1. Daniel Timins, Esq., CFP®
dan@timinslaw.com
450 7th Avenue, Suite 1500
New York, NY 10123
(212) 683-3560

2. All information contained in these
pages is for informational purposes
only. It should not be considered legal
advise. Please consult an attorney
before taking any steps based on this
information.

3. ◦ MEDICARE:
An “Entitlement ProgramEntitlement ProgramEntitlement ProgramEntitlement Program” – you paid for it, you get it
Pays for HEALTH care
◦ MEDICAID:
A “Needs Based ProgramNeeds Based ProgramNeeds Based ProgramNeeds Based Program”
(1) Must have the physical / mental need
(2) “Means Tested”: must meet asset & income limits
Pays for PERSONAL care / Activities of Daily Living

4. PART A: Inpatient Hospital Care
Pay up to $407 per month (if “Ineligible”)
PART B: Supplemental Medical Insurance
Pay $104.90 - $335.70 per month (see future slide)
PART C: Managed Care
Cost varies by plan
PART D: Prescription Drug Benefits
◦ $0-$50 per month; cost varies by plan; higher-
income consumers often pay more

5. Operating expenses
Semi-private room and meals
Nursing services
Social services
Use of hospital equipment
Rehabilitation services
Diagnostic testing

6. Skilled Nursing Facility
◦ Physician must certify rehab is needed for a
hospital treatment in last 30 days
◦ There is an ~ $157.50 per day coinsurance charge
for day 21 – 100
Home Health Care
◦ Pays for full cost up to 100 home visits, but MUST
occur after a hospital or skilled nursing facility stay
◦ Recipient MUST be confined at home
◦ PART B may cover additional expenses

7. “Luxury” and Elective surgeries
Most services performed outside of US
Procedures performed in federal facilities

8. (1) Everyone aged 65 and older who is receiving a monthly
Social Security (including survivor’s benefits), or
(2) People aged 65 and over who have deferred receiving
Social Security retirement benefits (must apply for
Medicare; others in “pay status” are automatically
enrolled), or
(3) 65 year old civilian employees of the federal
government who did not elect into the Social Security
system under the 1983 law, or
(4) People who receive or are eligible to receive railroad
retirement benefits, or
(5) Any spouse aged 65 and over of a fully insured worker
who is at least aged 62

9. What if I am not eligible for PART A?What if I am not eligible for PART A?What if I am not eligible for PART A?What if I am not eligible for PART A? YouYouYouYou
have to pay for ithave to pay for ithave to pay for ithave to pay for it!!!!
If insured worked for less than 30 quarters of
his or her life:
◦ Can voluntarily enroll by paying premiums of
approximately $407 per month
◦ Premium can increase monthly
If insured worked between 30 and 39 quarters
of his or her life
◦ Can voluntarily enroll by paying premiums of
approximately $290 per month
◦ Premium can increase monthly

10. Covers hospital expenses for up to 90 days for
each “benefit period” (spell of illness)
◦ A “benefit period” ends only AFTER recipient has been
out of a hospital OR skilled nursing facility for 60
consecutive days
◦ At that time a new benefit period begins
◦ First 60 days of benefit period are paid in full with an
~ $1,260 deductible
◦ Next 30 days of benefit period are paid in full with an
~ $315 coinsurance charge for EACH day
Also, there is an additional 60 “lifetime reserve
days” over an individual’s lifetime
◦ $630 coinsurance per day
◦ Recipient can choose when to use these days

11. Physician and Surgeon fees
Diagnostic tests in hospitals and Dr. offices
Physical or occupational therapy
Radiation therapy
Medical supplies and devices
Ambulance service
Pap smears and one yearly mammogram
Flu and pneumonia vaccinations
Emergency room care
Drugs that CANNOT be self-administered

12. Custodial care
Routine physical, eye & hearing exams and
tests
Eye glasses and hearing aids
◦ (potential 1 time exemption for hearing aids)
Routine foot care and orthopedic shoes
Immunizations
Cosmetic surgery
Dental care and dentures

13. Monthly premiums for PART B are based on your
income…
…but beware of a drastic bump-up on 30% of people
in 2016
If your yearly income in 2013 (for what you pay in 2015) wasIf your yearly income in 2013 (for what you pay in 2015) wasIf your yearly income in 2013 (for what you pay in 2015) wasIf your yearly income in 2013 (for what you pay in 2015) was
You payYou payYou payYou pay
((((in 2015)in 2015)in 2015)in 2015)
You MAY pay
(in 2016)File individualFile individualFile individualFile individual
tax returntax returntax returntax return
File joint tax returnFile joint tax returnFile joint tax returnFile joint tax return
File married & separate taxFile married & separate taxFile married & separate taxFile married & separate tax
returnreturnreturnreturn
$85,000 or less $170,000 or less $85,000 or less $104.90$104.90$104.90$104.90 $105$105$105$105----$160$160$160$160
above $85,000
up to $107,000
above $170,000 up
to $214,000
Not applicable $146.90 $223.00
above $107,000
up to $160,000
above $214,000 up
to $320,000
Not applicable $209.80 $318.60
above $160,000
up to $214,000
above $320,000 up
to $428,000
above $85,000 and up to
$129,000 $272.70 $414.20
above $214,000 above $428,000 above $129,000 $335.70 $509.80

14. PART B pays 80% of approved medical
expenses after an $147 annual deductable
Like PART A, PART B is automatic at age 65
◦ If you do not want PART B you must reject it in
writing by2 months of receiving Medicare Notice
◦ If you change your mind later you have to pay for
past-years (expensive)

15. Participants can elect to have Medicare benefits
provided by a managed care plan
◦ An HMO, PPO or insurance company (but MUST use a
preferred provider unless an emergency)
◦ The Participant still pays PART B premiums, and
usually pays more for PART C…
◦ …BUT deductibles are usually eliminated and copays
are lowered to reasonable amounts
◦ A Medigap policy may not be necessary (because
coverage is often redundant)

16. Benefits must be at least equal to (and
sometimes better than) those available
under Medicare
Additional Benefits:
◦ Prescription drugs
◦ Eyeglasses and hearing aids
◦ routine physical exams

17. You MUST have PART D unless you haveYou MUST have PART D unless you haveYou MUST have PART D unless you haveYou MUST have PART D unless you have
supplemental healthsupplemental healthsupplemental healthsupplemental health insuranceinsuranceinsuranceinsurance
A voluntary program available to all people
entitled to PART A and enrolled in PART B
Run through private plans that develop a list of
covered drugs
◦ Plans do NOT need to cover EVERY prescription drug…
◦ …BUT must cover at least TWO in each therapeutic
category and class
Premium is approximately $50 per month
(depending on the chosen plan)

18. ACTIVITIES OF DAILY LIVING (“ADLs”)ACTIVITIES OF DAILY LIVING (“ADLs”)ACTIVITIES OF DAILY LIVING (“ADLs”)ACTIVITIES OF DAILY LIVING (“ADLs”)
◦ Transferring (Walking)
◦ Bathing
◦ Dressing
◦ Eating
◦ Continence
◦ Toileting

19. Healthy Married Couple: When some aging
illness is diagnosed or no earlier than 70s
Single Person with No Kids: NEVER (Private
pay caregiving is better than Medicaid care)
Disabled Family Member: Immediately
Disabled Minor Family Member: Prior to them
attaining age 18

20. The type of Medicaid benefit youThe type of Medicaid benefit youThe type of Medicaid benefit youThe type of Medicaid benefit you receive determines “look back” periodsreceive determines “look back” periodsreceive determines “look back” periodsreceive determines “look back” periods
(I.e. the penalty for transferring assets)(I.e. the penalty for transferring assets)(I.e. the penalty for transferring assets)(I.e. the penalty for transferring assets)
Home / CommunityHome / CommunityHome / CommunityHome / Community CareCareCareCare
Personal care, physical therapy,Personal care, physical therapy,Personal care, physical therapy,Personal care, physical therapy,
home health care and home healthhome health care and home healthhome health care and home healthhome health care and home health
aid services;aid services;aid services;aid services; cccclinical or outlinical or outlinical or outlinical or out----patientpatientpatientpatient
basis; includes physicians, dentists,basis; includes physicians, dentists,basis; includes physicians, dentists,basis; includes physicians, dentists,
pharmaceutical, nurserypharmaceutical, nurserypharmaceutical, nurserypharmaceutical, nursery
Institutional CareInstitutional CareInstitutional CareInstitutional Care
Hospitals, medical facilities,Hospitals, medical facilities,Hospitals, medical facilities,Hospitals, medical facilities,
nursing homesnursing homesnursing homesnursing homes

21. You have to give away Money (gifting)You have to give away Money (gifting)You have to give away Money (gifting)You have to give away Money (gifting)
AND / ORAND / ORAND / ORAND / OR
You have to give up control of spendingYou have to give up control of spendingYou have to give up control of spendingYou have to give up control of spending

22. ASSETSASSETSASSETSASSETS
$14,850$14,850$14,850$14,850 in the recipient’s name
EXCEPTIONS:
•“Burial Allowance” of $1,500
•Life Insurance: $1,500 cash value
•Personal Property (unlimited)
•Client’s HouseClient’s HouseClient’s HouseClient’s House (ONLY for Home &
Community care)
•Supplemental Needs TrustsSupplemental Needs TrustsSupplemental Needs TrustsSupplemental Needs Trusts
•Medicaid TrustsMedicaid TrustsMedicaid TrustsMedicaid Trusts
•Retirement PlansRetirement PlansRetirement PlansRetirement Plans (IRAs) are exempted
from assets if they are in “payout status”
(Required Minimum Distributions or
Separate and Equal Periodic Payments if
recipient is under age 59 ½), in which
case payments are included in Income
MONTHLYMONTHLYMONTHLYMONTHLY INCOMEINCOMEINCOMEINCOME
HOME CARE: $825 per month$825 per month$825 per month$825 per month
• Any excess income must go to
the recipient’s “SPEND DOWN”“SPEND DOWN”“SPEND DOWN”“SPEND DOWN”
• Often goes to a “POOLED
TRUST”
INSTITUTIONAL: ALL of the
recipient’s monthly income in
excess of$50 must be paid to
the NH to offset Medicaid
payments

23. DepartmentDepartmentDepartmentDepartment of Social Services and Medicaid impose a “of Social Services and Medicaid impose a “of Social Services and Medicaid impose a “of Social Services and Medicaid impose a “LookbackLookbackLookbackLookback Period” forPeriod” forPeriod” forPeriod” for
transferring assets outside of the proposed recipient’s nametransferring assets outside of the proposed recipient’s nametransferring assets outside of the proposed recipient’s nametransferring assets outside of the proposed recipient’s name
Home & Community CareHome & Community CareHome & Community CareHome & Community Care
3 MONTH3 MONTH3 MONTH3 MONTH LookbackLookbackLookbackLookback
One Strategy:
Transfer all financial assets
(except $14,850) to a non-
spouse, wait one month for
bank statements to be
updated, then apply for
Home Care.
DOWNSIDE: If the recipient
needs Nursing Home care…
the 5 Year Look back rule
applies
NursingNursingNursingNursing HomeHomeHomeHome
5 Year5 Year5 Year5 Year LookbackLookbackLookbackLookback PeriodPeriodPeriodPeriod, and the Homestead, and the Homestead, and the Homestead, and the Homestead
can be attached by Medicaidcan be attached by Medicaidcan be attached by Medicaidcan be attached by Medicaid
EXAMPLE: In January, 2011 Mary transfers her Coop
and most of her assets to her son Joe (total of
$280,000), and applies for Home Care. In March
2015 Mary goes to a Nursing Home. She failed to
make the 5 year Lookback (4 years & 2 months).
Nursing Home Care in Manhattan equals
approximately $12,000 per month.
$280,000 (amount gifted) = 23.3 MONTH
$12,000 (monthly benefit) “Penalty Period”
Medicaid will not pay Mary’s Nursing Home benefits
for 23 months. ..and Joe is liableJoe is liableJoe is liableJoe is liable. Joe should have
paid for Mary’s care for 10 more months to get
through Mary’s Lookback Period.

24. DifferentDifferentDifferentDifferent Types of Trusts are required for ASSETS and INCOMETypes of Trusts are required for ASSETS and INCOMETypes of Trusts are required for ASSETS and INCOMETypes of Trusts are required for ASSETS and INCOME
Both require giving up controlBoth require giving up controlBoth require giving up controlBoth require giving up control
“MAPT”: Medicaid Asset“MAPT”: Medicaid Asset“MAPT”: Medicaid Asset“MAPT”: Medicaid Asset
Protection TrustProtection TrustProtection TrustProtection Trust
• Protects & transfers assets
• Your choice of Trustee
(anyone except you & spouse)
• Your beneficiaries keep the
assets at your death
Assets MUST adhere to look
back periods, so do in advance
Pooled TrustPooled TrustPooled TrustPooled Trust
• Hold excess income “Spend Down”
• You choose the Not-For-Profit
agency that runs the trust
• The agency keeps any excess
assets left at the time of death
Needs to be done around the time
you apply for Medicaid benefits

25. NO principle can be distributed
◦ Income distributions are optional
◦ A pure “Asset Transfer vehicle”
◦ Perfect for illiquid assets, such as real estate
Elder client is Beneficiary & Creator
Child(ren) is the Trustee
Look-Back Period still applies
◦ Does NOT work at the last minute – need to planneed to planneed to planneed to plan
Deed & account changes required; separate
tax return may be needed for invested assets

26. Step-up in basis is maintained at client’s
death
Assets are protected from children’s creditors
Client qualifies for Medicaid based on Look
Back period (Home / Institutional Care)
Trust can hold almost any Asset
◦ Example: LLP Fractional ownership of NYC parking
garages, investment real estate, investments

27. For 3rd Party Money (Ex: Parent’s $)
◦ Inter Vivos Supplementary Needs Trusts
◦ Testamentary SNTs (in Will)
For 1st Party Money (the Recipient’s $)
◦ Pooled Trusts (payback provisions apply)
◦ Inter Vivos SNTs (payback provisions apply)
◦ Promissory Notes (protects 40%-45%)

28. The “Community Spouse” is entitled to some assets and
income, but they are limited
If spouse is in a Nursing Home:
◦ $2,931 of income per month
◦ $74,820 - $117,240 of resources
If spouse has Home Care:
◦ Combined income of $1,192 per month
During the Medicaid Application process the well spouse
may exercise a “Spousal Refusal” to avoid inclusion of
his/her assets and income
◦ Medicaid may accept this, but will have a claim against the well
spouse when he/she dies
New “Spousal Impoverishment” rules avoid liens

29. 1.1.1.1. Determining HOW MUCH to transferDetermining HOW MUCH to transferDetermining HOW MUCH to transferDetermining HOW MUCH to transfer
◦ Proper income generation still required
2. Knowledge of Cost Basis / Capital Gains
taxes is more important than ever
3. Identifying ALL of the assets, income &
gifting is ESSENTIAL

30. Execute POAs & HCPs early
Gift early / Fund Trusts early
Pre-pay burials
Look into child / sibling care givers for
homestead exemption
Look at disabled parent / child pairs
Fund IRAs / Retirement as much as possible

31. Roth IRA Conversations do NOT avoid RMDs /
72t SEPP
◦ STILL have to take Required Minimum Distributions
Commercial Annuities are HORRIBLE for
Medicaid Planning (unless in IRAs)
Large cash values in Life Insurance policies
are also bad - $1,500 limit on cash value

32. An Employee?
◦ You “Hire” someone at 30 Hours Per Week
◦ Need Worker’s Comp / Disability
◦ Withhold for Payroll Taxes
◦ Should have a Time Card
If You Don’t…
◦ Worker’s Comp can GET YOU
◦ IRS / NY Tax authority can GET YOU
◦ Care Giver can GET YOU

33. “This is a family friend”
“She only accepts cash”
“We pay her under the table”
“Mom doesn’t like ________”
“We have known her forever”
“A friend recommended her”
“She can work 24 / 7”

34. 1. Hire an OUTSTIDE Social Worker
◦ Not biased toward care hours
2. Use an AGENCY for Care Givers
1. IF you choose an unlicensed Care Giver:
◦ Background Check!!!
◦ Do ALL things on prior page
◦ Keep receipts: Care may be Tax Deductible
◦ Do NOT pay cash
◦ Remove jewelry & financial statements