Can You Be a Solo Caregiver? Is It Possible to Do It Alone?

The easy – and probably unhelpful – answer is: “Sure, it’s possible.” – said, of course, with suitable emphasis on the final word!

After all, anything is supposed to be possible. Right?

But what we’re really asking is: Can I manage it? Will it work in my situation?

And the frustrating reality is, I don’t know.

What I can do is speak from my own experience and research.

But after it’s all said and done, you’ll have to look at this picture, talk it over with family and trusted advisers, and decide whether it would be feasible and realistic for you.

Perhaps the least useless thing I can do is to try to paint a picture of what solo caretaking might look like in the hope that it will give you a framework for your own decision making.

So, strap in, and we’ll start to think through the question: Can you be a caretaker all by yourself?

Preface

I’ll be speaking broadly. I’ll talk about a way solo caretaking could look, drawn from when I was the at-home caregiver for my dad, who died from Alzheimer’s Disease in 2016. I started caring for him in 2008. But we’ll also talk about caregiving variations, based on my research. 

The main thing I want to do is to provide you with a blueprint for having a conversation. You will want to talk about possible caregiving scenarios – and pitfalls – with family, friends, and trusted advisers. So, my hope and expectation is that you’ll take what you find useful and leave the rest. 

As an “assist,” I’ve prepared a step-by-step guide that you can feel free to download. It’s possible that you can simply Google “Alzheimer’s Proof Caretaker’s Guide.” 

But, search engines can be a bit dicey sometimes. So, you can always just point your web browser to AlzheimersProof.com and navigate to it that way.

Introduction

This video was prompted by a viewer-submitted question. As I reflected on the viewer’s situation, one thing I realized is that it is extraordinarily difficult – bordering on being practically impossible – to be entirely solo as a caretaker. 

As we move along, it’ll become apparent why I say this. But, what I sincerely hope is that you may also discover, upon reflection, that you’re not actually all by yourself. Or, at least, if you are genuinely alone, then I hope you may come to a deeper understanding of the challenges that lay ahead of you. Not to compound your worries! But simply to enable you to better plan for, and adapt to, circumstances as they arise.

Caretaking Rôle vs. Household Composition

First thing’s first. We should try to clarify what we’re talking about. You’d think that “solo caregiver” is fairly self-explanatory. But I think there are subtleties that need to be made explicit.

What does it mean to be “solo”? There are at least two senses. 

‘Solo’ in a Caretaking Sense

Firstly, there’s a caretaking sense. By “caretaking,” I mean assisting your loved one with the Activities of Daily Living (ADLs) – which I explain in a dedicated video – or supervising a cognitively impaired individual, or both

Just for reference, the basic “ADLs” are: bathing, dressing, eating, maintaining continence, toileting, and transferring (e.g., in and out of bed). 

Under the category of “caretaking,” we can further distinguish a primary caretaker from a solo caretaker. Taking the latter first, if you’re a solo caregiver – in a strong sense – then you are the only game in town (or the only player, as it were). It’s entirely and totally up to you – and absolutely no one else – to implement every aspect of your loved one’s care plan.

If you’re a primary caretaker, by contrast, then you have some people in relieving or supportive roles – even if only minimally. Consider a few examples.

Let’s say you have four siblings. One of your siblings drives mom to the doctor’s office. Another buys and delivers her diet-specific groceries and medicine. A third takes her to church on Sunday and spends the day with her. And a fourth can usually be relied upon to fill in for you if you have something come up.

Even so, mom lives in your house. You administer her medicines, prepare her meals, and otherwise tend to her daily needs. You watch her for the majority of the week. The bulk of caretaking duties fall upon you. We might say that you are mom’s primary caretaker. 

On the other hand, suppose three of your four siblings live out of state. The other one declines or refuses to help you with any facet of mom’s care. Here, you’re more of a solo caretaker.

Granted, there are cases that are harder to classify. More on that in a moment.

But… it’s not as important to classify the cases as it is simply to recognize that there are different levels of expected responsibility falling on you in each case.

Questions

One of the most pressing questions is: Which case is – or would be – closest to your situation?

Can you expect help with the actual caretaking responsibilities?

At this point, I’m thinking about unpaid help: assistance you’d get from family and (possibly) friends. We’ll consider the role of professionals in a few minutes.

If you’re closer to a primary caretaker, then your questions are things like the following.

How dependable are the secondary caregivers?

Do you have someone who can step in for you in an emergency?

When you get sick, for example, is someone willing to come into your place?

Bear in mind that an Alzheimer’s sufferer may have difficulty adjusting to a new environment. Often, they have enough trouble getting around a familiar place. If the place is comparatively strange, they can be especially difficult to manage.

Do you have a family member willing to be around you when you might be contagious?

Will someone take your loved one to their place for a week? 

Remember that the care environment may need to be safeguarded and secured in various ways. I’ve spoken in other videos about many aspects of this. You may need to install childproof locks on cabinets (to prevent your loved one from accessing dangerous chemicals or objects), change thumb-turn locks to double-keyed deadbolts (to reduce the risk of “elopement,” which is the caregiver’s term for when your loved one wanders away from the care environment), install closed-circuit cameras (to monitor them while you do other, necessary work), etc.

Even if you do have a family member who is willing to take dad for a week, it may be necessary for them to prepare their home for this eventuality well in advance

And if you have no one, how will you function as a caretaker if you are not feeling 100%? What if you become disabled? Etc.

For that matter, how will you sleep? Many of you may realize that Alzheimer’s, and other forms of cognitive impairment and dementia, often interrupt normal sleeping patterns. Usually, this results in an insomnia-type situation at night. Your loved one may have difficulty falling – and remaining – asleep. Sufferers who wake up in the middle of the night may wander. And, unless their environment is entirely free of potential hazards, this nighttime wandering can’t be ignored. 

Related questions include: How will you cook or otherwise prepare meals? Similar problems with wandering may appear during the day. If you need time in the kitchen, it may be possible to entice your loved one to join you – possibly by assigning them an easily accomplished or harmless task. But if they refuse to cooperate, or if they start to walk away, you’ll need to make sure they’re not getting into anything dangerous. And that can be easier said than done – especially if the timer’s going off and that dish in the oven is about to burn.

Now… some of these problems lead into another topic.

‘Solo’ in a Housekeeping Sense

Remember I said that there were two relevant senses of the word “solo.” The first was the caretaking sense. The second sense is related – and possibly overlapping.

And that’s the general question of whether you’re alone in your household. Apart from your afflicted loved one, are you literally the only other person in the home?

From this standpoint, we’re talking about whether you’re single, married, or otherwise “partnered”; whether you have kids; whether you have a roommate; or even, in some cases, whether there’s another aging adult that you care for already. 

The basic questions, here, are: Are you being helped in running the household? And do you have other people – besides your afflicted loved one – for whom you are responsible?

I want to keep the phrase “running the household” a little vague. After all, this is not a channel about good housekeeping. But, just so we’re on roughly the same page, I have in mind anything – and everything – that goes into making sure the house isn’t condemned and the people inside it don’t starve. Doing chores, paying bills, performing maintenance, and …whatever else.

There are too many household variations to list them all. But we can gesture toward four (4) broad types, under two overarching factors: whether the other people are helping you, or if they’re needing help from you.

Of course, there’s a sense in which any group of people thrown together under the same roof will sometimes help one another and sometimes need help from one another. 

But, for this exercise, what you want to ask yourself is: Are the other people in the household helping you in a consistent and meaningful way? Relatedly, you want to ask: Are the other people in the house needing substantial help from you on a regular basis?

We’re going to assume simple “yes” and “no” answers can be given. Real-life cases may involve “maybe” and “sometimes” answers. But… this uncertainty may help you decide what to do.

After all, if your household is already a “question mark” – before you bring in an Alzheimer’s-afflicted loved one – then you might have serious concerns about the viability of a plan that complicates your living situation further.

Ignoring those complexities for the time being, we can arrange the following possible answers. 

  1. One case is where you both give help to – and can expect help from – the people in your house. We might think, here, of two married or “partnered” people, for example.
  2. Another is where you provide help, but can’t expect or rely on any in return. An example of this would be a case where you also have young children in the house.
  3. A third is where you don’t really need to provide help, but you still get help. Maybe it’s your house, but one of your grown children lives with you. They pay their own way, as it were, but also do the dishes, maintain your car, mow the grass, etc.
  4. Finally, we can imagine a case where you don’t need to provide much help, but you don’t get much back either. Perhaps you have teenagers. Maybe they’re in college and working part time. They’re starting to pay for necessities and you don’t have to do much for them day to day. But they’re not around much. And they aren’t really contributing to the household. 

Some of this will dovetail with financial considerations, which I will say something about in a moment. But, for the time being, and at the risk of harping on the obvious, we can expect that it would be much easier to take on caregiving responsibilities in a household where you’re getting help than one where you’re not getting help.

Likewise, it would be harder to be a caretaker for someone with dementia if you’re also having to provide help to other people already (for example, children). 

Still, for all that, it may be possible to add an Alzheimer’s-afflicted loved one into any of the four scenarios. And this is because there are so many factors at play. 

For instance, it would make a huge difference if your afflicted loved one presently is in an early-stage – or has a mild form – of dementia as opposed to something more severe. 

‘Early’ vs ‘Middle’ vs ‘Late’ Stages

I don’t want this to be a video about Alzheimer’s various stages. I’ve gotten into that topic before – and it may be good to do so again in the future.

At the same time, we can’t avoid touching on the subject, here. But my remarks will be cursory and shouldn’t be taken as a detailed accounting of the progression of dementia.

What I want to highlight is that caretaking challenges are not static. They can and do change – sometimes dramatically, frequently, and unpredictably. 

Caveats notwithstanding, we can say that so-called “Early-Stage” Alzheimer’s is characterized by mild difficulties. Memory and reasoning are beginning to be impaired. But this impairment may go unnoticed – even by family and trained physicians. 

Possible “comorbidities” aside, your loved one may be able to maintain a large amount of independence. For example, they might be able to cook for themselves, handle basic finances, maintain good hygiene, etc. They might even still be able to drive. Though, this poses special problems and carries risks, as I discuss elsewhere.

From a caregiving perspective, it may not pose insurmountable or even especially difficult challenges to take in a loved one who is in an early stage of cognitive decline. In other words, caregiving – even solo – could potentially be sustained throughout the early stage of dementia.

That said, there are important qualifications. Firstly, given the subtlety of the symptoms, Alzheimer’s may not be diagnosed in its earliest stage. So, families may not be presented with the question of home care until after the dementia becomes more advanced.

I didn’t come in until my dad – by all accounts – was already in Middle-Stage Alzheimer’s.

Secondly, given the current state of the medicine – and enough time – the disease will (unfortunately) progress. This has numerous consequences. Chief among them, for this discussion is that, even if you are able to be a solo caretaker for a while – while symptoms are mild – you have to understand that symptoms will not be mild forever.

If you have a good reason for suspecting that your loved one’s dementia will not become more complicated, that’s one thing. For example, let’s say that your mom is simultaneously (and tragically) diagnosed both with Early-Stage Alzheimer’s and some form of advanced, inoperable cancer. Suppose that her physicians expect her death within 12 to 24 months and they think it likely that she’d still be suffering from only mild dementia during that interval. In that specific case, you’d have good medical reasons for worrying less about how to handle advanced Alzheimer’s than about how best to deliver so-called “palliative care.” 

Even so, you may feel more comfortable with a backup plan. After all, the exact progression of the cancer and the dementia are, to some extent, left to the educated guesswork of the doctors. And they are not all-knowing or inerrant.

One final word, here. If Alzheimer’s (or some other dementia) is recognized in an early stage, it may provide a prime opportunity to involve the afflicted loved one in the development of a sustainable, long-range plan for their care. If you simply take them in – and figure you’ll deal with any worsening of their condition later – you may foreclose on that possibility. 

Not only this, but if they do live long enough for the dementia to progress, then caregiving will become more complicated. And that is what you can expect by “Middle Stage.” 

It’s arguable that Middle Stage is the most difficult, from the standpoint of caregiving in general, and at-home caregiving in particular. Be that as it may, Middle Stage is characterized by a worsening of the pertinent condition. You’ll be dealing with a person who may still be mobile, but who is no longer reliable in terms of decision-making, memory, reasoning, etc.

To put it bluntly: It can be a bit like dealing with a child who has the physical abilities of an adult. 

Middle Stage is also often the longest stage. Possibly this is due to the fact that Early Stage may not be detected immediately. Bear in mind that the beginning of “Middle Stage” may not be much worse than the end of “Early Stage.” This might point to the clumsiness or inadequacy of the three-stage view. But my point is that the relevant degeneration and transition can be gradual. The home situation could be fine and manageable until… it’s not. 

And – especially if you’re all by yourself – you need to have some awareness of this progression so you can plan accordingly. After all, if it became necessary for you to look into nursing homes, it’s not clear how you would be able to manage visiting and applying to facilities while you’re buried in daily caretaking tasks. And nursing homes almost always have waiting lists.

And while the progression of dementia is somewhat predictable, there are numerous variations. 

For instance, Early Stage is usually said to last 1 to 2 years. Fair enough. But you should know that, occasionally, people report a precipitous decline in their loved-one’s cognitive function. 

This might occur after a major surgery, for example. My dad took a significant turn for the worse following a triple bypass and a colectomy (spaced out by several months). I’ve seen comments where other people have shared similar stories. It may happen that your loved one is compliant or reasonable one day; then – almost suddenly – they’re obstinate or uncontrollable.

If you can make it all the way to “Late Stage,” you might find that a lot of the Middle-Stage difficulties have subsided.  For example, your loved one’s mobility will be drastically diminished. And at a certain point, they will have a near-total impoverishment of their communication ability.

The huge caveat, here, is that Late Stage comes with brand new difficulties. Dealing with a bed- or wheelchair bound person is by no means effortless. They have to be bathed or wiped, changed, fed, hydrated, turned to prevent bed sores. Etc. 

When you imagine having to lift an immobile person and help them transfer, you may see why this stage can be extremely physically demanding. 

And speaking of those challenges, let’s talk about another set of considerations. 

Able-Bodied vs Disabled

Let’s go back to the beginning of the home-care-decision process. Whether the cognitively impaired adult is able-bodied will also matter. Although, this consideration cuts in two directions.

If your loved one has mild-cognitive impairment, then – all other things being equal – it would probably be easier to care for them if they were able-bodied rather than disabled. As stated, many early-stage Alzheimer’s sufferers can perform a lot of daily activities on their own. And while they will need some measure of monitoring and reminding, these kinds of assistance may be “low-impact” and might be manageable by a caretaker who has many other responsibilities.

On the other hand, if your loved one has more severe dementia, then – somewhat paradoxically – it might be easier to care for them (overall) if they were also physically disabled. This sounds bad, but it’s to say that an able-bodied person with significant dementia may be an elopement risk (meaning that they have a tendency to leave the safety of the care environment without the knowledge of the caretaker); or they may otherwise require constant supervision. 

I’ve told many stories – in other videos – of times that my dad created messes or safety hazards (whether for himself, for others, or both) in virtue of the fact that he was still ambulatory and mobile, but had lost his ability to recognize perils or to make good decisions.

That said, a severely impaired person who is also disabled may be at increased risk for other things – such as falling. They might fall out of bed, out of a chair or wheelchair, or – God forbid – down a flight of stairs or off the front porch.

To make all this even more complicated, it’s also predictable that – again, all things being equal – a physically disabled person would be more difficult to care for than one who is able-bodied. This is due to the obvious point that a person who is physically disabled will require help getting around, whether to the bath, shower, or toilet; in and out of chairs or bed; or whatever. 

Support Network

You also need to consider your – or your loved one’s – support network. And, here, let’s further develop the point – made earlier – that some cases are difficult to classify.

For example, let’s say you’re caring for mom or dad in your home, but that you have siblings who live in the same city. Suppose that they don’t usually assume caretaking responsibilities. 

Still, if they could or would assume some responsibilities in the event that you had a personal emergency, you would want to know this – and get that commitment – in advance of needing it. 

Is this a case where you’re a primary caregiving, or solo? Once again, and obviously, it doesn’t really matter what you call it. What matters is what help you can rely upon!

I am working on a separate video on talking and planning with family. The best practice is to have hard conversations before emergencies arise. Try to agree on a workable plan in advance.

See, again, the “Caretaking Guide” at AlzheimersProof.com.

Paid vs Unpaid Support

Family can be – and often is – a valuable resource. However, it has its limitations. 

What happens if your sister is out of town when you fall ill? She promised to help in the case of an emergency, but she’s just not around.

In such cases, you may need to augment your family network by paying for professional services. So, let’s round out our discussion by picking up the thread I laid down earlier.

There are numerous types of paid services. There may be home-care providers in your area. Some of these may require applications and approvals in advance. This is especially likely if your loved one requires skilled-nursing care, or if you will be – wholly or partially – relying on long-term-care insurance, medicaid, or medicare. 

I have a few videos sketching the basics of these. If you would be interested in more, please leave me a comment.

Of course, other options might include changing the care environment altogether. On this wavelength, there are Assisted-Living Facilities and Nursing Homes. 

A somewhat middle-of-the-road option would be an Adult Daycare. This is a facility you might be able to utilize alongside home care. For example, maybe you take your loved one to a nine-to-five daycare program Mondays, Wednesdays, and Fridays, but care for them at home the remainder of the week.

A final recourse (still thinking about maintaining homecare) is called Respite Care. Respite Care is designed to give the primary caregiving a short break. But, if the respite provider comes to the home, this may only be for a day or so. If you take your loved one to a respite facility, the respite interval may be a week at most. 

For some of the differences in care environments, see my dedicated video. Admittedly, it’s an older video. It might be time to remake it. Feel free to share your opinion in the comments.

Nursing Home 

The thrust of this presentation is the feasibility of solo, at-home caregiving. But, what if you determine that it’s simply not feasible? 

We should say, emphatically, that it’s not necessary to look at it as an either-or situation.

What I mean is, you shouldn’t think that either you care for your loved one in the home, or else you’re just not involved at all.

When my family made the decision to get my dad admitted to a nursing home, we saw – up close – the level of involvement that he and other patients received from the families.

And it was definitely a spectrum. On the tragic end were those people who received no visits from loved ones. Whether this was because they had no living relatives or because their relatives were unable or unwilling to come, I can’t say. And it probably depended on the case.

In the middle were those people who received regular visits from family members. Maybe it was the same day every week, or always on weekends, or whatever. But these patients had family members who remained involved in their lives.

On the other extreme, there were family members who – barring emergencies and illnesses – came to the nursing home every single day. These devoted folks – whether children, spouses, or whatever – maintained their role as caretakers, despite the change of care environments.

And here’s the crux. You may not be able to accommodate your loved one in your home (or in their home) all by yourself. But you could potentially still be involved as a caregiver – even daily.

I say “potentially,” because (as always) there are complications. For example, it would be an obstacle to daily visits if you had to make a four-hour drive to get to the nursing home. Obviously, all the income-specific considerations are still pertinent, here.

And there are ancillary factors as well. Unless you trust the staff implicitly, or you’re on site frequently, it’s a good idea to vary the days and times of your visits. I will have to get into more detail in another video.

But, in the same vicinity, nursing homes are often understaffed. What staff there is, may be overworked. This may lead to a situation – usually unspoken – where the staff depend upon you to deliver basic care to your loved one. And, well… there’s no delicate way to say this, but: You pay the same for the nursing home whether you are performing caretaking duties or the staff is. 

It may come down to the question of whether it matters more to you that your loved one is properly cared for, or whether you get what you (or someone) is paying for. 

Financial Considerations

Of course, professional home care, Adult Daycare, Respite Care and the like are not free services. Daycare and homecare can cost several thousands of dollars every month. And if you admit your loved one into a nursing home, the average expected monthly costs start at $4,000. 

You or your loved one might qualify – or be able to qualify – for Medicaid. But you should know that not all nursing homes accept Medicaid. Of those they do accept Medicaid, they may not accept it for every available bed in the facility. That is, Medicaid beds may be in short supply.

So the prospect of having – or electing – to pay for care (of any kind) leads immediately into a discussion of finances. …For which – once again – I have dedicated videos.

But… At the most basic level, the question is: What is your financial situation? Among the prominent “sub” questions, here, would be: What is your source of income?

We’d be at it all day if I tried to list all the possible combinations. So, let’s just make a few obvious, summary remarks. If you have to leave the house to go to a 9-to-5 job, then assuming caretaking responsibilities may not be sustainable for you in the long run. 

Things might be fine as long as your loved one has mild impairment, is in an early stage, or does not require constant physical assistance or supervision.

But what happens when the dementia advances and becomes more severe? What happens if a fall around the house confines them to a wheelchair? Would you be around them enough every day to notice the sometimes-subtle signs of worsening dementia?

Financially speaking: Could you manage to keep your current job and still be a caretaker?

If your income depends on you commuting to a business, then necessary in-home caregiving will have to be provided by someone else when the time for that comes. Either that or you will have to change your job, take an extended “leave,” or utilize some care facility. As mentioned, Adult Daycare could come into play. 

But, what would you do if your loved one is ill and can’t be taken to daycare? Or, what happens if (or when) their dementia advances and they become hard to control or they become ineligible for daycare? Or, what would you do if, as my dad did, your loved one flat refuses to go?

You may be able to cover limited periods of time with paid time off or family medical leave. But at a certain point, your employer may become less understanding. Or corporate policies might demand your termination – regardless of the good will of your immediate supervisor.

If your job is more flexible, or if you work from home, you might have an easier time in some respects. However, even here: How will you ensure that you can devote the necessary time to your job? How will you make sure you have a sufficiently quiet environment in which to work? 

It’s not always as simple as giving your loved one an arts-and-crafts project, or hoping they find something to do for a couple hours. What if they become agitated? Would you notice if they wandered off? Do you have some way of monitoring them? – All questions for “9-to-5’ers.”

Finally, a problem may arise more broadly for anyone thinking of taking an extended leave or quitting their current job to be a caretaker. If you’re not actively employed, you might find that some of your benefits – such as your health insurance – will be canceled or suspended. And if you ever found it necessary to rejoin the workforce or to try to get your previous job back, you might find that the position has been eliminated or filled. You might lose seniority. If you have access to a pension, its calculation might be negatively affected by the “lost” years.

There are cases where income may not be an issue for you. One might be if your partner or spouse is the primary breadwinner. Assuming they’re on board with the decision to take in your loved one, then – the idea is – you’d continue relying on their income. No changes. In theory. 

Of course, you’ll want to consider whether home care would negatively – and predictably – affect your spouse’s ability to earn a living. If your partner works from home but mom or dad’s raucousness keeps your partner from being able to uphold their job obligations, then things could get messy. What if your loved one has chronic insomnia and their nightly wanderings disturb the whole household? Would your spouse find it difficult to get to the office on time?

Even if things started off “okay,” you’ll want to ask: What happens if the home care starts to interfere with the day job? Will you err on the side of continuing care? Or preserving the job?

These are all genuinely difficult questions. 

Other cases of stable income might be ones in which you are able to live off a truly passive income stream – such as guaranteed pensions, royalties, or trust funds.

However, not all “passive income streams” are equal. Some may require periodic tending. Could devote enough time to this maintenance if you were also an at-home caretaker? 

Probably the most common case where you may have quasi-dependable income is if you’re fully (not “partly”) retired, and you have unfettered access to all relevant funds (including distributions from 401ks, IRAs, Roth IRAs, dividends, and Social Security). 

These can have complications of their own. And it’s beyond the scope of this video to tease out every aspect of relevance. But, if you’re not at least 59 ½, then you likely do not have unrestricted access to retirement funds. And if you’re not at least 62, then you wouldn’t be able to collect Social Security – assuming you’ve qualified for SSA retirement benefits. 

Even if you can withdraw money from retirement funds without penalty, you still have to keep an eye on your tax situation. And if distributions from your retirement account depend at all on market performance, then the next economic downturn could upend your ship. 

Eventually, if you’re not already doing so, you’ll be forced to take money out of qualified retirement plan accounts by way of the so-called “Required Minimum Distribution.” 

The point is that even if you think your finances are “taken care of,” it may not be best thought of as a case of “set it and forget it.” 

If you’re living off government assistance, you’ll want to be careful about altering the number of people in the household. Sometimes this can jeopardize your eligibility for some programs.

I can’t and won’t speak to this in any detail, here. Except, I will say that you should consult with experts before finalizing or implementing any changes. And you can see some of my other videos for basic overviews of some relevant programs like Medicaid and Medicare.

It’s worth pointing out that there are a few programs under which you might qualify for government subsidies as a family caretaker. I believe that Medicaid has such a program, sometimes falling under the umbrella of “Consumer Direction.” 

Once again, it’s beyond the present scope to detail such a program.

And, of course, eligibility for government programs isn’t the only concern. The amount of assistance you qualify for may change depending on your household’s total financial picture. In some cases, if you change the makeup of the household, you’ll also change that picture.

Obviously, the amount of income is also important for you to reflect on, regardless of its source.

A question would be: Is your current income level sufficient to pay for home-care services – on top of the other, usual household expenses? If not, then it will probably need to be augmented.

Now you might think that if you’re living – or thinking about living – in the same house as your afflicted loved one, then you would have access to their income as well as your own.

And sometimes this is true. But, there are complexities.

I don’t want to make this a video about the relevant ins and outs. However, I could do so if there’s interest. I’m simply trying to bring to the surface issues that may be of relevance.

In that vein, let me just gesture toward some big considerations. As mentioned a moment ago…

Firstly, if your loved one’s income partly consists of government assistance, and is predicated on their living situation, then changing the situation could change the level of assistance. (Boldface, italicize, and underline the word “could.”)

Secondly, be aware that most financial institutions – for example, banks, brokerages, insurance companies, investment houses, retirement-management firms, etc. – are on the lookout for anything that smacks of elder abuse.

If dad’s social-security check suddenly starts getting deposited into daughter’s account; or if mom’s financial adviser or life-insurance agent gets an out-of-the-blue request to “cash out” this or that account or policy; you will probably have to answer some questions before your request or transaction is executed.

This isn’t to say that you’re trying to do anything questionable! Nor is it to say that these kinds of financial requests can’t be honored. But you should be aware that there are levels of legislative protection that have been built into financial regulations over recent decades. And these result in legal “hoops” that sometimes have to be cleared before you can “pool” resources.

Best-case scenario? You’re able to involve your loved one in making all necessary – or desired – changes before their legal or mental competence is undermined (or even called into question).

This might include cashing out or closing some types of account, filling out beneficiary-designation forms, giving you durable or “springing” powers of attorney, opening joint accounts, transferring control or ownership of a financial holding or instrument, and so on.

Once your loved one loses his or her ability to make sound financial decisions, then many – even most (or all!) – of the necessary financial moves you would need to make wouldn’t be advisable (or realizable) without outside authorization. The chief avenue for this would be a conservatorship hearing in a court of proper jurisdiction.

However, appointment as conservator will almost certainly carry restrictions and require reporting to the court. At a basic level, this means that separate bank accounts will have to be maintained, funds shouldn’t be “comingled,” assets can’t be disposed of without court approval, etc. Additionally, conservatorship generally terminates upon the death of the person who was subject to it – so… your loved one. (The subject would be called a “conservatee” or “ward.”) 

If your loved one is still able – right now – to converse, decide, and think lucidly on these matters, then you could look into trying to arrange the asset picture in advance of any worsening of their condition. For example, if it is their wish that their financial resources be pooled with yours or otherwise used at your discretion then there is not a moment to lose.

Extremely important caveat! If your loved one is no longer legally or mentally competent, then they are unable to consent to changes to their financial situation. You might face serious – even criminal – consequences even if your loved one’s competency is questionable. All this is beyond me. You’d be wise to consult with legal and medical professionals to ensure that everything is above board. Just to be clear: What I’m saying is for general informational purposes only and should not be construed as any kind of advice. 

Suffice it to say… You still do need to be careful with any consolidating moves. 

Another point, here. If it’s even possible (that is, conceivable) that your loved one would eventually need Medicaid to help pay for the cost of care, then you have to take great care when assigning, disposing of, gifting, pooling, retitling, selling, or otherwise transferring assets. Because, once again, there are severe repercussions for not following Medicaid’s requirements to a “T.” It took me three dedicated videos just to scratch the surface of Medicaid-related issues. 

A Word on Emotions

I’ve been ignoring emotional factors because these are sometimes especially difficult to describe or quantify – partly because they are so bound up with who we are as unique individuals. But, they’re no less an important part of our lives. 

You need to consider the emotional impact on – and emotional makeup of – everyone involved. 

On the one hand, this means your loved one’s emotions. A diagnosis of dementia would be depressing to anyone with the wherewithal to understand it. It can also be bound up with or give rise to anger, hostility, and resentment.

Alzheimer’s is a mysterious disease. The effects that it can have on emotions are sometimes as puzzling as they are devastating. There is no formula that I am aware of that will predict exactly what you’ll get.

Before his decline, my dad was friendly, likable, and somewhat extroverted. He was also easygoing and, to a large extent, unflappable.

As his cognitive faculties eroded, he became aggressive, belligerent, and combative – with everyone around him. It’s not exactly clear how to understand what occurred. 

Did the dementia – so to speak – cause his emotions to “invert”? Did it cause an awakening and overemphasis of dormant negativity? Or did it destroy who he was and, in effect, leave us with someone new? 

The other side of the coin, in a solo-caretaking situation, is your emotional tendencies. 

If you are mellow and don’t get your feathers ruffled easily, you might be able to take caretaking challenges in stride. On the other hand, if you’re irritable and impatient – like I can be, for sure – then you’re in for an especially tough time.

These considerations need not be determinative or final. Alzheimer’s is always a wild card. And we’re often capable of rising to a challenge. So don’t sell yourself short. Don’t “ostrich” either. 

For those who are interested, I dive more into emotional factors in the companion video “Is It Hard to Be a Caretaker?”

Summary Remarks

Okay… this has been a long and bumpy road. Let’s try to take stock.

We started by thinking about what it means to be a “solo” caretaker. We distinguished being a primary caregiver, where others – whether family members or professionals – assist you in backup, respite, and various secondary roles; and being truly solo, where you’re literally handling all caretaking duties by yourself. 

But we also noticed that being a solo caretaker doesn’t necessarily mean you’re alone in your home – not counting your afflicted loved one, of course.

It’s difficult to be a caretaker at any level of involvement. It could be a challenge to take dad or grandma for the afternoon, let alone invite them into your house 24/7/365.

If you’re truly going it alone – both as a care provider and as a homemaker – then you’re in for major difficulties. Assuming you have your financial bases covered, however, and you just have to focus on caretaking, I don’t want to say it’s impossible. 

Still, you’ll need to have a plan for necessities like cooking, sleeping, and showering – just for yourself. And you’ll probably want to have some sort of lifeline in place if (for instance) you fall ill or become injured. This highlights the need for a viable short-term back-up plan.

This includes numbers for prospective, in-home professional caregivers, Adult Daycares, etc.

Looking farther into the future, you’ll want to have a plan – even if only provisional – for finding a nursing home should that route become unavoidable. This is part of a long-term backup plan.

If you’re more in the primary-caretaker camp, then some pressure might be off of you. But, even so, emotional, medical, and other factors might arise that make it infeasible (or ill-advised) to continue with in-home care. 

Additionally, worsening of your loved one’s dementia is, for all intents and purposes, inescapable. Though, of course, it’s possible that a comorbidity might arise and further complicate an already complex situation.

Regardless of your circumstances, you’ll almost certainly run into a situation – probably many – where you’ll need or want professional advice. This could be legal, medical, nutritional, psychological, whatever. You’d be well-served by trying to develop a network of connnexions before your need for expert guidance becomes urgent.

Okay. As difficult as it was to make this video, the really hard part is up to you. You have to reflect on these factors and make the decision. Then you have to put that choice into effect.

Please understand that the Alzheimer’s Proof project – both this channel and the associated website – were designed and intended to help you.

I hope you can turn to some of my resources and find some assistance and value in them.

Finally, let me remind you that I have a second video – written in tandem with this one – which you might find a useful supplement. And don’t forget to check out and download the free workbook that I prepared to walk you through reflecting and choosing a path for your family.

If you’d like to ask follow-ups to me, personally, you can type your comments below or email me at AlzheimersProof@gmail.com.

For legal reasons, I cannot give specific advice. But if there are general concerns, I may be able to speak to them in a future presentation.

Please know that I wish you all the best in this confusing and painful process. Thank you for watching. 

Medicaid & Private Assets: Look-Backs, Spend Downs & Tests

Introduction

There are really only three (3) ways to pay for long-term care expenses and nursing costs.

The first general way is with the proceeds from insurance policies. These might be long-term care policies, whether they are qualified policies or non-tax-qualified policies. It could be through short-term care policies; it might even be through hybrid, life-insurance / long-term care combinations.

For people who do not have insurance policies to cover their long-term care costs, the remaining payment options are, second, privately paying from your own income and assets and – for people who do have insufficient income or assets to pay for their care – the final option, third, is applying for government aid. Of course, the most relevant government-aid program is Medicaid.

So, the questions then become: How does one specifically qualify for Medicaid? Or, to put it another way: How does Medicaid determine eligibility?

Caveats

It is important to bear in mind that this is a complex conversation, in part because Medicaid-eligibility requirements are going to vary slightly (and, in some cases, significantly) from state to state. Because of this, you’re going to want to consult with an expert who is knowledgeable about your particular state.

Note: This post tracks along with a YouTube video I have on the same subject.

Medicaid Eligibility

There are two overarching considerations.

Number one, there are financial qualifications.

Number two, there are medical-eligibility requirements.

Most of what I’m going to say is going to have to do with the financial eligibility requirements (because they are so complicated). But let me say a bit about the medical requirements just right off the bat.

Medical Requirements

Generally speaking, Alzheimer’s-level cognitive impairments are going to be enough to qualify you – provided, of course, that they are sufficiently advanced in their severity.

In some literature, you will encounter phrases like “nursing-home-level care.”

The specifics of this are going to vary from state to state. So, once again, you need to seek advice.

However, often, this nursing-home level of care is going to be calibrated to the type of supervision that a person requires, if they have cognitive impairments. Or, it may be calibrated to the various Activities of Daily Living (ADLs) that they are lacking.

Financial Requirements

But what I’m mainly going to be concerned with is going to be the financial eligibility. That’s essentially determined by two (2) calculations or “tests”: an asset test, and an income test.

The question of assets is going to preoccupy us in this article. In a subsequent article, I’ll talk about the income test. (They are both intricate conversations, and so it is probably best to break the conversation up into two pieces.)

Why Are There Financial Qualifications?

The basic reason that these tests exist at all hearkens back to the stated purpose of Medicaid – as I sketched, previously. (For my written article, see HERE; for the companion YouTube video, see HERE.)

In a nutshell, Medicaid provides financial assistance, to help pay medical expenses for people who are impoverished.

And so, the obvious follow-up question is: Who qualifies as “impoverished”?

The answer to that question is determined by these two tests. Basically, the idea is if a person’s assets fall below a certain level, and their income falls below a certain level, then they count as impoverished.

So, as I said: Let’s now consider assets.

Medicaid Asset Requirements

Quick Answer

Essentially, a person has to have $2000 or less in order to qualify for Medicaid, from an asset standpoint.

Two Types of Assets

Now assets themselves are classified into two (2) categories.

The first are “countable assets,” or those that are nonexempt. The second are exempt assets, or those that are not “countable.”

The precise scope of the exemptions and countability will vary from state to state. So, once again, this underscores the need for you to have a conservation with an expert in your area.

Typical Exempt (Non-Countable) Assets

But, usually, an exempt asset is going to be something like these: basic pieces of property, such as the Medicaid recipient’s primary residence,[1] a car, and so on.

Another Caveat

You have to bear in mind that Medicaid can cover people of various ages; it’s not just for people who have Alzheimer’s Disease, dementia, and other cognitive impairments. Medicaid is more broadly applicable than that.

So, for example, it might happen that a 30-year-old Medicaid recipient has a primary residence, has a car, and can get around with no problem.

Now, while it is unlikely – not to say, ill-advised – for a person with advanced Alzheimer’s to be living alone or have a car, those restrictions are not imposed by Medicaid. They are simply result of the advancement of their disease.

What About the NonAfflicted Spouse?

But the real question occurs when an Alzheimer’s afflicted individual has a spouse who has no affliction. What happens with the assets in that case?

The answer is that the non-afflicted spouse – sometimes referred to as the “noninstitutional spouse,” or the “community spouse” – will also have some assets that are usually going to be exempt.

Those exempt assets will be similar to what was just surveyed for the recipient him- or herself and will usually include a primary residence[2] and a single vehicle.

Medicaid May Seek ‘Recovery’

You should be mindful of the fact that Medicaid will sometimes claim reimbursement for the sale of the home after the Medicaid recipient has died.

You should also be aware that Medicaid is supposed to seek recovery from money that it spends on a recipient’s care.

Because of its strict monetary eligibility requirements, a Medicaid recipient is unlikely to have had any property apart from a home. For this reason, Medicaid often becomes a lien holder against the primary residence, and it may seek to collect money that was generated from the sale of the home.

In a few cases, a home may be required to be sold in order to settle with Medicaid.

However, there are many exceptions to this. In some cases where the noninstitutional spouse or minor child or some other dependent is still living in the home, Medicaid may either be unable or unwilling to seek recovery.

This is complicated territory and, not to sound like a broken record, but you will need to discuss your situation with licensed professionals who are familiar with these kinds of cases.

Countable (Non-Exempt) Assets

For the most part, assets beyond personal effects – like furniture and clothing – will be counted. This includes cash and banking assets, whether they are liquid or “semi-liquid.”

For example, it will include unsettled annuities, bank accounts (like checking accounts, money markets, and savings accounts), as well as certificates of deposit, (or CDs).

Countable assets will also include brokerage and other investment accounts as well as myriad “funds” (such as ETFs, hedge funds, mutual funds, and so on).

It will include cash-value life insurance (whether adjustable life, universal life, whole life, variable life, etc.).

And, importantly, it will include retirement accounts – including 401(k)s and other employer-sponsored defined contribution plans like 403(b)s, 457(b)s, and other employer-sponsored, defined-contribution-type plans. But it will also include Individual Retirement Accounts / Annuities – such as the Traditional IRA and the Roth IRA.

Real-estate and other property, beyond the primary residence and the main vehicle, are also generally non-exempt.

For example, if you have a family cabin or vacation home, then that would be a countable asset.

If you have a boat or a recreational vehicle (RV), then these would be countable assets as well in most cases.

$2,000 Limit

And as I said before, a person having more than $2000 in countable assets will usually be considered (asset) ineligible for Medicaid – although some states like New York have set other asset limits.

What About Property Owned Jointly?

How does it work if assets are shared in common with the spouse?

There are two (2) sorts of state: a “50%” state and a “100%” state.

Each of these types of estates handles assets a little bit differently and I will run through each of these, in turn.

My unofficial count was that approximately 35 states are of the 50-percent type. So, I’ll start with that.

‘50-Percent’ (50%) States

Although the details vary, usually, it happens something like this: All the countable assets are totaled.

So, consider a married couple. Let’s call them “John and Jane.”

The couple’s countable assets will include (1) those that are owned entirely by John, (2) assets owned entirely by Jane, as well as (3) assets that they own together.

The current values or Fair Market Values (FMVs) for these are summed, and then the result is divided by two – hence the name, “50-percent state.”

In general, the non-Afflicted spouse is going to be able to keep half – that is, 50% – of the total, within certain limits.

Two (2) limits are of greatest pertinence: a lower asset limit (or, minimum amount), and the upper asset limit (or, maximum amount).

Minimum & Maximum Asset Limits

These amounts are likely to vary year to year, just like the Internal Revenue Service (IRS) varies the amount of tax deductions, or varies the amount of retirement contributions that you can make.

In 2020, the lower limit was $25,728, and the upper limit was $128,640.[3]

In theory, a person could ask Medicaid to keep an amount outside of those limits. This would be established through a Medicaid “Fair Hearing.” But, in practice, the stated limits are usually final.

50%-State Examples

Case #1

This is complicated stuff, so an example or two might be helpful. I will run through three different scenarios, just for illustration purposes.[4]

Let’s take a middle-of-the-road example to begin.

Step One

Total the assets. Let’s suppose that John’s assets and Jane’s assets, together, are worth $100,000.

Step Two

In a 50% state, we just learned that we take that total and divide it by 2 which (of course) gives us $50,000.

Step Three

Compare the answer to that division problem (the quotient) to the lower and upper limits.

Results

Since our quotient – $50,000 – falls somewhere between the lower limit of $25,xxx, and the upper limit of $128,xxx, in this case, the noninstitutional spouse would get to keep all $50,000.

(This is because $50,000 is less than the maximum-allowable amount, and more than the statutory minimum.)

On the other hand, the institutional spouse, can only have $2000. So, he or she would need to “spend down” $48,000 (on this example), in order to qualify for Medicaid.

(Warning: This is only considering assets! There’s also an income test, as well.)

Case #2

Let’s consider a case now where the assets are a little bit more substantial.

Step One

Let’s suppose that Jane and John both together have $300,000 in assets.

Step Two

Once again, applying the 50% calculation we would take $300,000 and divide it by two. The resultant amount is $150,000.

Step Three

Comparing $150,000 to our stated limits, we notice that it exceeds the 2020 upper limit of $128,640.

Results

This means that, in our second example, the noninstitutionalized spouse will only be able to keep up to the limit, or $128,640.

As always, the institutionalized spouse can only keep $2000. So, once again, the institutional spouse must spend down the rest of his or her “half.” So… that’s $148,000 (or, $150,000 – $2,000).

But, all the money that is over the limit must be spent down.

In this case, even the noninstitutional spouse was not permitted to keep the entirety of his or her “half” of the money. So, the noninstitutional spouse must also spend down the remainder of his or her share of the couple’s assets. Here, that amounts to $21,360 (or, $150,000 – $128,640).

Therefore, in this second case, the total spend-down amount is $169,360.

($148,000 from the institutional spouse plus $21,360 from the noninstitutional one).

Case #3

For our third example, let’s consider a case where the assets are far less significant.

Step One

Suppose that Jane and John have a total of $30,000 to their names.

Step Two

When we divide that number by two, we get $15,000.

Step Three

Comparing it to our limits, we observe that $15,000 is less than the minimum amount of $25,728.

Results

That means, in a 50% state, the noninstitutional spouse will get to keep all $25,728, despite the fact that that amount exceeds 50% of the asset total.

On the other hand, since the institutional spouse can only keep $2000, the remaining $2,272 would have to be spent down.

($30,000 of total assets minus $25,728 kept by the noninstitutional spouse minus $2,000 kept by the institutional spouse.)

Takeaway

We see that there is an asset “spend down” that occurs when one’s countable assets exceeds the allowable amounts.

100% States

As I said, not all states operate on a 50% basis. Some are what are called “100% states.” In these states, the noninstitutional spouse may keep all the assets, up to the prescribed limit.

100%-State Examples

In some cases, the practical difference is very slight.

Case #4

Step One

For example, again suppose that Jane and John have $300,000 of total assets.

Step Two

Compare the total assts to stated limits.

Results

In a 100% state, the noninstitutional spouse keeps up to the maximum-allowable amount. In 2020, this is $128,640.

Therefore, the noninstitutional spouse will keep $128,640. This is the same amount that the noninstitutional spouse got to keep in the comparable 50%-state example.

As always, the institutional spouse keeps $2,000, and the rest is spent down.

Case #5

On the other hand, if the assets are less significant, the 100% state approach starts to make a bigger difference.

Step One

So, suppose that Jane and John had a total of $100,000 of assets.

Step Two

$100,000 is less than the 2020 limit of $128,640.

Result

Therefore, in a 100% state, the noninstitutional spouse would keep all $100,000.[5]

Case #6

Step One

Similarly, suppose the assets totaled $30,000.

Step Two

$30,000 is less than the $128,640 limit.

Result

In a 100% state, the noninstitutional spouse would keep all $30,000.

Takeaway

Essentially, in a 100% state, the noninstitutional spouse gets to keep all the assets up to the limit, which is $128,640 in the year 2020.

‘Spend Down’ Doesn’t Mean ‘Give Away’!

Here we run into a potential pitfall.

Upon learning about Medicaid’s austere requirements, and upon surveying their financial situation, couples might be tempted to start giving away assets – whether it be to relatives, to friends or to charities.

This would be a bad idea and very dangerous course of action!

Medicaid’s ‘Penalty Period’

We’ll need to be exceptionally careful.

Medicaid asset transfer rules are every bit as stringent as its other requirements.

Running afoul of Medicaid asset transfer regulations can result in the imposition of what is termed a “penalty.” This is a period of time when the applicant would be ineligible for Medicaid because of procedural violations.

You should also be aware that the penalty period only begins once the applicant would otherwise qualify for Medicaid and often once the applicant is already in a long-term care environment and receiving care.

That means that the Medicaid applicant would be in need of the assistance but would be unable to get it because they are being penalized. In other words, you would be up a creek without a paddle!

The ‘Look-Back Period’

In general, at least for long-term-care scenarios, Medicaid can – and will – review an applicant’s financial history and financial reports going back a full 60 months, or five years.

This “scrutinizing interval” is referred to as the “Medicaid look back.”

What are they looking for?

Medicaid is looking for transfers that are inadmissible from the standpoint of its regulations.

Improper Gifting

Illicit transfers might include things that you might call “improper gifting” and also inappropriate sales.

Illicit gifting would be giving gifts apart from what would be reasonable to celebrate usual occasions (like birthdays and anniversaries) or beyond what would be expected and reasonable in terms of holidays (that is, holidays that your family normally observes).

So, for example, giving little Johnny $50 on his birthday, or buying him a video game might not raise any red flags. (Although, if you are in the process of Medicaid planning, you need to consult with an attorney about every move that you make!)

On the other hand, giving the family cabin to your brother and calling it “an Arbor-Day gift” will almost certainly land you in hot water.

So, don’t make that kind of a mistake!

But, seriously, even inadvertent violations of asset-transfer requirements can be penalized severely.

Your best bet is to consult with an attorney who is knowledgeable about Medicaid transfers.

Firstly, lawyers are liable for the advice that they give to you.

And secondly, it’s against federal law to advise anybody to make asset transfers in such ways to try and hide assets or to cheat Medicaid. If a person’s advice results in the imposition of a penalty, the person giving the advice can be criminally liable.

Caveat

Naturally, this article is not intended to be construed as advice of any kind. It is for general informational, or entertainment, purposes only. You need to consult with experts in your area – perhaps more in this case than others. This is because qualifying for Medicaid is serious business.

Improper Selling

You can get in a lot of trouble, even if you aren’t gifting assets, but if you’re selling them incorrectly.

This is especially the case if the sale price is below the fair market value (FMV) of whatever the item is.

For example, if your car’s blue book value is $10,000. You sell it to your granddaughter for 25 bucks.

This is going to do more than just raise eyebrows. It could get you into a lot of trouble!

Is Every Asset Transfer Illicit?

Now, that isn’t to say that no asset transfers or sales are permissible.

This is an important point because it’s to be expected that a person is transitioning into a new era of their life when going into a long-term care facility, or a nursing home, and they are going to be downsizing, and they’re going to be getting rid of some of their property almost for sure.

The point is that you would be far better getting competent advice when you make these changes, than you would be otherwise.

Permissible asset transfers might include: retitling the home in the name of a spouse or in the name of a caretaking child, or selling items at their fair market valueprovided, of course, that the proceeds from the sales are duly noted, tracked, and then reported as part of the countable asset calculation.

Once again, asset transfer rules are state specific, and any Medicaid planning and preparation should be done only under the express advice of an attorney.

Life Insurance

The real difficulty with life insurance is the cash value.

Not every life-insurance policy has cash value. This is going to apply (mainly) to policies that are built on a whole-life or universal-life chassis.

Most term-life policies[6] have no cash value and can (generally) be retained at any face amount.

The “face amount” is the big dollar amount written on the front page of most life-insurance policies. It’s the amount that you would expect to the beneficiary to receive in the event of the insured person’s death.

On the other hand, permanent policies are usually the ones that have cash values. These policies must be limited to $1,500 face values.

That means they can pay out $1,500, at most, in the event that the insured dies. If the face value is $1500, then the cash value is expected to be less than that.

Any contract exceeding these values most likely will need to be “surrendered,” or “cashed out.” (But do not do anything without consulting a competent Medicaid expert or planner!)

Cash-value policies also need to be tracked carefully, even if they are retained.

So, if a policy falls under that $1,500 threshold, it is still going to need to be carefully tracked because: (1) the cash value is still part of the countable assets, and (2) if the policy’s cash value increases or changes year to year, or if the face value goes up, then the policy may qualify this year but not qualify next year.

Final Words

Take a deep breathe.

Because… the income requirements are every bit as complex as the asset requirements!

We’ll tackle those next time.[7]

(Featured-image credit: ‘Robbie Owen-Wahl’ Link: animalaidunlimited.org
https://images.freeimages.com/images/large-previews/916/calculator-and-pen-indicating-work-study-1632106.jpg.)

Notes:

[1] You should also be aware that there are sometimes limits imposed in terms of how much equity can be inside the house and whether this is applicable or not often depends on whether it is the Medicaid recipient him or herself, who is in the home or whether it is the noninstitutional spouse where equity limits do apply. They tend to vary year to year. In 2020, the amount of allowable equity in a home is about $600,000. Technically about $595,000. In some states it can go all the way up to closer to $900,000 or about $893,000 in 2020.

Intuitively, the reason for the equity limit is so that a person sitting on a $2 million mansion could not qualify for Medicaid when the sale of the home would be enough to discharge both their medical expenses and more modest housing costs. Cases where the spouse is willing in the home equity.

Limits may or may not apply. Consult your Medicaid planner.

[2] See, again, the previous footnote.

[3] These limits may have changed, though; so, don’t too get too hung up on the specific amounts. Just try to get a grasp of the concepts. Your trusted Medicaid expert or planner will be “up” on the relevant limits.

[4] My numbers are entirely hypothetical.

[5] Conceivably, the institutional spouse could keep $2,000 and the noninstitutional could retain $98,000. Consult your Medicaid planner.

[6] Term insurance is usually regarded as “temporary,” since it is purchased for intervals called “terms.” Intervals may be 1 year, 10 years, 20 years, 30 years, etc. The insurance expires if the insured hasn’t died during the interval.

[7] I want to stress that this has been my good-faith effort to provide people with an accessible summary of the contours of Medicaid asset eligibility. However, I make no claims to completeness or expertise. I do not warrant that this information is accurate, error-free, or up to date. So, please, consult with a qualified expert to help you!

Intro to Medicaid: Medicaid Vs. Medicare; Long-Term Care

My dad Jim died of Alzheimer’s disease in 2016.

In order to help pay for my dad’s nursing home care, my mom had to reduce her already modest assets as part of what is commonly referred to as a Medicaid spend-down.

But what is Medicaid? How do you qualify for it? Who is it designed to assist? And why do so many people have to expend their life savings in order to get it?

Let’s take a look at Medicaid.

In this introductory article, I’ll lay some basic groundwork – and provide a few essential definitions and concepts.

In two follow-up articles, we’ll discuss the all-important financial qualifications: first assets, then income. So… stay tuned!

(Also, be aware that this additional content is already available in the form of YouTube presentations and can be accessed HERE and HERE.)

Disclaimers

First of all, I need to give the usual disclaimers and in fact I want to amplify what I normally stay. I am not an attorney. I am not a financial advisor of any kind. You can consider the topics that I discuss to be research leads just to help you as you are thinking through these issues and hopefully help to shorten your learning curve in some of these important topics. But nothing that I say in this video should be construed as advice of any kind. If you need actual recommendations and evaluations, you need to consult with licensed professionals in your area. In this case, I am talking about attorneys who are knowledgeable about Medicaid, or other Medicaid experts.

The usual disclaimers are especially important in this case. That’s because Medicaid is just so complex; Medicaid’s rules and regulations are subject to amendment and modification; eligibility and other limits can be expected to change almost annually; Medicaid has as many different variations as there are US states.

So, you should meet with someone, not just is knowledgeable about the rough contours of the entire program, but somebody who knows the nitty-gritty of your local situation or state situation and how best to advise you.

What is Medicaid?

Medicaid is a United States government program that is designed to help impoverished people pay their medical expenses.

Sometimes, Medicaid is referred to as a joint federal and state program. Other times, Medicaid is referred to as a federal program that is administered by the U.S. states. And, sometimes, it is thought of mainly as a state program that has infusions of federal cash.

The federal government generally provides funding for benefits that are mandated at the federal level, which makes sense. The states, in turn, provide administrative services. They also pay for state-specific benefits.

However you think of it, or by whatever name you call it, Medicaid has a foot on the federal level government as well as on the state level.

This is one key reason for its (aforementioned) complexity. Namely, the particulars of how the plan is implemented and managed are going to vary according to the state that you are in.

Medicaid Isn’t Only for Long-Term Care

It is important to understand at the outset that Medicaid is a broad program and can cover many different medical services.

For example, it can cover routine doctor visits. It can cover hospital visits, long-term-care facilities, nursing homes and the like of that.

The long-term-care applications will be my focus in this series (since it’s the obvious concentration of the website). But Medicaid can cover a lot more than that.

And if you have need for additional services, for yourself or for your family, I am sure there are other resources that will expand my treatment.

Potential Pitfalls

Because of the complexity of the topic, there are certainly going to be a number of pitfalls.

Firstly, it’s easy to confuse Medicaid with Medicare. Not only are the two words similar, but both programs are overseen by the same government agency, the Centers for Medicare and Medicaid services, or CMS. CMS is a major division of the United States Executive Branch Department of Health and Human Services, with the cabinet-level Secretary of Health and Human Services at the helm of both programs.

However, these programs differ in terms of who is eligible and what services are covered.

Medicare is basically health insurance for seniors. Some of the premiums might vary in terms of the amount that is paid. But, otherwise, Medicare covers seniors of any income level.

Here, “senior” simply means a person who is 65 years of age or older.

There is an important caveat.

Medicare is called upon to deliver health coverage to people of any age, provided that they also are recipients of Social Security Disability Income (or SSDI), or if they suffer from end-stage renal failure (or kidney disease). Medicare itself is complex.

Medicare is a complex program itself. For my own YouTube-video treatment, see HERE.

In broad strokes, though, Medicare Parts A and B cover hospital and doctor visits, respectively. Part D was added to help provide prescription-drug coverage.

You can talk about something referred to as Medicare “Part C,” also known as “Medicare Advantage” plans. (These function something like Medicare HMOs)

And, to complicate matters further, Medicare Parts A, B and D can be further augmented with what are called “Medicare Supplement” (or “Medigap”) plans. (These, in turn, are also designated with letters like “Medicare-Supplement A,” “Medicare-Supplement F,” and so on.)

Medicare & Social Security

Historically, Medicare has a fairly tight relationship with Social Security.

For example, although it does have a deductible, Medicare Part A is usually delivered premium-free to people who are fully qualified to receive Social Security benefits. It is in this sense that Medicare Part A is often referred to as “automatic.”

It is important to note that if you are not eligible to receive Part A cost free, you may be able to purchase it.

Medicare has long had this close association with the Social-Security program

In fact, Medicare’s eligibility age, 65, once corresponded to the Full Retirement Age (or “FRA”)[1] for Social Security recipients. Even though the full-retirement age has been increased for most retirees, Medicare’s eligibility age has remained the same.

Medicare part B is never free. Though it’s actual premium cost will depend on many factors, including your income level.

Medicaid Will Be Our Focus

As stated from the outset, going forward, this series will be concerned with Medicaid (and its financial requirements), the government’s financial-assistance program for impoverished people – regardless of their age.

So, we come to one quick way of distinguishing Medicare and Medicaid.

Medicare has an age requirement,[2] but no income requirement. As long as you are 65 years of age, or older, you are eligible for Medicare.

On the other hand, Medicaid has no age requirement, but it does have an income requirement.

To rephrase: Medicare covers people 65+ years of age, of any income level; Medicaid covers any aged person, but only if they are of a low-income level.

Which Program Covers Long-Term-Care Costs?

“Medicaid also covers long-term care costs, both in a nursing home and at-home care. Medicare does not provide this coverage.”[3]

As noted by CNN, long-term care and nursing home costs are not generally covered by Medicare.

Medicare really only covers “curative,” skilled-nursing care – in a Medicare-approved facility. And, even then, it only covers skilled-nursing-home costs, provided that your entry into a qualifying facility followed a hospital stay of at least three days.

Additionally, Medicare coverage is calibrated to what are termed “episodes of care.” And each skilled-nursing-home visit is only covered up to 100 days per episode.

So, since Alzheimer’s and related dementias are not “episodic” in the relevant sense, we can basically say that Medicare is going to be irrelevant for the purposes of long-term care and nursing home care.

Another reason for this irrelevance is that long-term care is often bound up with what is called custodial care, and this is to be distinguished from skilled nursing care.

Basically, custodial care is help with the activities of daily living, whereas skilled nursing care is what you would normally think of in terms of medical care, medical testing, the administration of drugs, and the like.

(For my YouTube presentation explaining the difference between custodial and skilled nursing care, see HERE. For my written article on the same topic, see HERE.)

As if things weren’t confusing enough as it is, Medicaid is able to pay some of the expenses associated with Medicare. Examples of this would include the Parts B and D premiums, the Part-A premium (when it is applicable), and the various Medicare “co-pays” and deductibles.

Intro to Medicaid Eligibility

Each state sets its own guidelines for eligibility, within various limits.

For many states, Medicaid assistance is available to people who are below, at, or near the federal poverty level, or FPL.

Recipients cannot have incomes that exceed about 130-140% of the FPL, adjusted for household size. And these low-income requirements are very strict.

In addition, Medicaid recipients are not allowed to have much by way of assets or, in the Medicaid terminology, “resources.”

But, these two financial tests – one pertaining to assets, and one pertaining to income – are quite intricate. So much so, in fact, that I will be devoting a separate article to each of these.

So, I invite you to stay tuned for those posts.

And, in the meantime, feel free to view the companion YouTube videos. My discussion of Medicaid’s asset requirements can be found HERE, and my coverage of the relevant income requirements is HERE.

Notes:

[1] Note that, in some literature, this is instead termed the “Normal Retirement Age,” or NRA. Presumably, FRA is more common due to the fact that the letters “NRA” more commonly designate the National Rifle Association.

[2] For the exceptions to this, see the previous section.

[3] “What Does Medicaid Cover?” CNN, <https://money.cnn.com/retirement/guide/insurance_health.moneymag/index21.htm>.