You are most likely reading this article because you had a family member that had a health event and the doctors have informed you that they are not allowed to go back home to their house and will need some form of health assistance going forward. This article was written to help you understand from a high level the steps that you may need to take to get them the care that they need and to get a preview of the Medicaid application process and the spend down process, if that’s the path that needs to be taken.
Everyone is living longer which is a good thing but it creates more complications later in life. It is becoming much more common that people have family members that have a health event in their 80’s or 90’s that renders them unable to continue to live independently. Without advance planning, a lot of the important decisions then have to be made by family and friends so it is important for even younger individuals to understand how the process works because you may be in this situation some day for a loved one.
Do I Have To Apply For Medicaid To Pay For Their Care?
What you will find out very quickly is any type of care whether it’s home health care, assisted living, or a nursing home, is very expensive. Very few individuals have the assets and the income to enable them to pay out of pocket for their care without going broke. It’s not uncommon for kids or family members to have no idea what mom or dad’s income and asset picture looks like. But no one is going to provide you with this information unless you have a power of attorney.
Power of Attorney, Health Proxy, and Will
A power of attorney (“POA”) is a document that allows you to step into a person’s shoes that have been incapacitated. It allows you to get information on their bank accounts, investments, insurance policies, and anything else financial. If you do not have a power of attorney, you need to get one quickly. A lot of financial decisions will most likely need to be made in a very short period of time. You will need to contact an estate attorney to draft the power of attorney. There are some choices that you will have to make when you draft the documents as to what powers the “POA” will have. They can usually be turned around by an attorney in 48 hours if needed.
While you have the estate attorney on the phone, you also will want to make sure that they have a health proxy and a will. The health proxy allows you to make health decisions from a family member if they are unable to do so. While it’s difficult to think about, health proxies will typically list out end of life decisions. For example, a health proxy may state that mom or dad refuses to have a machine breathe for them if they are no longer able to breathe on their own. The questions are tough to answer but it’s very important to have this document in place.
Home Care, Assisted Living, or Nursing Home
Prior to the health event, mom or dad may have been living by themselves at their house. Now the doctor is telling them that because of the damage done by the stroke, that they will not release them from the hospital until other arrangements are made for their care. There are three options to receive care:
- Receiving care in the home via home care by health aids
- Assisted living facility
- Nursing home facility
People that cannot pay for 100% of their care and that do not have a long term care insurance policy, typically have to spend down their personal assets and then apply for Medicaid. So let’s jump right into what is protected and not protected as far as income and assets for Medicaid.
Different Rules For Different States
Each state has different eligibility and spend down rules when it come to Medicaid. For purposes of this article, we will assume that the person needing the care is a resident of New York. If you live in a different state, the process will be similar but the actual amounts and the definition of “protected” assets may be different. It’s usually best to work with a medicaid planner, estate attorney, or local social services office that is located within your state/county to obtain the rules for your family member that needs care.
The Medicaid Rules In New York
There are different limits based on whether the family member needing care is married and their spouse is still alive or if they are single or widowed. In general, if a couple is married and one spouse needs care, more assets and income will be able to be protected and they will be able to qualify for Medicaid because they recognize that income and assets have to be available to support the spouse that does not need the care. But for purposes of this article, we will assume that mom passed away and dad now needs care.
In 2018, to qualify for Medicaid, an individual is only allowed to keep $15,150 in assets. The next question I get is “what counts toward that number?” It’s actually easier to explain what DOES NOT count toward that number. The only assets that do not count toward that threshold are as follows:
- Primary Residence
- 1 Vehicle
- Pre-Tax Retirement Accounts (if older than age 70½) – (However Required Minimum Distribution goes toward care)
- Irrevocable Trust (Funded at least 5 years ago)
- Pre-paid burial expenses
That’s it. If dad has $50,000 in his checking account, $20,000 in a Roth IRA, and a RV, the RV will need to be sold and he will need to spend down the Roth IRA and the checking account until the balance reaches $15,150 in order to apply for Medicaid.
Very important, while the primary residence is a protected asset for purposes of the Medicaid application, Medicaid will place a lien against dad’s estate for the money that they paid on his behalf. Meaning when he passes away, the kids do not automatically get the house. Medicaid will be first in line after the house is sold waiting to get paid. The amount depends on how much Medicaid paid out. If dad lives in a house that is worth $200,000 and Medicaid during his lifetime paid out $120,000 for his care, when the house sells, Medicaid will get $120,000 and the beneficiaries of the estate will only get the remaining $80,000.
When kids hear this they typically get upset because mom and dad worked their whole life to payoff the mortgage and maintain the house and now they are going to lose it to Medicaid. Is there anything that can be done to protect it? If the house was not put into a Medicaid Trust 5 years before needing to qualify for Medicaid then no, there is nothing that can be done. That’s why advanced planning is so important.
If dad worked with an estate attorney to establish a Medicaid trust 5 years ago, the attorney could have changed the ownership of the house to the trust, once dad makes it by 5 years without a health event, it’s no longer a countable asset for Medicaid and Medicaid cannot place a lien against the house. The question I usually ask our clients is “do you want Medicaid to get your house or do you want your kids to have it?” Most people say their kids but if advanced planning was not completed, you lose this options.
No Gifts To Kids
So what if you change the name on the house to the kids? It’s considered a “gift”. All gifts made within the last five years are a countable assets. It’s called the “5 year look back period”. When you apply for Medicaid for dad you have to provide them with a ton of information including 5 years of all statements for bank accounts and investment accounts. Also you have to provide them with copies of all checks written over the past 5 years that were in excess of $1,000. Medicaid is making sure that you did not “give” all of dad’s assets away last minute so he could qualify for Medicaid and avoid the spend down.
We have talked about assets but what about income? It’s not uncommon for a parent to be receiving a pension and/or social security. They are only allowed to keep $842 per month in 2018. The rest of their income will be applied toward their care. This can create some tough decisions if dad has to go to assisted living or a nursing home and the family has to maintain the house and meet his financial needs on $842 per month. Again, Medicaid it trying to recoup as much as it can to pay for dad’s care.
Medicaid Pooled Trust
There are ways to protect income above the $842 threshold through the use of a Medicaid Pooled Trust. Unlike the Medical Irrevocable Trust to protect assets that needs to be established 5 years prior, these trusts can be establish now to protect more income. They work like a special checking account that can only be used to pay bills in dad’s name. You can never withdraw cash out of the accounts. As long as dad is considered “disabled” by the social security administration or NYS he may qualify to setup this trust. There are not-for-profit entities that administer this income trust. Basically his income from social security and pension would be deposited to this trust account and then when bills show up for utilities, property taxes, car payment, etc, you submit the bill to the organization that is administering the trust and they pay the bill on behalf of that individual.
Home Care Limitation
Most individuals want to return to their home and have the care provided at their house via home health aids. This may or may not be an option. It all depends on the level of care needed. If Medicaid will be paying for dad’s care, you will need to call the social services office in the county that he lives in. They will send an “assessor” to his house to determine if the living conditions are adequate for home care and they will also determine the level of care that is needed. In general, if the estimated cost of home care is expected to be at least 90% of what it would cost for care at a facility, Medicaid will not pay for home care and will require them to go to an assisted living or nursing home facility.
Home health aids typically range in price from $15 – $30 per hour. Assume it cost $25 per hour, if dad needs care 8 hours a day, 7 days a week that would cost $6,083 per month. If you need a nurse or registered nurse to administer medication at the home, you are looking at $40+ per hour for those services.
Steps From Start To Finish
We have covered a lot of ground and this is just a general overview. But here is a general list of the steps that need to be taken assuming dad had a health event and you need to apply for Medicaid on his behalf:
- Contact an estate attorney to establish a power of attorney and requirement for Medicaid application
- Using the POA, begin collecting financial information for the Medicaid process
- Contact the county social services office to request an assessment to determine if home care will be an option if it’s in question
- If a spend down is required to qualify for Medicaid, work with estate attorney to develop spend down strategy
- If monthly income is above threshold, determine if a Medicaid pooled trust is an option
Hi, I’m Michael Ruger. I’m the managing partner of Greenbush Financial Group and the creator of the nationally recognized Money Smart Board blog . I created the blog because there are a lot of events in life that require important financial decisions. The goal is to help our readers avoid big financial missteps, discover financial solutions that they were not aware of, and to optimize their financial future.