legal action to recover payment.

I should also point out that Medicaid recovery is an important aspect of Medicaid planning.  You can see this link for more details on that topic.  https://www.galliganmanning.com/protect-assets-from-medicaid-recovery/

Talk with your estate planning attorney if you believe you or your spouse may require long-term care and before undertaking Medicaid spend down. Consider the requirements and rules of your state. Keep in mind that Medicaid gives you little or no choice about where you receive care. Planning in advance is the best means of protecting yourself and your spouse from the excessive costs of long term care.

Reference: Kiplinger (Nov. 7, 2021) “How to Restructure Your Assets to Qualify for Medicaid”

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Role of Insurance in Estate Planning

Insurance in estate planning addresses liquidity, tax concerns and is even a vehicle for affordable long term care coverage.

I often discuss life insurance when working with a client on their estate plan and the role of insurance in estate planning in general.  Some have term life insurance policies from when they are young, others whole life policies promoted to them as money available into late retirement, and even a few solely because of the tax benefits to life insurance.  It’s possible that life insurance may play a much bigger role in your estate planning than you might have thought, says a recent article in Kiplinger titled “Other Uses for Life Insurance You May Not Know About.”

If you own a life insurance policy, you’re in good company—just over 50% of Americans own a life insurance policy and more say they are interested in buying one. When the children have grown up and it feels like your retirement nest egg is big enough, you may feel like you don’t need the policy. However, don’t do anything fast—the policy may have far more utility than you think.

Tax benefits. The tax benefits of life insurance policies are even more valuable now than when you first made your purchase. Now that the SECURE Act has eliminated the Stretch IRA, most non-spouse beneficiaries must empty tax-deferred retirement accounts within ten years of the original owner’s death unless some other exception applies. Depending on how much is in the account and the beneficiary’s tax bracket, they could face an unexpected tax burden and quick demise to the benefits of the inherited account.

Life insurance proceeds are usually income tax free, making a life insurance policy an ideal way to transfer wealth to the next generation. For business owners, life insurance can be used to pay off business debt, fund a buy-sell agreement related to a business or an estate, or fund retirement plans.

Even more, life insurance is often a very good tool to pay estate taxes.  This is true for two reasons.  First, the tax has to be paid in dollars, so an infusion of cash from a life insurance policy provides funds to pay it without selling off other assets such as real estate or business interests.  Second, life insurance is an easy asset to include an irrevocable trust.  It would be held outside of your estate (thus doesn’t make your estate tax bill go up) and for most insurance you don’t need immediate access to it.  See here for more information:  https://www.galliganmanning.com/the-irrevocable-life-insurance-trust-why-should-you-have-one/

What about funding Long Term Care? Most Americans do not have long-term care insurance, which is potentially the most dangerous threat to their or their spouse’s retirement. The median annual cost for an assisted living facility is $51,600, and the median cost of a private room in a nursing home is more than $100,000. Long-term care insurance is not inexpensive, but long-term care is definitely expensive. Traditional LTC care insurance is not popular because of its cost, but long-term care is more costly. Some insurance companies offer life insurance with long-term care benefits. They can still provide a death benefit if the owner passes without having needed long-term care, but if the owner needs LTC, a certain amount of money or time in care is allotted.

Financial needs change over time, but the need to protect yourself and your loved ones as you age does not change. Speak with an estate planning attorney about the role of insurance in estate planning for you.

Reference: Kiplinger (July 21, 2021) “Other Uses for Life Insurance You May Not Know About”

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Protect Assets from Medicaid Recovery

Medicaid is a government program used by Americans to pay long-term care, typically for nursing homes or in-home care.   What some people don’t realize is that Medicaid seeks reimbursement for money spent on someone’s behalf after they pass away.  The Medicaid Estate Recovery Program (MERP) is used to recoup costs paid toward long term care, so that the program can be more affordable for the government, says the article “What is Medicaid Estate Recovery?” from kake.com. Beneficiaries of Medicaid recipients are often surprised to learn that this impacts them directly, and are even more surprised that you can protect assets from Medicaid recovery with some planning.

Medicare was created to help pay for healthcare costs of Americans once they reach age 65. It covers many different aspects of healthcare expenses, but not costs for long-term or nursing home care. That is the role of Medicaid.

Medicaid helps pay the costs of long-term care for aging seniors. It is used when a person has not purchased long-term health care insurance or does not have enough money to pay for long-term care out of their own funds.  Medicaid is sometimes used by individuals who have taken steps to protect their assets in advance by using trusts or other estate planning tools.  See here for more detail.  https://www.galliganmanning.com/can-i-afford-in-home-elderly-care/

The Medicaid Estate Recovery program allows Medicaid to be reimbursed for costs that include the costs of staying in a nursing home or other long-term care facility, home and community-based services, medical services received through a hospital when the person is a long-term care patient and prescription drug services for long-term care recipients.

When the recipient passes away, Medicaid is allowed to pursue assets from the estate. In fact, Federal law requires the states to have such a program.  Now, this is critical to recognize, but the scope of Medicaid varies widely between what state provided the benefits.  For the most part it means any assets that would be subject to the probate process after the recipient passes. That may include bank accounts, real estate, vehicles, or other real property.  Texas Medicaid recovery is happily limited to the estate.  So, there are many options to protect assets from Medicaid recovery in Texas.

In some states, recovery may be made from assets that are not subject to probate: jointly owned bank accounts between spouses, payable on death bank accounts, real estate owned in joint tenancy with right of survivorship, living trusts and any assets a Medicaid recipient has an interest in.

An estate planning attorney will know what assets Medicaid can use for recovery and how to protect the family from being financially devastated.

While it is true that Medicaid can’t take your home or assets before the recipient passes, it is legal for Medicaid to have a claim to assets before the beneficiaries, similar to the way other creditors of a decedent must be satisfied before beneficiaries receive property.  Let’s say your mother needs to move into a nursing home. If she dies, you’ll have to satisfy Medicaid’s claim before you can take possession or will pay the claim as part of a sale.

Strategic planning can be done in advance by the individual who may need Medicaid in the future. One way to do this is to purchase long-term care insurance, which is the strategy of personal responsibility. Another is removing assets from the probate process. Married couples can make that sure all assets are owned jointly with right of survivorship, or to purchase an annuity that transfers to the surviving spouse, when the other spouse passes away.

In most cases we can advance clients on how to change the the titling of their accounts to protect assets from Medicaid recovery before the person passes away.  We may also be able to create a Medicaid Asset Protection Trust, which may remove assets from being counted for eligibility.

As a final point, clients often encounter the medicaid claim in the estate, which is the first time an attorney is involved in the process.  Now, you may not have the same options to protect assets from Medicaid recovery because you’ll have lost prospective planning, but their are exceptions to recovery and ways to defend against the claim.  They are all very time sensitive however, so you should reach out to an attorney immediately upon encountering them.

Speak with an estate planning attorney to learn how to prepare for yourself or your parent’s future needs. The earlier the planning begins, the better chances of successfully protecting the family.

Reference: kake.com (Feb. 6, 2021) “What is Medicaid Estate Recovery?”

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