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Continuing my series on Medicaid expansion and Estate Recovery:

Medicaid-Estate-Recovery-ACA-Unintended-Consequences

Estate-Recovery-It-s-Worse-Than-You-Thought

Welcome to Chapter 3: "Medicaid is Welfare. It's right to expect repayment."

Our story so far: We now have some confirmation from the disclosures in some states' signup forms that it appears likely that Estate Recovery will apply to those enrolling in Medicaid through the ACA. For example, in WA:

On the WA state "Application for Health Care Coverage" (same application for both the expanded Medicaid called WAH-for WA Apple Health, and the Exchange's subsidized plans), there are these two sentences on page v of the instructions:

http://www.hca.wa.gov/....

“Things you should know about Washington Apple Health only:
By law (RCW 41.05A.090 and WAC 182-527), if you are age 55 or older AND receive WAH services, Health Care Authority (HCA) may recover from your estate (assets you own at the time of death) to repay HCA for the costs of health care assistance. This is called ESTATE RECOVERY.”

And in NY the form states:
When I sign this application, it means:

    I know that Medicaid will not pay medical expenses that insurance or another person is supposed to pay medical expenses that insurance or another person is supposed to pay.

    I give the Department of Health any right under the law to try to get payment for medical expenses from my spouse or the mother or father of my child, if my child is under 21 years old.

    I give the Department of Health the right to get paid, instead of me, the money owed to me by certain other companies or people in order to pay for my benefits.

    I agree to file any claims for health or accident insurance benefits, or any other claims for money or benefits, that I have a right to file.

    By applying for Child Health Plus, I agree to pay the monthly fee (premium) not paid for by New York State.

    I understand that once I get Medicaid coverage, if I am over 55 or if I am in a medical institution and not expected to return home, the Medicaid program may do the following in order to pay for my medical care:
        Take money I already have or that is owned to me.
        Take money that was made from selling certain things I own
        Take money from people who were legally responsible for me when I got benefits

Please share with us any form disclosures or other information you may have on this from your state, particularly if you live in a state that collects not just for long term care, as mandated by federal law, but has gone for the option to collect for all services provided to anyone 55 or older.

Yesterday I was able to have a conversation with someone in the NH Medicaid Estate Recovery Department. When I asked her if Estate Recovery would apply to those 55 and older who enrolled under Medicaid Expansion, if NH expands Medicaid, she said:

"As far as I know, yes."

Of course at this moment all of this is not implemented yet since NH has not yet accepted Medicaid expansion. Therefore I could not get answers to questions about how this would apply. She did mention that the NH Breast & Cervical Health Program is now an estate-recoverable item. I hadn't even thought about that: 55 or older and low income? The cost of that mammogram will be taken out of your estate! But I digress.

The person with whom I spoke was quite adamant that it would not be accurate to characterize Medicaid benefits received by those subject to Estate Recovery as a loan. Why not? "Because we don't charge interest!" And of course because there are some people they don't recover from: those under 55, those not using estate-recoverable programs, etc.

Likewise, she was firm that Estate Recovery is not a tax. There are very particular requirements as to what legally constitutes a tax, she told me.

OK, what would she call it, then? "A creditor claim. It's a creditor claim."

Creditor: A creditor is a party (e.g. person, organization, company, or government) that has a claim on the services of a second party. It is a person or institution to whom money is owed.[1] The first party, in general, has provided some property or service to the second party under the assumption (usually enforced by contract) that the second party will return an equivalent property and service. The second party is frequently called a debtor or borrower. The first party is the creditor, which is the lender of property, service or money.

The term creditor is frequently used in the financial world, especially in reference to short-term loans, long-term bonds, and mortgage loans. In law, a person who has a money judgment entered in their favor by a court is called a judgment creditor.

The term creditor derives from the notion of credit. In modern America, credit also refers to a rating which indicates the likelihood a borrower will pay back his or her loan. In earlier times, credit also referred to reputation or trustworthiness.

Then she explained that Medicaid is a form of welfare, and that it is only right that if people receive welfare, they should pay it back if possible.

So here is a very important question: Is Medicaid a form of insurance? Or is it welfare?
If it is welfare,  and if by taking it one becomes indebted to the state, what are the implications of enrolling millions of people under the ACA who may not understand that the option at the bottom of the income ladder is not insurance at all, but a form of welfare, incurring a debt one is expected to pay back?

It's only right, the person from the Estate Recovery office assured me. If people take welfare, they should expect to have to pay it back.

What do you think?

Poll

Should Medicaid Estate Recovery apply to people enrolled in Medicaid via Medicaid Expansion under the Affordable Care Act?

18%110 votes
4%25 votes
46%280 votes
31%192 votes

| 608 votes | Vote | Results

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Comment Preferences

  •  Medicaid is a means tested welfare program. (8+ / 0-)

    I think you're right that this is not understood.

    very interesting diaries.

  •  The Constitution sets up governmental agencies (3+ / 0-)
    Recommended by:
    tle, Horace Boothroyd III, bleuet

    to provide for the welfare of the populace. If our agents of government fail to do so, they are derelict. Derelict agents of government have to be fired. That's why we hire and pay them in the first place.
    The notion that agents of government are doing the public a favor is attractive to people who prefer to rule, rather than serve. If we let them get away with it, it is our fault.

    That said, since our currency is created and distributed by  federal governmental agencies, it is only good and proper that the currency flow back, to keep the cycle of circulation intact.
    Or, let's put it another way. If children don't want their parents' assets used up in their care, they should care for those parents themselves and take the assets in trade when the parents expire, as they inevitably will. Of course, in order to be able to do that, people have to be able to think ahead and lots of instinct-driven people seem incapable of that.

    Of course, the decision process would be much easier if Congress weren't intent on rationing the distribution of dollars as a constant event. Indeed, one of the reasons for leaving the states in charge of managing health care (insurance and direct payment) is because Congress has proved an unreliable provider. Not only is the distribution of dollars directed by crony affiliations and by the electoral behavior of the represented population, but the two cancel each other out, so that the populace is worse off (vide Mississippi, Alabama, Florida, Texas) as a result. That's why all but 12% of the population has decided that Congress is corrupt and why the President's stature has risen as he has stood up to the extortionists on the Hill.

  •  Am I understanding you (5+ / 0-)

    that you feel it is "unfair" for the state to recover (part of) the costs of health care provided to individuals from their estate?
    To whom is it unfair?  The individuals are DEAD. They received health care when they needed it, and were not left penniless and homeless.

     Rather than push them out of their houses and repossessing their cars while they are alive in order to pay for their health care, the state is "punishing" their heirs, who should apparently get anything they have when they die.

    Why should the heirs inherit anything when the rest of us paid for their parents health care?

    An entire industry of lawyers has sprung up to hide assets from Medicare and Medicaid- so that the rest of us pay for those individuals' care- and the hidden money can go to the individuals' heirs.  THAT is what is unfair.

    I am a strong supporter of single payer Medicare for all- But I recognize that health care is not free- it is paid for by the populice as a whole.  If costs are not recouped from estates, then while it may be "fair" to the heirs, it is unfair to everyone else.

    As my father used to say,"We have the best government money can buy."

    by BPARTR on Thu Oct 24, 2013 at 05:13:02 AM PDT

    •  I am interested to hear (2+ / 0-)
      Recommended by:
      ban nock, sturunner

      what others here think and feel about this issue. I may not  have much time today to post comments here myself, since I am on my way out the door to work. I'll catch up and reply as and when I can, but it might be some hours.

      If you act out of anger, the best part of your brain fails to function. - the Dalai Lama

      by beverlywoods on Thu Oct 24, 2013 at 05:22:29 AM PDT

      [ Parent ]

      •  Now that the government (4+ / 0-)

        is heavily subsidizing the health care of low-income people through the ACA, it's hard for me to understand why those covered through Medicaid should be treated differently. No one is going to try to recover the substantial subsidies received on the exchanges from people's estates.

        I hate the whole idea of Medicaid. Health care shouldn't be considered welfare anymore than it should be something you only get if you have money. We should have one system for everyone. And no one should be bankrupted or stripped of everything they own to pay for medical care.

    •  For the sake of argument (10+ / 0-)

      assume that 2 women both have incomes that fall below the poverty level and that they live in the same state that has accepted the Medicaid expansion and that the state has a policy of "estate recovery" for all expenses paid out through Medicaid for those over the age of 55.

      One woman is 45 and one woman is 56

      Assume both these women own their own homes free and clear because they have both worked hard and saved all their lives. Also assume that both these women have savings of appoximately 50,000. Assume they both fall prey to the same short-lived but fatal disease that unfortunately kills them off in a hospital during a two week stay and they both runs up hospital bills of $300,000 for surgeries, treatments, drugs, etc.

      The woman who was 45 will pass along her home and her savings to her heirs.

      The woman who was 55 will have liens placed on both her house and her savings and there will be nothing for her heirs.

      How is this fair? Estate recovery only occurs of you are over 55. Have an operation when you're 54, no problem. Have an operation when you're 57 - big problem.

      If you have a Medicaid lien on your house because you had an operation when you were 57 - does that mean you can never sell your house and move without discharging the lien?

      There are so many ramifications to this policy it's impossible to discuss all of them. And remember, we ARE NOT discussing nursing home care. We're talking about having a kidney stone removed, we're talking about a knee replacement, we're talking about cancer treatment, we are talking about common medical procedures for those over the age of 55.

      “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

      by Phoebe Loosinhouse on Thu Oct 24, 2013 at 05:49:50 AM PDT

      [ Parent ]

      •  I'd point out that most states do not have (7+ / 0-)

        estate recovery for expenditures other than long term care, and many exempt a certain amount of equity in the home (in NY, for example, its something like $800,000).

        •  ^^^ good to know. (1+ / 0-)
          Recommended by:
          elfling



          Is it true? Is it kind? Is it necessary? . . . and respect the dignity of every human being.

          by Wee Mama on Thu Oct 24, 2013 at 05:57:00 AM PDT

          [ Parent ]

        •  And you would be incorrect (6+ / 0-)

          from a previous diary:

          Mediaid Estate Recovery Practices and Programs

          According to an AARP chart, states that seek to recover ALL costs, possibly including "capitation charges" (more on that in a minute) include:

          AL, AZ, CA, DE, FL, HI, IL, IN, IA, KY, ME, MD, MN, MT, NE, NH, NJ, NY, ND, OH, OK, OR, RI, TN, UT, VA.

          I hope that this concern that has been introduced regarding estate recovery for those 55-64 under Medicaid and the ACA proves to be unfounded, but it certainly isn't looking that way to me.

          I do think this egregiously unfair practice of recovery can be fixed but I imagine it will take a Democratic House and Senate to do it, I don't know if it can be done by regulatory means alone - i.e. guidelines issued by HHS.

          “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

          by Phoebe Loosinhouse on Thu Oct 24, 2013 at 06:01:45 AM PDT

          [ Parent ]

        •  I agree with you (2+ / 0-)
          Recommended by:
          ban nock, VClib

          Johnny. I have been reading this diary from the start. I have come to assume that what I have read only applies to anyone who gets Medicaid expansion coverage under Obamacare that will launch in states that expand Medicaid for the poor.

          I have just read Wisconsin`s Estate Recovery program and is exactly as you say.

          http://www.dhs.wisconsin.gov/...

          What I note in your comment though, is that you are referring to today`s law under estate recovery, and not when Obamacare becomes law to those who are trapped therein.

          I also agree, that if what I have read is true on Medicaid expansion as being written here --- it is a trap on seniors.

          Old men tell same old stories

          by Ole Texan on Thu Oct 24, 2013 at 06:38:15 AM PDT

          [ Parent ]

      •  You raise interesting (7+ / 0-)

        points.  It is no more fair than the bizarre situation that for the middle class if you get sick when you are 64 you currently have to pay for everything but if you turn 65 you automatically have Medicare.  So poor people at 64 are on the hook and rich people who are 65 are not.

        In effect, the law currently assumes that anyone over 65 is indigent and anyone under 65 can pay all their medical expenses. ( Unless you are really poor, in which case Medicaid will help out.)  

        So in your example, if the person was middle class, the 35 year old would leave nothing to her heirs, and the 65 year old would leave an estate.   Just the oposite of the Medicaid example you give.

        That is why I suport Medicare for all-  even though itwould reduce my own income.  In the medicare for all scenario, everyone has the same insurance, everyone pays for it via their taxes, and those taxes are progressive.  I don't think that healthcare should be predicated on leaving estates to heirs.

        That said, I am not at all opposed to individuals saving and leaving estates to their heirs (within limits- no dynasties).  In that case, they are choosing not to spend the money in their own lifetimes, but choose to give it to their kids.  I am opposed to individuals gaming the system so that Other people pay for their health care while they "save" the money to give to their kids.  Does that make my position clear?

        As my father used to say,"We have the best government money can buy."

        by BPARTR on Thu Oct 24, 2013 at 06:02:45 AM PDT

        [ Parent ]

        •  Me too. We need Medicare for All (4+ / 0-)
          Recommended by:
          susanthe, Hawksana, tardis10, beverlywoods

          end of story.

          Medicare is one of the best-run most popular programs in America.

          And the funny thing is that it is a:

          universal, government run single payer medical program.

          So to all the people who keep pushing the fact that "America will never accept a single payer program" - WE ALREADY HAVE

          There is no qualification for Medicare except for being 65.

          Why do the Republicans want to means test it? So that they can dismantle it and turn it into a welfare program just like we are discussing in this thread. And America might be dumb enough to fall for it.

          They will try to appeal to Americans by saying "Why should you pay for Bill Gates healthcare?" and act like the poor and middle class are paying for healthcare of the rich and get them to agree to means testing without seeing that the real issue is that the 1% doesn't want to pay for the healthcare of the 99%.

          We should all get healthcare - no exceptions. Doesn't matter about age, class, wealth, whatever, we should all have healthcare.

          “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

          by Phoebe Loosinhouse on Thu Oct 24, 2013 at 06:11:14 AM PDT

          [ Parent ]

          •  Medicare does not pay for long term care (0+ / 0-)

            If you need to be in a nursing home, you pay until you qualify for Medicaid, then Medicaid pays.

            Estate recovery is perfectly fair, in my opinion. If taxpayers pay for your dad's long term care, and you don't, then why do you get to inherit his assets? Those assets should pay for his care.

            There are some exemptions, surviving spouses are not kicked out, I'm sure that the laws could be improved, etc.

            But the basic idea, that your assets should be used for your care, seems fair to me.

            "If Republicans were once the daddy party, now they're the abusive ex-husband with a substance abuse problem party." Henry Blodgett 11/13/2013

            by Urban Owl on Thu Oct 24, 2013 at 07:41:15 AM PDT

            [ Parent ]

            •  No one said Medicare paid for long term care (2+ / 0-)
              Recommended by:
              tardis10, SingleVoter

              I think most people know that it doesn't.

              The scope of this discussion to restate it for those who aren't following is:

              Should low income people over the age of 55 with assets have their estates charged for routine medical services and healthcare simply because they are over 55 when someone with the same income and assets receiving the same services who is 54 receives it gratis in the same program

              We are not discussing long term care

              “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

              by Phoebe Loosinhouse on Thu Oct 24, 2013 at 07:58:37 AM PDT

              [ Parent ]

              •  You proposed Medicare for all (0+ / 0-)

                As the solution to the Medicaid estate-recovery. The issue of estate-recovery comes up in practice for long term care.

                And to your narrow question  which seems based on questionable information, no, it's not fair, and there should be a claim on assets for everyone covered by Medicaid for whatever reason.

                With the appropriate exemptions for surviving spouse, etc. that currently apply for old people.

                The basic point, that taxpayers should not subsidize inheritance, should still hold.

                "If Republicans were once the daddy party, now they're the abusive ex-husband with a substance abuse problem party." Henry Blodgett 11/13/2013

                by Urban Owl on Thu Oct 24, 2013 at 08:28:18 AM PDT

                [ Parent ]

                •  Sorry I missed your point and it's a good one (1+ / 0-)
                  Recommended by:
                  beverlywoods

                  People in more enlightened countries
                  than ours provide cradle to grave medical care and that is what I would desire for us.

                  That removes the entire question of inheritance from the equation. A universal social contract to care for the ill in any circumstance, regardless of age or wealth simply doesn't address the issue because it doesn't have to. Those countries get their pay-off from any estate in advance by charging reasonable taxes on the wealthy while they live.

                  I did use the word enlightened. We are not enlightened in this country. People spend way too much time on trying to figure out if someone "deserves" to eat or have healthcare when other countries have simply said "if they're human, they're in!".

                  “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

                  by Phoebe Loosinhouse on Thu Oct 24, 2013 at 08:41:25 AM PDT

                  [ Parent ]

      •  Not to mention... (2+ / 0-)
        Recommended by:
        elfling, beverlywoods

        Someone 55 to 65, with low (near poverty) income can have (ALL) state/fed "assistance" recovered from their estates ....
           where as, someone with go0d income ... who GETS ($100s in SUBSIDIES/month ---"assistance") help/FREE --- and will consequently benefit by paying only $130/mo for their full healthcare ... will n0t have to pay (thru "estate recovery") for ANY of those subsidies.  

        [Example of a case I know of, who makes $42k/yr ... and will be subsidized for ALL BUT $130/mo they'll have to pay for a "metal" plan.]  ...and NO subsidy "estate recovery".

        And ... the LOWER INCOME insured, doesn't QUALIFY for SUBSIDIES! (and a $130/mo premium).  ...No. It looks like they are 'automatically' signed-up for Medicaid (and will get their estates 'clawed back').  

        ...seems like a regressive "means testing".  No?
        (or am I missing something here?)

        ~A govt lobbied, campaigned and selected by corporation... is good for corporation. Bad for people.~ -8.88 -8.36

        by Orj ozeppi on Thu Oct 24, 2013 at 06:53:12 AM PDT

        [ Parent ]

    •  Could at least spouses have a claim before (0+ / 0-)

      the government? The spouse is usually also older, and if the individual is eligible for Medicaid it implies the spouse is on hard times too.



      Is it true? Is it kind? Is it necessary? . . . and respect the dignity of every human being.

      by Wee Mama on Thu Oct 24, 2013 at 05:55:18 AM PDT

      [ Parent ]

      •  No asset recovery while surviving spouse still (2+ / 0-)
        Recommended by:
        denise b, Wee Mama

        alive. That is part of the law. Same with minor children, or disabled children. Special consideration is given for adult children who have been living in the same home as the deceased as well. Some states will defer the recovery, and a few states will have a negotiated settlement with the adult children.

    •  What about their spouses? (1+ / 0-)
      Recommended by:
      elfling

      Maybe their heirs deserve nothing because only the spoiled heirs of rich people deserve to sponge off the public.

      But is it fair that a spouse loses everything and lives out their last years in poverty?

      The thing about the parent of their minor child gives me pause too. Does that other parent also have to agree to it, considering that this couple might be divorced and and have no financial connections anymore other than caring for their child?

      Ed FitzGerald for governor Of Ohio. Women's lives depend on it. http://www.edfitzgeraldforohio.com/

      by anastasia p on Thu Oct 24, 2013 at 07:37:06 AM PDT

      [ Parent ]

    •  I have some concerns (4+ / 0-)

      First, is that we need clarity. If care received through Medicaid is actually a loan and not insurance, that's something people need to know and understand. It's a quite real scenario that some people would probably leave a house to their kids rather that seek treatment for cancer, especially if the treatment is not expected to increase their life expectancy significantly.

      Is this what we intended with our policy?

      I see medicaid for nursing homes as being a bit different, because a significant portion of those costs are just living expenses and further they're usually for people who are quite a bit older, with fewer dependent dependents. There are more alternatives (like home care). It's not the case that the person's future productivity will be lost because they declined nursing home care.

      If the cost of say a hip replacement or stroke treatment is coming out of the estate, why not their free public education? Why not their excess Social Security payments?

      It's just not how we expect it to work, and really, probably not in our best policy interest for it to work that way.

      Fry, don't be a hero! It's not covered by our health plan!

      by elfling on Thu Oct 24, 2013 at 09:59:39 AM PDT

      [ Parent ]

    •  Are you assuming (0+ / 0-)

      that the heirs in question are children? What about spouses? Or children who are sharing their houses?

  •  Why should the state try to recover the money? (6+ / 0-)

    If the Federal Govt. is covering 100% of the cost (at least for the first 2 years, slowly falling to 90% by 2022), then why should the individual states try recover the money?

    •  ^^this^^ (0+ / 0-)

      I don't have a problem with estate recovery per se, but this is an important point.  However, is the federal govt paying for all Medicaid, or just the expansion?  If only part, it sounds like determination of which part is fed and which is state might get complicated.  

      I also wonder about what heirs would be charged; the amount Medicaid actually paid, or the hugely inflated billing that has been SOP at hospitals for uninsured patients?

      I am become Man, the destroyer of worlds

      by tle on Thu Oct 24, 2013 at 05:47:41 AM PDT

      [ Parent ]

    •  the feds require estate recovery for some (3+ / 0-)
      Recommended by:
      Wee Mama, Urban Owl, VClib

      costs.  that said, it wouldn't surprise me if recovered amounts go into some Medicaid restricted pot, offsetting future Medicaid reimbursements from the feds.

    •  The states administer (1+ / 0-)
      Recommended by:
      VClib

      the program on behalf of the feds.  You don't think they should recover money if people have used the program but had more assets than are allowed under the guidelines?

      •  Well, yes I do, (0+ / 0-)

        but this should be determined during the application process, and of course anything paid due to Fraud should indeed be recovered.  If folks qualify for medicaid, then later in life are better off enough to save something up, I don't think they should then have to hand it over.

        •  I think you may have missed (1+ / 0-)
          Recommended by:
          VClib

          that the Medicaid expansion under the ACA removes the asset tests. There's no limit in that new aspect of Medicaid on assets, only on income.

          If you act out of anger, the best part of your brain fails to function. - the Dalai Lama

          by beverlywoods on Thu Oct 24, 2013 at 04:02:20 PM PDT

          [ Parent ]

  •  It is completely and supremely unfair (9+ / 0-)

    that people between the ages of 55 and 64 who are enrolled into Medicaid as part of their state's new Medicaid expansion as per the ACA should have liens placed on their assets (remember that the expansion removed means testing) when someone who receives exactly the same care and coverage but who is aged 40-54 would NOT be subject to the same liens and expected to repay for their care.

    Once people who have assets but little income who are over 55 figure this out, there will be an incredible uproar.

    For those who have NOT been following beverlywood's diaries -

    NO, this is not strictly regarding nursing homes and long term care. There are many many states who can and do attempt to recover any and all care that is provided to anyone over the age of 55 simply based on them being over the age of 55.

    Prior to the expansion, when means testing was in place, this was a moot issue, sine the Medicaid enrollees probably had few assets to tap.

    But with the expansion and the recent recession and unemployment, particularly of those over the age of 50, there will be likely MILLIONS who will fall into this trap - their homes, their savings, their retirement nesteggs will all be subject to "estate recovery"

    This is a flaw in the ACA and it needs to be fixed. Once AARP and a large group of older people get, this, they will begin a movement to recall the ACA - I gurantee you and it will get legs. Just imagine the commercials that could be made around this.

    “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

    by Phoebe Loosinhouse on Thu Oct 24, 2013 at 05:34:09 AM PDT

    •  Liens for What? Feds Pay 100% Then States Recover (1+ / 0-)
      Recommended by:
      fauve

      money they never spent? What kind of racket is this?

      We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

      by Gooserock on Thu Oct 24, 2013 at 05:49:05 AM PDT

      [ Parent ]

      •  If I understand it correctly (0+ / 0-)

        States recover according to the federal recovery law and their own state laws, and then hand over the federal portion of the recovered money to the feds.

        If you act out of anger, the best part of your brain fails to function. - the Dalai Lama

        by beverlywoods on Thu Oct 24, 2013 at 02:46:21 PM PDT

        [ Parent ]

    •  Good time to LOWER the Medicare eligible age (8+ / 0-)

      to 55 for everyone.  If this issue actually becomes a thing, then perhaps a "progressive" response would be to lower the Medicare eligibility age to 55 (as opposed to the current push to raise it to 67).  Probably would save lots of money (overall medical costs for this age group, and insurance rates for everyone else (i.e. younger) would likely go down too).

      •  Yes, this would answer this issue. (3+ / 0-)
        Recommended by:
        tardis10, fauve, beverlywoods

        I completely agree - it is actually the perfect solution. Well done. It's the bridge between Medicare for ALL and the ACA that will work.

        It would probably even HELP the ACA be profitable for the insurers for those who care about that (I don't) because it will keep the exchange pools to younger and presumably healthier participants and might cause the costs of policies on the exchanges to go even lower.

        “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

        by Phoebe Loosinhouse on Thu Oct 24, 2013 at 06:46:12 AM PDT

        [ Parent ]

    •  When read in full, the linked application says: (3+ / 0-)
      Recommended by:
      ban nock, Urban Owl, elfling
      By law (RCW 41.05A.090 and WAC 182-527), if you are age 55 or older AND receive WAH services, Health Care Authority (HCA) may recover from your estate (assets you own at the time of death) to repay HCA for the costs of health care assistance. This is called ESTATE RECOVERY. Estate Recovery does not occur until after death and the death of your surviving spouse, if any. HCA may recover the costs for state-only funded long-term care services received at any age.
      HCA may recover the costs for state-only funded long-term care services received at any age.

      This is a complex topic that financial planners have been addressing for years with clients who need help with it.  There’s even a “For Dummies” book about it, though I’m not sure it’s comprehensive, it’s okay for basic information, like this:


      In 1993, the U.S. Congress passed an act that requires each state to demand repayment for Medicaid benefits that had previously been provided to certain citizens for certain services:

      Certain citizens: People over the age of 55 who have received Medicaid payments within a specified period of time.

      Certain services: Payments for nursing homes and nursing care facilities, home and community-based services, related services at hospitals, and prescription drugs.

      There’s a war on the middle class and poor people in the US.  Fear, confusion, and doubt are some of the weapons used against them.  Knowledge and information are essential for people to be able to defend themselves.

      • Google “Medicaid estate planning”
      • Check with Medicaid and HHS. There’s useful info on their websites
      • Use your community resources

      This topic is complicated because estate recovery is implemented differently in the states. It also conflicts with probate laws that vary from state to state. In other words, what’s true in one state isn’t always true in another.

      There may be confusion over the designation “long term care.”  The same healthcare services and medical treatment can be given to two different people and estate recovery may apply to one but not the other.  The factor that makes the difference is whether the patient has been placed under long term care.  Of course for people who don’t have an estate, none of this would be a concern.

      There is no existence without doubt.

      by Mark Lippman on Thu Oct 24, 2013 at 07:03:58 AM PDT

      [ Parent ]

      •  Whay you are highlighting doesn't make (4+ / 0-)
        Recommended by:
        tardis10, fauve, elfling, beverlywoods

        any difference to this discussion.

        We all know that states can and do recover for Medicaid long term care/nursing homes for anyone of any age. That's no surprise.

        What most people are unaware of is that many states attempt recovery NOT just for nursing home and long term care but any and all other services that were provided under the medicaid umbrella if the recipient is over 55.

        By law (RCW 41.05A.090 and WAC 182-527), if you are age 55 or older AND receive WAH services, Health Care Authority (HCA) may recover from your estate (assets you own at the time of death) to repay HCA for the costs of health care assistance.
        You do see that it says "health care assistance" without any qualifier, right?

        WAH is Washington Apple Health and is simply the instate name for Medicaid under the expansion.Washington's Apple Health aims to simplfy Medicaid
        There is no indication that it is only long term care, quite the opposite.

        I would be happy and relieved to learn if there is absolutely no concern for someone over 55 with assets who receives care under the Medicaid expansion in regards to liens and estate recovery outside of long term care. So far, no one has demonstrated that.

        “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

        by Phoebe Loosinhouse on Thu Oct 24, 2013 at 07:26:16 AM PDT

        [ Parent ]

        •  Your answer is in the referenced statutes: (3+ / 0-)

          RCW 41.05A.090 and WAC 182-527 and in federal law referenced by both statutes:

          Title 42 USC Sec. 1396p

          People with assets at risk should seek help from a qualified professional if their own efforts don't answer every question.  

          Acting on the advice of anonymous uncredentialed individuals on the internet isn't advisable.

          There is no existence without doubt.

          by Mark Lippman on Thu Oct 24, 2013 at 08:18:29 AM PDT

          [ Parent ]

          •  I completely 100% agree (2+ / 0-)
            Recommended by:
            lurker123, beverlywoods

            with your reply and it is what I would do for myself if I suspected that this issue or possible non-issue would affect me.

            It is something to be discussed with an elder-law professional and the state's Medicaid office and probably both.

            I am grateful for beverlywood writing her diaries because I for one would not have known it was even a possible issue without her diaries.

            “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

            by Phoebe Loosinhouse on Thu Oct 24, 2013 at 08:23:33 AM PDT

            [ Parent ]

          •  part of it (0+ / 0-)
            (a)  Imposition of lien against property of an individual on account of medical assistance rendered to him under a State plan  
             (1) No lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except—  
             (A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or  

             (B) in the case of the real property of an individual—  
             (i) who is an inpatient
            in a nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and  

             (ii) with respect to whom the State determines, after notice and opportunity for a hearing (in accordance with procedures established by the State), that he cannot reasonably be expected to be discharged from the medical institution and to return home,  
            except as provided in paragraph (2).

            Paragraph (2) protects family members [spouse, children under 21] living in the home.

            This still allows liens after death with no other qualified family members living at home.

            (b)  Adjustment or recovery of medical assistance correctly paid under a State plan  
             (1) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made, except that the State shall seek adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan in the case of the following individuals:  
             (A) In the case of an individual described in subsection (a)(1)(B) of this section, the State shall seek adjustment or recovery from the individual’s estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of the individual.  

             (B) In the case of an individual who was 55 years of age or older when the individual received such medical assistance, the State shall seek adjustment or recovery from the individual’s estate, but only for medical assistance consisting of—  
             (i) nursing facility services, home and community-based services, and related hospital and prescription drug services, or  

             (ii) at the option of the State, any items or services under the State plan (but not including medical assistance for medicare cost-sharing or for benefits described in section 1396a (a)(10)(E) of this title).

            There seems to be a state option to be broad in recovery except for Medicare cost sharing and what I think "section 1396a (a)(10)(E)"is help to federal SSI recipients.

            What "related" relates to and how is unclear to me.

    •  Why would their be a "movement to recall ACA," (0+ / 0-)

      which is actually providing coverage for this people, rather than simply closing this loophole?

      Ed FitzGerald for governor Of Ohio. Women's lives depend on it. http://www.edfitzgeraldforohio.com/

      by anastasia p on Thu Oct 24, 2013 at 07:38:46 AM PDT

      [ Parent ]

      •  There should be a campaign for fix and (3+ / 0-)
        Recommended by:
        tardis10, SingleVoter, beverlywoods

        repair, which is how Democrats would address this issue.

        Republicans would use it in their "repeal" arsenal.

        Plus, individual states could simply state that their policy is no estate recovery for services outside of long term care for any new enrollees over 55 who come into Medicaid due to ACA expansion that would not have previously qualified due to means testing.

        For example, in the Washington State application above, it could be altered to reflect that ONLY long term care would be subject to estate recovery and then I don't think there would be any issue. The way it is currently written says that ANY health services used by someone over 55 are recoverable.

        “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

        by Phoebe Loosinhouse on Thu Oct 24, 2013 at 07:50:58 AM PDT

        [ Parent ]

  •  Having worked for legal aid (1+ / 0-)
    Recommended by:
    icemilkcoffee

    I think I can show some light on this.

    Medicaid pays for nursing home care - but not until you reach the income/wealth requirements.  Lawyers have found ways to get around this requirement, which essentially means that people with money and assets are taking advantage of a poverty program.  States are aware of this, and are trying to go after the assets of people that have used some of the legal strategies to try and shield assets.

  •  I am faced with exactly this situation right now. (4+ / 0-)
    Recommended by:
    lurker123, tardis10, elfling, beverlywoods

    I live in Oregon and just received paperwork yesterday asking me to choose between the state's expanded Medicaid (OHP) coverage or apply for a subsidy on my husband's employer-provided insurance (HIPP).

    Until reading this diary, I had considered it a "no-brainer." I would obviously pick the OHP expanded Medicaid option. But I will be 52 next month. I can't pick that if it means risking our home and assets. My son's college education. My husband's retirement. I can't do that.  

    My mother was on Medicaid before she died, and I was absolutely grateful for the help they gave her. It allowed her to stay in the care facility she needed. After she passed away, I gladly and gratefully wrote a check to the State of Oregon for the entire remaining amount in her bank account. That was about $80.00, if I remember correctly, because she had already sold her home/assets and USED them up before she qualified for Medicaid. But she was in her 70s and she did not have a family still using those assets!

    Obviously I have some investigating to do! Thanks for this diary, beverlywoods!

    Metaphors be with you.

    by koosah on Thu Oct 24, 2013 at 08:00:28 AM PDT

    •  You're probably fine. (2+ / 0-)
      Recommended by:
      koosah, elfling

      Read the age on the application and what age it says "estate recovery" kicks in. 55 seems to be the magic number aside from long term care which will be recovered regardless of age.

      If you have questions, call your states Medicaid office.

      “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

      by Phoebe Loosinhouse on Thu Oct 24, 2013 at 08:08:18 AM PDT

      [ Parent ]

      •  But won't that potentially be ten years of (3+ / 0-)
        Recommended by:
        lurker123, tardis10, beverlywoods

        recovery? From the time I turn 55 (in three short years) until I turn 65 (when Medicare kicks in)? That will be ten years for them to "recover" all they pay out on whatever care I require during that decade.

        Fortunately, there are a lot of phone numbers on this green piece of paper I'm looking at. My family has been enrolled in FHIAP until now, which is an Oregon program that subsidizes employer-provided coverage. That program is being discontinued and everyone is getting enrolled in one of the new Cover Oregon programs. The folks at FHIAP have been awesome during this process. I'm confident they will know where to find the answers I need.    

         

        Metaphors be with you.

        by koosah on Thu Oct 24, 2013 at 08:23:12 AM PDT

        [ Parent ]

      •  And to re-iterate Mark Lippman above (4+ / 0-)
        Recommended by:
        lurker123, koosah, tardis10, elfling

        call an elderlaw professional or any other credible knowledgeable source within your own state since this is all state specific

        “Human kindness has never weakened the stamina or softened the fiber of a free people. A nation does not have to be cruel to be tough.” FDR

        by Phoebe Loosinhouse on Thu Oct 24, 2013 at 08:26:32 AM PDT

        [ Parent ]

  •  "as defined by... the Social Security Act" (0+ / 0-)
    409.9101 Recovery for payments made on behalf of Medicaid-eligible persons.—
    ....
    recovery shall be accomplished by the agency filing a statement of claim against the estate of a deceased Medicaid recipient
    ....
    The acceptance of public medical assistance, as defined by Title XIX (Medicaid) of the Social Security Act, including mandatory and optional supplemental payments under the Social Security Act, shall create a debt to the agency in the total amount paid to or for the benefit of the recipient for medical assistance after the recipient reached 55 years of age....
    http://www.flsenate.gov/...

    One can argue that the expansion Medicaid is under the Patient Protection and Affordable Care Act and not the Social Security Act.

    This probably will get litigated if a fully Democratic Congress doesn't clarify it.

    •  sorry (1+ / 0-)
      Recommended by:
      beverlywoods

      the PPACA explicitly places Medicaid expansion under the Social Security Act:

      SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME
      17 POPULATIONS.
      18 (a) COVERAGE FOR INDIVIDUALS WITH INCOME AT OR
      19 BELOW 133 PERCENT OF THE POVERTY LINE.—
      20 (1) BEGINNING 2014.—Section 1902(a)(10)(A)(i)
      21 of the Social Security Act (42 U.S.C. 1396a) is
      22 amended—
  •  There is also another legal question (0+ / 0-)

    If the low-income, high-asset people over 55 can use a what effectively is loan program, then why can't any person such as Mr. Healthy Invincible Middle Aged Homeowner have access to a no-premium, no-interest asset-secured health care payment loan program under the equal protection requirement of our Constitution?

    •  it might not be such a good deal (0+ / 0-)

      If you read the article from Dr. Orient, she explains that with managed care come "capitation charges" which are also recoverable. The capitation charges in AZ, according to Dr. Orient, come out to $40,000 per year, which could potentially be assessed against one's assets even if no actual medical servcies were used.

      If you act out of anger, the best part of your brain fails to function. - the Dalai Lama

      by beverlywoods on Thu Oct 24, 2013 at 02:53:47 PM PDT

      [ Parent ]

  •  And another legal question is why can't employers (0+ / 0-)

    who provide medical coverage ask for repayment from your estate?

    You may say it is insurance. The employer may say it is insurance merely for medical providers, not for the employee.

    And is fair to one's fellow employee that you get the same $X/hour wage and say $300,000 worth of health care and they often got less health care payouts than what they paid in premiums?

  •  And should courts just take the PPACA (0+ / 0-)

    as the voters in the 2012 elections and most federal elected representatives and senators did, with no recovery by either states or employers?

  •  There is also the practical matter (0+ / 0-)

    If my estate can get whacked with a US-sized hospital bill because I get care under Medicaid I might chose to rent out my US home and live in a foreign country from age 55 to 65 where I might be able to buy high-quality health coverage for $100/month.

    Some OTHER landlord will be out $10,000/year.

    The federal government might get $500/year in income tax on my net rental income and lose 40% of $10,000/year Mr. Rich Landlord would pay in income tax.

    Does the federal government want to lose $3,500/year of surefire federal tax revenue for ten years ($35,000 total)on the mere chance I might use lots of Medicaid coverage?

  •  In principle it is fair, but in practice it is (0+ / 0-)

    rather arbitrary:
    1. Why the 55 cutoff? Why are Medicaid recipients under 55 off the hook?
    2. presumably everyone making up to 4X FPL, are all getting some kind of government assistance to buy health insurance, without regards to their assets. Why no recovery from these people?

    It just seems to be too punitive towards low income people. I think the whole law needs to be looked at again. At the very least, the asset recovery should be sliding scale. If somebody was living in a $2 million mansion and using Medicaid- I have no problem with the government recovering from their assets. On the other hand, what is the point of taking somebody's $40k trailer? Especially if that $40k could potentially break the cycle of poverty for their children and grandchildren. There should be an exemption for the first $25k of your primary residence (for example), and a sliding scale recovery for the estate value above that.

    Another idea for a reform is to just limit recovery to long-term care.

  •  Inequitable application of Estate Recovery (0+ / 0-)

    26 states are currently moving forward with Medicaid Expansion (and which may or may not have their own state laws re: "estate recovery" for those aged 55+). Of those 26 states, 11 use the federal Healthcare.gov website to apply for coverage- see list below. Interestingly, that application does NOT mention anything in the fine print that I can find about estate recovery for those qualifying for the expanded Medicaid; neither in the instructions, nor in the actual "read & sign" section.

    Keep in mind- federal regulations require that Medicaid applicants be given written notice on their application about estate recovery. So, does that mean that residents using the federal health care application in these 11 states (AZ, AR, DE, IL, IA, KY, MI,NJ, ND, OH & WV) will not be liable for estate recovery (even if their state laws require it)?

    That leaves 15 states with Medicaid Expansion, using their own Marketplace websites/applications.  A quick online survey shows 5 additional states also do NOT include estate recovery in their applications: CA, DC (Dist. Of Columbia), MD, NM (using Fed application for just 2014), VT.  

    In this blog we have read that WA state and NY do include Estate Recovery clauses for 55+ ages in their applications. Three other states also include Estate Recovery in their applications available online: CO, MA, OR.

    Remaining states which do not easily show their applications online (I will try calling them next week): CT, HI, MN, NV & RI.

    Total so far- It appears that of the 26 states with Expanded Medicaid for 2014, there are 16 states which do NOT include Estate Recovery in their applications, 5 states which DO include estate recovery (only for those low income people who are 55 or older), and 5 yet to be determined. How is this equitable in any sense?

    Ironically, part of the Federal application (“Read & sign” section), reads, “I know that under Federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability.”

    (hopefully the auto-censors don’t eat my post again!)

    •  thanks for this info (0+ / 0-)

      and thanks so much for going to the effort to look up the applications in all these states.

      You raise some good points here. Looks like we need to keep digging into this question.

      If you act out of anger, the best part of your brain fails to function. - the Dalai Lama

      by beverlywoods on Tue Oct 29, 2013 at 11:26:22 AM PDT

      [ Parent ]

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