Medi-Cal Planning from Start to Finish


Kirsten Howe

Kirsten Howe

Attorney at Absolute Trust Counsel
67 articles 

In this series of posts we will focus on Medi-Cal for our over-65 clients who need assistance with long-term care. We will take you through the laws and what we do for our clients, from the initial meeting until we receive that eligibility letter, to help them qualify, apply for and receive Medi-Cal, for long-term care.

The Initial Appointment – Gathering Information

Every client’s case is different, of course, but our over-65 clients come to discuss Medi-Cal planning with us for a few common reasons. In our initial meeting we must uncover what exactly their situation is so that we can recommend solutions. One common scenario is our client has recently discovered he has a degenerative illness, such as Alzheimer’sdisease, and he and his wife are worried about their future, worried about spending all their savings at the rate of $10,000 or more per month for the husband’s long-term care. The client may be unmarried with a similar diagnosis and not wanting to burden her children if she runs out of money paying long-term care expenses.

A third scenario involves a client already in a nursing home, already paying unbelievable amounts of money for care every month, and the spouse or other family members are in a panic. Each of these cases presents us with a different set of possible solutions to explore and we must ask lots of questions, including:

What Kind of Care is Needed?

Medi-Cal provides a wide variety of services that fall under the umbrella of long-term care. For those who would otherwise require nursing-home level care but prefer to and are able to remain in their homes with the available support, Medi-Cal has a number of Home and Community Based Services (HCBS). Which programs are available varies by county. Some programs directly provide support through agencies that contract with the county. Some programs allow the Medi-Cal recipient to hire caregivers they select themselves, which could be friends or family members. For some of our clients, remaining in their home is just not possible. Medi-Cal also provides support to those in need of nursing-home level care in nursing homes.

What Planning Do We Have or Can We Do?

One very important preliminary step is to make sure we have the legal ability to do planning, now and in the future. As long as our client has the mental capacity to do the necessary planning, everything is fine. However, if our client no longer has the mental capacity necessary to understand the work we do and to participate in the planning, we check documents- trusts and power of attorney- to see if someone else has been granted the power to do planning.

Medi-Cal planning often requires our clients to give away their property. This power to give away property is often not included in trusts and powers of attorney. Two very common misconceptions: husbands and wives can do just about anything with each other’s property, especially in a community property state like California; and all powers of attorney are the same. The law, however, is that without your written authorization nobody, not even your spouse, can legally give your property away to anyone, including themselves. To do so without proper authority could be considered theft and elder financial abuse and it would not be recognized as a completed gift for Medi-Cal eligibility purposes.

What we need to see is a written power of attorney that authorizes someone else to give away our client’s property in order to qualify for Medi-Cal. This is not a power that is granted in most powers of attorney. If the client has a trust, then his trust must also authorize his trustee to give away his property, which, again, is not a common trust provision. If our client has not given these powers to anyone and still has the capacity to do so, creating an appropriate power of attorney and trust language is usually one of the most urgent items for us to do. If our client does not have capacity some planning options will not be available.

Most clients who are considering applying for Medi-Cal are also interested in avoiding Estate Recovery. As we will discuss in more detail in a later post, payments made by Medi-Cal on behalf of the recipient can be recovered from his probate estate upon his death. The need to create an estate plan that avoids probate is obvious here. When our client has capacity or another person has legal authority through a power of attorney, we will want to create a revocable living trust and make sure it owns all appropriate assets.

In our next post we continue to explore the preliminary questions we cover in our first meeting with our clients.

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2010 Tax Statistics in the USA

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More women between the ages of  55 under 60 yrs of age worked in 2010 compared to the number of men in the same age group.

In both men and women, the top earning age group is between the ages of 46 under 55 yrs of age. Disparity in income between men and women is almost double in favor of men.

738k men are still working past age 76 yrs of age and contributed to about $7M in taxes.




Nurses identify 10 needs health startup should focus on

The following list was compiled from interviews with Sheila Antrum (president and senior vice-president, health adult services, UCSF Medical Center), Daphne Stannard (director and chief nurse researcher, Institute for Nursing Excellence, UCSF Medical Center), and Alberto Garcia (patient care director, health adult services,UCSF Medical Center).

Why are we sharing this? UCSF’s Center for Digital Health Innovation was formed three years ago to help improve patient care using technology, and we’d like to see more collaboration between health systems and entrepreneurs in health care. Please reach out to us if you’re working on any of these issues!

1. Patient and family navigation technology. Health systems employ many people as “navigators” to guide patients and their families from one location in a hospital or clinic to another. We like the idea of such technology that in addition to guiding patients through the hospital, helps patients and family members stay abreast of clinical updates. For example, for a patient getting surgery, the app would help guide the patient from the waiting area to the preoperative area and then would later alert the patient’s family members when the surgery has been completed. This solution relies on deep integration with existing hospital technologies, including the electronic health record (EHR) and hospital scheduling software.

2. Virtual hospital sitters. UCSF and other health systems spend millions of dollars each year hiring people to sit at the patient bedside to monitor for falls, self-harm, or other deleterious behaviors. If sitters could be partially replaced with robots or other virtual technology, UCSF could keep patients safe while saving huge amounts of money on workforce costs.

3. Artificial intelligence for the hospital. Advances in machine learning and artificial intelligence (AI) have opened the door for predictive modeling to enhance patient care. From ICU monitoring systems that model patients’ vital signs and produce patient-specific care recommendations, to identifying patterns in care that can have significant impacts on patient outcomes, the future potential for AI in health systems is substantial. Beyond the use of patient data, Sheila and her colleagues expressed interest in AI for the hospital environment – a system in which the environment adapts to patient needs. Such technology could be used for better managing inpatients with pain, delirium, or for promoting mobility for hospitalized patients.

4. Automated documentation within the electronic health record. It’s well accepted that both nurses and physicians spend too much time documenting in electronic health records (EHRs). Nurses, in particular, spend large amounts of time transcribing information from pumps and other patient devices to the EHR. Automated documentation between connected devices and the EHR would improve workforce efficiency and also allow hospitals to more quickly and accurately assess risky states for the institution and the patient, and optimize accordingly. Why hasn’t this happened already? EHR integration between devices is notoriously cumbersome, leaving nurses to take on this effort manually.

5. Virtual home-health communities. Telehealth is rightly a huge area of interest for healthcare innovation. But most telehealth companies are focused on 1:1 patient and provider visits. We see a future in which one provider is able to hold virtual group visits, for example for patients discharged from the hospital with similar conditions. Using population health management tools and the hospital discharge team, these patients could also be matched with a community of patients in their neighborhood, or connect with each other through a virtual platform with relevant resources and communication functions.

6. Price transparency tools for the inpatient setting. There needs to be a better way to track the costs patients face on an ongoing basis. In addition, price transparency tools need to interface with EHRs. Differing reimbursement offered by different plans to each health system have made this issue an ongoing challenge for patients and providers.

7. Pain management dashboard. Current stand-alone technologies exist for chronic disease management, but a pain management dashboard embedded within the EHR could lead to a better and safer tracking of patients with chronic pain issues. With the growing pain medicine epidemic, better and safer pain management is hugely important. Right now, pain management is a fragmented process, requiring patient, pharmacy, nursing, and provider input. An integrated dashboard that allows for cross checking with outpatient pharmacies and the CURES database, pain scoring, and ordering would help ease this currently manual process.

8. Technology to enable safe patient handling. Care teams constantly have to move, position, and lift patients —  even when they shouldn’t. And these tasks can be taxing to staff and result in significant hospital liabilities. Similarly, the safe handling of hospital waste is still a very manual process. Robotic technologies that automate these tasks are appealing from a time, cost, and safety perspective.

9. Research management application. For providers and care teams, it is difficult to know if a patient is enrolled in a clinical trial, which can create significant safety issues. For example, if a patient enrolled in a clinical study is admitted to the hospital and is administered a medication that interacts with a study drug, the patient could be at significant risk for a drug interaction. At present, there is no automated way of managing and flagging patients enrolled in trials. With a better research management application that connects to the EHR, an automated research interface would flag patients who are part of a trial and provide additional supporting materials regarding safety measures that must be followed.

10. Apps for frontline staff. Frontline nurses attend to almost all of a patient’s basic needs. In doing so, they often juggle up to 25 pieces of paper with critical information. Ideally, nurses could use charting software that would help manage and streamline all this information.

Motherhealth is looking for investing partners, doctors and developers for a Health Mobile Outpatient application that will match, monitor and report patient generated health data, including video chats with care providers, cancer care coordination analytics, genetic and lab tests health data sharing and more. Email Connie Dello Buono at ; 1708 Hallmark Lane San Jose CA 95124

7 Things to Review During Medicare Open Enrollment by Emily Brandon

Medicare beneficiaries will get an opportunity to make changes to their Medicare Part D coverage between Oct. 15 and Dec. 7, 2014. Many retirees will experience premium increases, changes in covered drugs and new cost-sharing requirements if they don’t switch plans. Here’s what you should review during the annual open enrollment period so you can select a new prescription drug plan if necessary.

Covered medications. Prescription drug plans are permitted to tweak the roster of medications they cover each year, and it’s important to double-check that your current medications and any new prescription drugs you expect to use in the coming year will be covered. “The first thing people should look at is whether all of their prescriptions are on the formulary,” says Casey Schwarz, policy and client services counsel at the Medicare Rights Center, an advocacy organization. “A plan can have very low premiums, but if the drug you would like to take is not on the formulary and not covered, then it is not such a good deal.”

Premium prices. The average Medicare Part D monthly premium will increase by 4 percent to $38.83 in 2014, assuming beneficiaries remain in their current plan, according to an analysis of 2015 Part D plans by researchers at Georgetown University, the University of Chicago and the Kaiser Family Foundation. However, beneficiaries in six of the most popular Part D plans will see their premiums increase by at least 10 percent, and one Part D plan increased premiums by 52 percent. About 1.5 million beneficiaries (8 percent) will experience a premium increase of $10 per month or more, while 985,000 beneficiaries (5 percent) will experience a premium decline of at least $10. “You have to weigh the amount of the change in premiums versus the inconvenience of making a shift,” says Jack Hoadley, a health policy analyst at Georgetown University and co-author of the report. “We know that some people are looking at premium increases that can be as much as $20 a month or more. In those kinds of situations, the payoff for making a switch can be substantial. If the change in your premiums is only a dollar or two, it may not be worth making a change.”

Cost-sharing changes. Prescription drug plans change the copayments and coinsuranceassociated with covered drugs each year. For the first time in 2015, all Part D plans will use tiered cost-sharing. Most plans have five tiers, including two for generic drugs, two for brand-name drugs and one for high-cost specialty drugs. Medications in each tier have different out-of-pocket costs, ranging from copayments to passing along a percentage of the bill to beneficiaries. “There are likely to be changes in the cost-sharing amounts that plans charge for drugs, drugs taken off the formulary and new utilization management tools like prior authorization,” says Juliette Cubanski, a policy analyst at the Kaiser Family Foundation. “Even if people are happy with the coverage that they have now, it does make sense to take a little bit of time to look at your coverage and see how it might be changing and see how your needs have changed.”

Deductibles. Most part D plans (58 percent) charge a deductible, which is typically a standard amount of $320 (44 percent). However, 14 percent of plans will charge a smaller deductible next year, up from 4 percent in 2014. “Plans that do lower or eliminate the deductible typically make other changes that might actually translate into higher costs for people,” Cubanski says. “While it might look appealing not to have that deductible, if the premium is so much more expensive that you end up paying more on an annual basis, that might not be a very good value payoff for people to be making.”

Preferred pharmacies. The majority of prescription drug plans (87 percent) now offer beneficiaries lower cost-sharing requirements if they fill their prescriptions at selected network pharmacies, up from 72 percent in 2014 and just 7 percent in 2011. For example, the AARP MedicareRx Saver Plus prescription drug plan charges a $20 copayment for a preferred brand drug at a preferred pharmacy, but the cost jumps to $45 at another in-network pharmacy that is not preferred. And beneficiaries enrolled in the Humana Walmart Rx prescription drug plan pay $1 for preferred generic drugs and $4 for non-preferred generics at a preferred pharmacy, versus $10 and $33, respectively, at other in-network pharmacies. “It’s important to understand if the pharmacy where you go to fill your prescriptions is part of the network of plans with the preferred cost-sharing,” Cubanski says.

Medication restrictions. Some Part D plans require beneficiaries to get prior authorization before they will cover certain drugs, require patients to try a lower-cost drug before paying for an expensive medication or limit the amount of medication you can buy at one time. “It may be worth paying a little bit more to get the one that doesn’t include the restrictions,” Hoadley says.

Consider other options. There will be just over 1,000 prescription drug plans offered nationwide in 2015, and Medicare beneficiaries will have a choice between an average of 30 plans. You can view the coverage options in your area using the Medicare Plan Finder at “Each year, plans make adjustments to their premiums, their formularies and whether they have prior authorization or other restrictions on use, and what worked for a person who was taking a particular array of drugs last year may not work for them this year,” Hoadley says. “It’s worth seeing if there is money to be saved or better coverage to be acquired.”


Connie Dello Buono, Medicare Specialist AHIP Certified 408-854-1883 helping Medicare families with Medicare planning.