Fong Law Group

What Is Hospice Care at Home?

Hospice care is a type of health care that patients with terminally ill conditions rely on at the end of their lives. This type of care focuses on pain management and emotional, spiritual, and familial support for patients nearing the end of their lives.

There are several options for receiving hospice care, including being cared for at home. The type of intimate care a patient receives while in hospice is more conducive to being received at the patient’s home. This becomes a team effort, and it helps to have a peaceful environment when receiving care.

Who Can Benefit From This Type of Care?

Patients with serious illnesses like cancer, heart disease, dementia, kidney failure, or other fatal conditions benefit from hospice care. This type of care can help the patient live a more comfortable life while decreasing the emotional burden of grief for families by preparing them for the loss of their loved one.

When Is Hospice Recommended?

Hospice care should not only be considered by those who have loved ones nearing the end of their lives. While most of these services are generally reserved for people with six months or less to live, early hospice care can be beneficial for patients and their families as well.

You may wish to consider such services in the following cases:

• The patient has a serious decline in their physical well-being
• After a diagnosis of Alzheimer’s disease or dementia
• You have decided to forgo any treatment to improve your physical treatment or care for your illness

Who Makes Up a Hospice Care Team?

Your hospice team can consist of many different types of people. Various professionals and volunteers may be involved in end-of-life care. Some of those you may see on your care team can include:

• Doctors
• Nurses
• Social workers
• Spiritual advisors
• Trained volunteers

Who Pays for Hospice Home Care?

Like any other health care option, these services can quickly become very expensive. Fortunately, there are several ways to cover the cost, including:

Government Programs

If you qualify for government assistance, there may be insurance plans specifically designed to cover the cost of hospice care.

Seniors enrolled in Medicare Part A may qualify for a Medicare hospice care benefit. This benefit program allocates money to pay for such care at home.

For terminally ill patients on Medicaid, hospice care may be covered depending on the state.  

The Department of Veterans Affairs may also provide coverage for these care benefits for seniors who have served our country.

Private Insurance

Check the terms of your insurance policy to determine if your health insurance covers hospice care. Your policy may cover all or part of your hospice care needs.

Options for Uninsured Patients

Even if you do not have health insurance, you may still have coverage options. There are charitable organizations that work with elderly and disabled individuals who need help paying for hospice care services. Hospice care organizations also often have internal departments that work with patients who qualify for this type of care but are indigent or do not have health insurance.

Is In-Home Hospice Right For You?

Making this choice is an important part of your end-of-life care plan. Be sure to gather as much information as you can before deciding whether this type o care is best for you. For example, you may want to consult Medicare’s hospice compare website or CaringInfo.org’s website for other hospice locator tools.

If you have questions about Medicare or Medicaid, contact your elder law attorney to learn more.

Bill Advocates for Seniors Who Seek At-Home Medicaid Care

Seniors who need assistance with everyday activities such as dressing, bathing, and eating are eligible for Medicaid Long-Term Services and Supports (LTSS). Unfortunately, hundreds of thousands of people who qualify for these services – but wish to receive them in their homes or a community setting – end up on extended waiting lists.

In many cases, these seniors then find themselves with no choice but to live in nursing homes or other institutional facilities for months, or even years, if it is the only way they can access the day-to-day support on which they rely.

A piece of legislation focused on meeting the needs of this population of older adults has recently been reintroduced to Congress by U.S. Sen. Bob Casey (D-PA) and U.S. Rep. Debbie Dingell (D-MI).

Aging in Place: When You Want to Live Independently

Living at home as you grow older can have a positive impact on your physical and emotional health, as well as on your wallet. According to one 2022 study, aging in place includes such benefits as the following:

• Maintaining a sense of independence and autonomy in one’s community
• Living in a familiar setting
• Enjoying a more fulfilling social network
• Decreasing feelings of loneliness
• Saving on the cost of long-term care facilities

Where Does the Medicaid Waiver Fit Into HCBS?

Older adults qualifying for Medicaid LTSS who wish to receive services in their home or community generally must wait to be granted a waiver before Medicaid will cover the cost of their home care.

As each state administers its own Medicaid system and waiver program, the wait time can vary depending on where you live. The income and asset thresholds for waiver programs can also differ from state to state, as can the types of home care that are covered.

These are among the main reasons why you may want to consult with your elder law attorney, who knows the rules and regulations specific to the state where you reside.

Home and Community Based Services (HCBS) Access Act

The Home and Community Based Services (HCBS) Access Act, originally introduced in 2021, seeks to secure for these seniors a real choice between receiving care at home or in an institution.

A one-page PDF summary of the HBCS Access Act outlines six specific steps that the proposed legislation is designed to provide:

• Enhanced Medicaid funding for HCBS
• Grant funding for states that would develop their capacity to serve individuals who prefer to receive home care
• Resources for states meant to ensure professional caregivers have stable jobs and wages
• A stronger workforce in home care
• Training for family caregivers
• Improved methods for evaluating the quality of HCBS

According to a 2021 report from Justice in Aging, 25 of the 50 states spend twice as much on institutional care as on HCBS for seniors and people with disabilities.

In addition to seniors eligible for Medicaid LTSS, many people with disabilities would benefit from the legislation if it is passed.

Support From Others

Sixteen U.S. representatives are co-sponsoring the HCBS Access Act, and numerous advocacy organizations for older adults have endorsed the legislation as well.

“I’m helping introduce the HCBS Access Act, which expands Medicaid HCBS funding that will help ensure Americans don’t have unnecessary delays in accessing the care they need,” U.S. Sen. Jeanne Shaheen (D-NH), one co-sponsor, said in a news release about the Act. "This bill is an important investment not only in the accessibility of care, but also in creating better jobs for home care workers and support for family caregivers.”

Earlier this year, Sen. Casey and Rep. Dingell also reintroduced a related bill, the Better Care Better Jobs Act. The goals of this legislation are to boost funding for HCBS, make millions more individuals on Medicaid eligible for these services, and create new jobs for home care workers.

Because Medicaid can be such a complex system to navigate, be sure to consider consulting with your elder law attorney.

Does Medicaid Cover Self-Measured Blood Pressure?

According to the American Heart Association, high blood pressure contributes to many significant health conditions, including heart attack, heart failure, stroke, and kidney failure. In the United States, 121.5 million adults suffer from high blood pressure, also known as hypertension.

While half of these individuals have improved their conditions, others have uncontrolled blood pressure, which can harm their health. Self-monitoring one’s blood pressure can help control this condition. Depending on your state, Medicaid may cover part of the cost.

What Is Self-Measured Blood Pressure (SMBP)?

Medical care is an important part of blood pressure management. Yet, you can also help your doctor treat you by monitoring and recording your symptoms at home. This is called self-measured blood pressure (SMBP). When combined with a doctor’s support, SMBP might improve your health.

You can use a manual blood pressure cuff or an automated blood pressure device to monitor your BP. With at-home measurements, you can record your blood pressure levels over time. Your doctor can use this information to help treat you.

The Benefits of Monitoring Blood Pressure at Home

Some evidence suggests that SMBP with clinical support may be more effective than medical care alone.

• When you measure your blood pressure at home, you can assess your condition regularly. You do not have to wait for a medical professional to evaluate your BP. If your blood pressure becomes dangerously high, you can inform your doctor and seek emergency treatment.
• By keeping track of the fluctuations in your blood pressure at home, you can give your doctor detailed information to help with your treatment. For instance, your doctor can use the information to decide what kind of medication and dosage to prescribe.
• Sometimes, blood pressure levels change depending on the situation. SMBP can identify forms of hypertension that present differently. At-home measurements can reveal white-coat hypertension (when a patient’s BP is high at the doctor’s office, but at a healthy level at home) and masked hypertension (when BP readings appear normal in a doctor’s office but are high in other settings, such as at home or work).

Why Might Medicaid Beneficiaries Need Coverage for SMPB?

Per Medicaid.gov, one-third of all Medicaid beneficiaries have high blood pressure. With uncontrolled hypertension disproportionally affecting low-income, nonpregnant adults on Medicaid, SMBP coverage and reimbursement through Medicaid can be beneficial for many.

Does Medicaid Cover Home Blood Pressure Monitoring?

Medicaid covers SMBP in certain states. Yet not all states have coverage. Continue reading for more information.

What Does SMBP Medicaid Coverage Include?

Depending on your state, Medicaid’s coverage for self-measured blood pressure could include the following:

• Provider reimbursement for medical support
• BP measurement devices for you to use at home (manual blood pressure cuffs or automated blood pressure devices)

In most states with SMBP coverage, Medicaid takes care of medical care as well as devices. Other states cover just one or the other. The American Medical Association outlines what Medicaid provides in each state.

Which States Cover Medical Support and BP Measurement Devices?

The following states provide coverage to some extent for both medical support and devices:

• Arizona
• Colorado
• Delaware
• Hawaii
• Idaho
• Indiana
• Michigan
• Nebraska
• New Jersey
• New Mexico
• North Carolina
• North Dakota
• Ohio
• Oregon
• Texas
• Virginia
• Wisconsin
• Wyoming

These states only cover durable medical equipment (manual blood pressure cuffs or automated blood pressure devices):

• Alaska
• Arkansas
• California
• Connecticut
• D.C.
• Illinois
• Iowa
• Kansas (only covers manual blood pressure cuff)
• Louisiana
• Maine
• Maryland
• Massachusetts
• Minnesota
• Mississippi
• Missouri
• Nevada
• New Hampshire
• New York
• Utah
• Vermont
• Washington

The following states reimburse providers for supporting patients with SMBP. However, Medicaid does not pay for at-home devices.

• Georgia
• Kentucky
• Montana
• Rhode Island

Speak With an Attorney

If you have high blood pressure, self-measurement might help. Consult with an attorney to learn more about whether you could be eligible for Medicaid coverage in your state.

What Is Respite Care? Can It Help With Caregiver Burnout?

It is easy to burn out when you are responsible for providing full-time care to an aging or disabled loved one. In some cases, caregiver burnout can result in resentment toward the individual they care for, despite their love for them.

The fact is, we all need a break sometimes. That is why respite care exists. If you are a caregiver who needs to take time for yourself, read more to learn about respite care.

What Does Respite Mean?

Taking respite means having a temporary period of rest. For primary caregivers, this typically refers to securing short-term care for your loved one – even several weeks or months – so that you can recharge amid the very real burdens of caregiving.

In finding respite, you also might make time to practice self-care, from going to the gym to connecting with friends. Do not forget to find ways to maintain your sense of self while you are in the midst of giving so much of your time and attention to someone else.

Caregivers Want Information About Respite Care

In a 2022 survey of caregivers, Caregiving in America found that most were unaware that respite care was available. Many caregivers need more education about their options for respite care and how to build a network of support to share the load of providing financial and emotional support to an ailing loved one.

Here are some of the study’s findings:

• Fifty-nine percent of respondents reported that they were the primary emotional support system for a sick or impaired loved one.
• Twenty-two percent of respondents said they worked more than 40 hours per week as the primary caregiver to a disabled family member.
• Forty-eight percent of respondents disclosed they needed emotional support for themselves.
• Forty-four percent of respondents shared that they wanted information about where to find respite care.

Caregivers need information about maintaining their own health while supporting a family member. It is essential to prioritize yourself when caring for an aging or disabled relative.

Preventing Caregiver Fatigue

The challenges of taking care of an ailing loved one can be extremely stressful. More than that, the strain of serving as a caregiver – often unpaid – can make a real and lasting impact on your own health if not kept in check.

Symptoms of burnout among caregivers may include the following:

• Losing sleep and extreme fatigue
• Feeling hopeless
• Having a quick temper
• Lack of interest in your favorite activities

If you or someone you know has taken on the responsibilities of caregiving, be aware of the signs of burnout and actively seek support. Respite care is among your potential options.

What Is Respite Care?

Respite care gives caretakers a chance to relax and take a break from the responsibility of providing full-time care to loved ones who are aging or disabled. Respite programs offer short-term replacement care. These providers will step in for a short period to take on the responsibility of caring for your loved one.

The types of care you can expect them to take on may include the following:

• Bathing and dressing
• Cooking and cleaning
• Helping your loved one eat, drink, and take their medication
• Getting into and out of bed
• Assistance with the restroom
• Spending quality time with your loved one
• Helping with exercise and personal care

How Much Does Respite Care Services Cost?

The cost of respite care varies depending on how long you use the service. You can schedule respite care for several days, weeks, months, or longer.

Who Pays for Respite Care?

Private insurance will typically not cover respite care, unfortunately. If your loved one is covered by Medicare or Medicaid, you may be able to secure five consecutive days of respite care. Your loved one must be receiving hospice care benefits for Medicare to cover respite care.

Finding Respite Care

Several organizations provide respite care. If your family member is covered by Medicaid, you can speak to a Medicaid planner in your state to determine what programs may be available. As mentioned above, Medicare covers respite care under its hospice benefit.

If your loved one is not covered by Medicare or Medicaid, don’t worry; there are private organizations that provide this service. These organizations include:

• National Adult Day Services Association (NADSA)
• Your Area Agency on Aging (AAA)

In addition, connect with your attorney to talk through your options.

Becoming a Family Caregiver for an Ailing Loved One

Taking on the responsibility of providing full-time care for an aging or disabled loved one can be a rewarding experience. Being a primary caregiver helps you rest assured that your loved one is receiving compassionate care from someone who will go above and beyond to ensure they are comfortable and looked after.

Despite your good intentions to create a comfortable environment for your loved one, full-time caregiving is a significant time commitment. There is also a financial reality that the caregiver must face. Fortunately, family members who want to serve as caregivers may have options to help cover the expense.

What Is a Caregiver, and What Do They Do?

Professional caregivers work intimately with seniors to meet their needs as they age. As individuals get older, their needs change and they may need more help going about their day.

Examples of the kinds of help caregivers provide include:

• Bathing and grooming
• Help with toileting
• Medical appointments and medication compliance
• Transportation
• Companionship
• Cooking, cleaning, and grocery shopping
• Care for animals
• Laundry
• Coordinate benefit care/speak to insurance companies on the senior’s behalf, if authorized

Family Caregivers: Know the Downsides

Having a family member serve in the role of caregiver can make for a better experience for your loved one and, in some ways, give you peace of mind as well. However, there are some downsides to be aware of if you are considering becoming a family caregiver.

Your own health, both physical and emotional, can be negatively affected when taking on the burden of caring for a family member. Be sure to engage in self-care, maintain a healthy diet, and watch out for signs of stress and burnout. When you do need a break, consider looking into respite care.

If your loved one has specific medical issues that will require the attention and expertise of a professional health care provider, you may want to reassess whether you should take on the role of family caregiver.

Taking care of a loved one who is getting older or who is disabled will likely require a great deal of your time, too. You may find yourself not performing as well at work or having a longer commute as you fulfill the needs of your ailing loved one. Not to mention that your own immediate family may be missing out on valuable time with you while you are caregiving elsewhere.

In turn, this could mean you will have less time to hold down a full-time job. In fact, a 2020 AARP survey showed that about 20 percent of family caregivers reported experiencing a high level of financial stress. Nearly 30 percent of them stopped saving altogether as a result of providing care for their loved one.

In these challenging economic times, you must be able to support yourself while ensuring the best care for your aging family member.

Can Family Members Get Paid for Their Work as a Caregiver?

Fortunately, certain programs are available to help family members care for ailing relatives. You may need to do a bit of research to find the right option for your circumstances.

• Medicaid Self-Directed Care

For individuals on Medicaid, the Medicaid Self-Directed Care Program is one option that gives them the authority to manage their services. In certain states, this program offers recipients the ability to use the resources allocated for home care to pay a family member to help them with their daily needs. The Medicaid Self-Directed Care Program lets seniors have more autonomy over their care.

Note that such programs vary by state, however, and not all states will have an option like this. Each state may also use different criteria to define who qualifies as a “family” caregiver. Find your local Area Agency on Aging to learn more about the possibilities, or call your local Medicaid agency.

Note that, generally, Medicare will not cover the costs of caregiving by a family member.

• Veteran’s Benefits

If your loved one is a military veteran, there are special benefits available to cover their home care, including the Veteran’s Directed Home and Community Based Services program. This program gives veterans a flexible spending budget that the veteran can use to pay a family member to act as their caregiver.

• National Family Caregiver Support Program

Note that this program does not pay caregivers directly. Rather, it helps fund several different types of services for family caregivers, from training in caregiving to respite care. Learn more about this program.

• Long-Term Care Insurance

If you are thinking ahead to who will care for you as you age, you may consider long-term care insurance when creating an estate plan. Certain long-term care insurance policies allow the policyholder to pay family members to work as caregivers. However, that is not true for every policy. Some policies do not allow policyholders to pay family members to work as caregivers if they live in the policyholder’s home.

Before taking out this type of insurance policy, you should speak to your attorney to ensure you are properly advised.

Medicaid Expansion: What Might It Mean for You?

As of late 2022, more than 84 million people were enrolled in Medicaid — a number that has steadily increased in recent years. Amid the pandemic, total enrollees climbed by 20 million people from 2020 to 2022 alone.

Meanwhile, the debate among lawmakers on further expanding Medicaid in some 11 states continues to evolve. Depending on where you reside, passage of such an expansion could mean you become newly eligible for Medicaid.

What Is Medicaid?

Medicaid is a nationwide program designed to provide public health insurance for low-income individuals, including seniors and people with disabilities. Established in 1965, it serves today as the single-largest source of health coverage in the U.S.

Because Medicaid is jointly run by the federal government and state governments, its benefits — and your ability to qualify for them — can vary greatly depending on your state.

As a result, certain populations, even if they are living in poverty, may not be eligible for Medicaid. For example, in some states, a healthy, childless adult couple under age 65 with limited means may not qualify for health coverage through Medicaid if their state has not adopted Medicaid expansion.

What Is Medicaid Expansion?

Medicaid coverage across the country has evolved since the program was first created. Different states may employ different eligibility criteria, income limits, or application requirements.

In 2010, the Affordable Care Act (ACA) attempted to expand Medicaid coverage to adults between 18 and 65 with incomes below a certain level, regardless of their age, family status, or health. The ACA also sought to supply those whose incomes fell within specific limits with premium tax credits that would help them afford the purchase of a private insurance plan.

Yet, the Supreme Court ruled that the federal government could not force states to expand coverage. States can decide whether to expand Medicaid to cover more people. This has created a coverage gap: Those who have incomes below 100 percent of the federal poverty level and who live in states that have opted against expanding Medicaid may not qualify for Medicaid, or for the premium tax credits.

Medicaid Expansion States

As of early 2023, most states have adopted the ACA’s broadening of Medicaid. Per the Kaiser Family Foundation, the following states – in addition to the District of Columbia – have expanded Medicaid coverage per the ACA:

• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• Utah
• Vermont
• Virginia
• Washington
• West Virginia

States Without Medicaid Expansion

States that have not adopted Medicaid expansion per the ACA include:

• Alabama
• Florida
• Georgia
• Kansas
• Mississippi
• North Carolina
• South Carolina
• Tennessee
• Texas
• Wisconsin
• Wyoming

Medicaid Expansion Developments

The map of Medicaid expansion states continues to evolve, however:

• South Dakota voters approved a ballot measure adding Medicaid expansion to the state constitution in November 2022. The expansion will go into effect beginning July 1, 2023.
• In February 2023, the North Carolina House of Representatives passed a bill to expand Medicaid. It now awaits review in the Senate.
• Meanwhile, also in February 2023, the Wyoming House of Representatives declined to address a proposed Medicaid expansion bill.

Arguments Against Medicaid Expansion

In states without Medicaid expansion, those opposed to expanding coverage have voiced such concerns as increased costs and a higher risk of fraud.

For example, some argue that Medicaid expansion would burden their state’s budget. Although the federal government funds the majority of expanded Medicaid, it does not completely cover the costs; states pay 10 percent. In the case of Wyoming, House Majority Floor Leader Rep. Chip Neiman has raised concerns that the federal government would not uphold the federal match, leaving the state to bear more financial responsibility.

Others contend that Medicaid’s most vulnerable beneficiaries may face greater competition for resources, that other health care options are available to those in need, or that expansion may not ultimately translate into better long-term health outcomes.

How Older Adults Can Find Out if They Are Eligible for Medicaid Coverage

In states that have adopted expanded Medicaid, you may qualify if your household income lies below 133 percent of the federal poverty level, according to HealthCare.gov.

For older adults, most states provide Medicaid to those who receive Supplemental Security Income (SSI). To be eligible for SSI, individuals must have low incomes, limited assets, and be unable to work due to a qualifying mental or physical impairment. Per the Kaiser Family Foundation, some states expand Medicaid to older adults and disabled people whose income surpasses the SSI limit but falls below the federal poverty level.

You may be able to qualify for Medicaid through the Medically Needy program if your state has established one. The Medically Needy program allows people to enroll in Medicaid when they have significant medical expenses. When they subtract their medical spending from their total income, they can qualify for Medicaid if their income, minus health care expenses, falls below a specified limit (which also varies by state).

To find out whether you qualify for Medicaid, consider consulting the following tools:

• The Benefits.gov Eligibility Checker will ask you questions regarding things like household income, number of dependents, and citizenship status to help you determine whether you might be eligible for Medicaid generally.
• The HealthCare.gov site can offer additional insights, including:
  • Guidance on Health Insurance Marketplace applications
  • Income calculators
  • Premium tax credit information
  • Q&A tool to determine eligibility for cost-sharing reductions

Again, the rules governing Medicaid and its complex eligibility criteria varies widely by state. To find out whether you may be able to receive public health insurance through Medicaid, consult with your attorney.

How Medicaid's Money Follows the Person Program Aids Seniors

Congress established the Medicaid Money Follows the Person (MFP) Program to provide states with federal funding to help seniors who are receiving care in institutions but want to live at home.

However, it is not a permanent program and is due to expire in September 2027. Advocates have pushed for Congress to make MFP permanent, ensuring that states have funding for seniors who wish to return home from long-term care facilities.

What Is the Medicaid Money Follows the Pereson (MFP) Program?

MFP was established in 2005 to increase Medicaid enrollees’ access to home- and community-based services (HCBS). In part, its goal is to allow seniors to avoid nursing homes and other institutions, and instead receive care in their own homes and communities if they choose. Other beneficiaries of the program include people with disabilities.

MFP allows the Centers for Medicare and Medicaid Services to remove the restrictions that are placed on how funds are allocated for long-term services. It increases the use of HCBS services instead of long-term services and support.  

How Does MFP Help Older Adults?

Throughout its existence, MFP has helped seniors who otherwise would have been institutionalized maintain control over their lives by providing a chance at independent living. In the nearly two decades since the program began, MFP has helped more than 107,000 people move from a nursing home or a long-term care facility back into their home. One evaluation found that MFP results in greater life satisfaction among participants.

Returning home from an institution is a tall task for most seniors. A major concern is the lack of staff to take care of an individual’s medical and personal needs. In many cases, seniors must rely on family members. MFP helps ease the burden of transitioning from care facilities back home.

Examples of the type of support MFP provides seniors as they move back home typically include:

• Help paying for groceries
• Short-term transitional housing
• Security deposits for rental homes and apartments
• The cost of necessities for setting up a home (e.g., stair-lifts, wheelchair ramps)

Can MFP Help Seniors Secure Housing?

The federal government funds the Medicaid Money Follows the Person program. Medicaid is prohibited from paying for housing directly. MFP allows states to use money from the program to pay for case management and transitional support services for seniors.

To address the needs of low-income seniors, state governments have used MFP funds to partner with housing authorities and developers to ensure more housing options are available for seniors who want to live independently.

Will the Medicaid Money Follows the Person Program End?

MFP has been a Medicaid demonstration program since 2008. Demonstrations are used to determine whether programs should become permanent. More than 40 states and territories currently are a part of MFP.

However, Congress has inconsistently funded MFP. The uncertainty about whether the program will have long-term funding has made it difficult for states to budget, so over time some states have been opting out of the program entirely. If MFP expires in 2027, many more seniors will be forced to live in long-term care facilities, losing the independence they desire.

It remains to be seen whether Congress will make the program permanent. If it does, states will have a set amount of money to increase seniors’ ability to live on their own as they age.

Learn more about the program at Medicaid.gov. For further guidance, speak to your elder law attorney.

Highlights of How the Omnibus Bill Will Benefit Older Adults

The Senate and House have cleared the passage of a year-end $1.7 trillion appropriations bill that will benefit older adults on a number of fronts.

The bill, which runs more than 4,000 pages and includes a wide variety of legislation, heads to President Biden next for his signoff.

Here is a breakdown of some of the highlights that relate to supporting older Americans:

Health and Housing

• Opt to age at home – The Money Follows the Person (MFP) Program has been helping older adults age in their own home or a community setting, rather than in nursing homes, since 1972. The newly passed bill extends MFP through September 2027.
   
• Age in place safely – The omnibus bill has also doubled funding for the federal government’s Older Adult Home Modification Program from $15 million to $30 million.
  
  For seniors with limited income, this program covers the cost of simple, low-cost home modifications – such as railings and temporary wheelchair ramps – that help them age in place safely.
   
• Provide for your healthy spouse if you are on Medicaid in a nursing home – Medicaid beneficiaries who must reside in a long-term care facility but have a spouse still living at home will continue to see their healthy spouse protected from poverty.
  
  Known as spousal impoverishment rules, these protections ensure that the healthy spouse receives income while their institutionalized spouse keeps their Medicaid eligibility. These protections, which are adjusted each year, will continue to be in place until September 2027.
   
• Continue to see doctors online – Lawmakers have extended access to telehealth services for Medicare enrollees for another two years.
   
• Find affordable housing with support services – The Housing for the Elderly Program has received a billion-dollar bump in funding as well.
  
  This program seeks to aid seniors with very limited income in securing housing that is within their means while also offering supportive services such as assistance with cooking and cleaning.

Retirement Savings

• Contribute more to retirement – For older workers, the omnibus bill raises what are known as “catch-up” contribution limits for retirement savings. Taxpayers ages 60 to 63 will be allowed to contribute an extra $10,000 to their 401(k) starting in 2025.
   
• Access 401(k) funds for emergencies – If you need to take money out of your 401(k) before reaching age 59½, under certain circumstances you will no longer have to pay the 10 percent penalty fee for withdrawing money early. As of the end of 2023, you will be allowed to withdraw up to $1,000 a year for unforeseen emergencies without incurring a penalty.
   
• Wait longer to withdraw money from your retirement accounts – Previously, you were required to begin withdrawing money from your retirement plan account starting at age 72. This mandatory withdrawal is known as a required minimum distribution (RMD).
  
  As of January 1, 2023, the new bill allows you to hold off until age 73 to take funds from these types of private retirement accounts.

Protecting Spouses of Medicaid Applicants: 2023 Guidelines

The Centers for Medicare & Medicaid Services (CMS) has released the 2023 federal guidelines for how much money the spouses of institutionalized Medicaid recipients may keep, as well as related Medicaid figures.

What Are Spousal Impoverishment Rules?

Spousal impoverishment is a concern for older couples when there is one spouse who requires long-term care and applies for Medicaid.

Before the federal government enacted spousal impoverishment protections, many healthy spouses faced poverty when their partners needed long-term care. The spousal impoverishment rules are based on the idea that spouses will provide for each other.

Community Spouse Resource Allowance

In 2023, the spouse of a Medicaid recipient living in a nursing home (called the “community spouse”) may keep as much as $148,620 without jeopardizing the Medicaid eligibility of the spouse who is receiving long-term care.

Known as the community spouse resource allowance (CSRA), this is the most that a state may allow a community spouse to retain without a hearing or a court order. While some states set a lower maximum, the least that a state may allow a community spouse to retain in 2023 will be $29,724.

Monthly Maintenance Needs Allowance

Meanwhile, the maximum monthly maintenance needs allowance (MMMNA) for 2023 will be $3,715.50. This is the most in monthly income that a community spouse is allowed to have if their own income is not enough to live on and they must take some or all of the institutionalized spouse's income.

The minimum monthly maintenance needs allowance for the lower 48 states will be $2,288.75 ($2,861.25 for Alaska and $2,632.50 for Hawaii) until July 1, 2023.

In determining how much income a particular community spouse is allowed to retain, states must abide by this upper and lower range. Bear in mind that these figures apply only if the community spouse needs to take income from the institutionalized spouse.

According to Medicaid law, the community spouse may keep all their own income, even if it exceeds the maximum monthly maintenance needs allowance.

The new spousal impoverishment numbers (except for the minimum monthly maintenance needs allowance) take effect on January 1, 2023.

Home Equity Limits

In 2023, a Medicaid applicant’s principal residence will not be counted as an asset by Medicaid if the applicant's equity interest in the home is less than $688,000. States have the option of raising this limit to $1,033,000.

Pros and Cons of a Medicaid Asset Protection Trust

A Medicaid Asset Protection Trust (MAPT) is one option a person may consider to protect their assets from Medicaid and nursing homes or long-term care.

A MAPT is an irrevocable trust created during your lifetime. The primary goal of a MAPT is to transfer assets to it so that Medicaid will not count these assets toward your resource limit when determining whether you qualify for Medicaid benefits.

However, creating an irrevocable trust comes with a certain lack of control over the assets you transfer to this trust. Before making such a significant decision, consider some pros and cons to see if this long-term care strategy is right for you.

Benefits of a MAPT

1. You Can Still Benefit From the Assets of a MAPT

Although transfers of assets to a MAPT cause you to relinquish your ownership and control of them, the finality of the arrangement is not as harsh as it sounds.

In creating a MAPT, you select a person (trustee) who manages the trust assets for your benefit. So, if you transfer investment accounts to the MAPT, you can still receive the income generated from these investments. If you transfer your home, you can still live there. In exchange for giving up control of your assets to a MAPT, your assets no longer count against you for Medicaid eligibility purposes.

2. Your Assets Are Safe From Medicaid and Other Long-Term Care Creditors

Once your assets are in a MAPT and other criteria are met, Medicaid can’t seize them or ask you to spend them down to pay for your nursing home or long-term care costs. These assets also are not subject to Medicaid’s estate recovery program.

As a result, your heirs can benefit from the assets without the interference of Medicaid or liens it could otherwise file against your estate after you pass.

3. You Can Choose Your Beneficiaries

A MAPT also functions as an estate planning tool. This is because you can designate who receives what remains of the trust upon your passing. The beneficiaries you choose will receive the assets per the terms of the trust agreement, and the chances of a probate court getting involved are diminished.

In addition, you may be able to retain what is called a “limited power of appointment.” This allows you to change who the beneficiaries of the MAPT will be, should your wishes or family circumstances change.

4. Assets Are Protected From Your Beneficiaries’ Creditors

Even though you can designate a MAPT’s beneficiaries now, those beneficiaries do not have full access to the trust’s assets because of how it is structured. This also means their creditors do not have access to it. And, if your child is a beneficiary and is going through a messy divorce, neither does their spouse. You can also designate how bequests to beneficiaries can be used.

5. Protection From Capital Gains Taxes

A properly drafted MAPT preserves the full capital gains tax exclusion on the primary residence (currently $250,000 per spouse). Later, when a person’s beneficiaries sell the home, it would be valued at the market price at the date of gifting and not at the original purchase price. This can avoid or significantly minimize the capital gains tax that your heirs may owe.

Drawbacks of MAPTS

1. Timing Is Everything

For a MAPT to function as intended, it needs to be created in advance to avoid the Medicaid lookback period. In most states, this is five years for nursing home or institutional care. In some states, there may also be a lookback period for community Medicaid care (home aides, local programs, etc.).

If less than five years have elapsed since you created your MAPT, you may still be responsible for some or all of your long-term care costs until sufficient time has passed.

2. Income From MAPT Is Countable by Medicaid

Although assets in a MAPT may not be “countable” by Medicaid toward your resource limit, these assets may still generate income. If this income is payable to you, it may cause you to exceed the income limit permitted in your state.

If this happens to you, you may have other options, such as utilizing a pooled income trust, or may decide you will contribute partially toward your care.

3. Giving Up Control Is Non-Negotiable

A trust will not qualify as a MAPT if you retain control other than the limited power of appointment that may be permitted in your situation. You must accept that a person you select to act as trustee will manage the trust, distribute funds and income from the trust, and also be the effective owner of the assets.

In addition, creating a MAPT but not transferring assets to it is ineffective. You need to fully commit to the concept for it to benefit you.

4. Setting Up a MAPT Is Costly

Creating and implementing a MAPT is a complex legal task requiring many hours of work and expenditures made on your behalf. In addition, because MAPTs are tied to individual state and federal laws, the expertise of a qualified Medicaid attorney is essential.

You should expect that this expertise comes at the cost of several thousand dollars or more. However, your potential savings could be exponentially greater for you and your family. For this reason, the price is often well worth it.

5. Potential Effects on Care

It’s important to realize that while the MAPT strategy is designed to preserve assets and wealth, it assumes that a person will rely on Medicaid to pay for a portion of their care. However, Medicaid does not cover all facilities. For example, many assisted living facilities are not licensed as assisted living programs and only accept private pay residents. Thus, relying on Medicaid could affect the choice and quality of care a person may receive.

The pros and cons discussed above are not exhaustive, and there may be other ones that apply to your situation. Investing in a MAPT is a highly fact-specific process, and MAPTs are not suitable for everyone.

You should speak with your attorney to discuss how a MAPT may affect other benefits you receive, your overall estate plan, its tax consequences, and whether it is right for you.