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Chapter Nineteen

Protecting Your Assets from Long-Term Care Expenses



           Protecting your assets from the devastating effects of long term care expenses is one of the most important wealth preservation and wealth transfer issues for the 21 century.  Understanding the risks and the options available to you will allow you to make informed decisions.  Most individuals have accumulated assets to fund their retirement.  Failing to protect these assets from long term care expenses may result in not having sufficient resources to live through retirement.


            Married couples must protect assets from these expenses because odds are significant that at least one spouse will require long-term care.  If the assets earmarked for retirement are consumed to pay for one spouseís long term care expenses, how will the other spouse produce retirement income on which to live? In addition, you may have accumulated significant assets that you wish to eventually pass on to your children or grandchildren.  These assets may be depleted or significantly reduced by long-term care expenses without proper planning.


What Is Long-Term Care


            Long-Term Care is care provided to an individual who has a prolonged physical illness, disability or cognitive impairment.   Someone who requires long-term care can no longer live without assistance due to physical or cognitive impairment.  Long-term care may be provided in the home or in a nursing home or assisted living facility.


            There are three levels of care associated with long-term care.  Skilled care is generally continuous, around-the-clock care which is ordered by a doctor and delivered by a skilled medical worker.  Intermediate care is generally care that is needed daily or a few times a week.  Intermediate care is provided by trained medical workers and is doctor supervised.  Custodial or personal care is care provided to assist someone in performing activities of daily living (ADLs).  Custodial care may be performed by unskilled persons.


            Activities of daily living include:  bathing, continence, dressing, eating, toileting and transferring.  Cognitive impairment includes memory loss, orientation difficulty and reasoning impairment. 


What is the Probability I Will Need Long-Term Care?


            Although you will never know with 100% certainty whether you will or will not need long-term care, some statistics may help put the risks and probabilities of needing long-term care in perspective.

  1. Life expectancy after age 65 is 17.9 years.  With advances in medical technology, we are continuing to live longer.  The longer people live, the greater the chances they will need long-term care. The Older Population, A Profile of Older Americans: 2001, Administration on Aging.


  2. Approximately 44% of people reaching age 65 are expected to enter a nursing home at least once in their lifetime.  Of those entering a nursing home approximately 53% will stay one year or more.  Stillman and Lubitz, "Medical Care" 40 (10):965-967 (2002).


  3. The average stay in a nursing home is 2.4 years. Metlife Market Survey of Nursing Home and Home Care Costs 2004.


            As you can see, the odds are significant that you will need long-term care at some time in your life.  Due to the devastating effects of an extended long-term care need on your finances, it is prudent to know your options for protecting against this risk.


How Much Does Long-Term Care Cost?


            Fortunately for Louisiana residents, the average cost of long-term care in Louisiana is below the national average.  The national daily average cost of a private room in a nursing home is $192 per day.  In Louisiana, the average cost is around $100 per day.  This cost varies depending on the facility.  On an annual basis the average cost in Louisiana is $36,500.  If the average stay is 2.4 years, the average cost totals $87,600.  Keep in mind that this is the average. For many people the cost will be below this amount; however, for many the cost will be much more.


How Will You Pay For Long-Term Care


Self Financing


            For those individuals who have sufficient assets and/or income to pay for long-term care expenses out of pocket, they may choose not to do anything.  Private payment allows maximum flexibility over choices of care in the home or long-term care facility; however, there are drawbacks. 


            The main drawback of private payment is exhausting large amounts of assets that were earmarked for retirement or for transfer to the children or grandchildren.  In addition, you must be absolutely certain you have sufficient resources to pay for care for extended periods.  Carefully weight the risks of a worst case scenario of both spouses receiving extended long-term care.  Insuring this risk can protect large amounts of assets from long-term care expenses.  You would probably have a difficult time naming a single homeowner who does not insure their home against fire damage or destruction.  People with sufficient wealth to rebuild their home ten times over insure against the risk of their home burning to the ground when the risk of a house fire is one in eighty-eight.  However, when it comes to long-term care many people wish to self insure through private payment when the risk that long-term care will be necessary is one out of four for those over age 65.


Can you afford nursing home care?  Take this test and see.  First, add up all your annual sources of income from pensions, social security, and retirement plans.  If you are married, add both spouses' income.  To that figure add all investment income from interest, dividends, rents, etc.  From your total income, subtract the annual cost of a year in a nursing home in your area.  If the difference between your income and the cost of a nursing home is a negative number, you've got a real problem.  You will have to start spending your principal immediately.  Principal will have to be spent to pay both the nursing home and to pay the living expenses for the spouse still at home.  If the number is positive, ask yourself this question: "Can I live on that?"  If the spouse at home could not survive on the difference between your income and the cost of a nursing home, principal will be consumed to meet expenses.


If you must spend principal, how long will your assets last?  Remember if you consume principal this year to pay the nursing home, there will be less to invest to produce income next year.  If there is less to invest, your investment income will probably go down.  If your investment income goes down, you will probably need to consume more principal next year to meet nursing home costs.  This is the start of an accelerating downward spiral.


Individuals with significant wealth and/or income should consider long-term care insurance because they have the most to lose and can afford the premiums.  The decision, however, should be made after considering all of the options and risks involved and by obtaining multiple professional opinions.


Long-Term Care Insurance


            For individuals with significant assets to protect and who meet the medical underwriting requirements, long-term care insurance can provide the most options and the best protection for your assets.  Long-term care gives you the option of receiving care in your home or in a long-term care facility. The main disadvantage of long-term care insurance for those who qualify is the cost of the premium.  The cost goes up if the policy is issued for an older insured versus a younger insured assuming all else is equal.  Waiting to purchase long-term care insurance may cause the premiums to become too expensive in later years, or the insured may later develop a medical condition and fail to meet the underwriting requirements.


Purchasing Long-Term Care Insurance


            There are many insurance companies offering long-term care insurance and there are many types of policies with various features.  Make sure you purchase a policy from a reputable company with strong financial ratings.  There are a number of ratings companies to consider such as: A.M. Best, Fitchís, Duff & Phelps, Moodys, Standard & Poors and Weiss.  Financial strength is critical because the company may have to pay on your policy 30 plus years in the future.  Also ask about the companyís history of rate increases.  Although you cannot be singled out for a rate increase, the insurer can increase rates for classes of insureds.   If the initial premiums seems too low in comparison to other like policies, either the policies are not an apples to apples comparison or the company issuing the cheaper policy may have a history of rate increases. 


Types of Long-Term Care Insurance Policies


            There are many types of policies and many bells and whistles that may be added to each policy, so doing your homework is a must.  The first question to ask is whether the policy is "tax-qualified" or "non-tax-qualified".  Most policies issued today are "tax-qualified".  The Health Insurance Portability and Accountability Act (HIPPA) created the differences between the two types of policies, and a "tax-qualified" policy is clearly advantageous.  Policies purchased prior to January 1, 1997 are grandfathered and considered "tax-qualified" even if they do not meet all of the criteria.


            To be "tax-qualified", the policy must be guaranteed renewable and benefits are triggered if you are chronically ill.  Chronically ill is defined as an inability to perform at least two activities of daily living or if you need substantial supervision to protect your health and safety due to cognitive impairment.  In 2005, premiums for "tax-qualified" policies  are included with other medical expenses (subject to 7.5% AGI floor) and are deductible according to the following table:



In addition, benefits paid by an indemnity policy are tax-free.  Policies paying under the expenses incurred method are tax-free up to the amount of the expenses incurred.  Policies that are "non-tax-qualified" may use different benefits triggering criteria, including the requirement that care be "medically necessary".  Moreover, "non-tax-qualified" premiums are probably not deductible, and benefits received may or may not be counted as income.  This area of the law is unclear.  For these reasons you should only purchase a "tax-qualified" policy.


Benefit Triggers


            The benefit triggers are events that cause your long-term care policy to pay a benefit for eligible services.  Pay close attention to the benefit triggers required by various policies.  Activities of Daily Living (ADLs) are the most common benefits triggers.   Activities of Daily Living typically include: bathing, continence, dressing, eating, toileting and transferring.  A policy that is "tax-qualified" must use a benefit trigger that pays a benefit upon your inability to perform at least two ADLs.


            Another benefit trigger required of "tax-qualified" policies is cognitive impairment.  This benefit trigger is satisfied if you are unable to perform specific tests of cognitive function.  Alzheimerís disease or other dementia are types of cognitive impairment.


Elimination Periods


            Most policies do not start paying a benefit immediately after the benefit trigger has been satisfied.  An elimination period will delay payment of benefits for a certain number of days.  During the elimination period, the insured will be responsible for paying for 100% of the long-term care expenses incurred. Typically the elimination period is for 30, 60, 90 or 180 days.  A shorter elimination period will cause the premium to increase for an otherwise identical policy; however, a longer elimination period will require the insured to pay more out of pocket for long-term care expenses.  You must determine which trade-off is best for you.


            Elimination periods may be calculated a couple of different ways.  If the elimination period is calculated using days of service, only the days the insured receives services will count towards the elimination period.  If the calendar days method is used, every day of the week counts including days the insured does not receive long term care services.  Obviously, the calendar days method is more beneficial.


            In addition, some long-term care policies require that the insured satisfy the elimination period once in the insuredís lifetime.  Others require that the elimination period be satisfied each time the insured requires long-term care.  Prior to purchasing a policy make sure you understand how the elimination period is calculated.


Other Riders and Optional Benefits


            Waiver of Premium riders allow the insured to discontinue premium payments when benefits are received.  Some policies require a waiting period until the waiver of premium becomes effective.


            Non-forfeiture Riders will refund some of the premium payments to the insured the event the policy is cancelled or discontinued.


            Premium Refund at Death pays to the insuredís estate an amount equal to the premiums paid minus benefits paid.  Typically, premiums must have been paid for a minimum number of years and death must occur prior to a certain age, usually 65, 70 or 75.


 Indemnity and Expense-incurred Benefits Payments


An indemnity policy will pay to the insured the daily dollar limit of the benefits purchased once the benefits trigger is satisfied.  These payments may be used to pay for the type of care wanted and may be provided by a family member or licensed home care provider.   For example an indemnity policy that pays $150 a day will pay this amount after the policy triggers are satisfied and the elimination period has expired regardless of the amount of actual expenses incurred.  Once the policy triggers are satisfied, the indemnity payments may be used to pay for expenses that the policy does not cover such a payment for care from family members. 


            The expense-incurred (also known as a reimbursement plan) method will pay benefits only when the insurance company determines that the insured is eligible for benefits and the claim is for covered services.  The insurance company will pay up to the lesser of the expenses incurred for covered services or the dollar limit of the policy.


Types of Services Covered


            Different types of long-term care policies cover various types of services.  Common types of services include: nursing home care, home health care, personal care in your home, respite care, hospice care, services in assisted living facilities, and adult day care centers.  You should inquire as to what types of services are covered and have it in writing.  Ideally look for a policy that will pay for personal care in the insuredís home.  Taken a step further, some policies will pay for care in the insuredís home provided for by family members.


Many policies are more restrictive with regard to care provided in the home.  For example, some policies will only pay for care in the home if the care is provided by licensed home health agencies or licensed home care providers.


            Some policies place further restrictions on the type of facility covered.  If you are admitted to a facility that is not covered by your policy, benefits will not be paid for eligible services.  Definitions of the types of facilities may differ from policy to policy, so make sure the policy covers all of the options with regard to your future care needs.


Amount of Benefit


            The amount of long-term care coverage may be stated in several ways.  A key issue is how much coverage is needed and how long will the benefit be paid.  The policy benefit limit is generally listed as a certain dollar amount per day over a period of years (1, 3, 5, 7 or lifetime payments).  Many people in Louisiana choose around $100 per day.  If the benefit period is 7 years, the maximum lifetime benefit amount will be $225,500.  If the daily expenses are less than $100 per day, the benefits will last longer than 7 years if the policy pays benefits under expense-incurred method (reimbursement method).


Under the indemnity method, the policy will pay the benefits over 7 years regardless if daily expenses are less than the daily benefit limit.  Extra benefits may be accumulated for future long-term care needs beyond the 7 year benefit period.


There are several factors to consider when determining how long the policy benefit should be paid including price and amount of assets that require protection.   At a minimum the policy should pay for at least three years of coverage.  This time frame will give the insured ample time to transfer assets to children or grandchildren and then wait until after the three year look back period expires to apply for Medicaid.


            The effects of inflation must also be addressed.  The policy may have to pay out a benefit many years into the future when long-term care costs have significantly increased.  Without protection against these increases, a policy benefit that is adequate today may be grossly inadequate many years from now.  If an inflation rider is added, the benefit amount will be increased by the amount of the inflation adjustment.  The inflation adjustment will either be calculated at a simple or compounded rate.  A compound inflation rider provides a greater amount of protection from future increases in long-term care expenses; however, it is also a more expensive rider.


Other Long-Term Care Financing Options


Reverse Mortgages


            A reverse mortgage may be a viable planning option especially for homeowners who are real estate rich and cash poor.  A reverse mortgage allows a homeowner to remove equity from their home to raise cash while retaining ownership of their home. This cash may be used to pay for long-term care expenses or any other need that may arise.  The repayment of the reverse mortgage can be deferred until the homeownerís death.  The amount of the reverse mortgage depends on the homeís value, the interest rate and the age of the borrower.  An older borrower may remove more equity from the home than a younger borrower.  The lender is paid back upon the death of the borrower or if the borrower sells the home.


Long-Term Care Riders on Life Insurance


            A rider may be added to a life insurance policy which will use some of the death benefit to pay a long-term care daily benefit.   A typical rider may pay out 2% of the death benefit per month, and each insurance policy and rider is subject to their own restrictions. 


            Many annuities provide for penalty-free withdrawals form long-term care expense.  Typically the annuity owner must be receiving care in a nursing home to receive these penalty-free withdrawals.


Asset-Based Coverage


          One of the obstacles many people have with traditional long-term care insurance is the fact that premiums must be paid for coverage that may never be used.  Although that is how homeowners, automobile and health insurance works, many people donít see long-term care insurance in the same light.  The risks of depleting oneís estate is often just as great or greater when faced with a long-term care crisis. 


            An alternative to the "use it or lose it" proposition with traditional long-term care insurance is asset-based coverage.  Asset based coverage converts some of the assets that would be at risk to long-term care expenses into a life insurance policy or annuity that pays for long-term care expenses usually for a three to four year period.  The policy will pay for long-term care when its benefits trigger has been met (typically the same as for traditional long-term care policies- two ADLs or cognitive impairment). A rider can often be added to provide additional or lifetime coverage.  Here is where the benefits of asset-based coverage shines:  if the insured never needs long-term care, the policy pays the death benefit to the insuredís beneficiary.  So coverage is there to protect the rest of the assets if a long-term care need arises, but if the policy is never needed, the benefits are paid to the insuredís beneficiary of choice.  If only part of the long-term care benefit is used, any remaining benefit is paid to the insuredís beneficiary.




            Many people are under the false assumption that Medicare will pay for long-term care expenses.  Although Medicare covers some long-term care expenses, the coverage is very limited and subject to restrictions.  Typically Medicare Part A will pay for the first 100 days of nursing home care.  Medicare will pay for 100% of the first 20 days.  After 20 days, you are responsible for paying a co-insurance amount equaling $114 (2005).  After 100 days, Medicare pays nothing.  In addition, Medicare is restricted to daily skilled nursing home care for post hospital extended care services which must be ordered by a physician; performed under the direct supervision of a licensed nurse; and is reasonable and necessary for the treatment of an illness or injury.  Furthermore, the patient must be admitted to a nursing home within 30 days after being hospitalized for a minimum of three consecutive days.  Most long-term care recipients require custodial care.  Custodial care is not covered by Medicare.    In summary, Medicare will pay very little, if any, of the costs associated with long-term care.




            Medicaid is a joint federal and state program which provides medical care to eligible persons.  There are numerous methods to qualify for Medicaid; however for the purposes of this book, discussion will be limited to qualifying for Medicaid benefits for long-term care.  To qualify for Medicaid benefits for long-term care, you have to be poor and age 65 or older.  The qualification rules look to both the income level of the applicant and the amount of assets owned by the applicant.  In other words an applicant cannot have too much income, nor own too many assets in order to qualify for Medicaid.


Income Limitations


            To qualify for Medicaid the monthly income levels of an applicant must be less than $1,737 per month (2005).  This includes income from all sources.   Under an alternate test, the Medically Needy Spend-Down Program, if the applicantís income is greater than $1,737 per month but less than the facility rate, the applicant may still qualify after certain adjustments are make to their income.


            For example, assuming the resource test is met and the applicantís monthly income is $2000 per month.  Because their income is greater than $1,737 (2005) per month but less than the facility rate, to qualify for Medicaid the applicant must reduce their income by the Medically Needy Income Eligibility Standard Deduction ($100 in Orleans Parish); the Supplemental Security Income Standard Deduction ($20); and deduct long-term care related medical expenses.  If, after these adjustments, the income is less than the Medicaid facility rate, the applicant qualifies.


            The Minimum Monthly Maintenance Needs Allowance permits the institutionalized spouse to transfer income to the community spouse (the spouse at home) to meet a minimum threshold of monthly income.  If the community spouseís monthly income is less than $2377.50 (2005), the institutionalized spouse may transfer income to the community spouse to reach this minimum amount of monthly income.  The transfer of income to the community spouse at home will help the Medicaid applicant meet the income limit.


Resource Limitations


            In addition to the income test, the resource test must also be met.  A Medicaid applicant cannot have resources in an amount greater than $2,000.  If both spouses are institutionalized, the applicantsí cannot have combined resources greater than $3,000.  Resources include cash, assets or possessions which can be converted into cash. 


The resources of both spouses are counted at the time of application.  For Medicaid purposes, there is no distinction between separate and community property.  All of the resources of both spouses are considered at the time of applying for Medicaid.  After the institutionalized spouse is deemed eligible for Medicaid, assets received by the non-institutionalized spouse are not considered in determining the institutionalized spouseís continued eligibility for Medicaid.  Basically, Medicaid will take a snapshot of the resources of both spouses at the time of application.  If the available resources are less than $2000 at the time of application, assets later received by the at home spouse will not disqualify the institutionalized spouse for Medicaid.  This concept will come in handy when we discuss a helpful planning technique.


            Any income and/or principal distribution from trusts paid to the Medicaid applicant or spouse, is considered income in the month received.  Furthermore, income that is not spent by the Medicaid applicant is considered a countable resource.  Assets in trust that may be paid to the Medicaid applicant or spouse is a countable resource.


Exempt Resources


            Certain assets are considered exempt resources and are not included in the $2000 resource limitation.  These exempt assets include, but are not limited to:

  1. The family home if the applicant intends on returning home or if the spouse or a dependent resides in the home.  Up to 160 acres of surrounding contiguous land may be included with the family home.  Proceeds from the sale of the family home remain exempt if reinvested in another family home within three months.


  2. Household furnishings not it excess of $2,000.


  3. Personal effects not in excess of $2,000.


  4. Wedding and engagement ring.


  5. Vehicle with a fair market value of less than $4,500 unless used for employment, medical treatment or essential daily activities.


  6. Cash value of permanent life insurance with a face value of $10,000 or less.


  7. Burial spaces (unlimited value if fully paid for; otherwise amounts paid in installments are considered burial funds and are excludable up to $10,000).  Burial spaces must be for the Medicaid applicant, spouse or immediate family and includes: mausoleums, crypts, plots, grave sites, urns, caskets, vaults, headstones and arrangements for opening and closing the gravesite.

Community Spouse Resource Allowance


            The Community spouse is allowed to retain $95,100 (2005) in non-exempt assets.  Amounts over this amount are available assets to the applicant spouse.  Once the spouse qualifies for Medicaid, the community spouseís resources may increase over the Community Spouse Resource Allowance without disqualifying the institutionalized spouse.  The institutionalized spouseís resources, however, may not exceed $2,000.


Penalties for Transferring Assets:  The Look Back Period


            Many people attempt to meet the resource limitations by removing assets from their estate by transferring these assets to the children or grandchildren.  The look back rules impose penalty periods for certain transfers.  In 1993, OBRA extended the look back periods to 36 months for outright transfers and to 60 months for certain transfers involving trusts.  The look back period starts from the date the applicant is both institutionalized and submits a Medicaid application.  When the application is made prior to institutionalization, the look back period starts on the latter of the two dates.


Transfers Involving Trusts


            The trust rules are a little more confusing and I will try to keep this explanation as straightforward as possible.  A transfer by the Medicaid applicant to a revocable trust remains an available resource to the applicant.  Thus, the look back periods do not apply.  However, a transfer from a revocable trust to a person other than the applicant is considered a transfer subject to the 60 month look back period.  For irrevocable trusts, transfers into the trust to the extent that those payments could not under any circumstances be made to the Medicaid applicant are subject to the 60 month look back period.  All other transfers involving trusts are subject to the 36 month look back period.


Calculating The Period Of Ineligibility


            If a transfer occurs during the look back period, the Medicaid applicant will be ineligible for Medicaid benefits for a period of time.  The time period is calculated by dividing the fair market value of the transfer by the applicable private pay rate.  The private pay rate is the average cost for a private pay nursing home resident in Louisiana ($3,000 in 2005).


            The length of the penalty period is without limitation.  If a very large transfer is made during the look back period, it is possible to cause a period of ineligibility for the duration of the applicantís lifetime.  The period of ineligibility generally starts to run the month after the transfer was made.  If multiple transfers were made, the periods of ineligibility run consecutively with no overlapping ineligibility periods. Careful planning is extremely important when planning asset transfers.


            For example, if Boudreaux made a transfer of $150,000 in January 2004 to his children and applies for Medicaid and is institutionalized in June of 2004, the transfer took place during the look back period.  To calculate the ineligibility period, divide the amount of the transfer by $3,000 (which is the applicable private pay rate).  Boudreaux will be ineligible for Medicaid benefits for 50 months from the date of the transfer.  To avoid this period of ineligibility, Boudreaux must wait until 36 months after the transfer to apply for Medicaid.  During this time he must pay out-of-pocket for nursing home care.


Planning Techniques


Converting Countable Resources Into Exempt Resources


            The family home, as an exempt resource, is a valuable planning tool.  The general idea is to convert cash and investments that would otherwise be consumed by Medicaid spend down into an exempt resource, in particular, the family home.  This objective may be accomplished in the following ways:

  1. Pay off the mortgage.


  2. Make improvements on the home such as a new roof, new paint, updating the kitchen and bathrooms.


  3. Make the home handicap accessible.


  4. Purchase a more expensive home.


            It is advantageous to pay off the mortgage on the family home versus other types of debt.  Debt incurred to purchase an automobile, for example, will reduce the value of the automobile by the amount of the debt.  The debt on the car or other non-exempt resource will reduce the amount of total countable resources.  Debt on your home, however, will not reduce the total countable resources, because the home is an exempt asset.


The Half a Loaf Strategy


            This technique is used as a last alternative to save some of the assets from Medicaid spend-down.  If no other steps were taken and the applicant, who has significant countable resources, must apply for Medicaid, the non-exempt assets must be spent-down prior to qualifying for Medicaid.  During the course of the spend-down, most of the assets may be consumed.  If the applicant attempts to transfer these assets within the look-back period, the period of ineligibility may run many years if the asset transfer was large in value.  The half a loaf strategy attempts to salvage approximately half of the countable resources from Medicaid spend-down.  Careful calculations are done to determine an amount of resources to transfer from the applicant that will produce a known period of ineligibility.  The applicant retains just enough assets to pay for nursing home care during this period of ineligibility caused by the transfer.  When the period of ineligibility is over, the applicant should just be running out of assets (by paying for nursing home expenses) which were not transferred.  This method can save approximately half of the assets from spend-down.  The other half is consumed by spend-down during the period of ineligibility.


Insuring the Look-Back Period


            An alternative to the half a loaf strategy is to purchase long-term care insurance which pays a three year benefit.  Assets can be transferred from the applicantís estate causing a three year look-back.  The long-term care policy will pay for care during the look-back period.  When the look-back period ends, the applicant, now impoverished through asset transfers, applies for Medicaid.


Medicaid Annuities


Another planning option is to convert countable assets into an irrevocable income stream and potentially save some assets for the heirs and the community spouse.  The countable assets are used to purchase an irrevocable immediate annuity payable for a term of years not longer than the life expectancy of the annuity owner.  Any payment made after the life expectancy of the owner is considered a transfer of assets. The payment must be for a period of time not longer than the ownerís life expectancy to meet the actuarially sound requirement.  If the payout is for a longer period of time, a transfer of assets is deemed to have occurred with penalties if within the look-back period.


    The asset is no longer considered a countable resource, but rather an income stream payable to the Medicaid applicantís spouse.  So long as the payments are made solely to the applicantís spouse the "name on the check rule" applies, and none of the payments will affect the Medicaid recipients eligibility.  After the Medicaid applicant is approved, the spouse at home may receive an unlimited amount of income and accumulate an unlimited amount of resources so long as payments are made solely to the spouse at home.  The annuity is purchased prior to application for Medicaid.  After this "snapshot" date of the Medicaid applicant and the community spouseís finances, the community spouse (the spouse not applying for Medicaid) may have an unlimited amount of income and resources without jeopardizing the Medicaid applicantís eligibility. 


In Louisiana, the state must be listed as the contingent beneficiary of the annuity for any amounts Medicaid paid for long-term care.  Although the State of Louisiana must be listed as the contingent beneficiary, this technique can help provide additional income and resources to the spouse at home and protect assets from spend-down.


A note of caution, not all annuities are capable of meeting the requirements for this technique to work.  Prior to purchasing an annuity when attempting this strategy, consult an attorney who specializes in Medicaid.


Other Considerations


Relatives of Medicaid applicants should review their wills to prevent the Medicaid applicant from becoming disqualified for benefits.  The Medicaid applicant/recipient should not be the beneficiary of any asset nor the legatee of a will.  By receiving assets or an income interest in assets, the Medicaid applicant/recipient will be unable to meet the income and asset limits for eligibility.  Related persons should take caution not to die intestate leaving the Medicaid applicant/recipient as an heir.  Consider leaving these assets to the Medicaid applicant/recipientís spouse, children or grandchildren.  A properly drafted will in this situation is a must.


Estate Recovery


The State of Louisiana is required by the Federal Government to seek reimbursement from a Medicaid recipientís estate for certain services provided.  Recovery is limited to nursing home and community based services, related hospital and prescription drug services for recipients age 55 or older.  Typically the only significant asset remaining in the Medicaid recipientís estate is the family home.


            The State of Louisiana cannot seek recovery from the estate of the Medicaid recipient until after the surviving spouse is deceased.  Recovery is also not allowed if the Medicaid recipient has a child under age 21 or a child who is blind or disabled.  Recovery cannot be sought if a sibling lives in the home of the Medicaid recipient and has lived there at least one year prior to the Medicaid recipientís admission to a nursing home, or if a child of the Medicaid recipient resides in the home and has resided in the home at least two years immediately prior to the Medicaid recipientís qualification for Medicaid.  The child residing in the home must also be able to show that he or she provided care to the Medicaid recipient that allowed the Medicaid recipient to reside in their home rather than a nursing home.


            Recovery is limited to the greater of the first fifteen thousand dollars or one-half of the median value of the homestead in each parish.  Estate recovery will also not be sought in cases of undue hardship or if the recovery is deemed economically unfeasible.


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This book is not intended to be legal advice.  Neither John E. Sirois, Raymond James Financial Services, Inc. nor John E. Sirois, A Professional Law corporation are responsible for the consequences of a particular transaction based on the contents of this book.  All financial, retirement and estate plans should be individualized as each person's situation is unique.  Competent financial, tax and legal advisors should be consulted prior to any transaction.  The information has been obtained from sources considered to be reliable, but we do not guarantee that the forgoing material is accurate or complete.  Any opinions are those of John Sirois and not necessarily those of Raymond James.  Expression of opinion are as of this date and are subject to change without notice.



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