Frequently Asked Questions about Protecting Your Assets from the Nursing Home

Question 1: How much do nursing homes cost?

Answer: According to a recent survey, the average length of stay in a nursing home is two and a half years. Nursing home costs average $70,000 a year, with an average cost per stay of $170,000.

 

Question 2:   Will Medicare pay for my nursing home costs?

Answer:  No. Medicare does not the pay the expenses of long-term care incurred for day care at adult centers, home care by relatives or employed caretakers, and nursing home care. Medicare pays limited benefits for skilled nursing care only.
 

Question 3:  What government program will pay for my nursing home costs?

Answer:  In the United States, the government program that pays for most nursing home care is Medicaid, which is a federal and state medical program for persons who meet certain asset and income levels. Some veterans are entitled to veterans benefits to pay for their nursing home care.
 

Question 4:  How can I avoid being impoverished by the high cost of nursing home care?

Answer: The answer usually depends upon your marital status, and whether you are already in the nursing home or you anticipate a lengthy stay in the nursing home. It is almost never a good idea for people who aren't facing a lengthy in the nursing home to give away assets.
 

Question 5:  If my spouse is going into a nursing home, can he or she transfer all of his or her assets to me and qualify for Medicaid?

Answer: Probably not. To determine the eligibility of the spouse who is going into the nursing home to receive Medicaid, all of the non-exempt assets held by the husband or wife are added together and then the total divided equally between the spouses. Of the half attributed to the spouse going into the nursing home, that spouse is disqualified from receiving Medicaid until his or her share of the assets are reduced to $2000.

The spouse outside of the nursing home can retain half of otherwise non-excludible assets, up to a maximum (of around $100,000, an amount that changes annually), plus the residence, plus some personal property, plus burial reserve, plus automobile, and other miscellaneous items.
 

Question 6:  Can I transfer my assets to my children just before I go into a nursing home and still qualify for Medicaid?

Answer:  Probably not. Under the 60-month Lookback Rule, eligibility for Medicaid may be denied if the person going into the nursing home transferred assets for less than fair market value within 60 months before his application for Medicaid benefits.

And be very careful about giving away assets: once you have given away your assets, you cannot get them back by legal action. Don't rely on your children to "do the right thing" and hold the assets for you in case you need them. See Question 11 below and our "Pitfalls of Giving Away Your Home" for some good reasons why you should not give away your assets.
 

Question 7:  Should I use a trust to protect my assets?

Answer:  Absolutely YES!  Assets are usually transferred to children or other family members either outright or to a trust for your benefit.   A trust can be more desirable than an outright transfer to a child because:

a) You may have a bad relationship now or in the future with: 1) your child or 2) your son-in-law or daughter-in-law

b) Your child may: 1) get divorced, 2) have creditors or go bankrupt, 3) invest your assets unwisely, 4) spend all of your assets during your life, or 5) spend all of your assets as soon as you die.
 

Question 8:  How can I protect my house?

Answer:   Put your house in a trust.    The Medicaid applicant may retain a principal residence. The homestead is exempt property. After the Medicaid recipient's death, however, the house can be sold and Medicaid reimbursed unless there is a surviving spouse. Maybe a transfer or sale of the residence to the children with the parent reserving a life estate is advisable. Although the value of the life estate might still be at risk during the applicant's life, there are certain planning possibilities available to protect the life estate.
 

Question 9:  Isn't it wrong to hide assets in order to qualify for Medicaid?

Answer:  Hiding assets in order to qualify for Medicaid is a crime. That's not what elder law attorneys who help their clients become Medicaid-eligible do.

It is not illegal to structure one's assets in an effort to qualify for Medicaid nursing home benefits. Elder law attorneys advise their clients on the Medicaid law and what can and cannot be done legally within the law.

Come to Law Office of INNA Fershteyn and Associates today (718) 333-2394 and learn how to protect your assets from Nursing home and how to qualify for Medicaid assistance.

Tutor reveals Ivy-admissions madness of rich penthouse parents

Lacy Crawford’s first novel, “Early Decision” (William Morrow), out this week, was inspired by the 15 years she spent working as an independent college-admissions counselor to the rich-and-powerful’s sons and daughters in Manhattan, Chicago, Los Angeles and London. For a fee, Crawford would help them with their entry essays and applications to get them the one thing they couldn’t always buy — a spot in an Ivy League school. She shares her stories (with the names and some characteristics changed) with The Post.

 

Though I worked for 15 years as an independent college-applications counselor all over the United States and Europe — with students whose parents thought nothing of flying me in every weekend to try to make Harvard say yes — nowhere was the college-admissions race more competitive than in New York City. 

WRITE STUFF: For a fee of $7,500, Lacy Crawford would help the sometimes indifferent children of wealthy New Yorkers write their college-entry essays.

 

Here the frenzy is amplified by money and power as it only can be in New York; college admissions are the culmination of a scramble that begins with nursery school. Here, too, the opportunities for obsessive parents to break a student’s heart seem sharper than anywhere else.

My abiding memory of tutoring New Yorkers is of sitting with one girl as night fell late in October. Tears coursed down her cheeks and onto the hem of the distinctive skirt of her elite private school. She was too upset to sip from the mug of hot chocolate her housekeeper had brought up. Her parents were working late, as they always did, and other than the staff, we were alone in the house. Spread on a table before us were college essay drafts. 

“It’s hopeless,” she sobbed. “I’ve got nothing.”

From her bedroom window, where we sat, an unobstructed view of Central Park stretched north to the autumn sky.

How does a young woman with so much come to feel she’s got nothing? My students were almost all thoughtful and diligent, but their parents had fallen into a terrible trap, having raised their children to reach for the stars without teaching them how to so much as stretch out an arm. 

For many of the children of the most ambitious, wealthiest parents in the city, the college-admissions process begins when a child is 2, with the hiring of a consultant to deliver nursery-school acceptances.

Once in school, if the child is slow in any subject, parents hire tutors. If the tutors fail, the parents will knock on doors until they find a learning specialist who agrees to identify a trumped-up deficit in a student’s capabilities — in other words, to label the child in some way learning-disabled — after which the parents will force their excellent school to exempt the child from certain obligations, so she no longer has to take four years of math, say, or timed tests. 

The college list will be drawn up no later than sophomore spring, and it will include only trophy schools — the Ivy League, Duke, Stanford — selected not for fit but according to where the parents have influence. If a parent went to a college, it’s a “legacy school,” and it goes at the top of the list. If they know a trustee, that’s in Position No. 2. And so on down the line.

By junior spring, the “early decision” school is chosen, meaning a single application will be made by Nov. 1 with the promise that the student will attend if admitted. Statistically, this is the best chance a student has of acceptance at top schools, and it’s not a problem to apply so early for students who have had years to tour their choices and who don’t have to fill out financial-aid forms. 

The summer before a student’s senior year, the parents work to secure the golden ticket — a recommendation letter from a trustee of the first-choice school — while the student interns for an exclusive institution (a neuroscience lab, a political office) or performs community service in a far-flung locale (building schools in Bangladesh).

Finally, after 15 or so years of parents managing every variable, there comes the time when a student is expected to do something all by herself: fill out the actual application. Write an essay in her own voice. 

By this point, our coddled child has no faith in her own words at all. Her own ideas and feelings, like a language she has not practiced, have fallen away. 

Her parents wanted more than anything to protect her, to give her the world. Instead they’ve taken away her capacity to know it.

Faced with that blank page, the students panic. They freeze. Their entire lives have been pointed toward this one test of their worth: Who wouldn’t suffer writer’s block? The parents yell. Everyone sobs.

That’s when they called me.

I had been an independent college-applications adviser for almost a decade when I moved to Manhattan in 2007. For the three years that followed, I tutored some of the city’s most elite high-school seniors, working under the radar, a hired gun who slipped in and out of penthouse apartments and jogged up the side steps of brownstones like someone’s mistress. 

From 2000 to 2010, more than 90 percent of my students were accepted at their top-choice schools. My name was shared among wealthy families who would not have dreamed of hiring one of the big college-application consulting shops; they wanted exclusivity, someone other students couldn’t have.

In fact, often I was asked to create false invoices (substituting, say, “child-care services” for “educational consulting”) when I billed my $7,500, all-in fee. Five days a week, from August to December, I took the 6 train from Midtown to 68th or 77th and walked west to Park or Fifth, where I sat with wealthy students struggling to free themselves from their parents’ dreams so they might have some hopes of their own.

One father requested that my meetings with his son take place in the Midtown offices of his private-equity group. His son would take the train in from Greenwich and meet me there. I offered to meet the boy somewhere easier, but no. It wasn’t safe, the father explained, as he led me into the vast glass space of his office, where his son was sitting; in fact, he had personally walked to Penn Station to meet his son’s train and escort him here.

Then he took out his checkbook and asked me, in front of the boy, what I’d charge to write his essays.

You see the logic? I love you so much I won’t risk letting you take a cab in the city, and I wouldn’t dream of letting you use your own voice to apply to college. But you can’t expect a student to write effectively in the first person if his own father has no interest in what he might say.

One young man had been flown in from Paris to work with me. He was very bright, but his English was not good enough for a top American college. Even if we could get him in, he’d struggle. His mother would not hear of this. She was engaged in a ferocious divorce from her diplomat husband, and while the blond boy and I sat there, working in the two-story atrium of their living room, professionals in slim suits wandered the apartment with notepads and cameras, making appraisals of every item that might be removed. 

One evening, the mother met me when I arrived.

“We will say he’s black,” she said.

Excuse me?

“My ex-husband, he’s not seeing the application, so we’ll say what we want. We lived four years in Senegal. Our name is exotic. So, we will check the box and say he is black.”

I said this was not a good idea.

“Why not?” she pressed me. “Can they ask for proof?”

Her son sat silent as a stone, blue eyes fixed on his notebook, while the appraisers’ cameras flashed on the Picassos on the walls. 

In the months to follow, I failed to dissuade the mother of her plan. Her son was not admitted.

She, like so many others, was dumb-struck, devastated, when it didn’t work out. (This is why, year after year, new clients kept calling: They hear the horror stories of wonderful kids who got in nowhere.) 

These parents haven’t anticipated that college-admissions officers might be able to hear the hollow pretense of the packaged student, the shellacked essays full of an editor’s semicolons but lacking a heart. 

They don’t know a trustee’s letter can also be a curse: One trustee of an Ivy League school confided in me the secret code she shared with the dean of admissions. If she felt obligated to write the letter for social reasons, the student was referred to formally — Miss Cabot, Mr. Peabody. If she believed in the student, he or she was called by name. 

“I’ve had about 100 percent success both ways,” she told me.

The girl whose bedroom window opened onto Central Park struggled all fall. She was writing boring essays about her community service (she interned relentlessly at charities all over the East Side) and sweating her “B” average. 

She did not know that she was all but guaranteed admission to her top choice — let’s say it was Yale — where a building already bore her name. She didn’t think she could get in, and if it weren’t for that building, she’d have been right.

But her parents could not imagine her going anywhere else. The whole process seemed to my student a trap: She had to gain admission to and attend a school where she knew she didn’t belong. How could she write an honest essay?

We got out of that penthouse apartment and walked the park as winter bore down. I noticed she knew a great deal about Central Park; her nannies had taken her here often, of course. But there was more. And one day she confessed to me her secret: Afternoons, after school, she directed her driver to several pet stores in the city, where she bought the most miserable, chewed-up, sickly gerbils and hamsters she could find. She carried them in their cardboard boxes to the grassy spots in the park and set them free.

“I know they probably get eaten that first night,” she told me, crying. “Rats. Raccoons. Pale Male. But still, imagine that one day of freedom. It’s better than whatever would have happened in that store.”

And just like that, we had a college essay. She wrote about the rodents, yes, but she also wrote about the gardens she knew so well, and how the city of her birth had grown up around the park. She covered Manhattan history and the biology of raptors in 500 words. It was terrific. 

Her parents were horrified. They forbid her to submit the essay — what would Yale think? But she did so anyway.

You’ll know how this story ends. She got into Yale, of course, early decision. But her real success was in giving the admissions officers the kind of honesty that is harder and harder to find in these days of tiger parenting. And, I like to think, in clearing a path to her own life, she graduated and became an apprentice gardener with the city Parks Service. She’ll have to work her way up to Central Park, her own front lawn, but she is finally doing what she wants to do. 

This is the biggest secret to success in the college applications madness: It’s not about getting kids in. It’s about allowing them to grow up.

Source: NY Post

Office of Medicaid Inspector General (“OIG”) recently issued an updated Special Advisory Buletein on The Effect of the Exclusion from Participation in Federal Health Care Programs (“Special Advisory Bulletin”)

The Office of Inspector General of the U.S. Department of Health & Human Services (“OIG”) recently issued its updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs (“Special Advisory Bulletin”), which describes the scope and effect of the legal prohibition on payments by federal health care programs for services and items furnished by or at the direction of an excluded individual. 

The OIG is empowered to impose civil money penalties against health care providers who employ or contract with an excluded person to provide items and services for which payments may be made under a federal health care program. Additionally, the OIG is further authorized to impose liability on an excluded person if the person orders or prescribes an item or a service while excluded and knows or should know that a claim for the item or service may be made to a federal health care program. For health care providers enrolled in Medicare and Medicaid, ensuring regulatory compliance remains crucial and screening for excluded persons is a key element in compliance.

Exclusion From Federal Health Care Programs

The effect of an OIG exclusion is broad—no payment may be made by a federal health care program for any items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person. This broad prohibition also extends beyond direct patient care. For example, the following instances of indirect services are prohibited:

o    Services performed by excluded individuals who work for or with a hospital, nursing home, home health agency, or managed care entity when such services are related to, for instance, preparation of surgical trays or review of treatment plans, regardless of whether such services are separately billable or are part of a bundled payment;

o    Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling prescriptions for drugs that are billed to a federal health care program; and

o    Transportation services that are paid for by a federal health care program, such as those provided by excluded ambulance drivers or ambulance company dispatchers.

Excluded persons are also prohibited from furnishing administrative and management services that are payable by federal health care programs, even where the administrative and management services are not separately billable. For example, the following would be prohibited:

o    An excluded individual serving in an executive or leadership role at a provider that furnishes items or services payable by federal health care programs; and

o    An excluded individual providing other types of administrative and management services, such as health information technology services and support, strategic planning, billing, accounting, staff training and human resources, unless wholly unrelated to federal health care programs.

Additionally, items or services furnished at the medical direction of or on the prescription of an excluded person are not payable when the person furnishing the item or services knows or should know of the exclusion. This prohibition applies even where the federal payment itself is made to a state agency or provider that is not excluded.

CMP Liability

An excluded person violates the exclusion if the person furnishes to federal health care program beneficiaries items or services to be paid by federal health care programs. An excluded person that submits such a claim or causes such a claim to be submitted may be subject to a civil money penalty of $10,000 for each claimed item or service furnished during the period of exclusion. The individual may also be further subjected to an assessment of up to three times the amount claimed as well as subsequent denial of reinstatement into the program. Similarly, such conduct may also lead to criminal prosecutions or civil actions. For example, knowingly presenting or causing to be presented a false or fraudulent claim may subject the individual to criminal liability for fraud as well as civil money penalties.

CMP Liability For Employing Or Contracting With An Excluded Person

A provider may be subject to liability if an excluded person participates in any way in the furnishing of items or services (including providing direct or indirect patient care, administrative and management services, and items or services furnished at the medical direction of or on the prescription of an excluded person) when the provider knows or should know of the exclusion. Liability may result even if the excluded person does not receive payments from the provider for his or her services. Similarly, an excluded person may not provide services payable by federal health care programs, regardless of whether the person is an employee, a contractor, or a volunteer or has any other relationship with the provider.

Under certain and limited conditions, an excluded person may be employed by or contract with a provider that receives payments from federal health programs:

o    Where the federal health care program does not pay, directly or indirectly, for the items or services furnished by the excluded person;

o    Where a provider employs or contracts with an excluded person to furnish items or services solely to a non-federal health care program beneficiary.

Providers that identify potential liability on the basis of the employment of, contracting with, or arranging for services with an excluded person may be required to use the OIG’s Provider Self-Disclosure Protocol (“SDP”) to disclose and resolve the potential liability.

How To Determine Whether A Person Is Excluded

To aid providers, the OIG maintains a List of Excluded Individuals and Entities (the “LEIE”) on its website. The New York State Office of the Medicaid Inspector General maintains its own list as well.  When verifying individuals and entities using the LEIE, the Special Advisory Bulletin recommends that providers maintain documentation of the initial name search performed, such as a screen-shot and any additional searches. Because the LEIE contains information available at the time of the exclusion, providers should also verify by searching for other names (e.g. maiden name) as well. Additionally, although a provider may contract with another entity to screen a person or entity against the LEIE, a provider is nonetheless charged with the responsibility of determining and knowing whether an individual or entity has been excluded.

Conclusion

For health care providers enrolled in Medicare and Medicaid, due diligence and monitoring of employees and contractors, as well as potential employees and contractors, is absolutely necessary. The failure to do so may result in liability such as exclusions and civil monetary penalties. Moreover, in light of the Federal and State governments ongoing and increased efforts to protect against fraud and abuse, effective regulatory compliance efforts remain crucial.