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Long Reher Hanson Minnesota Elder Law Attorneys
MEDICAL ASSISTANCE: A SUMMARY OF THE BASIC
ELIGIBILITY REQUIREMENTS Laurie Hanson
Long, Reher & Hanson, P.A.
www.mnelderlaw.com 2008 Long, Reher & Hanson, P.A.
Course Overview
Long-term care payment sources
Basic Medical Assistance Eligibility
Assets Spousal Impoverishment
Laws
Long Reher Hanson Minnesota Elder Law Attorneys
Course Overview
Income Transfers Appeals/hardship waivers MA Waiver programs
Long Reher Hanson Minnesota Elder Law Attorneys
Long Reher Hanson Minnesota Elder Law Attorneys
Why does this Matter?
Planning for persons who are living with disabilities who must maintain or obtain eligibility for public benefits to meet basic needs and use. To enhance quality of life – to live as
independently as possible for as long as possible
To ensure that assets can be protected to supplement and not supplant government benefits.
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WHAT IS LONG-TERM CARE?
A person who needs assistance with activities of daily living, such as bathing, dressing, eating, transferring, is a person who needs long-term care.
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Long-term care settings
Home Health Care Adult Day Services Assisted Living Skilled Nursing Facilities Board and Care Homes Group Residential Housing Hospice Care
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•Private pay/private insurance
•Medicare and supplemental insurance
•Long-term care insurance
•Veterans Benefits/ Veterans Home
Long-Term Care payment sources.
Medicaid
State and Federal program Minnesota’s Medicaid Program is
called Medical Assistance Basic Medical Assistance Medical Assistance for the nursing
home Home and Community-Based
waivers Long Reher Hanson Minnesota Elder Law Attorneys
Long Reher Hanson Minnesota Elder Law Attorneys
Home and Community Based Medical Assistance programs* for persons under age 65: *Also known as “waiver” programs. Mental Retardation or Related
Conditions (MR/RC) Community Alternative Care (CAC) Community Alternatives for Disabled
Individuals (CADI) Traumatic Brain Injury (TBI)
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Home And Community Based Medical Assistance Programs for people 65 and Older:
Elderly Waiver Program (EW)
Special Income Standard Elderly Waiver program (SIS EW)
Alternative Care program (AC) (not MA)
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Medical Assistance Services
Medical Assistance benefits include:
Hospitalization, physician services, some dental and eye care, medical supplies and treatments, etc
Mental health services for adults and children
Nursing homes
Home health care.
MA ELIGIBILITY GENERAL REQUIREMENTS
Minnesota resident Categorical Basis of Eligibility
65 and older Blind or Disabled Pregnant woman Under 21 Parent or caretaker of
dependent child Financially Eligible
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Basic Financial Eligibility
Single $3,000 in available assets Income spenddown
Married Community spouse asset
allowance + $3,000 Income spenddown
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WHICH ASSETS COUNT TOWARD THE $3,000?
Excluded Assets (no) Unavailable assets (no
– but used on asset assessment)
Available Assets (yes)
Available assets Assets are available if the owner has both
legal authority and actual ability to use them for self-support and assets are not excluded or unavailable.
Include savings and checking accounts, stocks, bonds, CDs, contracts for deed, IRAs, certain real property, collections, cash surrender value of life insurance policies, etc.
Premarital agreement has no effect.
Excluded assets
Homestead subject to limit in some circumstances (eff. 1/1/06)
Household goods and personal effects
Assets of trade or business One motor vehicle
Excluded assets
Insurance payments to repair or replace lost, damaged, or destroyed property
CSV of certain insurance policies Revocable burial fund: limit is $1,500 Irrevocable funeral trust:
Services limited to $2,000 No limit for burial spaces and space items
Prepayment of funeral
Life insurance or annuity: Itemized agreement with funeral home Amount paid same as in agreement Irrevocable primary beneficiary: “any
funeral home as its interest may appear”
Irrevocable contingent beneficiary: “estate”
Unavailable assets
Unavailability proved by showing legal or actual barrier to disposal of asset that cannot be overcome. Unavailable assets may include:
Next four slides…
Unavailable assets
Share of an estate that has not been probated
Property involved in a pending legal action
Non-homestead real property
Considered unavailable as long as applicant is making reasonable effort to sell
Asking price is no more than estimated market value on real property tax statement
Reasonable offer: no less than 2/3 EMV
Jointly held assets
General rule: Presumption that joint tenants own pro rata share
Exception: Checking or savings account, time deposits owned by MA applicant
Savings bonds: Unavailable if owned jointly and in possession of person who is not applying for MA
Life Estates and Joint Tenants
Life tenant has the right to: Live in the property throughout lifetime Receive all profits from the property
Life tenant has continuing obligation to: Pay property taxes, fire insurance,
maintenance Life estate is extinguished at
death unless after August 1, 2003
Trusts: available?Depends on:
(1) Kind of trust involved
(2) Who established the trust
(3) Whose assets were used to fund the trust…and
Trusts: available?
(4) Whether the trust is revocable or irrevocable
(5) Whether trust was established during lifetime or through a will
(6) Provisions of the trust agreement
Kinds of trusts Revocable trust
Irrevocable Trust
Trust with springing provisions
Supplemental needs trust
Special needs trust
Pooled trust
Other assets Annuities Continuing Care Communities
Bob’s and Kate’s assets
Certificates of deposit $125,000 Kate’s IRA $65,000 Bob’s IRA $35,000 Homestead $300,000 Automobile $ 20,000 Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Bob’s IRA $35,000 Homestead $300,000 Automobile $ 20,000 Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Available Bob’s IRA $35,000 Homestead $300,000 Automobile $ 20,000 Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Available Bob’s IRA $35,000 Available Homestead $300,000 Automobile $ 20,000 Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Available Bob’s IRA $35,000 Available Homestead $300,000 Excluded Automobile $ 20,000 Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Available Bob’s IRA $35,000 Available Homestead $300,000 Excluded Automobile $ 20,000 Excluded Household stuff $15,000 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available
Kate’s IRA $65,000 Available Bob’s IRA $35,000 Available Homestead $300,000 Excluded Automobile $ 20,000 Excluded Household stuff $15,000 Excluded 1/2 lake property $50,000
Bob’s and Kate’s assets
Certificates of deposit $125,000 Available Kate’s IRA $65,000 Available Bob’s IRA $35,000 Available Homestead $300,000 Excluded Automobile $ 20,000 Excluded Household stuff $15,000 Excluded 1/2 lake property $50,000 Unavailable
TERMINOLOGY: Married Couples
Community Spouse Ill Spouse (long-term Care Spouse) Asset Assessment Date Community Spouse Asset
Allowance Community Spouse Income
Allocation.
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Community spouse asset allowance
CSAA = 1/2 of non-excluded assets on asset assessment date with a
Minimum of $29,389
and
Maximum of $104,400 assets at time of MA application =
CSAA + $3,000
Date of Institutionalization
Protected Assets: CSAA $29,389 MA limit $ 3,000
Excess Assets: $ 2,611
Date of MA application, if in 2008:$29,389 $3,000
$35,000
Date of Institutionalization
Protected Assets: CSAA $50,000 MA limit $ 3,000
Excess Assets: $ 47,000
Date of MA application:$50,000 $3,000
$100,000
Date of Institutionalization
Protected Assets: CSAA $104,600 MA limit $ 3,000
Excess Assets: $112,400
Date of MA application, if in 2008:$104,400 $3,000
$220,000
Kate’s and Bob’s community spouse asset allowance
Total non-excluded assets CDs $125,000 Kate’s IRAs $ 65,000 Bob’s IRAs $ 35,000 1/2 interest in lake property $ 50,000
Total $275,000
1/2 of total is $137,500, which is greater than $104,400, so CSAA = $104,400. Excess assets to be reduced = $167,600.
MEDICAL ASSISTANCE:
DISCUSSION OF INCOME RULES
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Types of income
Excluded income Reverse mortgages Payments form low-income home
energy programs In-kind income Cash from sale of property Tax refunds Reimbursement of expenses
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Types of income
Available income Received by individual or on her
behalf Earned Income Unearned Income
Annuity payment RSDI, SSI Trust disbursments Regularly received gifts Lump sums
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Income Rules for Recipients in the Community
MA recipient is required to pay portion of income towards cost of services
Income standards for persons living in community: 100% FPG, currently $851 OR Spending down to 75% FPG ($639).
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Income Spenddown for Single Person in Community:
Income of Individual $2,000.00 less Medicare Part B -
96.00 less standard -650.00 less insurance premium -100.00
Income applied to care $1,154.00 Cost of Care $5440.00
less -1,154.00MA pays: $4,286.00
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Income Spenddown for Single Person in Nursing home:
Income of Individual $2,000.00 less Medicare Part B -96.00 less personal needs allowance -
84.00 less insurance premium -100.00
Income applied to care $1,720.00 Cost of Care $5,440.00
less - 1,720.00MA pays: $3,720.00
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SPECIAL INCOME RULES FOR MARRIED COUPLES
Community spouse is eligible for a spousal income allocation if his or her income does not meet a minimum income level
Minimum of $1,751 up to Maximum of $2,610 Calculation takes into account
ONLY excess shelter costs.
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SPECIAL INCOME RULES FOR MARRIED COUPLES
This amount changes every year Otherwise spenddown is the same
as for single person Only applies to long term care MA
(LTC MA) or EW
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Income Spenddown for Married Person in Nursing home:
Income of Ill Spouse $2,000.00 less Medicare Part B -96.00 less personal needs allowance - 84.00 Less community spouse allocation -1,500.00 less insurance premium -100.00
Income applied to care $ 220.00
Assets
Eligible?
Income
Is reduction of assets necessary?
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REDUCING ASSETS Paying monthly expenses Purchase of excluded assets Paying debts Prepaying funeral expenses Repairs to house Transferring assets??
Transfer warnings Federal law 1997: Makes it a
misdemeanor for paid advisor to counsel or assist in transfers if results in penalty period. Found to be unconstitutional.
Deficit Reduction Act of 2005: Affects transfers on or after February 8, 2006
Loss of ownership and control: once given away, assets are no longer yours.
What is a transfer?
Gift Sale Reduction in ownership interest Waiving the right to an
inheritance or income Refusing or failing to take
action to obtain a PI settlement
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Whose transfers matter?
Transfers made by: Applicant, Recipient, Spouse, or Any person, court or administrative body on
behalf of applicant or spouse
Must be reported and may affect eligibility IF THE TRANSFER IS FOR LESS THAN FAIR MARKET VALUE
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What is an uncompensated transfer? Uncompensated value of transferred (or
refused) asset =Fair market value less encumbrances and
compensation received.
Fair Market Value $250,000Sale Price $200,000
TRANSFER ($50,000)
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Transfer rules, in general
Transfers of assets or income For less than FMV Within the “lookback period” (36
months for transfers before 2/8/06 and until 2/09, then gradually increasing to 60 months by 2/11)
Ineligible for LTC coverage for a specific period of time
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Services to which transfer penalty applies
During a PERIOD OF INELIGIBILITY, Medical Assistance will not cover “institutional care.”
Nursing facility services
Level of care in any institution equivalent to nursing facility services
Home or community-based services including EW, AC, CADI, TIB, CAC, and DD
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Transfers: Presumption
Any transfer of assets or income is presumed to be for the purpose of establishing or maintaining MA eligibility.
Applies to transfers by CS after MA eligibility established for LTC spouse.
Any transfer to preserve estate, avoid probate, or reduce taxes is deemed “improper.”
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Calculation of period of ineligibility
Divide the amount transferred by the Statewide Average Payment for Skilled Nursing Facility care (SAPSNF)
As of the date of the application Currently $4,772 from 7/1/08
through 6/30/09
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Transfers before Feb. 8, 2006
Add total uncompensated transfers in any one month of the 36 months preceding the MA application
Divide by the SAPSNF, currently $4,772
Penalty period begins the month after the first transfer
Transfer of $200 or less OK except during pre-existing period of ineligibility
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EXAMPLE
TRANSFER $50,000 October 2005
$50,000 ÷ $4,772 = 10.48 months
PERIOD OF INELIGIBILITY
Transfer made in October, 2005
11/05 ----------------------------------9/06 (.48)
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EXAMPLE TRANSFER $200,000 June 2005
$200,000 ÷ $4,772 = 41.91 months
PERIOD OF INELIGIBILITY
If apply before July 2008 (within 36 months), full POI is imposed.
If wait to apply until after 36 months:
June 2005 --------------- July 2008The effective waiting period is 36 months.
APPLY JULY 1, 2008at the earliest
Transfers on or after 2/8/06
Lookback period of 60 months will be phased in
Period of ineligibility is calculated by dividing total assets transferred within 60 months by SAPSNF
Transfers on or after 2/8/06
Period of ineligibility begins: For recipient: the month for which
county can give 10 days advance notice, not to exceed three months after report/discovery of transfer
For applicant: the month in which individual is receiving long-term care services, applies for MA, and would be eligible except for transfer
SAME EXAMPLE
TRANSFER $50,000 October 2006
$50,000 ÷ $4,772 = 10.47 months
PERIOD OF INELIGIBILITY
•10.47 MONTHS FROM
•Date of application for Medical Assistance AND
•When otherwise eligible but for the period of ineligibility
Transfers on or after 2/8/06 There is no cap to the period of
ineligibility. No minimum allowable transfer. Can have a snowball effect Ineligibility begins when individual
applies and is otherwise eligible Care costs can exceed amount
transferred 67
EXAMPLE 1: Monthly Charitable Gifts
$500/month x 4 yrs = $24,000
TRANSFER of $24,000
POI: $24,000 ÷ $4,772 = 5.03 months
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EXAMPLE 1 (cont’d)
POI is 5.03 months
|____________________________________________|August ‘08 January (.03)Month of Application Ends 5.03 months later
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EXAMPLE 1 (cont’d)
Monthly long-term care cost = $6,000
Cost of care during POI:
$6,000 x 5 = $30,000.00$4,772 x .16 = $ 763.52$30,763.52
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Types of
Transfers
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Promissory notes, loans, and mortgages must:
Have repayment term that is actuarially sound
Provide for payments to be made in equal amounts during term of loan, with no deferral and no balloon payments made
Prohibit the cancellation of the balance upon the death of the lender
If terms are not met, balance is a transfer.
Purchase of life estate interest
The full amount that a person pays for a life estate in someone else’s home will be considered a transfer UNLESS the purchaser resides in the home for a period of at least one year after the date of the purchase.
Paying a relative can be an uncompensated transfer
Payment for services by a relative is a transfer unless:
The parties have a notarized written agreement dated at or before time of service, requiring paymentOR
Payment for services is made with sixty days of when services given
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Transfer of real estate The transfer is complete when:
Deed is executed AND Deed is delivered.
Date of delivery is earlier of: Date of recording Date of delivery as stated in affidavit Date of judicial order creating the
interest Date upon which interest devolves at
person’s death
PURCHASE OF ANNUITIES AS TRANSFERS
See Bulletin No. 08-21-04 dated May 27, 2008 on DHS
web site
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ALLOWABLE TRANSFERS:
Exceptions to the transfer rules
Allowable transfers of home To spouse, disabled or blind child of
any age, child under age 21
To sibling with equity interest
To caretaker child (not grandchild)
For value
Denial would cause undue hardship
Other exceptions to transfer rules To spouse at any time, or to 3rd
person for sole benefit of spouse To disabled or blind child or sole
benefit trust Transfer into trust for any disabled
person under age 65 (or a pooled trust for people of any age)
Return of assets
Return Assets: Example Eleanor transfers $200,000 to her son
in August and applies for MA in August.
POI is 41.91 months, beginning in August
Eleanor’s cost of care is $6,000 each month which her son returns to her and she uses to pay for care.
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Example (cont.) The period of ineligibility is reduced
each time money is returned. After six months, $36,000 will have
been returned; thus the total amount transferred to son is reduced to $164,000.
New POI = 34.38 months. At this rate, POI will be reduced to
18.5 months; $88,282 protected.
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Other exceptions to transfer rules (cont.)
Individual intended to dispose at FMV Transfer of excluded assets other
than homestead
Denial of eligibility would cause undue hardship
Undue hardship waiver: MN
Based on imminent threat to individual’s health and well-being
Evaluation criteria: Whether the individual was the victim of
financial exploitation Whether the individual has made reasonable
efforts to recover transferred property Other factors relevant to determination of
hardship Cause of action against transferee if granted
Undue hardship waiver: DRA
State develops procedures in accordance with standards specified by Secretary of HHS
NF can file application on behalf of individual 30-day bedhold payment to NF: NOT IN MN!! Undue hardship exists when denial would deprive
individual -- of medical care such that individual’s health or life
would be endangered; or of food, clothing, shelter, or other necessities of life
Criteria for determining if cause of action exists
C/A exists if transferee knew or should have known:
Transferor was resident of LTC facility or receiving that level of care in community
Transfer was being made to obtain or maintain MA eligibility
Transferee actively solicited transfer with intent to assist person obtain or maintain MA eligibility
Cause of action against transferee
Transfers made by applicant and not reported on application
Transfers by recipient during ongoing eligibility and reported too late to create period of ineligibility
If undue hardship waiver is granted to transferee
Liens Medical Assistance lien
against non-homestead real property
Notice of potential claim against life estate and joint tenancy interests
Estate recovery County may place claim against
estate for MA when: Person was over 55 and received MA/AC. Persons resided in medical institution for
6 months or longer and could not have been expected to return home.
Claim is against estate: of recipient, if single of surviving spouse, if married.
Estate recovery (cont.) If claim is against estate of surviving spouse,
claim limited to assets that were marital assets or held jointly during marriage (But, Barg may change this!)
Estate includes: Probate assets Some non-probate assets (joint tenancy,
POD and TOD accounts) Life estate or joint tenancy interest in RE
created on or after August 1, 2003
In the Estate of Francis E. Barg
Opinion issued by MN Supreme Court on May 30, 2008, which held:
1. Federal Medicaid law does not preclude all recovery from estate of surviving spouse of MA recipient.
2. Federal law limits scope of recovery to only those assets in which deceased MA recipient had a legal interest at the time of death and only to extent of MA recipient’s interest.
Thank you for your attention!
Long, Reher & Hanson, P.A.
www.mnelderlaw.com(952) 929-0622