What is Medicaid?
Medicaid  is a
federal government program that provides financial assistance to persons age 65
and over, or those under 65 who are disabled and who are in need of substantial
medical assistance. Medicaid is a needs-based program a person must have a
medical need for the assistance and must be of limited financial means before he
or she may qualify.

Planning
Tip: Medicaid is very different from Medicare. Medicare is health
insurance available to all persons over age 65 who qualify for Social Security,
as well as those who are under 65 and who the Social Security Administration
determines to be disabled. Medicare will not pay for nursing home, assisted
living or home health care on a long-term basis. Medicare will only pay for this
type of care for up to 100 days, and only for the purpose of providing
rehabilitation following a three-day or longer hospital
stay.

Unfortunately, with the rising costs of long-term care, many
people cannot afford to pay privately for home health care, assisted living, or
nursing home care. According to the 2006 Study of the MetLife Mature Market
Institute, the national average cost for a private room in a nursing home is
over $75,000 annually. The national average cost of in-home care is between $17
and $19 per hour. As noted in a recent Harvard University Study, 69% of single
people and 34% of married couples would exhaust their assets after 13 weeks in a
nursing home. For those whose assets won’t last 13 weeks much less the rest of
their lives Medicaid planning becomes an important consideration.

Planning
Tip: Most people do not have sufficient assets to pay privately for
long-term care. Medicaid planning is most appropriate for these individuals, a
growing segment of the population.

What is Medicaid
Planning?
The term Medicaid planning involves either spending down
or otherwise protecting a person’s assets so that he or she has minimal assets
and can meet the financial criteria for Medicaid qualification (which can be as
low as $2,000 for a single person). Although based on federal law, Medicaid
rules are different from state to state, and even county to county, and
therefore it is important to consult with a legal expert in the field of
Medicaid. Furthermore, the transfer of assets, purchase of financial products,
or otherwise disposing of assets has tax implications for the transferor as well
as the recipient, necessitating the advice of a tax advisor. Finally, a
financial advisor is a necessity to help clients choose the correct financial
products as part of an overall Medicaid planning strategy.

Planning
Tip: Medicaid planning requires input and a coordinated effort from the
client’s legal, financial and tax advisors, all of whom should be knowledgeable
in Medicaid planning.

Medicaid
Pre-Planning
Medicaid planning can be divided into two types:
pre-planning and crisis planning. Pre-planning is for those individuals who have
not yet begun to spend their assets on private care, but may need to in the
coming years. Crisis planning is for those individuals using their life savings
for long-term care (either at home or in a facility) with a substantial risk
that they will run out of money.

In pre-planning cases, life insurance
can provide tremendous planning benefits when implemented correctly. The
purchase of a single premium life insurance policy by an irrevocable trust, or
subsequent transfer to such a trust, will not only replace a couple’s net worth,
it will protect the cash value of that policy from Medicaid. Alternatively, if
not owned by an irrevocable trust, the cash value of any life insurance policy
will count against the amount of assets a person can keep and still qualify for
Medicaid.

For example, assume Mr. and Mrs. Jones, both age 65 and in good
health, have $450,000 of assets. At their age, a single premium of $100,000
would buy a second-to-die death benefit of nearly $450,000. If an irrevocable
trust owns the policy and neither Mr. or Mrs. Jones have access to the trust
assets, after a certain period (most likely 5 years), their entire net worth
would be protected from Medicaid, and Mr. and Mrs. Jones would still have
$350,000 left to live on. Mr. and Mrs. Jones could transfer more assets to the
irrevocable trust, if they desire. In fact, if the couple also purchased a
five-year long-term care policy (or a life insurance policy with a long-term
care rider), they could protect all of their assets from Medicaid, even with a 5
year look-back period.

Planning
Tip: With pre-planning clients, life insurance owned by an irrevocable
trust, perhaps combined with long-term care insurance or a long-term care rider,
can provide significant Medicaid planning benefits.

For those who
choose to plan early, the use of an irrevocable trust combined with life
insurance and/or long-term care insurance can provide optimum asset protection
for an aging client. When gifting is used as a planning strategy, the person
receiving the gift often needs advice on how to invest the money they receive.
Thus, Medicaid planning also opens the door for the financial advisor to
converse with younger family members about the need for proper planning,
including the need for disability insurance and long-term care
insurance.

Planning
Tip: Medicaid planning can open the door for the financial advisor to
begin working with and planning for younger generations, while establishing the
need for disability insurance and long-term care insurance.

Medicaid Crisis Planning
Even with crisis
planning there are significant planning opportunities for our clients. While
transfers either outright to a family member or to an irrevocable trust create a
penalty period for the person making the gift, sometimes a planned strategy
involving gifting and the use of an annuity can provide a valuable crisis
planning tool. For example, assume Mr. Jones suffers a stroke and ends up in a
nursing home, and his cost of care exceeds the couple’s monthly income by $4,500
per moth. Since the couple has assets of $450,000, they are $346,360 over the
allowable limit of $101,640 for a married couple. One under-utilized but very
effective strategy is for the couple to purchase a Medicaid Qualifying Annuity
(MQA) in favor of the healthy community spouse, Mrs. Jones. By converting the
excess assets into an income stream, Mr. Jones can now qualify for Medicaid and
the MQA provides Mrs. Jones with extra income to supplement the loss of her
husband’s income (which must be paid to the facility).

For a single
person in crisis planning, a plan of partial gifting plus the purchase of a
single premium immediate annuity may be appropriate. Keep in mind that any time
a Medicaid applicant makes a gift, whether it is to another person or to a
trust, Medicaid will impose a penalty based on the size of the gift. The penalty
is the equivalent of a waiting period the larger the gift, the longer a Medicaid
applicant must wait to obtain eligibility. Because of the severe penalties for
gifting, clients should not undertake this type of strategy without the legal
advice of a Medicaid planning attorney.

Planning
Tip: Annuities play a crucial role in Medicaid planning, particularly
with crisis planning.

Identifying Possible Medicaid
Clients
In determining which clients are appropriate for Medicaid
planning, it is important to consider the client’s age and life expectancy,
monthly income, monthly medical expenses and other assets. Take Anna, a 72
year-old woman residing in an assisted living facility costing $3,500 per month.
She has other medical expenses, including prescriptions, of $300 per month. Her
only income is from social security, which amounts to $1,200 per month. Anna is
depleting her savings at a rate of $2,600 per month, just for medical expenses.
Anna has $450,000 in a brokerage account, which on its face sounds like a lot of
money, given she is only spending approximately $36,000 per year on her care.
But when we take into consideration the fact that Anna may very well need more
care in the future, which could cost as much as $10,000 per month, and given her
life expectancy of 13.96 years, it is clear that Anna’s assets may not be
sufficient to cover her long-term care expenses for the rest of her life. Anna
is not only an appropriate client for Medicaid planning, she is a crisis
planning client.

Planning
Tip: It is important to take a client’s age, medical needs, monthly
expenses and income into consideration to determine whether Medicaid planning is
necessary or appropriate.

Conclusion
Due in
part to the rising costs of long-term care and the fact that we are an aging
population, Medicaid planning is a growing area of practice for attorneys, CPAs,
financial planners and insurance professionals. However, as evidenced by the
content of this newsletter, Medicaid planning requires that these disciplines
work together collaboratively to ensure that the client avoids the numerous
pitfalls that exist in this area.