certified medicaid planner course · or included as part of a initial retainer. 10 ....

1

Certified Medicaid

Planner Course © - Strategic Marketing Partners, LLC

SESSION 16

POST-ELIGIBILITY ISSUES,

ADVOCACY OPPORTUNITIES AND

VETERANS’ BENEFITS

Post-Eligibility Issues

(continued)

So you’ve gotten Medicaid to

approve eligibility…

Now what?

2


(Continued)

A. Post Approval

1. Notification

• You should get a notice of approval of benefits.

• Be sure to let the client know benefits have been

approved.

• Double check the determination to make sure an

error was not made:

– Could affect copay or CSRA asset allocation.

3


(Continued)

2. Monthly Co-Pay/Income Procedures

• Let the client know what the monthly co-pay is.

• Explain how income comes in and gets paid to the

nursing home and retained.

• Explain process of interrelation of Miller trust.

• Make sure income accumulation does not cause

the patient to be over resourced.

4


(Continued)

3. Random Audits

• Cases are randomly audited depending on audit

procedures.

• Often cases require additional verification of

assets or income.

• Explain the audit procedure and for the applicant

to be on the lookout for a notice of an audit.

5


(Continued)

4. Annual Redetermination

• Explain to the client the need to re-apply for

Medicaid every year.

• Make sure everyone understands who will be

responsible for the reapplications (client or

planner).

• Calendar the reapplication and schedule a visit

before the application is due.

6


(Continued)

5. Unreported Income Notifications

• Medicaid agency has access to IRS income

notices.

• IRS sends a report annually for any aid recipient.

• If any account reports income that is not listed as

income on the application, a notice is sent

requesting additional information to explain.

• Often triggered by interest income.

• Sometimes can lead to a surprise by the planner

and the client. 7


(Continued)

6. Change Notification

• Must notify the Medicaid department of any major

change in circumstances:

– Change in income.

– Receipt of lump sums.

• Usually given 10 calendar days to notify.

• Failure to notify could result in loss of benefits.

• Common exception: Social security COLA

changes are generally updated internally because

of cooperation with SSA. 8


(Continued)

7. After-Acquired Assets

• Patient must report and spend down new assets

acquired after eligibility approved.

• Community spouse’s asset acquisition ignored.

• Disclaimer: Any inheritances must be declared

(refusing an inheritance could cause a divestment

penalty).

9


(Continued)

8. Fee Anticipation

• Resource limits put a limit on funds available for

additional professional fees:

– Legal fees to defend an erroneous determination;

– Additional planner fees to file re-apps; and/or

– Accounting fees.

• Any post-eligibility fees might need to be prepaid

or included as part of a initial retainer.

10


(Continued)

B. Asset Issues

1. Re-title CSRA Assets

• Assets retained as part of the CSRA need to be

transferred into the sole name of community

spouse.

• Required as soon as possible, but usually provided

one year from date of application to complete

transfers.

• Must demonstrate compliance on re-app.

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(Continued)

2. Update Estate Plans

• Patient’s estate plan should attempt to avoid

probate and reduce recovery exposure.

• Especially important for community spouses.

• Not everything should be directed to the patient.

• Must take into account elective share.

– Divert elective share to testamentary trust if state rules

allow.

• Consider divorce to eliminate exposure to

recovery. 12


(Continued)

3. Community Spouse Eligibility

• Just because a community spouse is in the

community doesn’t mean they’ll stay there.

• Take advantage of 5-year lookback window to do

planning for community spouse if possible.

• Prepare for possibility of need for care for both

spouses at the same time.

13


(Continued)

C. Income Issues

1. Changes Impacting Copay

• Report changes.

2. Boosting Expenses

• To get more spousal allowance, boost shelter

expenses (rent a divested home or take a

mortgage on a home).

3. Petition for Increase in Spousal Allowance

14


(Continued)

D. Miscellaneous Issues

1. Moving

• Patient can move from facility to facility

– Medicaid follows inside state.

– New rules and new application if outside state.

2. Bed Holds

• Know your state’s policy on bed holds for time

away at hospital.

3. Correspondence and Communication

• Have plan to get notices timely. 15

Advocacy Opportunities

A. Administrative Advocacy

1. Use a Fair Hearing

– Increase CSRA

– Correct CSRA Error

– Correct Income Error

– Increase MMMNA

– Object to Wrongful Denial

– Hardship Waiver

16


(Continued)

2. Fair-Hearing Procure

• Request a hearing within the time allowed.

• Notifications give time to request hearing (e.g., 30

days).

• Hearings can be conducted in person or over the

phone – applicant (or representative) makes

argues own case and caseworker argues theirs.

• Can be represented by counsel or anyone of

applicant’s choosing.

• Can appeal adverse ruling.

17


(Continued)

B. State Court Advocacy

1. Appeal Administrative Decisions.

2. Mandamus Actions.

3. Increase CSRA.

4. Increase Spousal Allowance/MMMNA.

5. Establish Guardianship or Conservatorship

6. Ratify Agent’s Actions (under POA)

18


(Continued)

7. Ratify Guardian/Conservator Actions

– Medicaid Plan

– Divestments

– Conflicts of Interest

– Termination of Spousal Rights

8. Trust Creation or Modification

9. Divorce

10.Heir Representation

11.Decedent Probate

19


(Continued)

C. Federal Court Advocacy

1. Reigning In State Law

– Federal pre-emption

2. §1983 Claims

– Civil rights violations through denial of benefits.

20


(Continued)

D. Miscellaneous Issues

1. Client Identification

– Identify client.

– Client’s and agent’s goals sometimes in conflict.

2. Conflicts of Interest

3. Multi-Licensed Professionals

4. Unauthorized Practice of Law

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Veterans’ Benefits

• This is not a course on planning for VA benefits.

• For those who don’t do them, it should be

understood that VA offers an Aid and Attendance

Benefit.

• Asset eligibility follows a lot of similar Medicaid

limits (but is more like Medicaid before the DRA).

• Most incomes are too high to qualify for a benefit,

but costs of custodial care or assisted living will

offset income and establish eligibility.

22

Veterans’ Benefits (Continued)

• Asset eligibility often established with a balloon

annuity similar to Medicaid pre-DRA.

• EVERY VA BENEFITS CASE SHOULD ALSO BE

CONSIDERED A POSSIBLE MEDICAID CASE.

• All VA benefits planning should take into account

the eventual need for Medicaid eligibility:

– Just because it didn’t cause a divestment penalty for

VA benefits does not exempt a transaction from

causing a penalty for Medicaid.

• VA Benefit Planners are being sued for not taking

into account later need for Medicaid. 23

Veterans’ Benefits (Continued)

• Medicaid applicant must file for all other forms of

assistance available – VA benefits if applicant or

spouse is a veteran.

• VA life insurance factors into life insurance.

• VA has burial available for veterans if no funds to

buy pre-paid funeral trust.

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Questions

• Questions????

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