E18-richard-bullock-medicaid
Alex:  [00:00:00] Let me underscore point if you get Medicaid to cover your long-term care costs after the age of 55 it's not actually Medicaid paying for it with a blank check.
It's almost like a loan. Because once you die, they can come back and put a lien against your assets for the amount that they 
Guest: paid
 
Amy: Welcome back to mastering Medicare. I am one of your co-hosts Amy Schiffman, and I'm here with our co-host Alex Mohseni. We are back yet again for our second episode of 2021, and we have an amazing guest today. Amazing. Amazing. So this guest today, Alex, you are going to love because even though [00:01:00] we are mastering Medicare, we are going to talk today about Medicaid because it's certainly why not?
I mean, we've been talking about Medicare, let's talk about Medicaid. They probably kind of crossover at some point and we have an amazing guest Robert Bullock, who is the founding partner. I'm just going to make this up of the elder law center in Washington, DC, who I've known since I started doing house calls, you were always so nice to me, Robert, so 
Guest: nice.
Oh, nice. How many 
Amy: years ago was that? Okay. Let's not age me too much, but probably 12 years ago. 
Guest: Well, 
Amy: 12, 12 years ago. And you and I had several cases together of patients that I saw and you had either stepped in to help them out. Or had referred them to me and we worked through them together. They were, you know, people with difficult families that weren't getting along or people who needed to get into the Medicaid system.
And this is your expertise. You're kind of like, I'm going to be like obnoxious and call you the godfather of Medicaid [00:02:00] as opposed to the grandfather of Medicaid. Is that all right? If I call you the doctor, 
Guest: there are a few in the metropolitan area who would, would, would claim that title, but I'll give it to you today.
Okay. I'll accept that today. I'll I'll accept it today. And also what you touched upon is a nerve, because I'm going to fix you an auto of the godfather movie. 
Amy: Okay. Well, there we go. We're not going to go to the maps then. Okay. You're not going to do that. Okay. But 
Guest: Alex, because there are others who do Medicaid planning.
There are a few firms in Maryland before. I think in DC, very few and a lot of people in Virginia. Okay, 
Amy: great. Well, we want it. We want to understand sort of the ecosystem in which you work, but Alex, I want to kind of go back to you just really quickly, because today's a really special day. We want to hear about something.
Tell me, yes. 
Alex: We're really excited because today we, with this episode, we actually have our very first sponsor and we want to take a moment to thank our sponsor. For this episode rise, virtual Medicare marketing and sales [00:03:00] summit. Rise is this, this Medicare marketing and sales summit is a three-day live streaming virtual event for professionals in the Medicare advantage.
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Sales summit.com to learn more. Again, Medicare marketing sales, summit.com. And basically if you're in the Medicare advantage, Medicaid or health plan space, you need to attend this conference. Make sure to use promo code P O D 15. That's P as in Patrick ODI 15, to get 15% off again, big. Thanks to our sponsor rise.
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Amy: Thank you, Alex. [00:04:00] All right, so let's go straight to our guests. Tell us what Medicaid is. What is Medicaid? 
Guest: Wow, that's a good question. The Medicaid is is complicated and there are four or five different programs that are independent of one another.
And serve different groups. The, the, the and it's universally misunderstood in, in because the, the cornerstone of Medicaid is long-term care eligibility. And that is when someone is in a nursing home. And is deficient in their activities of daily living and also qualifies economically. And that is [00:05:00] Medicaid eligibility in long term care which is an eight separate animal and is heavily regulated and is where most lawyers practice in terms of Medicaid, eligibility, planning.
The second aspect of Medicaid is what's called Medicaid waiver programs. And I've never understood that I always had trouble when I learned this because when I learned it, I discovered this was back in 99, 2000 that I went around to the elder law bar and everybody talked about it, but they were just doing minimal planning, sort of picking low hanging fruit.
And they didn't really understand Medicaid. So I went back and I found the people who passed the legislation. I read all the legislative history and I basically had this thirst of knowledge because I had a crazy Jewish mother who told me to Excel and to keep going and going and going. Okay. The and.
I learned everything I could in terms of legislative history and spoke to them. So Medicaid waiver means that they waived the [00:06:00] enforcement of formal rules because Medicaid is a jointly administered program at state and federal and the, the, the feds put up half the money. And that world is is remarkable.
In terms of understanding Medicaid has many, many rabbit holes. They're just specialists in those areas. But in any of that, it's a joint program. And the waiver programs the States said when medic 65, when it came in, we have a special population we want to serve, and we want you to waive the rules of enforcement because the rules of enforcement on the legislative side, where universal application, if you set amounts or set eligibility it's for everybody, nobody, there are no exceptions.
The waiver. Allow the States to come up with programs and those programs have expanded in DC by example, to be gigantic and incredibly responsive to the needs of the community and brings services into the home because the goal being with waiver programs to allow people to remain in [00:07:00] their environment, but get the services they need.
So there are, and forgive me, there are four or five of them, none of which I can recite at this time of day. But there's a disability waiver and there's a there was an Alzheimer's wave in Virginia for a number of years that I still don't know if they have it. The special need waivers, there were all types of waiver programs offered in every jurisdiction.
The eligibility requirements are different than they are for long-term care because it's a waiver program. Let me go back for a second. You are not guaranteed waiver services. You are guaranteed. If you're eligible long-term care services in a nursing home. So if you meet the eligibility requirements, bingo green light, you get paid for eight, 10, 12 grand a month.
Covered Medicaid waiver is subject to the discretion of the state. By example, in Maryland, the normal line you give to someone is the waiting list can be anywhere from 2000 to 8,000. In DC, it's a robust program and [00:08:00] there's a tremendous amount of services in the home that are provided. And you can, you can choose in terms of your services to whether you want to self-directed that as you design your own Medicaid waiver plan or the DC government designs the plan for you and provides the help, even to the extent that you can pay the help and get reimbursed that comes in the aides and assistance.
Or can I wait, 
E18-richard-bullock: wait, 
Amy: hold on. Before you go on. Cause I'm the queen of a little bit of interruption here, so I just want to make sure I love to repeat back to you. What I feel like you just said, because it's. Can you imagine I've been doing this for however long, you just taught me three things. So I'm going to repeat back to you a little bit of something that I just understood that the Medicaid program is a combined federal state program that the rules for Medicaid are in fact are in fact pretty universal, but there are these waiver programs within 
Guest: no, that's almost [00:09:00] correct.
Each state. Right. Probable Gates. That's a, that's a good word. Isn't it? Big word. Is Alex still with us or did he take it? Okay. The the I want to tell everybody out there, I'm looking at a screen. This guy's got oughta a yellow shirt is very good looking. With a deep tan and Amy and I, I was white.
That's all it is. 
Amy: I got to change the lighting,
Guest: everything about Medicaid. Once you get below, the surface is complicated. So the, the answer to that, the reason I interrupted you is every state because it's a federal state partnership, the States make their own. 
Amy: Okay. So the States are making their own rules. Okay. So you have 
Guest: certain parameters within certain parameters.
I'll put the 
Amy: fence upset. Right, but then there's the waivers and what you said, which I found the most important thing that you said is that the [00:10:00] waiver programs in general allow for help to go into the home. So that's the difference is that when you think about the regular Medicaid that you were just talking about that's to get people into the long-term care programs in nursing homes, not to be confused with the same building may also house rehab paid for by part a after a hospital.
But that it's paying for people to literally live room and board in places called nursing homes and Medicaid will pay for it to the tune of eight to $12,000 per month of taxpayer dollars. But the waivers are what we call an alternative to that system. So that in like I know the state of Maryland as an example, the community first waiver, it allows for.
Aides like private duty aides, CNAs home health AIDS, whatever you want to call them to then get paid by the state to go in and then take care of people in their homes as an alternative to. [00:11:00] Nursing home care. Yeah. I think that that does that summarize it. And then there's multiple waivers. That's do similar things for different populations, but the idea is don't go into the nursing home.
We don't want you with the nursing home cheaper than going 
Guest: into the nursing. Right. And, and what, what, what the Medicaid people have to do is evaluate the services you'd be getting at home. And are you familiar with IEP individualized education plans? We are children. I have a disabled child, so I went to 21 years with them.
The the, the application process for the waiver in DC, when you're a participant and you want to direct the services is like an IEP. The, the paperwork is dramatic. It's consumed with the paperwork and one has to know how to navigate the system. It is not for amateurs. It is not the amateurs.
And everybody thinks it is because it's it's a government program and we should be able to access it just like we do social security [00:12:00] or well, primarily social security. So it doesn't work that way. This is it's a complex, complex, right complex. There are complex regulations governing everything and it's difficult to navigate.
It's impossible to navigate without getting some help. While I got the floor, the third piece of Medicaid was the Obamacare and that, that provided expanded the poop of eligible eligible people to provide health insurance for another class of people who could move in and become eligible for Medicaid.
And that's Medicaid as in health insurance, Medicaid and every state has different variations. One of the States, I think, Kentucky, what are they? That was a different, those on the Obamacare thing. They, they tried to oppose a work requirement to the, to the Obamacare type of Medicaid. And they have, I think, I think it was, I just think they wrote an article that it was successful.
So there were three different areas you want to look at when you're talking about Medicaid. What what [00:13:00] most of the client community that deals with elder law attorneys is involved with is the eligibility for long-term care. That's that's I think the bulk of the work here about 80% of Medicaid is that maybe 10 to 15% is that doesn't add up.
It is Medicaid waiver. So Robert, 
Alex: what are the different ways that a senior can qualify for Medicaid to cover their long-term 
Guest: care? Well, the, the the first, the first piece in the simplest explanation is they have to be medically eligible. It's the guy who, who I learned Medicaid from Sean, Michelle it may don't make him listen to this.
So he'll know I said his name. He's a godfather, not by the way. When I met him, he's he had on his belt. I remember this was 2003 phones and I made some reference to the godfather when he pulled up the foliage, the whole godfather movie recorded. [00:14:00] Okay. So the, the cloth, the qualifications, like a light switch, it's that simple.
The first light switches medical. Okay. Period. How do you get medical eligibility? You get an evaluation and there is a, I forget the name of the form. It'll come to me in a minute. And you, you get a level of chaos. And that's your first ticket. If you get, 
Alex: can I pause you there for a second? Is it basically failure to do activities of daily living or must you have like some severe 
Guest: diagnosis of it?
No, it's activities. It via diagnosis helps, but it's a failure to do the activities of daily living and it's uniform assessment instrument. How do you like that? I remember. And the, that whole process, Alex. Interesting. We'll just put a box around, getting a level of care that has been a whole subject of a number of cases.
It's changed somewhat everything. When I came through, it was new from 2000 to now. So we were sort of the, the breaking [00:15:00] edge of they were implementing stuff. And the first breed of elder law attorneys was absorbing it for the first time. So the, that, that we had someone who was mentally disabled, I was working with a care manager and I didn't quite fit the activities of daily living, but we convinced them that the mental disability was sufficient to get them there eligible.
I think that well, I don't wanna start naming homes and so forth, but yeah, so that's the, that's the story. And am, if you're really an advocate for the person to the nursing home, What we do is we're onboard right from the beginning because you don't get that medical eligibility and you're out the door.
And when you're close, You want to make sure that, you know, who's doing it and the contract agencies change every two years and the system changes every three years. So you have to be on top of it, just to clarify, 
Alex: are we talking about eligibility to get Medicaid period as a, as a or a specifically 
Guest: for long-term care long term care, [00:16:00] only set of rules.
And the, the, the second piece was the light switch. The first one was kind of like that it came right back to it. And remember that the first one was medical and the second is financial. And when you get to the heart and soul of the Medicaid politics and issues, you're talking about financial eligibility.
Okay. And every state has input into the rules. And the rules are complicated and it's just planning financially for longterm care. In my view is as is similar to tax planning. There are rules where they actually, the theory is that the Medicaid long-term care eligibility financially is, is designed for married couples and the ability to preserve money for the spouse who is not in the facility.
[00:17:00] Okay. It's that simple. And, and the, the spouse who was in the facility has to have, for example, in the district, it's $4,000 or less in comparable assets. And now I bet you're going to ask you what accountable assets it goes on and on and on in terms of the eligibility. But the concept is that a married couple is the center of the target, and you are allowed under the rules to transfer assets.
Between them and do, and have other planning tools that allow a couple to qualify for long-term care and preserve assets for the community spouse. That's that's the heart and soul of, of Medicaid planning. And there are a hundred bells and whistles and you can call me at any time, but don't call me at night again.
Okay. 
Amy: Wait, can I ask a quick question? What percentage of people are doing this in advance and what percentage of them are doing them in [00:18:00] crisis 
Guest: mode? It, it it's, it's mostly crisis mode. It's mostly crisis mode. If if you. At one of the, one of the things that we do part of the firm is what's called life care, planning and management.
And it's, it's not rocket science, it's getting one's stuff together. People, people, you can do Medicaid planning if you do the planning. And, and I'm going to go on a tangent here because we do estate planning and people are always calling. I have all these intakes it's going to be a late night tonight and, and but they want a power of attorney and advanced, advanced medical director that a will and a trust.
Well, How do you know what you want to before you do the planning? So th th the, the steps and it's universal, if you look on the, on the LinkedIn, all these attorneys are doing shows about estate documents and what [00:19:00] have you. It's not the right way to do it. Forget about your estate documents. Are you going to do planning and what kind of planning you're going to do?
And you're going to do Medicaid planning and Amy, if you can't do the Medicaid planning, because it's just not the right time you make the documents such that someone is authorized to do the Medicaid planning. If you become disabled and can't do it, how do you do that with a power of attorney or a revocable trust?
There are a number of ways you can do the planning later, but put the seeds in place that will give someone the levers to do it when you need to do it. 
Amy: So just one, I'm going to keep interrupting. So if people are doing stuff, either in advance, they're doing it well, nobody's in a nursing home. Like they haven't had a hospitalization, they haven't ended up in rehab and there's not this like panic of how the hell are we going to pay to take care of blah, blah, blah.
Yeah. But you are obviously getting people from the community and you are seeing people who are already in some sort of nursing home facility at probably post [00:20:00] hospitalization. Am I right? Right. Okay. And they want to stay there or they want to stay somewhere and have it all paid for 
Guest: correct. Yeah. And, and, and the, the, again, there are 10 that Jean coffee is the head of the Medicaid long-term care policy.
He was the first guy that I learned Medicaid from, and he has the ability. To take all the complexities of what he does. And he lectured about DCC in your resource group. You remember that he could make, take the most complex thing and simplify it? I don't know how good I am at that. I guess the people listing will, will be the judges of that.
But it's, it's, it's complex to understand. And frankly, I got so carried away. I forgot what you would inquire. 
Amy: What I wanted to know was no, it's, it's fine. The, the issue and you forgot to. Okay, great. You got carried away. So the other [00:21:00] question is people are accessing you from the community and they are accessing your services once a spouse or somebody is in.
Like crisis mode or just out of the hospital. So I'm sort of curious to know the 
Guest: it's much higher on the prices. It's 
Amy: much higher on the crisis. And they're actually usually sitting in a nursing home getting quote unquote rehab paid for by parte waiting for the 2100 days or whatever. And then they kick 
Guest: in to even that one.
Yes. The answer to your question is yes, that, that that process is, is basically memorize. I understood process for people. So people like us. Yeah. The, when you're dealing with the clients, everybody comes in and says, you got to, we got a a hundred days of Medicare, which you 
Amy: don't really get, but keep 
Guest: going.
Right. Well, so, so that's where you, you, you start and then back it up because they're in the hospital. I'll generally, [00:22:00] well, th th th the unfold, unfortunately, the, the, the journey begins with the hospitalization and the, the real catastrophes are the strokes or the falling. Which by the way is of epidemic proportion.
We had a lady who came in, she was 98 and and I did a consult. And then I remembered the falling thing that I wanted. I ran out in the hall and I gave her the papers on falling. She was with her kids and we chatted and laughed and so forth and she fell down the stairs. The next day died. Yeah. So yeah, it was absolutely unbelievable that yeah, so falling, falling or whatever, and they're in, they're in the hospital or you're absolutely correct.
They have been discharged to the hospital and let me, let me expand on the expansion. You know, what happened? I lifetime is the three-day rule. Right. You know, and, and yet every single little area, and we could hit 50 in a conversation I've got involved in, because [00:23:00] again, we were there at the beginning, so it was all new, the three day rule.
How do they, how do they count three days? We've 
Alex: talked about that. It's actually very good. Well, it's actually very confusing whether you're counting midnights or what time is it from the time that the order is placed or like, and I've read conflicting information 
Guest: on it. What they did initially is that the hospitals one in town here were discharged to the nursing home and the person gets to the nursing home and they don't have Medicare coverage.
So the going into rehab and, and they got nothing. So you want to get them out and that's like $4 million okay. Into long-term care as, as fast as you can. And Amy that's when the Medicaid eligibility kick in, because you're absolutely right. That the first period of time in the nursing home is generally in skilled nursing.
Now they've changed all the [00:24:00] names of the stuff, but for the audience, it's very simple to understand. You'd go. Just like you said, You're hospitalized. You go to rehabilitation a skilled nursing facility. You have a certain amount of time of eligibility, and that's something you should talk to somebody about this.
No one really understands that because you can advocate at that. I, there cam managers now who, who worked in this area? Huge. Large population. But I would attend those meetings where they would determine the days of eligibility and I won't, and that's a whole nother topic that I could explain. And and then when the, but they want to get them into a Medicaid bed from that 21 days or 30 days or 15 days.
And then you get into the whole world, what's a Medicaid bed and it keeps changing. Some facilities are dual certified beds. Some have a single certified beds. That's what we call in Yiddish. A Magilla that you got to understand if you're an advocate in the field. Okay. 
Amy: So let me stop you for [00:25:00] just one second.
So let's go, let's just talk about these facilities for just a second. Not by name, but just in general. So you get discharged from the hospital, which is your part, a stay, and then you end up cause you got Medicare and then you end up now in a rehab facility. 
Guest: Also, let me stop you there. Oh, how do you know what rehab facility you're going to.
Amy: Because they ran do they, they rolled the dice. And then they then they put something into a computer and then the rehab facilities go, Ooh, me, me, me, me, me. I've got a male bed. I've got a female bed. And then everyone fights for this for some reason, unless they've got COVID I guess maybe then they go, no, we don't have anything.
But like, I guess they, they basically then say, okay, yeah, we've got a bed, but then sometimes if you know that you might be going. To pursue Medicaid because maybe you've been in the hospital for a while and you're sort of like, Oh, now's the time to get my Medicaid planning. You are looking for a facility that may also have Medicaid beds and not every facility has Medicaid beds.
Okay. 
Guest: Almost that, that world, there was [00:26:00] one that had no fruit in my formative years had no coverage. They didn't take Medicaid. Back in the thousands, 
Amy: they all take Medicaid. Oh, I didn't realize that. I thought some were just like, no, we just do rehab. I'm good. Like, I'll just take my party dollars and my 600 bucks a day.
And no. So 
Guest: that's it. I think the thing that, and that's the problem of how deep you go into it is every aspect of what you just talked about requires advocacy. And that's a different route. But Jay, when, when I asked you, where do they go? Well w how do they determine that? Like you, you're absolutely right.
It's a universal program that that has an acronym, but a facility raises their hand says, we'll take them. What are they looking for? Money exactly the maximum. So they're looking at the disability and the discharge papers, and they want the 
Amy: maximum, maximum per diem that they can get. If they're like, Oh, we want the [00:27:00] sickest of the sick, as opposed to like the post hip fracture, which just needs PT for like 14 days or whatever, whatever it is.
Okay. So what you're saying is that. People are coming out of the hospital there, you know, we're dice, rolling it with the regular, the random acronym computer program, and everyone raises their hand and then you win and you get to go to this and that, you know, neuro rehab a and then suddenly they're like, Oh my God, we're not gonna be able to bring dad home, or we're not gonna be able to bring my husband home.
So now they go looking for you. So the question would be is. Is there somebody in that facilities that that's like the like elder law whispers, like you need help, like what's happening there. Like, what's that? Yeah. 
Alex: And I want to add onto that. If you're 75 you've, you've never had anything to do with Medicaid and you're in, in the rehab.
And now they connect them with you. How quickly can things get done to try to qualify for Medicaid 
[00:28:00] Guest: right away? You go into emergency mode. It's Alison I view it as litigation that there is a, when you, when you strip Medicaid to the, to the core it's an application. And as an eligibility worker, there are eligibility workers in every jurisdiction and they say yes or no to the application period, 
Alex: that's it.
How quick, how quickly do the state Medicaid programs 
E18-richard-bullock: respond 
Guest: once? You'll file. You it's an asset. You, your, your hand is raised and you're attracted to a facility because you're Medicaid pending 
Amy: immediately, Medicaid pending as long as, as long as you file while you're in the hospital 
Guest: file, whatever, whatever you're wherever you are, that journey you're in.
Amy: Right? I mean, does the state, I mean, this is what I find funny. And Alex, you might be like, what? I think the state puts Medicaid specialists in every nursing home. 
Guest: That's [00:29:00] not in every nursing home, but the applicant in the bigger facilities, Dell, they're not in the, in the facilities. Maybe the very, the very, very big ones have a Medicaid worker.
I haven't seen that for years, but, but workers are assigned to certain facilities. So someone I've worked with DC may have two or three of the nursing homes in DC. The, the the, the key is to, to, to move toward a person, say yes to Medicaid eligibility, and it's anywhere in the process. It's a fire drill to get the application in, because it requires a lot of backup information with the nurses.
No, instead of Maryland, the number of years ago is the rule is they, they call it dumb. Everybody in America knows the the the gifting rule. Okay. They, how many years do they look back? 
Alex: Well, hold on, hold on before you say that. Cause that is the next thing that I wanted to talk [00:30:00] about actually is the, the five-year look back.
And what does that really mean? But we do need to take a quick pause and thank our sponsor again. So again, our sponsor for this episode is rise, virtual, Medicare marketing and sales summit. They're hosting a three-day live streaming virtual event for professionals in the Medicare advantage sales marketing, product design and member engagement world.
This awesome conference is taking place February 19th, 22nd and 23rd, 2021. In the midst of COVID all virtual with on camera networking interviews, visit Medicare. Marketing sales summit.com com to learn more. Basically, if you're in the Medicare advantage, Medicaid or health plan space, you should attend this conference.
Please use promo code P O D 15. That's P as in Patrick Odie one five to get 15% off again, Medicare marketing sales summit. Thank you. Okay. Now Robert talked to us about [00:31:00] this five year. Look back. What does that mean? And what are the landmines 
Guest: around this? And as simply as I can say it everybody calls it a look back, period.
I once heard a lecture and I don't believe it's in the statute is it's a reporting requirement. So it's a, it's a five year reporting requirement. Then question is, have you gift and you gifted anything in the five years. Above a certain level. I think at the, every jurisdiction has a different amount. And and what is a gift?
A gift is giving something that is called quote uncompensated transfer unquote. And there you're asked on your application to report that the very last applicant, the question on most of the applications. Okay. And what it does is it doesn't if you, if you have given money away, Medicaid's [00:32:00] theory is that you should have paid the nursing home.
So let's, let's assume, you know, a married couple gives a hundred thousand dollars to the children. The father has been diagnosed with dementia or Alzheimer's type. The road does not look pretty and they want to shove the assets out and they gifted and it was done in contemplation of Medicaid, eligibility and Medicaid rules.
Say, if you did that in the last five years, You may be eligible for Medicaid because the hurdle being medical eligibility, financial eligibility, and the last piece is, did you give anything away? And if you did, you're paralyzed. So you're eligible for Medicaid, but you have a penalty period of where you have.
Let me recap. 
Alex: Yeah, let me recap just to make sure we're not missing the headlines here. So so if you are a senior and you know, like things are not looking good and you're probably going to end up in a nursing home or your family believes [00:33:00] that of you your hope is that you can get Medicaid to pay for it because otherwise it's going to cost maybe a hundred thousand dollars a year.
To do that, but the only way you can get Medicaid to pay for it is if you meet the medical eligibility. So it's hard for you to kind of do your activities of daily living and you must meet the financial eligibility, which means you must have very few assets, almost nothing left. And that's why people might want to gift 
Guest: things is because they're trying to make 
Alex: it look like.
They are asset poor. Right? But medic Medicaid is saying, if you do that, we're gonna know we're going to look at it. We're going to look at any transactions in the last five years. So if you're shuffling assets around just to qualify for Medicaid, we're going to catch you essentially 
Guest: exactly the presumption being that, that you gifted it in contemplation, Medicaid eligibility, but you have the absolute, right.
And that's why I told you it's litigation. To overcome that presumption that th that [00:34:00] it wasn't, it wasn't it. By example, if you've been gifting your grandchildren back to the year, one, $5,000 a year, every year for no Medicaid, contemplation and so forth and so on. And it continued right through that five-year period, often Medicaid will say no.
That was a continuing gift that had nothing to do with obtaining Medicaid eligibility. So, but there, there are many planning tools that can be used to convert the gift or what have you all legal planning tools. So I want to be sure. And let me add, because I think it's important that I've missed one piece with a married couple.
The spouse, the person in the community gets a community spouse resource allowance, the woman, the woman, or man at home. The wife or husband gets eight in every state. It's a little bit different. The feds put the height of the top and the bottom, but that person gets, I think it's 125, 130,000. I don't know the precise [00:35:00] number right now.
And that person gets that much from the estate. So the community spouse get certain things money. She gets to the home. She gets a car, she gets personal property. She gets a certain type of a, of CDs scratch that certain type of annuities. And what have you 90% of the planning is involving taking excess money and purchasing annuities, annuities.
We're a safe Harbor for eligibility back when when, when Amy's hair was a different color and, and.
She said there's no swearing in this presentation. So, yeah. So, so back then, whenever I was talking about all the way to now, basically, and keep the community spouse, that's the theory of Medicaid, by the way, the soul of Medicaid is the community spouse resource allowance. 
Alex: Okay, right now, litigation [00:36:00] is one way to try to protect the assets that have been shifted around.
Guest: I did I do the eligibility process as litigation and, and 
Amy: literally litigation. 
Guest: I see. Okay. Seems like a job, but what's your job as the lawyer and what's running 
Alex: the, for the method I've read and please teach us, is there certain types of trusts? That one can do in order to protect the assets. Can you talk to us about what those certain types of trusts are and when one should do look at them and do them?
Guest: Well, it's a good question. The, the the, the simplest concept is that eight trusts are either revocable or irrevocable. And if they're irrevocable, they're separate legal units that get a tax ID number. And and I have a separate trustee. And what have you If you Clance for assets into one of those trusts [00:37:00] and there, there are many attorneys who just specialize in those asset protection trusts.
And what have you the that is a a transfer. So the when you really strip the ball clean, it starts to five years running. So if I'm doing Medicaid planning for you and we, we got a huge chunk of money that we want to preserve. We can put it into an irrevocable trust now, and it's going to start that clock running for the five years.
That's the concept. So let 
Alex: me, let me ask you about that. Cause that's one piece that was a little bit unclear to me. So If, if grandma is trying to get Medicaid to cover her long-term care next week. And she puts everything into a long-term trust today. I mean, irrevocable, irrevocable trust today.
It's still, you still need to wait five years. Exactly. So you really should be [00:38:00] putting your assets into an irrevocable trust. At least five years before you think you might need Medicaid. Is that okay? That is an 
Amy: incredible, that's an incredible piece of like take home knowledge right there. And 
Guest: that goes right back to what Amy asked me at the beginning.
Because as if you're, if you're in your seventies, which I have found we're downtown metropolitan firms. So I see a lot of, we get a lot of calls and the age of challenge I have found now is 70 on it's it's it's just the dice roll, right, right now. Yeah. And it's an epidemic, a proportion, but, but the planning that would take places back when I'm 70 and I would begin to change my estate and my planning, and then my plan to create one of those trusts and and start the five years running.
Now that the, the real savvy people, and I don't mean to assault anybody who, who want [00:39:00] to do that, do it. But people just, just generally, don't like to do that, you know, there's, they got to know someone who's done it, or know someone who's running the five years and so forth and so on because it's an irrevocable trust.
You're putting the money in there and there are all sorts of bells and whistles, but it's not magical. It's the same five. If you're not, it's not an automatic Anthony a question. No, that's that is an uncompensated transfer. I talked about that it's to a trust, doesn't matter who it's to, and there's going to be a penalty period because it's within, inside the five years.
Robert if 
Alex: you have a very simple financial situation, let's say you're 60, 65 years old. And your only asset is, let's say you have a couple hundred thousand dollars of equity in a primary residence, and you're listening to this podcast and you'd like to put it into an irrevocable trust and do whatever other sort of, kind of planning and preparation you need in order to be ready for the future.
Can you give us some ballpark estimate as to what are the legal fees? Roughly that it might cost to do [00:40:00] this. Cause I, I think a lot of people don't engage attorneys when they should, because of this like hourly rate thing and they think they might be charged, you know, $20,000, then they can't control it.
There's so much fear and anxiety about legal fees. Can you talk to that about, 
Guest: about that? It's it's a very good point. And What I, I asked people a lot. Have you ever worked with an attorney before and the answer's yes or no. Most have no. And, and I indicate I have been a client. And as between dental surgery being a client, I don't know which one I would select.
Okay. So I understand the plight of these people, what I have I need to get so dramatic about it, but what every, there, there may be 10 attorneys in the metropolitan area who do this with a level that I would be confident referring and we all know each other. And what have you and everybody does it differently.
So I can only speak for myself in terms of the way that [00:41:00] I do it. Okay. I, well, I'm blessed at this age, not to have to accept every case anymore. And to that end, what I insist on is doing a consult. You can't be a good client in Medicaid, no matter what you tell me, because you don't know about it. And in Medicaid planning, I want to partner.
So the first step, and if you need to be all done from ever Davy Crockett on TV, but first understand, and then be understood so that we do it on a consult basis. Initially. With all of the relevant parties, because the first question you asked, what are you siblings going to say about this? And so forth.
You know, I want all the players and, and we've had fist fights in the conference room and I will spend, what I determined to do is I will spend much time as necessary to get you to where you need to be. So you understand it because it's overwhelming. And then double that down with the w the wife is in total crisis.
And the [00:42:00] sun is coming from California and the.is here and, and they want to get Medicaid because they want grant Papa's money and they want the 
Amy: money 
Guest: coming in and asking about, about Medicaid. So what I do is a consult and I do not accept engagements at the consult. I do not solicit representation. If there's 
Amy: a fist fight, it's like, you're definitely not going to be a client.
Like, that's sort of like, you kind of have like a bifurcating moment. You're like, Is there going to be a fistfight, if not, no, we don't. We can't take care of you here. Elder law center can't really help you. Yeah. Those are the ones 
Guest: that I take. So, so that's the, and I don't know if it's ethical to start talking.
Fees. Every attorney says that when it starts about what are your fees or what are your fees? So I want to be cautious, but we charge as low as we can for the consult. It's it's not a moneymaker, it's there usually two attorneys in there and all we call somebody else. And, and, and, you know, I try to give as good as I get.
You've gotta be educated. [00:43:00] And and there are, it's very difficult in that stage because as Amy said, and I'm serious, there are a lot of conflicting interests going on. And, you know, people out there know this, the daughter comes in or there are no estate documents. So you got to go for guardian, you got to do a guided conservative.
So we do that in the framework of a consult, and then we give them their options. My ultimate goal is to educate you so you can do it yourself. And we have some people who do that, who actually who actually do it themselves, I think, got to spend the time to learn. And it's a job. Gets it managing someone who's getting Medicaid is a job and either you're going to do it or you're going to hire someone to do it.
And we, number of people do it themselves when it's simple, but I wouldn't do it. 
Amy: I have, this is, this is fascinating. I have two questions. Number one is this seems like it's so hard and it does seem like it's so complex. If you are somebody who. Doesn't have the resources to hire [00:44:00] a lawyer. I mean, I feel like in my house calls practice, I was taking care of a ton of people who have Medicare and Medicaid.
And I'm like, I don't think this person was like running out to hire you. Like, how did all of this happen for them? Is it because they kind of came into the system because they were already in Medicaid, the other kind of Medicaid that was low income when they were 64. 
Guest: It it, the, the answer is yes and no, but it helps to be on some type of Medicaid as you move through the system, because they've already had some sort of determination of, of well it's waiver or any Medicaid program that's requires disability.
You already have that ticket. You've already been determined to be disabled. And you 
Amy: have like a, and you have like a, like a Medicaid helper, social worker person who's within the system. That's kind of escorting you through, into the Medicare, Medicaid state. 
Guest: And every it circles back to that facility.
Every facility has a Medicaid person. Let's scratch that. I can't say every facility, but [00:45:00] most now have eight individual or individuals who are responsible for collecting the information in Maryland member. Alex, you said five years. Well to get into certain facilities, many facilities in Maryland. When you apply just to go in with your application, you have to give them five years records of all of your accounts.
And I wonder as you go, 
Amy: I already don't want to apply for Medicaid. By the way, I just already just sounded like so overwhelmingly, like, I don't know where I'm going to find all those pieces of paper. 
Guest: I talked about Medicaid pending. Okay. So you could be one of the requirements on Medicaid, pending facilities for admission in Maryland is you've got to give all this stuff during the application.
Amy: Okay. So you can't be Medicaid pending until they have all the paperwork, 
Guest: what jurisdiction plus or minus, depending upon what 
Amy: you're saying, right. Okay. My, my second question is this, and then I'm gonna have an, Alex has a question. Then you have been so amazing. We're going to figure out if there's anything else left to ask you, which is a thousand more [00:46:00] things.
But my second question is, you know, what I find interesting, and I think this leads into a topic we're going to be talking about. With our next podcast is actually assisted living. Medicaid does not pay. Even though somebody may level into something that could be totally taken care of at something that's half the price, AKA and assisted living.
Why haven't the States figured this out? Why do they want to keep paying these like Primo costs eight, $12,000 a month when maybe there's an assisted living? That's like 5,000 because the person levels in for, you know, I mean, if they can stay at home, they can certainly be in an assisted living. They don't need like.
Peg tubes and all these, I mean, not everybody's so super sick. They need a nursing 
Guest: home. I, I don't quite understand what you're, what you're asking, 
Amy: why won't Medicaid pay for something that's like an assisted living as opposed to mandating 
Guest: it. So that's a political question because and then if we, [00:47:00] if we push that button I was so curious about the approach of Medicaid to everything that I went back and interviewed people who were involved in the legislation.
I'm going to answer your question, but of interest. I love trying this out is that the Medicaid bill that was passed in 1964 65 was the Medicare bill. It was Medicare because the fight was between the States and the federal government. And then Medicaid is that joint program. Medicare is a federally funded insurance program was revolutionary at the last moment.
They negotiated a Medicare deal with the federal government, picked that up and they took that bill and moved it over here and made that Medicaid. It has absolutely no frame or reason as to what the situation is today. Not so in terms of assisted living, it wasn't even contemplated there weren't assisted living units.
Amy: That's what I thought you were going to say is that they [00:48:00] made the law without having the modern day healthcare system or the modern day sort of like what aging looks 
Guest: like. And the same assisted living has been exacerbated by when I started assisted living, was people selling their homes and move in to assisted living.
This does the chic sunrises. Oh, the 
Amy: CCRC, which basically like, Oh, you know, I'll pay $250,000 and it's sort of like, it'll take care of me through the rest of my life. Or 
Guest: I have a lady who paid. Last night talking to her agents, she selected her neighbors as powers of attorney. They have no idea what to do when they're in their seventies and she put $500,000 down three months ago, went in the place should have never got in and was, has been, she spent six nights there since December 1st.
And she's been in the hospital since $5,000 for CCRC. That's a whole, that's a topic for another 
Amy: year coming back to we'll discuss 
Guest: that. The the, the, the, the short version of the assisted living is they [00:49:00] took the, the, the middle-class, the upper middle-class sell your home, move in, whatever, and it wasn't very expensive.
It was four or five, $6,000 a month back then. And what happened is that my, what happened with me is I gotta get them out of the nursing home, out of the assisted living into a nursing home and getting Medicaid eligible is I can't afford it anymore. That's right. 
Amy: That's exactly right. That's the, that you just hit 
Guest: record.
Well, let me add, let me add quickly that what happened is the, the assisted living facilities responded to that by, by because we have the housing crisis, the depression of whatever year it was, what it was the recession of 98. I just made that up. But
for now, so they would, they do. The backend, they, they, they created what you now are inundated with. Everybody's going to a memory unit. What the hell? What the heck is the memory unit? Okay. Assisted living 
Amy: with assisted living with another, like another label on the 
Guest: front door. 
[00:50:00] Alex: It's in assisted living with locked doors.
That's what 
Guest: it is though. That's a lot. Yeah. It's the books down from there. Six different levels of memory care. I'll let you pick what you, it's a color 
Amy: code. It's a color coded assisted living. Exactly. 
Guest: Okay. 
Alex: Rob, I do want to touch on that. I do want to touch on a really important topic. 
Guest: Yeah. You answered my question.
Amy: Yes, no, you haven't answered his. He needs to go. Now 
Alex: I know that we're under a little bit of a time crunch. 
Guest: So add a really annoying. We talked about Caribbean. I'm sitting here with the peanuts 
Amy: watching. No, I am not in the Caribbean. I am in the Festa.
Guest: Okay. 
Alex: We talked about putting your assets into an irrevocable trust in order to qualify for Medicaid, but we didn't talk about Medicaid estate recovery and how [00:51:00] the trust might help with that. Could we, could you talk about what is Medicaid estate 
Guest: recovery? The it's not my strongest suit two right now. The Medicaid as keeps employees, they get you're coming in because they make a divest assets and, and pay for the nursing home.
And then if there's anything left at the end that they can claim against your estate. It, it, it really I'm not embarrassed to tell you that there's some things that are not current on the estate recovery. It is a field unto itself, but when you do your planning, you're, you're doing that also. So there'll be no assets available for estate recovery.
And, and by example, one of the, one of the vehicles you use regularly is a revocable trust because a revocable trust, the moment you die becomes irrevocable. So in, in certain jurisdictions, because I don't want to mistake the law anywhere in certain jurisdictions. It's not, it's not in your probate estate.
[00:52:00] So it was not in your probate and the state Medicaid cannot assert a lien against that because Medicaid asserts a lien on your, any assets in your probate estate that what they can assert on the probate estate keeps getting more expensive. Actually I know more than I thought I did. It keeps getting more expansive state by state.
And once again, the elder law attorney in the estate planning goes all the way back to what Amy asked at the beginning about developing your plan. You look at making assets unavailable for a state recovery. 
Alex: Right. So, so let me underscore point if you get Medicaid to cover your long-term care costs after the age of 55 it's not actually Medicaid paying for it with a blank check.
It's almost like a loan. Because once you die, they can come back and put a lien against your assets for the amount that they 
Guest: paid and that's your state and that, that the 
Alex: assets that are still left in your [00:53:00] state. So even more reason to move your assets into a trust because otherwise. Medicaid will essentially take everything that's left because long-term 
Guest: care is so expensive.
I, I, the, the, the answer is really that's a broad base. I think more of a myth. They won't take everything that's left if you properly plan for it. And by example, if, if there's a home. There are all sorts of exemptions for a home. If you have a child with a disability living there, if the spouse is living there and there are all sorts of exceptions and there's a rule it's memorized said, it's just like tax law.
So show the Sholay the elder law by the rule and we can do. And it is, it is a mandate of Medicaid that they encourage you to get Medicaid for married couples. So they also encourage you to do the planning. And part of that planning is making assets unavailable for a recovery. Yep. Okay. So [00:54:00] those are some they're going to take, they don't, yeah, they don't take all of your assets if you're properly planning and protected and the home, I just gave you one example, by the way, on that loan point And it's on topic on another top of another topic, but supplemental needs trust that is I have a daughter who has down syndrome and she is allowed.
She gets a social security disability, scratch that. Let's say she gets a Medicaid SSI. You're allowed supplemental security income. And that means you, you have to have low income all assets, but the point is you're allowed to take your assets and put them into a supplemental needs trust. Now, this is a , that's all you need to know for, for an individual making their own trust, their own money.
And what it is is definitely what you said, Alex, it's a loan because a D for a, when, if you get any type of Medicaid, when that person dies, Medicaid submits the bill and says, if there's anything left in the trust, it goes to us. [00:55:00] Okay. 
Alex: Interesting. There is a really interesting and actually sad article in the Atlantic about this.
And I'll post it in the show notes because clearly one can protect one's assets. If you engage an attorney such as you Robert, but unfortunately, a lot of people either don't think about it. They don't know or think they can't afford it, or simply can't afford. An elder law attorney, and then they get put into a situation where are lifelong and generational assets sometimes can be can be destroyed.
And it's a really sad situation. 
Guest: Great voice doesn't need any 
Amy: there is a reason that he is my co-host it's really because he has a very like, like meditative hypnotic voice. Yeah. And you spend your whole time going, what is that accent? Is it 
Guest: Latvian? 
Alex: It is half flat and half 
Guest: summarize what you just said again, because I had a response to that, but I digressed wait, was that [00:56:00] Oh, I don't know.
What was I going to throw up? And you said I could interrupt. Okay. Well, we'll get to the fee situation. I believe the concept is wrong. Okay. About fees. Okay. This is an investment. And, and, and, and let's talk about mom and dad or mom and the facility and, and running 15 grand a month. You do the math, what that is.
Amy: And like one month it's like their ROI on that is like a duh it's it's like, yeah. Is that your tagline? 
Guest: No, I don't do that. I cleanse what I say, well, you can pay the nursing home and you can pay me, you know, I, I don't, I don't like that at all, but yeah, there's, there's a lot more involved when you're doing the application in terms of the community spouse.
So what happened w what I'm going to stay up. So. This fee thing and everybody freezing. Okay. Is you got a job to do and you, and you got to [00:57:00] learn how to do it 
Amy: or ship. You need mentorship and you need guidance. And this is the, this is always, I mean, we've talked about this. We actually had an early podcast and I don't want to take up too much more time, but.
I do want to just drive this one point home, which is one of the successes in sort of business or starting something new is really knowing who to ask and knowing when to say, you know what? This is just like, I can't like Dr. Google this, you know, I can't like, you know, Google Esquire, this one, like this is not going to be something I can figure out on my own.
And to basically say, this is part of good financial 
Guest: planning. Good. Yes. Or you can still do the eligibility process in crisis. We we've had, we've been knock on wood. We've had my Medicaid people have three approvals in the last two weeks on very difficult applications. Wow. But, but the key to success, 
Amy: you feel like it's still a success when it's like, ding, ding, ding, we got it.
Like, it's like still a moment 
Guest: that was [00:58:00] kind of cool. Attention to detail. That's that's yeah, that's really, really critical. Actually. It's my daughter who was a Medicaid specialist. No. Went off to law school and had babies and so forth and she's come back and she's very good at the stuff. And you got to be very patient with people.
You gotta get a lot of records. But Alex, that on the feed thing I want to make that clear is that's why I do a consult. That's exactly why I don't want your money. I want to educate you. I want you to do it yourself. At the end, we'll decide what your options are. And I, and every attorney who does this stuff, does it differently.
Some do a consult and then a letter afterwards, I find that it doesn't work because you get this comprehensive letter explaining, you know, what to do, and you're clueless as to what the rules are and how to do it. So I, I pulled away from that. Others give you a free time, which I don't. I think it's a big mistake with clients because they ha they have to understand what they're doing.
Unfortunately, they're saddled with a job J O B and that's what I tell them. This is work and it's gonna take time. And [00:59:00] so, okay. So. 
Amy: This, this is really okay. First off, I just want to say thank you because we kind of are always like, Oh, we're gonna try and wrap it up just a little bit, because we want to give you a break, give our listeners a break.
But I think first off, this has been amazing. I almost feel like we need to have him back on for the second podcast. So we'll just preplan for that. And of course I will spontaneously call you at any moment in time, but not after 9:00 PM. Okay. To set that up. But I do want to just give Alex an opportunity to do one more sponsorship.
Give it a go. 
Alex: Yes. Again, w we want to thank our sponsor rise, virtual Medicare marketing and sales summit. They're hosting a three-day live streaming virtual conference for professionals in the Medicare advantage space on Friday, February 19th, to 22nd and 23rd, 2021. Visit Medicare marketing sales, summit.com and make sure you use promo code P O [01:00:00] D one five that's P as in Patrick, P O D one five to get 15% off again.
Thank you so much to rise for sponsoring us. 
Amy: Yes. Thank you. All right. So I, I want Alex to have first dibs at maybe doing his summary, but I could also do a little summary, but I think you're so much better at it than me. Do you want to like, do it. 
Guest: I guess my main 
Alex: takeaway is that if you're above the age of 50 you should probably get an elder law attorney and do a consultation and start figuring this stuff out.
If you leave it for later, it will be tremendously more difficult and it could cost you hundreds, thousands of dollars. That's my main takeaway. 
Amy: How can we find Robert? 
Guest: Yeah, Robert, 
Alex: you got to, I'll share with you what I have in Robert, and if I have anything wrong here. So his main practice is a www.edlc.com.
[01:01:00] And you can also find him@avvo.com. Is that right? Robert? 
Guest: That's the precise? Yes. Okay. So 
Alex: your practice, the locations are, are you just 
Guest: PC or also. But I I'm licensed in all three jurisdictions. So we have outposts in, in Maryland and Virginia. There's been a lot less of that with COVID Medford. I've just come back from six months.
I don't know. I'd lost track of the time at the office, but we're under strict lockdown procedures. Matter of fact, we had two in the legal community today who diagnosed. And one, one was a lawyer who apparently went home and infected her 80 year old. Or his 80 year old parents. Yeah. So we're fucked out, but we do everything virtually and, and, and it's, and it's working and we have drop-offs the information would have been, yes, DC, Maryland, Virginia unlicensed.
Then we, we we had all of the counties and I, I do want to say to the audience. I, I was [01:02:00] was screaming at Amy, let me know. And 15 minutes before she calls me with the connection and here I am. So I did no preparation, which I vowed. I'm never going to do again. So I'm a little bit off on the rules.
You can call me if they do four or five, two zero, zero, zero, zero. Don't ask me how I got that number, 
Amy: but gave you ample damn notice. 
Guest: What was the number again? Two, Oh, two four five two zero zero zero zero. And if anybody's got quick questions or what have you, you know, I work long hours and I enjoy talking and you know, w w w what you, when you get you give, and I've worked a lot with the disability community because of my daughter.
I deal with parents, parents of special needs children get, get either free depending upon the situation or, or the, the most we can do. If they've got a special needs child, that's a, because there's also Medicaid for, for those individuals also Medicaid waiver and what happened. I, I want to add one more thing and that is if I [01:03:00] could, the, the w the planning has evolved into is there are Medicaid chop shops, not in this area, but there were a lot in the hospitals, Amy, when, when, when we were in the hustle, I forget the name of the, you could go down and you could be A hockey puck and you get Medicaid eligibility.
Okay.
Through the wazoo and you get Medicaid to build, they would every hospital. And, and what I discovered is it was impossible to understand DC hospital Medicaid. No one was able to explain how hospitals got Medicaid so quickly for people in the hospital. So another one that's the exploration I had to do.
Yeah. Because I was curious, intellectually curious, and, and every one of these was bouncing out to get information, particularly in the, in the district. So your planning is just more than Medicaid. I think when you do your estate planning, it's called life care planning and management, [01:04:00] and it's, it's, it's a need of mine is everything's gotta be pulled together and, and, and people don't do it.
Period. That's it. Okay. If they're in 
Amy: denial, people are often in denial about aging, right? Yeah. 
Guest: I, that I hired an attorney to do mine and I made them adhere, making it here to strict deadlines and Alex part of that planning and getting the stuff together. If you're doing your Medicaid evaluation at the same time, because not only do you need the Medicaid, but you have the wife in the house.
And how, and she's failing. So you got to get her out into an assisted living. You got to sell the house, you gotta, you gotta market the house. And I, I have a unique experience because 20 years I did commercial regular work and I'm a more aggressive than litigator. So all of those skills are needed on the life care planning and management.
It's fascinating because it pulls together everything. Oh, wow. Two people to take care of 
Amy: minds, me to stay organized. That's what I'm that's [01:05:00] that's my take home message. Amy, stay more organized. So I just want to thank everybody. Who's been listening for our second episode of 2021. This is Robert Bullock.
From the elder law center. And I am Dr. Amy Shiffman with my co-host Alex Mohseni and you can find us on the web@masteringmedicare.net. That is mastering medicare.net, Alex. Anything 
Alex: else? No, that's it. Robert, this has been absolutely amazing. I really appreciate you taking the time to talk with us.
And I think our listeners are going to have a bunch of questions and we can probably do a follow-up episode sometime soon. 
Guest: Amazing. I hope what you're saying is is some, some vision of reality that makes
and I'll deny everything I said on this thing got 40%. Yeah. You'll be like, can you 
Amy: edit like the 47th minute?