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Medicaid Planning Trend: Home Care Instead of Nursing Home Care

Medicaid Planning Trend: Home Care Instead of Nursing Home Care

Plus, FREE Online CLE Class

In a post-pandemic environment, there is a major move afoot to transition from institutional setting care to Home and Community-Based Services (“HCBS”).

Nursing homes, on a whole, have never been a popular destination – more of a necessary evil. But the pandemic made this worse. Given that the elderly and frail were in the most affected population hit by Covid-19, institutional care settings – most especially nursing homes – became ground zero for the spread of infection and the lion’s share of pandemic-related deaths.

The ease at which a nursing home population can be negatively affected by the virus has clearly put a chilling effect on moving new residents into facilities. People are looking for any way possible to remain at home.

Medicaid is the single largest pay source for long-term care in the US. Over one-half of all facility care is paid for by Medicaid.  Medicaid is inherently biased towards nursing home care, since from its inception in 1965 the program was primarily designed to cover nursing homes as the only long-term care option.

HCBS care was an add-on to Medicaid that came much later in 1981. States were allowed to experiment with providing Medicaid coverage for HCBS care through home care or assisted living waivers under 42 USC Sec. 1915(c). Since then, all states have initiated some type of waiver program for HCBS, but the states lack the standardization of nursing home care Medicaid eligibility.

This has been mostly good for those in need of care, but the lack of standardization or lack of full funding has led to a number of downsides that have restricted nursing home patients from getting the HCBS care they needed.

HCBS Waiting Lists

The biggest problem with most HCBS programs is the lack of proper funding.  As a result, you have a managed care program like Florida’s.  A senior in need of care must be evaluated to get on the waiting list. The waiting list is triaged based upon the level of care and urgency that the person needs. Oftentimes, the wait for care can be over a year long.

Most people don’t go looking to get on a waiting list a year or two before they need care, they seek it out when it becomes necessary. Because a nursing home resident is prioritized for managed home care as a way to move expensive nursing home patients into less expensive homecare settings, nursing home patients jump the line.  This has not gone unnoticed. Some actively seek nursing home placement so they can move the priority of their case to the front of the line and go back home with Medicaid-covered home care services.

In states like Michigan, which has a limited number of MI Choice Waiver “slots” based on funding, a patient in need of care either gets a slot or is forced into a nursing home even when home care environment would be less restrictive and more cost-effective for the state. Nursing home level care coverage by Medicaid is an entitlement; whereas, HCBS waiver care is at the whim of the state budget allocation.

Strict Income Limits

For nursing home Medicaid, some states utilize an income cap to determine eligibility.  Income caps for nursing home eligibility can be defeated in each state that uses them by having an income trust (also known as a Qualified Income Trust or Miller Trust) to place income in. The income placed in the trust is disregarded for purposes of eligibility. That essentially means that for income-cap and non-income-cap states, the ultimate disqualifying factor is whether the patient has more income that the cost of care.  Since most do not, virtually everyone can qualify for Medicaid in a nursing home under the income standards – cap or not.

HCBS waiver care is a lot more restrictive in some states.  In many states, there is a strict income cap.  If an applicant has just one dollar more in income than the limit, they are denied care.  They are not allowed to spend down to the income limit.  Those patients are often forced into the nursing home simply because their income is over the cap, even though it’s dramatically less than the cost of care they need.

A good example of this is the Star Plus HCBS program in Texas.  Star Plus uses 300% of the Federal Benefit Rate as the income limit.  For 2021 the income cap is $2,328. If the patient has $2,329 or more in income, they simply do not qualify. On the other hand, if that same patient goes into a nursing home, they can put income into a Miller Trust and qualify for Medicaid coverage. The inability to use a Miller Trust to satisfy the Star Plus income cap forces those who have slightly higher income into nursing home facilities at a much higher expense to the state.

But some states have caught on and allow the Miller trust to be used. Arizona, for instance, allows for excess income to be placed into the Miller Trust to qualify a homebound patient eligibility for Arizona Long Term Care System (“ALTCS”) waiver care. New Jersey has also allowed the use of Miller Trusts to defeat the income cap for Assisted Living Waiver applicants.

Confusion About Availability

While there is substantial standardization of nursing home Medicaid programs, there are no two state HCBS waivers exactly alike.  States often run numerous different HCBS Waiver programs with varying degrees of eligibility and different targeted audiences.  What this causes is general confusion about what program is most suitable for the senior in need of care.

Typically, a state has at least an aged HCBS waiver program along with a Program All-Inclusive Care for the Elderly (PACE) program. Both have similar eligibility requirements but operate a little differently.  HCBS typically provides home care and some adult daycare only, which is usually limited in scope to a set number of hours based upon state expenditure caps and/or the applicant’s health needs.  The PACE program typically allows for a money-follows-the-patient approach and provides all health coverage for the patient regardless of which stage the patient is in.

Additionally, most states have expanded home care waiver programs that have a broader scope than just elderly. These can include, in some state, access to group homes.

Because most of these programs are accessed through different agencies, it leaves the aged consumer in need of direction and guidance to both determine which program makes the most sense and access the program through the strict eligibility requirements.

Community Spouse Protections

Spousal Impoverishment protections were created in the Medicare Catastrophic Coverage Act of 1988 (MCCA ’88) along with the first-ever lookback period and transfer of asset penalties. This affords protections to the at-home spouse when one spouse enters a nursing home.  However, there was a spotty application of spousal protections when a person stayed home and receives Medicaid-funded HCBS care.

The Affordable Care Act passed in 2010 required that all HCBS programs treat the non-Medicaid spouse as a “community spouse” even though both spouses technically live in the community.  This had the effect of extending uniformly, Medicaid protections to the non-recipient spouse in a home care or assisted living waiver care environment.

The only problem was that the provision mandating those protections had a 10-year sunset clause and needed to be renewed by subsequent legislation.  The Trump administration signed into law a few extensions that allow for the use of these protections when seeking HCBS care today. Further legislation has been proposed to make these protections permanent.

Estate Recovery Applies to HCBS Care

For those who are not aware of estate recovery, it is the program by which the state is allowed to recoup Medicaid expenditures for a patient from the patient’s estate after death.  Typically, the largest asset subject to recover is the patient’s house.  Estate recovery rules range from the most milquetoast recovery provisions in states like Pennsylvania, Michigan, Florida, and California to extremely aggressive in states like Missouri and New Jersey.

Most people think that estate recovery is limited to nursing home expenditures; however, states are required to recovery from anyone over the age of fifty-five who receives HCBS care as well.  So essentially, they’ll let a person stay in their home and receive home care coverage through Medicaid, but recoup those expenditures from the home’s value after the patient dies.  Recovery can be delayed if there is a spouse living in the home.

The net effect of HCBS estate recovery is that it makes the HCBS program the equivalent of a reverse mortgage, where equity is pledged to cover care expenses and collected by the state after the patient has died. There are often advocacy tools that can be used during the eligibility process to either avoid or minimize the effect of estate recovery when a patient seeks HCBS care. The goal of a Medicaid Planner in these types of cases is to maximize the availability of the patient to stay at home with Medicaid-funded care while protecting the assets exposed to either the spenddown or estate recovery.

New Federal Proposal

As part of the initial Biden infrastructure program called “the American Jobs Plan,” $400 billion would go towards providing a wider access to HCBS care. While this bill is still in the early stages, there seems to be bipartisan support for enhancing patients’ abilities to access HCBS care by making the programs more robust and giving states the money to fully fund programs so as to avoid the imposition of waiting lists.

This will expand the range of services that an average senior will be able to access, making it more likely that they will be able to stay at home with an appropriate level of care.  What this will also do is expand the need for advisors, Medicaid Planners, in particular, to dig into the nuances and complexities of these HCBS programs and be creative in developing eligibility strategies.

Free Online CLE Class

To help you get a better idea of the HCBS Medicaid landscape, you are invited to join us for a FREE one-hour class that is CLE eligible. This class will be offered to attorneys and non-attorneys who are in the Medicaid Planning space or are looking into entering the field.

The 1-hour online CLE class entitled “Medicaid Planning: Intro to Medicaid Home Care” will be held June 4th, 2021 at 1:00 pm ET. For those able to attend the live program, the video will be available on-demand for all who register prior to the presentation.

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A Place for Mom to Go Broke

With the Covid-19 Pandemic underway and stay-at-home orders in place over most of America, everything has changed.  That includes how much television I watch. Between binge watching the latest shows on Netflix, I was watching the news today hoping for some sign that life was going to get back to normal soon.  During the commercial break I saw an ad from A Place for Mom that made me so upset, I felt the need to write about it to expose the ugly truth behind this otherwise innocuous company.  I especially feel the need to call out Joan Lunden and expose the boondoggle known as A Place for Mom because they are actually hurting seniors.

A Place for Mom is a company that is a nursing home referral service. As the name implies, A Place for Mom will help people find a facility to place their parent when the parent needs long-term care. This is a “free” service to the user … or at least is inaccurately billed as free by the company. If the company were a true non-profit that used donations to help guide people in time of crisis, that would be great.  That’s basically how they present themselves to the public.  But A Place for Mom is not the virtue of altruism – not even close.

This issue came up a few days ago as well when I was talking with an attorney in northern California who approached me about mentoring him to help add Medi-Cal Planning to his longstanding law practice. During the call he said that he talked with a nursing home placement specialist, known at A Place for Mom as a “Senior Living Advisor,” who said that it was hard to do placement in a facility that accepted Medicaid because of how few beds were available.

I had to chuckle and told him he needed to consider the source. I let him know that the high-end nursing homes pay these placement specialists a referral fee. The going rate for referral fee is one month’s expense at the facility.  Most of those facilities charge over $10,000 per month. This placement specialist only gets paid when she refers someone to a facility that pays a referral fee and each placement is a big payday. In most markets, independent referral agents can easily make a quarter of a million dollars a year referring only a couple dozen people. They make no money referring the family to a facility that doesn’t pay a referral fee or if the patient is Medicaid/Medi-Cal eligible.

A Place for Mom is no different. They only refer people to nursing homes within their “network,” which excludes less expensive facilities and many facilities that accept Medicaid-eligible patients. You say, though, “Aren’t they only excluding a few of the crummiest nursing homes that service Medicaid patients?” One would think that was true, but Medicaid pays for a majority of nursing home expenses in the US and the vast majority of nursing homes accept Medicaid.  But most cannot afford to spend big sums on referral fees to placement specialists like A Place for Mom and the anti-kickback laws seem to prohibit paying referral fees for referral of an authentically benefit-eligible patient (See: OIG Advisory Opinion No. 14-01).

The result of this is staggering. First, A Place for Mom arguably misrepresents itself as a one-stop shop to find a care facility that is appropriate for a senior in need.  But in reality, it will only refer people to a handful of high-priced facilities that, in turn, line A Place for Mom’s pockets. Additionally, like selling you a high-priced automobile, the placement specialist makes more if the patient spends more. The placement specialists are incentivized to push more expensive facilities on unsuspecting seniors and their families who are reaching out during a time of crisis.  If you deceptively take advantage of people in crisis, you are a profiteer that is preying on the most vulnerable seniors.

And Joan Lunden the profiteer-in-chief.  She is called by A Place for Mom an “advocate for seniors,” but she is nothing more than a paid spokesperson using her once-held clout as a Good Morning America talk show host to give legitimacy to A Place for Mom’s offering to seniors. This costs people real money.  Lots of people.  And drives up the cost of care.

A Place for Mom addresses the cost issue on their website.  In the FAQ section it says: “WILL THE COMMUNITY CHARGE ME MORE IF I USE YOUR SERVICES?” The answer provided by A Place for Mom is enlightening:

This is our favorite question!  We offer our personalized, time-saving service at no charge to you or your family. How is that possible, you ask? A Place for Mom is paid by our participating providers and communities, so we are able to offer you a completely cost-free service with no hidden fees. 

Furthermore, each community that partners with us specifically agrees that it will charge a family the same rate as all other consumers who move in, including being eligible for the same discounts as other families, and it will not charge or try to recover any of APFM’s fee from the family. In short, you should not be charged any additional amounts because you used our services.

This answer is intellectually dishonest and betrays the real mission A Place for Mom company should be about (helping seniors instead of exploitation of the elderly). Of course, nursing homes don’t charge you more if you come in through A Place for Mom, they charge EVERYONE more! The referral placement service is not “cost-free” in any way whatsoever.  The patient doesn’t pay the fee to A Place for Mom, the facility does.  Who does A Place for Mom owe their allegiance? It is clearly owed to the nursing homes that butter their bread. The net result of not charging someone for placement services is that the cost is spread out over all residents in the facility. That raises the cost of care for everyone – even those who do not come into the nursing home through a placement service.

But there is something far more insidious that is a by-product of this “no-cost” approach to nursing home placement. It’s my understanding that A Place for Mom does not do a full financial workup on the people needing care.  This has two disastrous side effects. The first is erosion of the community spouse’s protected share and the second is the secondary transition when the patient spends all of their funds on the over-priced nursing home that was recommended by A Place for Mom.

To understand the first part is to understand the Medicaid spenddown.  When a couple places one souse in the nursing home while the other spouse remains home, Medicaid rules carve out a protected share of the couple’s assets that are protected for the at-homes spouse, called the “community spouse” in the Medicaid rules. The protected share is called the Community Spouse Resource Allowance (“CSRA”), which for 2020 is set at a maximum of $128,640 (ignoring all the viable Medicaid Planning techniques we could use to protect even additional resources). So if the couple has $250,000 in assets, they would only need to spend down about $120,000 in assets.  If A Place for Mom refers the couple to a high-priced nursing home that costs $12,000 a month, then the couple would have spent down assets to the protected share within about 10 to 11 months – a relatively short period of time.

To keep the institutionalized spouse in the high-priced nursing home, the couple would be forced to privately pay beyond the Medicaid spenddown because the facilities typically do not accept Medicaid, or in the case of some assisted living facilities, they accept Medicaid but require the patient to privately pay for 18 or 24 months until the facility will release a Medicaid bed. This forces the couple to spend down the community spouse’s protected share – leaving the healthy spouse extremely vulnerable and using up the funds that should be saved for the community spouse’s future retirement needs.

Once the couple spends resources down to the CSRA, they have the choice of either spending the protected share or moving the patient to one of the majority of nursing homes that accept long-term care Medicaid coverage. The couple would be Medicaid eligible once they had spent down to the CSRA limit but not access the benefit because the facility that A Place for Mom sent them does not accept Medicaid payment.  To move to a Medicaid-approved nursing home can be problematic.  Medicaid-approved nursing homes can take private-pay patients ahead of Medicaid-eligible patients in the admissions process. This could cause the patient to not get into the facility of his or her choice when they need to move and forces the patient to stay longer at the non-Medicaid nursing home.

This brings us to the second issue which is the fact that once a patient has completely depleted their financial resources in most of these A Place for Mom nursing homes, they are forced to move out of the facility to a new facility that accepts Medicaid. Because they are in the more expensive facility that A Place for Mom referred them to, they will likely have spent down their assets in that nursing home at a faster rate than they would have otherwise – hence why I refer to it as A Place for Mom to Go Broke – faster.

The patient will ultimately be discharged to a facility that accepts Medicaid.  Because most conditions requiring nursing home care are degenerative. That means the patient will be forced to re-locate at a time in their life when they are worse off than when they entered the high-priced nursing home and that kind of transition to a new environment is highly traumatic to the elderly patient. Had the patient be placed in a proper facility from the start, the likelihood of transfer will be minimal. What’s in the best interest of the patient is at odds with what’s in the best interest of A Place for Mom and their cadre of costly nursing homes.

Finding someone a nursing home that works well for them is not something anyone would pay $10,000 to purchase as a service. Geriatric care managers do the same service in an unbiased and patient-centered way for usually less than $2,000 on average. These so-called placement specialists are merely extended sales agents for the upper-crust nursing homes and they disguise this as a “cost-free service” to unsuspecting seniors and their family members needing help. When someone appears to owe you a duty to give you proper advice about your best housing alternatives, but the advice is tainted by the referral fees paid by the nursing homes they refer you to, in the law we call that a conflict of interest. And there is virtually nothing regulating this.

I believe that everyone in a facility that pays kickbacks to A Place for Mom or their ilk would be ideal representative class members for a class action suit against the whole lot of them for lack of full disclosure and the resulting higher cost of care.  Additionally, states should enact prohibitions against these kickback referral programs and leave placement to patient-centered geriatric care managers or truly philanthropic organizations that believe in helping seniors rather than bilking them through the back door.  And lastly, Joan Lunden should be ashamed of herself for perpetuating this kickback scheme, resign from involvement in A Place for Mom and donate what is likely to be her exorbitant fees to a fund that can help seniors who truly need placement help – unbiased and genuine placement help. If she truly wants to help seniors she should stop being a disingenuous shill for high-priced nursing homes and actually find a way to help seniors get the real care they need.



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Advisor Alert: Learning Medicaid Planning Can Keep You From Getting Sued

There was a time when I knew nothing about Medicaid Planning. Nada. Zip. Zilch.

I remember asking the person who said he did Medicaid Planning a very basic question: “How do you make any money helping poor people get health insurance?”

That question betrayed my lack of understanding of how Medicaid is more than just a health insurance program for the poor, it is a financial backstop for the elderly in need of long-term care services. The LTC Medicaid side of the coin is a complex set of rules about what assets are exempt, what can and can’t be given away and to whom it can and can’t be given. In order to qualify, an applicant must have typically spent down most of their life savings.

But if you don’t know or understand any of this, a few things can happen. The first is very obvious. If you are advising someone who is in need of long-term care and does not have adequate insurance, failing to understand their options can lead to giving poor advice. More legal and financial advisors give BAD advice in the area of the long-term care spenddown than there are advisors giving GOOD advice. Most of that comes from a simple lack of understanding, which can be easily fixed.

The second negative impact on advisors working with elderly clients is the risk of a lawsuit. With the number of people needing advice concerning the long-term care spenddown, there is a growing volume of legal and financial advisors giving poor advice, often leading to Medicaid ineligibility periods (also known as penalty periods) or a dramatic and fully preventable loss in assets. This proliferation of bad advice has created a growing field of litigation: LTC Medicaid eligibility malpractice.

Every legal or financial advisor who works with seniors exposes themselves to LTC Medicaid eligibility malpractice from failing to understand how the advice that they give impacts or hinders Medicaid eligibility. Bad advice can have negative consequences. If those consequences cause the person receiving advice to be adversely affected, the legal or financial advisor can be sued and held accountable for the damage they caused.

This damage can manifest itself in one of two ways.

The first is for someone to be ineligible for Medicaid when they would have been eligible or become eligible sooner, but for the advisor’s bad advice. A good example of this is when a financial advisor tells a client who inquires about gifting that they can gift up to $15,000 per year per person.

In a recent case I saw this happen where the advisor had dispensed this advice but failed to mention that the gift limit, he was referring to was for the gift tax only and did not apply for Medicaid. The client had gifted over $80,000 within the last two years before having a stroke and going in the nursing home. Her family filed her Medicaid application thinking those gifts were exempt from the lookback, only to have Medicaid penalize the applicant for a full year of ineligibility.

The second way to incur liability in this area and cause damage is to give advice that causes a patient to spend more money on the cost of care that the law requires. Under the current Medicaid rules, you can actually easily overspend your assets on the cost of care. Most legal and financial advisors do not understand the asset limits, how they are different for single or married applicants, and how to calculate the resource limit.

Over the next decade, you will hear countless stories of legal and financial advisors who were successfully sued because they did not understand how their advice conflicted with LTC Medicaid eligibility and spenddown rules. Don’t let one of those stories be about you!

Our whole Medicaid Planning support program is developed around the idea of helping people with scant knowledge of long-term care and the Medicaid spenddown system become knowledgeable advisors. Even if you don’t intend to do Medicaid Planning full time, a good understanding of LTC Medicaid and allowable asset protection techniques under the rules can be very helpful.

When I started out, I didn’t understand much and had to spend years piecing it together. That’s why I created our training system that provides continuing legal education and professional education to help raise awareness, the largest textbook on the subject ever written, and direct practice mentoring and support for legal and financial advisors. It’s like putting Miracle Grow on your Medicaid Planning practice and is the best prophylactic against getting sued for lack of knowledge ever developed.

For more information visit:

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Learning Medicaid Planning Just Got Easier

If you’re in one of the countless estate planning practices that has seen a drop-off in interest over the last few years, you’re not alone. With the increase in the estate tax exemptions and the proliferation of online document vendors, many estate planners’ practices have gotten stagnant or harder to maintain.  This has led to huge interest in adding Medicaid planning to an existing estate planning practice.

Most people in need of long-term care planning services reach out first to the estate planner that helped them craft their will, trust and powers of attorney.  More often than not, the estate planner chooses to pass those cases on to a Medicaid planner instead of helping the clients themselves – missing out on critical business and often losing the client relationship.

The biggest reason many estate planners don’t do Medicaid planning is the complexity of the long-term care Medicaid eligibility rules and the high stakes of not getting the planning right.  That risk is real, but can be heavily mitigated if you want to add a vibrant and growing need to your estate planning practice.

In most cases, long-term care Medicaid planning is done in a crisis situation where there is an active need to reposition assets to minimize the exposure to the Medicaid spend down.  The art of Medicaid planning starts with a firm understanding of both the spenddown rules, asset classifications, and allowable transfers. Most Medicaid planners do not have the time to apprentice newcomers into the field because anyone doing this kind of work has more clients than they have time to help them all.

There is a huge need for more Medicaid planners and a great opportunity if you are looking to add Medicaid planning to your practice.

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    The Iron Throne Is Replaced With A Wheelchair

    SPOILER ALERT: If you are one of the few people who have not seen the Game of Thrones Finale yet, read at your own risk.

    Disability advocacy rarely gets the attention it deserves. But in a true sign of the times, one of the most iconic symbols in a decade – the Iron Throne – was literally replaced with a wheelchair as a result of the Game of Thrones finale. The death of the Mother of Dragons in the throne room led her remaining dragon to torch the Iron Throne until literally melted in a pool of hot magma. Whoever was left to sit on the throne would need a new throne.

    As the leaders of Westeros convened to determine the future of the seven kingdoms, it was suggested that Brandon Stark be elected by the lords to be the new king. He reluctantly accepted the position, but only after his weaknesses as paraplegic were openly discussed. Henceforth in Game of Thrones lore, the new king of the six kingdoms (the North remained independent) is known as Brandon the Broken, First of His Name. In a modern world, he would be known as Brandon the Handi-Capable King.

    Being disabled does not me being “lesser than,” even though that was the way society has portrayed people with disabilities in the past. Even FDR, our modern version of Bandon the Broken, was keen not to be photographed in a wheelchair for fear of the negative stigma of weakness it would convey to the public.

    Game of Thrones showed that even a paraplegic, in the world of brute force, can ascend to the highest throne in the land. And with the Iron Throne reduced to nothing, it’s good that the new king of Westeros doesn’t need a throne. He comes with one in the form of a wheelchair. Of course, it’s not likely that King’s Landing is WDA (Westeros Disability Act) compliant. So the upside to the Mad Queen torching the city is that new reconstruction of King’s Landing can include long overdue wheelchair ramps, bathrooms and doors wide enough for a wheel chair to fit through, and maybe even a new elevator to help King Brandon get to the upper spires of the rebuilt Red Keep.

    As one of the highest watched shows in history, Game of Thrones has now in one quick instance become the most pro-disability show ever. And to everyone struggling with a disability who feels like the world does not work easily for them as it does others, they can remember that if Bran the Broken can replace the Iron Throne with a wheelchair … so can anyone else.

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    The Advantage of Becoming a CMP™

    The Advantage of Becoming a CMP™ Webinar
    Thu, May 2, 2019 3:00 PM – 4:00 PM EDT

    Learn how to become a Certified Medicaid Planner™ and how this can improve your practice.

    Medicaid Planning is a growing practice area for law firms and financial advisors who are committed to helping clients navigate the long-term care spenddown. Much like the US Tax Code, the Medicaid Code is complex and difficult for most seniors to understand. A Certified Medicaid Planner has demonstrated the proven skill to help clients like that with a deep understanding of the complexity of these rules and their practical application.

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    Medicaid Planners Find Huge Advantage in Becoming a CMP™

    Medicaid Planners Find Huge Advantage in Becoming a CMP™

    If you haven’t heard about the Certified Medicaid Planner™ designation by now, it’s one of the fastest growing accredited designations in the country.

    The focus of the CMP™ designation is to demonstrate a planners’ high skill and experience in Medicaid Planning, as well as a planner’s commitment to both high standards and high ethics. The CMP™ Governing Board was established nearly a decade ago to help set standards in the field of Medicaid Planning and devise a testing system to validate skill in the field. No other multi-discipline organization is committed to this goal.

    Medicaid Planning is a growing practice area for law firms and financial advisors who are committed to helping clients navigate the long-term care spenddown. Much like the US Tax Code, the Medicaid Code is complex and difficult for most seniors to understand. A Certified Medicaid Planner has demonstrated the proven skill to help clients like that with a deep understanding of the complexity of these rules and their practical application.

    Families are often dealing with the Medicaid spenddown at the same time as a crisis health care situation that caused the loved one to enter the nursing home. With the high cost of care, a Medicaid Planner’s role is vital to ensuring that the patient does not spend more on the cost of car than the law requires.

    The high cost of long-term care is the single biggest risk to retirement assets ever in the history of the United States. Uninsured patients needing long-term care services are unable to get the financial help they need without relying on the Medicaid system. Advanced Medicaid Planning will always maximize savings for the patient and his or her spouse, making the work of the Certified Medicaid Planner™ invaluable and providing the planner and the planner’s clients with a huge advantage.

    If you want to learn more about becoming a CMP or how certification will help you, join us The

    Advantage of Becoming a CMP™ Webinar Thursday, May 2, 2019 3:00 PM – 4:00 PM EDT

    Click on the following link to sign up:


    Seats Still Available for Upcoming Medicaid Planning Courses

    If you missed the recent Medicaid Planning course in Las Vegas, you have several opportunities coming up to learn Medicaid Planning. The Nuts & Bolts of Medicaid Planning course is the most comprehensive course on Medicaid Planning ever developed and designed to help any professional advisor add Medicaid Planning to your practice.

    This course, taught by one of the leading long-term care Medicaid Planning experts in the country, will give you the insight you need to add Medicaid Planning to your practice or help solidify your Medicaid Planning skills. With the growing number of seniors needing long-term care, you need to know this material to be an effective estate or asset protection planner.

    The course has become a hit among estate planning law firms wanting to grow their practice and service aging clients though the addition of Medicaid Planning services. In addition to a powerhouse 2-days of Medicaid Planning immersion, the course is approved for 9 credit hours of continuing legal education.

    The small-group intensive format allows for interaction with the presenter.

    If you were unable to attend the Las Vegas course, there are other upcoming courses available that may fit your schedule even better:

    Cleveland, OH June 6-7, 2019

    San Diego, CA July 22-23, 2019

    Los Angeles, CA September 24-25, 2019

    Washington, DC October 10-11, 2019

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      Congress Missed Deadline to Extend Medicaid Spousal Impoverishment Protections

      When married couples seek home care paid for through Medicaid, each state runs a Home and Community Based Services (HCBS) program that provides coverage. Prior to the enactment of the Affordable Care Act (ACA), there was no uniformity among the states as to whether to apply the traditional spousal impoverishment rules for nursing home Medicaid to HCBS Medicaid. Spousal impoverishment protections allow for the protection of resources and income for the benefit of the well spouse safe from contribution towards the infirmed spouse’s cost of care.

      The ACA rectified that problem and mandated that all states apply the spousal impoverishment protections of the long-term care institutional Medicaid program to the HCBS home care programs. The only catch, it contained a sunset clause that expired on December 31, 2018.

      Congress put a temporary band-aid over this problem at the end of the year with a 3-month extension signed by President Trump. This was done in an effort to give Congress the time to debate and deliberate on a permanent extension.

      The temporary extension ran out a few days ago on March 31, 2019. Without additional congressional action, the provision sunsets and states will be able to ignore spousal impoverishment protections for tens of thousands of married seniors receiving HCBS care, potentially exposing considerable amounts of community spouse assets to depletion or forcing seniors to move from home into skilled nursing homes where the spousal impoverishment protections are absolute.

      A bipartisan bill introduced by Michigan Reps. Debbie Dingell (D-MI) and Fred Upton (R-MI), would be a permanent solution to this problem. The Protecting Married Seniors from Impoverishment Act has not yet received an up or down floor vote in the US House. We will be keeping close tabs on this and looking to see if states start taking liberty with home care eligibility requirements.

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      Free 2019 Medicaid Planning Desk Reference

      Get Up To Date With New 2019 Medicaid Numbers

      The Centers for Medicare and Medicaid Services (CMS) have issued new annual spousal impoverishment figures for 2019.  You can download a complimentary FREE 2019 Medicaid Planning Desk Reference.   The full numbers are contained in the Desk Reference, which you can download for free by clicking the link at the bottom of this article.

      Here is a quick recap of the new figures and what they mean:

      2019 ASSET LIMITS

      The New minimum Community Spousal Resource Allowance (CSRA) is $25,284. The new maximum CSRA is $126,420.

      To get your FREE 2019 Medicaid Planning Desk Reference, click here.

      Reminder, in the straight deduction states like Florida and California the Max CSRA is the pure asset cap.  Any asset amount below that is sufficient to qualify for long-term care Medicaid.  For example, if a couple has $100,000 in countable assets, then in the straight deduction states they do not need to spend down any further.  Also, in straight deduction states the minimum CSRA is never a factor in planning.

      In the one-half deduction states like Michigan, Pennsylvania, Kansas and Ohio, the minimum and maximums CSRA limits are both used.  For example, take the couple with the $100,000 in resources on the “snapshot” date (i.e., the date of admission to the nursing home or the hospital when the state requires a valuation of all assets available by the couple for the spenddown).  In a one-half deduction state, the CSRA calculation would assess one-half of the total countable resources as the CSRA.  Take total countable resources of $100,000 and divide by 2 to yield the CSRA of $50,000.

      Where the maximum is used in a one-half deduction state is when the countable resources exceed twice the maximum.  For instance, a couple with $300,000 would only be able to set aside $126,420 for the CSRA.  The remaining assets would be exposed to the Medicaid spenddown.

      The minimum CSRA is a floor and only factors in when one-half of the total amount of countable assets falls below the minimum threshold.  For example, if a couple has $40,000, then the CSRA would not be $20,000 because that’s below the minimum.  The CSRA in that case would default to the new minimum $25,284.

      Also note: In most states the new CSRA limits apply to snapshot dates in 2019 only. Typically, if an applicant’s snapshot date is 2018 but they apply in 2019, the CSRA amount will be based on the CSRA for snapshot date in 2018 and not the application date of 2019.  If you are looking for a prior year’s CSRA limits, please contact our office and we can help you locate the appropriate and applicable CSRA limit.

      2019 INCOME LIMITS

      The Minimum Monthly Maintenance Needs Allowance (MMMNA) is $2,057.50 (for all states except Alaska and Hawaii).  The new maximum amount is $3,160.50.  These allowance limits are set mid-year and these numbers remain in effect until July 1, 2019.  This figure is used as part of a formula to determine how much of the patient’s income a community spouse can keep to live on.

      The new Community Spouse Monthly Housing Allowance is $617.25 (for all states except Alaska and Hawaii).  This figure factors into the spousal allowance formula to determine if excess shelter expenses can be used to boost the MMMNA.   For example, if the community spouse has a large rent or mortgage payment or is in independent or assisted living, the excess costs for shelter can allow the community spouse to keep more of the institutional spouse’s income to help cover the expenses.  Like the MMMNA, this number also changes mid-year and remains in effect until July 1, 2019.


      The new minimum Home Equity Limit is $585,000.00.  In the handful of states that have adopted an upper limit, that amount is $878,000.00 for 2019.  NOTE: This limit does not apply if the patient is married; but if the community spouse dies and the home automatically becomes owned by the patient spouse as a result of joint ownership on the deed, it could cause the patient to become ineligible for Medicaid.


      If you want more information on how to calculate the CSRA or how to maximize the conversion of excess assets to income you should consider purchasing the Medicaid Planning Guidebook or taking the Medicaid Planning Course. We provide a full range of support for advisors of all varieties to assist with their Medicaid Planning cases, including advisor mentoring and case design services.  We also have live training courses coming up that will enable you to add long-term care Medicaid Planning to your practice.  Make 2019 a more profitable year by helping your clients long-term care Medicaid eligibility and asset protection – we’ll show you the way!


      To get your FREE 2019 Medicaid Planning Desk Reference, click here.

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      Interest in Certified Medicaid Planner Designation Grows as VA Benefit Rules Get More Strict

      For nearly the past decade, the Certified Medicaid Planner designation has been awarded to competent advisors seeking to set themselves apart in the planning field as the best of the best. Interest in this designation has grown substantially in the last few weeks, partly as a result of new rules issued by the Veterans Administration (“VA”).

      The new VA rules greatly impinge upon the ability of veterans to get the VA Improved Pension, also referred to commonly as the VA Aid & Attendance benefit. This is a little-known benefit that can be used to help pay for care at home, in a nursing home or in an assisted living facility. While the benefit is typically not as hefty as Medicaid’s assistance, it is paid to the claimant a cash payment. The claimant can be the veteran, the veteran’s spouse, or the veteran’s widow, provided that the veteran served during a period of wartime. The benefit is means tested, but until recently it was rather easy to reposition assets to qualify.

      Much like the evolution of Medicaid eligibility over the years, the VA has moved to further restrict access to the benefit by punishing those who give away assets to qualify. Medicaid has had some version of this since the late 80’s when it started with a 30-month lookback, then moved to a 36-month lookback in in the 90’s and eventually to a 60-month lookback in 2006. The VA is attempting to mimic Medicaid in several aspects by adopting a 36-month lookback on asset transfers, but starting the penalty the month after a transfer is made. It has also taken the Medicaid’s maximum protected amount for community spouses and adopted that as a bright-line asset test for applicants, currently $123,600.

      The complexity of the new eligibility requirements will mean that fewer veterans and their families will be able to tap the benefit. For planners, it will drive some out of the business similar to how restrictive rules did with Medicaid planners years ago. Those who choose to continue on with VA benefit planning will need to learn the new rules and start thinking like a Medicaid planner.

      For some, it has meant to move their practices into Medicaid planning. In the last few weeks, the CMP Governing Board has seen a sizable uptick in interest with many advisors active in the VA benefit arena looking to grow their businesses by adding Medicaid planning. We have resources that can help you add Medicaid planning to your practice, including the largest textbook ever written on the subject, online and in-person educational programs that are second to none, real-time practice mentoring and case development, and back-office Medicaid application services to support your practice. Many planners choose to enhance their practice by getting the nationally-accredited Certified Medicaid Planner designation.

      To learn more about the CMP designation, click here for a free download of the “How to Become a CMP” brochure.