Increasingly, as clients speak to me about their wills, we migrate onto the subject of protecting their assets in the event they need nursing home or other long-term care. When someone needs nursing home care or has very heavy medical expenses that they cannot afford, Medicaid comes into consideration. It's a jointly run federal and state program that provides for medical care in this situation. Understanding how the potential need for Medicaid impacts your estate planning is important to understand.
Medicaid may provide coverage for certain types of medical care for people age 65 and older, if they can't afford hefty medical expenses that Medicare doesn't cover. Diseases like Alzheimer's and dementia often require care not covered by Medicare. Medicaid looks at your income and assets (resources) to determine eligibility. Certain types of property are exempt from being considered "resources" for purposes of Medicaid eligibility. If a person who's been on Medicaid dies with resources, Medicaid may have the right to be paid back typically from probate assets. This is one reason people create a living trust for assets - to prevent Medicaid from having access to assets for payback.
Medicare is health insurance for individuals age 65 and over, who are entitled to Social Security retirement benefits, or have received Social Security disability benefits for two years. It is the primary payer of health care coverage for those 65 plus. But it does not cover long term "custodial" care, which is what most people need with diseases like Alzheimer's or dementia. Non-skilled nursing home care or home health aides, not covered by Medicare, may be covered by Medicaid.
Medicaid is a jointly funded federal/state program originally designed to provide medical care to the "poor." It may provide coverage for certain types of medical care for folks age 65 and older, when they have hefty medical expenses that Medicare doesn't cover.
Many people learn about Medicaid only when they realize they no longer have the funds to care for themselves or a loved one. This can happen after funds are expended for home care for a long time or when a declining person has one too many medical needs in a row. For example, with Medicare, a hospital stay is covered as well as a period of time in a nursing home or rehab facility, if the patient's condition can be remediated or improved with the treatment. However, progress must be shown to receive Medicare coverage in a skilled facility.
Let's say a person falls, breaks a hip, has slight dementia and then progress isn't shown. When the permitted rehab days expire, Medicare may not provide continued stay in rehab or a skilled nursing facility. Then what? Medicare does not cover custodial care (non-skilled nursing care) in a nursing home. That's when folks may get involved with Medicaid, because out-of-pocket costs begin to mount and they may not have substantial cash reserves to pay these bills.
New York uses a "spend down" approach to determine eligibility for Medicaid. This means that you are required to spend down your income and assets on health care costs before you qualify for Medicaid. Both "income" and "assets" are subject to Medicaid fine print. In a spend down state, like New York, a person is eligible for Medicaid once medical expenses exceed income above the base amount. Medicaid counts both earned income (from salary or wages) as well as unearned income (dividends, interest, investment income) when determining eligibility. There are some small exemptions, such as for the cost of health insurance, but most income is included.
Medicaid also looks at your assets or "resources" when determining eligibility. An exempt resource, like a home you live in, is not counted as an asset to be spent down. Assets you give away do not count if you are applying for "community" or non-nursing home Medicaid. However, if you are applying for Medicaid for nursing home care, your "resources" include property you've given away during the prior 60 months. This five year look-back rule is critical in asset protection planning for Medicaid. If an applicant has resources in excess of the eligibility limits, he will not be eligible for Medicaid until he incurs medical expenses equal to or greater than the excess resources. The eligibility limits for income and assets are very low.
Certain types of property are exempt from being considered “resources” (or assets) for purposes of Medicaid eligibility. These include:
If a person who’s been on Medicaid dies with resources, Medicaid may have the right to be paid back typically from probate assets. This is one reason people create a trust to own assets – to prevent Medicaid from having access to assets for payback. A trust is a non-probate asset.
Clients want to know how they can keep their money and have an individual be eligible for Medicaid if that is needed down the road. We recommend using an irrevocable trust to accomplish the goal of preserving assets for the family unit while enabling a person to qualify for Medicaid. If a nursing home application must be made within 5 years of the time a gift in trust is made, it is possible to use other funds to pay out-of-pocket health care costs and wait until the five year period runs (from the date of asset transfer) before a Medicaid application is filed.
An irrevocable trust or Medicaid asset protection trust is often used to protect assets if a person seeks to qualify for Medicaid. The trust is set up with assets contributed by the person who may need Medicaid. Those assets are transferred into the name of the trust.
The trust is managed by a trustee, who can be a family member or an independent person or financial institution. There are many advantages of making a gift in trust, as opposed to outright to beneficiaries:
This is an irrevocable trust that essentially limits the use of trust funds to "income only." If the trust provides that income cannot be used for the creator of the trust (known as the "grantor" or "settlor") and/or the trust invests only in non-income producing assets, the underlying asset (e.g. a family home) will not be considered an available resource for Medicaid.
If the trust is funded with assets which produce income, but the income is paid only to beneficiaries (e.g. children or grandchildren and not the "grantor") the underlying asset is not considered a resource for Medicaid, nor is the "income" of the trust considered the income of the Grantor for Medicaid planning purposes.
If a trust owns investment assets and an adult child is named as the income beneficiary, the trustees will distribute the income to the child. While the child cannot be required to use those funds for a parent's care, there may be a fundamental understanding that this could be the case.