Episode 14 The Ins and Outs of Medicaid With Valerie Geiger
In the twenty plus years of helping people plan for the cost of retirement and long-term healthcare we identified one consistent theme among among families and caregivers. People don't like to talk about money. Life Care affordability planning families who are facing long term health issues and increasing health related expenditures to make better informed financial decisions during a time when there are so many unanswered questions. It's time to face this topic ahead on address the emotional charge of discussing money and discover practical ways to bridge the gap between a long-term healthcare plan and your ability to hey for it alone. Welcome to Life Care Ford Ability Planning with Tom. West and our vet read from signature estate and investment advisers. Today is going to be a great podcast. You know they all are however today they have a special guest and that is Valerie. Geiger and Valerie is a founding partner of Kucha Anneli Geiger. PC and has been practicing in the field of elderlaw. Since two thousand and four Valerie focuses in the areas of Medicaid. Planning and Estate Planning Valerie. Welcome to the show. How are you? I'm good how are you all welcome. Welcome welcome gum. Yeah so we know Valerie not only through work with the life care affordability plan but we also share Insight Memory Care Center. We're both board members on that right now. So I get to work with Valerie and all kinds of ways. Nice Valerie from what I understand. You're an elder law. Turn is correct. That's correct fantastic. What is an elder law attorney? If you don't mind me asking an elder law attorney is an attorney whose practice focuses on individuals with disabilities he's special needs for example Dementia Down Syndrome etc.. We deal with other clients to our typical. We do estate. He Planning Medicaid. Planning probate special needs trusts guardianship conservative ships. Big words big words. I I won't ask for all the definitions. We'll just we'll just roll so Thomas. Why did you bring your on the show today? I mean obviously she fits right in with what you guys do and that. That'd be the obvious answer but you guys known each other for a long time cracked. Sure well you know as as as a as a trusted colleague. I have known Valerie for real long period of time I was I was thinking about the sequence of some of our different podcast episodes. And we're coming off of a great conversation about Medicare and a lot of times when we're thinking thing about how families consider ways to pay for different approaches to chronic illness or injury or whatnot after Medicare Medicaid is usually really one of the concepts that sort of top of mind for a lot of consumers that are out there so what we thought we would do. Today is to bring Valerie infrastructure. Some comments about you know. We're on the ground floor. Should people start building. Their understanding of what Medicaid really is and I think when we were thinking about how that interfaces with a lot of our life care affordability not plan. Where does it fit and you know what are good ways to make decisions about how you pay for it? When we're thinking about Medicaid and in the context of life care affordability planning so really Valerie? First question for you is tell us what what Medicaid is what what are we talking about. What Medicaid System? How does it work? Medicaid is is the public benefit that pays for long term care. It's often confused with Medicare. But it is Medicaid And it is the only public benefit that is income and asset sensitive that that helps finance long-term care nursing home. So what do you mean by income and assets sensitive so there are income and asset tests that you have have to go through. Where if you want eligibility for Medicaid so you can't have too much money in qualify for Medicaid basically? Okay all right so talk a little bit about eligibility ability we know that there's that financial component from an asset and from an income standpoint. Could you talk about that. Could you also talk a little bit about healthcare and eligibility on Coronas. Well sure to be eligible for Medicaid. You have to be needy. In two categories you have to be medically needy and you have to be financially needing to be medically needy. You have to be deficient in what they call activities of daily living your dressing bathing ambulation an acceptable so you need to be efficient. At least two or more of those activities of daily living and have what basically call a nursing home level need of care right so it's not someone who is newly diagnosed with dementia. They're not gonNA be medically needy. You also need to be financially needy. So there are income and asset tests there are some assets that are are deemed exempt for Medicaid eligibility in the Commonwealth of Virginia. A majority of assets are what they call countable for Medicaid eligibility. And what everyone here's about is the two thousand dollars you can't have more than two thousand dollars right. which it there's more to the story but that's the kind of general guideline when the other thing is everybody thinks? Oh I get to keep my house. That's true yeah. That's true with some bells and whistles you right so you get. If you're married you gotTA spouse you. Keep the house. If you're an individual who is unmarried carried then yeah for maybe about six months and then we gotta do something with the House and back to your point about eligibility and needing help with activities of daily living there is a difference between assisted living and nursing level of care. And you know here locally in the northern Virginia area there aren't a lot of living that take Medicaid so people just assume. Oh I could just move into anywhere with Medicaid but eligibility part is really really important from a medical perspective. It's super important. And I think people confuse the types of care they they they've think it assisted living and nursing home interchangeable. And it's not right right very different so you know there. It's it's worth pointing out to our audience. There exists a space where somebody might not be able to safely live by themselves and even though they might not have financial resources to pay for care they might not be healthcare. Qualified defied for Medicaid which is one of our uncomfortable spots and I think I remember the in in in one of the things. Also true is sometimes people might be medically eligible but have too much in assets or income and that that that speaks a little bit too concepts around Medicaid planning winning. So you know one of the things that you do Valerie is for folks that have too much money and might be thinking ahead about the possibility of qualifying in for Medicaid. There's a handful of things that that it. There's a handful of rules that we have to be mindful of and there's a handful of things that might be appropriate to consider so so. Walk US through Medicaid. Planning what do you do with clients that might be overreach source gives us a little bit of background there. It was so the first thing that we do at the office. Is We do a resource assessment. So we sit down and run through the assets like an eligibility worker would for Medicaid to determine what amount amount you are actually what they call over resource by. So how much money do you have. Most how much is going to be accountable. And GonNa keep you from from being eligible for Medicaid. Then we look at that amount and we'll look at the plan of care and we try to run through different planning options of okay How best can we preserve assets but at the same time qualify for Medicaid Medicaid and the preservation of assets is? I often get the question of. Is that legal or can you do it. You can because everything that we're doing is based on the Virginia Medicaid Manual also. I I read the manual constantly. Know all the rules. What can what can can we not do in order to to preserve but also gain eligibility Can can you give an example of some of those different kinds of techniques. So we're in the again in the office we have pre need planning versus. Okay now. We're in a crisis. We need the right eligibility. Not right away Pre planning I think a lot of people here about the trust the trust and it's the irrevokable it's near Vogel Bill Medicaid Planning Trust. You're moving your assets out of your name into this trust. Hopefully you have a good family in place that can manage the stress because you no longer own on the assets and what we hope is there's a calculation of how much you should keep your name. How much should go to the trust? But but you're basically moving asset data your name and hoping thing that you know. You won't need Medicaid in five years because Medicaid has a look back that's actually sixty months the application asked What have you transferred in sixty months? And if you give away gifts or make uncompensated transfers get penalized. Yeah and but you know being in the senior housing healthcare world for fifteen years. Like I've heard this over and over and over again but then the other side of the question is people don't really realize when you're doing that and doing Medicaid planning what your options are they medicaid doesn't doesn't cover everywhere and it's not going to cover maybe the nicer places. That's in your neighborhood that you thought might be an option for you down the road right like talk a little a bit about that. When you're talking with families still my step one in in the meeting is yes I want to understand the assets and I and we WANNA think about Medicaid but I also both very much push? What's the plan of Care Right? Okay and that drives the planning so if the plan of CARE is to never go to a nursing home then why are we talking about Medicaid right right because that's not really I mean it might be have to be the person's fall back option but if the if the main goal is I i WanNa keep the person at home or eventually go to assisted living or memory care then then Medicaid planning should not be our priority right well and so many people say oh I can stay home and I can get the Medicaid waiver aid. Come to my house with. That's to still has a lot of hoops. You gotTa jump through it. It's the same Medicaid eligibility. Has Like we discussed. It does not pay for twenty four seven care so you're gonNA have to offset With your own assets. The other hours of the day that it's not being covered or family members around the clock or family members. Right you you yourself or a loved ones are going to have to pick up because they do. Maybe eight to ten hours a day. Roughly Right and I think one of the things that For people in the audience that that don't have an understanding of how much of the nation's Virginia's long-term care bill gets paid by by Medicaid. It's a pretty significant percentage of how people have a lot of these care costs covered. It's also useful to know that part of the reason that Medicaid doesn't pay for all sorts of different facilities as they're paying less to a nursing home than what you would to pay out of pocket they they basically are paying the nursing home a discounted rate that sometimes as much as twenty five percent or more under whatever the private pay rate. It is so it's useful to consider as as we're sitting here this year. How the environment is changing? You have more and more people aging into a space as for the good of be needing help and you know we have you have a service providers like nursing homes having the choice of whether they want to cater to people that can pay full freight or to administer types of care like assisted living or home care. The people have to go out of pocket for or do they want to chase a business model. Where they're GONNA be being paid less than full market rate? It's a challenging environment and I'm glad that you brought up that. Think the future of Medicaid and the challenges of how the the nation in the state are going to be paying for all this. It's going to continue to be a more challenging world in sort of that Medicaid space which I think people need to be aware of. Yeah two more points. I wanamaker's that Medicaid is state regulated whereas Medicare's Federal Medicaid estate so state by state of changes in what's available global and the processes might be slightly different and back to the idea of the business of the nursing home. As I mentioned earlier. You can get Medicaid waiver in your house but again the home care agencies that provide that service are in the same position as the nursing homes. where the money they're gonNA get for Medicaid? Reimbursement isn't as much much as they would get and private pay so or Medicare so the business of a nursing home in the business of a home care agency. They have to decide decide that they are willing to take less pay for in order to service that space and and are the two that point. The nursing homes in northern Virginia have decided they they don't want to be in that business and and we have a bit of a nursing home bed shortage It's really hard to get a nursing home bed. Because in Medicaid well disappear general in general because a lot of facilities heavy there they mostly downsized and up to their rehab because they can make more money focused on the Medicare and they can make more money. And it's not just here in Virginia. I've talked to we have clients that have family members and other parts of the country. And I've made calls and it's the same all over the place that it goes back to. What the business this of the nursing home in today's world versus what it might have been forty years ago? But what I want to say. Basically Medicaid is a choice. But it's only a choice for some but most people. It's not the best choice right. And what do people give up again by choosing go this pre-planning Medicaid route other than maybe just which facility. They might choose well if they do the pre planning route with the trust. They're definitely giving giving up control and of their assets. which my finding is? It's it's a rare that the clients are saying. Yes I want to do this because because the you know you work your whole life to build up your own nest egg and the last thing you're thinking I was. I just want to hand this over Bryant. You have to really have a trusted family member or person that you can hand off to to that because the because the whole point of the trust is that if you do actually need the money that the people who actually are in control of it will turn around and give it back to you Right but they don't have have to give it back to you so you have to have the right team in place for this that kind of planning to even work and I think the other piece in value could talk on this too. I mean as as has as a medicaid recipient. You're you're effectively award of the state at that point and the ability to self direct a lot of your different care airplane. That's one of the other things that might be taken away from you. You're not able to choose from this wide menu of service providers or different settings of care physician. You're just like you know you have to check and see if your physician takes Medicare or your particular insurance. Not As many physicians take Medicaid anymore. Yes so you're really kind of at the mercy of the facility that you're in because they have the doctor the doctor coming there those are the doctors are GonNa Take Medicaid. And so you're you're not having choices. What's there at the facility? That's what's what your providers are men without other resources. You're not going to be able to take transportation tation to go to see XYZ doctor right and once again. I mean there's there's lots of services that Medicaid provide outside of the senior population that we're talking about right now outright. And there's there's a space for that that that's not where we're going to focus today but it is the right choice for some. We're not trying to say that it's not right choice. It is the right choice for some but those people out there and I ran into several of them over the fifteen years that that was just their default without really understanding all of the other options. That's right and so I think people need to take the time to not just say. Oh I'm just going to plan on Medicaid when the time comes you gotta do your research early Seve. That's even going to work for you right And I think that when we were considering the families that life care affordability planning is making the most impact on. It's really families that are right. Not on on the edge of qualifying for Medicaid to begin with most of the folks were the Laker. Ford Ability. Plan makes the most impact or folks that would have some pretty significant assets assets that hypothetically would have to be spent through or transferred to a trust before Medicaid would even be an option right and I think part of the ground that we're covering today is is you really want to be sober about the things that you'd be giving up and what that environment might look like to just decide whether that is an option that you WANNA proactively actively consider as compared to maybe that's the last resource or the last option for you so so in instead of just racing to that Medicaid Aid Recommendation Valley. One of the things that you talked about. was you know. Somebody's coming into your office. You do a resource assessment. You figure out what the family and the the decision making sort of capacity is in lieu of Medicaid for people that have money to pay for care. What would what do you? Where do you start in terms of giving recommendations mediations in an as as an elder law attorney for families? Where do you start so every case I believe is organic? You have to listen to the client. Listen to the facts and circumstances uh-huh chances of I believe that they're probably going to have sufficient assets and the plan of care does not include wanting to nursing home which usually doesn't Then then I am asking that we form a team that we get a director care manager on board that we talked to financial financial advisor and come up with that plan too so that they can come the anxiety of the client of with this team. We are going to be able to put a plan together. You are going to be able to finance this. This isn't going to bankrupt corrupt you. We don't have to go from zero to sixty right to the Medicaid planning. Let's let's talk to people who know how to actually analyze your finances and give you kind of that analysis of no you're going to be okay And I'd like to see that. First before we start doing any medicaid planning. I WANNA know. I'd rather them come. I'm to you and you say okay. You're three we have an an and a lot of times you know. It's not that a lot of times. It's not your three. So why are we going to do something. A little. More drastic of Medicaid planning. We don't need to so you've painted a picture in our audience had about a plan involves involves You know a collegial team with different areas of expertise legal and medical and financial What makes a plan work among those different professionals? What are the what are the things that you need to see on how those different skill sets interact with clients what what makes for a good it functioning plan in your mind when the team talks to each other so the team has to get along? has they know each other. And be willing to share information and really it produces a great product for the client because you have three different disciplines coming up with the best plan for the for that person. Sure and you know in you you can. You can speak to this too. There's a lot of times that there are some responsibilities on the part of the client and the family thirteen member to just about say. Maybe you can talk talk a little bit about well. What are the areas where it looks like from a professional standpoint? Things should be setting up a very well but then things might go left or they might go off the rails talk a little bit about the responsibilities of family members or clients being a good team member for their own plan. Right one of the things. When I left the senior housing healthcare world and jumped over to finance to focus on the life care affordability plan in senior housing healthcare? We always have family meetings right. That's just what we do in your World Valerie. You have family meetings as well in the finance world. That didn't really happen. There was usually one person right so when you are bringing the three disciplines together it's really important for the family to be involved also in the financial conversation and it might be the first time ever that that that's happened and so what we found through the life care. Planning process is by bringing everybody to the table and allowing the person that's been managing the finances to explain some of the rationale. What did to express what they were most hopeful full four when they made the decisions and for everybody to acknowledge that the job of the money has now changed like the idea that this person was retiring and going to leave a big nest egg big to the kids and the grandkids? That is usually a conversation has to happen early because now there's healthcare costs that nobody anticipated right So it's very very important to have family members involved and we know that not all families are gonNA come together and kun-bae we as the professionals that do this day to today know that sometimes we have to help families navigate some circumstances before we can continue to move forward to the next phase of the plan but very very important to get the family really evolved. Well it's necessary. Because presumably at some point they're going to be handing off the nest egg so to speak to their age and under the Financial Poverty Ernie right and if that person doesn't have have any idea of what the principle of the document was thinking what their wishes were. Then you're handing them something blind in saying go so oh that is critical the critical conversation for everybody. Same thing with like advanced directives. Like you can't have an advanced directive saying that you do want this. Don't want that and have nobody in your family understand what it is that you really want. Sure why I think just in terms of some wrap up thoughts for today I'm going to paraphrase something that Valerie just said which is in order for this team to aid the family and the client to make effective decisions. There has to be an understanding of what the new priorities are. You know what that plan of care is that can drive the best clinical or therapeutic outcomes. What that setting looks like with the living arrangement is and there needs to be agreement? Ema on what the new goals are or the new most important things and sometimes it's hard for families to muddle through. All of the priorities agrees that they used to have and all these new priorities. That are just now urgent in front of him. And that's something that we really try hard to do with professionals like Valerie to help family sauce out. What the new most important things? Sometimes they think the most important thing is to protect the money until you get into all the other conversations right and I think that part of what is is rewarding. Certainly speaking for myself is is to give people permission to ask for help that has cost associated with it. I think too often people. We'll go out of their way not to ask for help. Maybe it's because they're not comfortable accepting the situation they're in maybe because they've had priorities in the past that like you said about maintaining legacy but I think that the process at least with a life carrier Ford Ability Plan that we've tried to build you know is taught by a a lot of the principals at Valerie outlined in terms of what makes for a functioning plan. But I'm glad at least coming from a legal professional who who really makes sure that the family has the ability and the permission and the authority to make these kinds of decisions that that's something that's important for everybody to consider. Let's start are at the conversation. Let's start the conversation Eric. That's our ideas for today. That was fantastic. A love the fact that she was here because that gave a lot a lot of insight to a lot of people. Tommy are if they want to reach out to you and connect with you guys specifically and I know that you all her contact information. Valerie's contact information. How do they get a hold of you guys? It's best way Valerie. Go and tell you from a Kootenai Geiger. We're in Fairfax Seven. Three four eight one. Six four six four and your the website. COACHING GEIGER DOT COM. Yep in Virginia Fairfax Virginia concussions from elsewhere and then per the Minnesota uh-huh and for life care for it ability. Planning you can go to afford life. Care Dot com wonderful wonderful. Thank you guys so much for your time today. Thank you and thank you for joining us today on the life. Care Ford Ability Planning podcast with Tom and our vet. If you've not subscribe to the podcast yet please. Click the subscribe now button below this way when Tom and our vet come out with a new podcast directly on. You're listening device. This makes it much easier to share these podcasts. With your friends and family that need to hear it. Thanks again for listening today for for everyone at life. Care for two -bility planning this Johnson reminding you to live your best day every day and we'll see you next. Time is an opinions provided here are those of the individual speakers cours all content is informational only and is not intended to be an endorsement or recommendation of any particular investment strategy or other course of action Russian. 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