Colleen Bratkovich - Welcome. My name's Colleen Bratkovich. I'm an attorney with the elder law firm of Zacharia Brown. Zacharia Brown is a boutique elder law firm located in the suburbs of Pittsburgh, Pennsylvania. And today the presentation is, "What are the options to keep my loved one safely at home?" 

My goals for today are to discuss with you Medicaid waiver programs for home and community based care. Strategies for reducing excess resources when applying for Medicaid. VA resources, aid and attendance, and VA healthcare. Housing and living arrangements. Outlining caregiver duties, providing for personal care, social needs and transportation. Ensuring proper nutrition and medical care. Unique considerations and common pitfalls in family caregiver arrangements, and sample caregiver agreement review. The reason this is important is at the end of the day, we all would prefer to be cared for at home. In addition, we would prefer to take care of our loved ones at home if we're able to accomplish that. But with the government programs, the rules as they exist, it can be difficult to navigate what's the best way to try to help our family member stay at home in the community. 

So, first we're gonna start talking about payment options for long term care at home. So if we have a loved one who we are trying to keep at home, how are we going to pay for it, okay? So, now, somebody can be living in what's called independent living, okay? It's often still in a facility, but they can be receiving government provided services and supports for long-term care at home because that is their home, okay? So independent living, now the rent itself is typically private pay, and that would be the same as if you're paying a mortgage or even living in a paid off home, keeping up your property taxes, homeowner's insurance, the regular utilities, and other expenses that you do have in keeping up your home. Individuals may move into assisted living, personal care, memory care communities. There are options for private pay, also getting money from the VA and long-term care insurance. Now, an individual who's living in assisted living, or personal care, or memory care, typically is not receiving what we would refer to as at home care. Although that may be their home, that would be considered to be facility or institutional care. At home care, while, as I mentioned, it could be part of independent living, is typically in the original residence or perhaps in a child's residence, if the individual requires more supports. But they're living in their home, the ways that going to pay are private pay. So that can be that we are private paying for a caregiver agency. We are private paying an individual caregiver. We are paying for a family member to take care of us. 

Long-term care insurance does have its place, so I won't talk much about it. I don't sell long-term care insurance and I don't really particularly go out and advocate for it either. If an individual or a client has long-term care insurance, it's always going to be a benefit. It's going to help us in stretching our healthcare dollar. But traditional long-term care insurance typically has shortfalls. There's typically an exclusion period on the front end where the monetary benefit is not going to kick in for a certain period of days or months. Or be triggered by some other indication, a doctor needs to certify they need help with two activities of daily living, or there's some other trigger that's going to allow that policy to kick in. Typically it's not going to cover the cost of care in full, there's probably a $100 a day limit, or there might be a three year limit, or there could be a specific dollar figure once it pays out a hundred thousand dollars the policy is ended. And families, I think struggle too with when to take long term care insurance. Because sometimes they are afraid of taking the long-term care insurance benefit when the individual is at home because the cost is lower, thinking that, well, they'll save it for when the individual moves into a nursing home later and it's more expensive. 

But in some cases, when the individual moves into the nursing home later, they're already eligible for Medicaid or they're close to being eligible for Medicaid. And they really won't have any value to their long term care policy that they paid into for so many years. So, it's definitely part of the discussion. It's going to be helpful if clients have had it and they can continue to afford it. And if they qualify to make a claim, that might be the time to do it. Now, not everybody's long-term care policy is going to provide for home care, but that is an available option for some folks, okay? I'm going to talk about the LIFE program, where it's referred to federally as the PACE program. In Pennsylvania, where I practice, we already had a PACE program for prescription assistance for seniors. So we call it LIFE here, and I'll talk about that. And the Aging Waiver program, or the Medicaid Waiver program to provide helped individuals under the Medicaid program in their homes, okay? And we'll talk today too, about veterans benefit eligibility. Again, the VA benefit, there's healthcare benefits, there's cash benefits, and it all can be part of our plan to try to help an individual stay at home longer. 

So we'll start with the Medicaid home and community based services waiver program. So, this is a program where your federal Medicaid dollars, your state has elected to permit the federal Medicaid dollars to be used to provide some at home care. And different states implement it in different ways. Some states will permit those waiver dollars to be used to pay for assisted living. In Pennsylvania, where I am, they do not. You can only use the Medicaid waiver at home and only if your income is under a certain limit. So, for somebody in Pennsylvania, who's applying for the home and community based services, they have to be a resident. They have to be 60 years of age or older. They meet the level of care needs for a skilled nursing facility, okay? So they have to be what's called nursing facility clinically eligible. So they medically would qualify to go to a nursing home, and then meet the financial requirements as determined by our county assistance offices. So that is the Medicaid application that goes through the department of human services. 

So some of the services that the individual can receive at home are not gonna be limited to just the actual personal care services. I think that oftentimes people have some knowledge maybe that that benefit is available to have personal care, but it's much more than that, okay? So, sometimes they'll do home modifications or accessibility adaptations, adult day program services, community transition services. So, that's helping individuals who maybe already are in a skilled nursing facility and would like to come home. Helping them with establishing a residence, helping them with, if they need security deposit and first month last month's rent, to move into an apartment from the nursing home, maybe even needing to get some furniture, and things of that nature. Help with meals. So home delivered meals, home health services, non-medical transportation, personal response services. So, the pendants or the bracelets that somebody can alert if they've fallen at home and need assistance. Respite care. So, if the individual maybe is at home and receiving some family supports and then other Medicaid waiver services. That individual could go into a facility for respite care if the primary caregiver was unable to care for a certain period of time. Service coordination. Okay, again, just having that service coordinator in place to be able to figure out what the individual needs and how best to utilize the services as they exist. Making sure that they're getting their medications, and that they are receiving their physical therapy or occupational therapy. That their caregiver is coming. That if they need grab bars put in the bathroom, or briefs, or gloves to be ordered.

 That there's somebody making sure that they're overseeing that the individual's getting the things that they need. Counseling services, nutritional services, the nursing services as we mentioned before. Physical therapy, speech therapy, whatever therapies the individual needs, okay? So as I mentioned, in Pennsylvania, we call it the LIFE program. Which is living independently for the elderly, okay? This is a managed care Medicaid or managed care program. Well, it's actually just say managed care program, but if you are eligible for Medicaid, you do not pay anything for it. But it provides comprehensive, all inclusive package of medical and support services. And again, nationally, it's known as PACE and oftentimes it's equated to an adult day program, but it's a lot more, okay? So, to be eligible for this program, you have to be 55 or older. Again, you have to meet the medical needs or the nursing facility clinically eligible. So you would be medically eligible to go into a nursing home. Meet the financial requirements as determined by your local county assistance office, okay? Through the department of human services here in Pennsylvania, or be able to privately pay. So, at the time of recording this, I would say, I think most of those programs, so in the Pittsburgh area where I am, it's geographically determined. There's three big companies that all provide these LIFE programs. And it's geographically determined by zip code. So depending on what zip code you live in is what provider you use. But all the providers are around 4,500, $5,000 a month for private pay, if somebody's private paying. 

So, in my line of work, most of my clients, we either already have the individuals eligible for Medicaid when they're enrolling in the program, or we are working quickly towards getting them eligible for Medicaid to cover the cost of the program. So financially requirement, or meet the financial requirements, or be able to private pay. You have to reside in an area serviced by a provider, so based on your zip code, and be able to be safely served in the community as determined. So if they come out and do an assessment, they need to make sure that either you have family supports for the other hours, or that you are able to live independently for a number of hours of the day, even if you're receiving these other services. If somebody requires 24 hour round the clock care, and they try to enroll in this program, and they don't have care for the other hours, they're not gonna be appropriate for the program. They should be moving into a facility. So the services available under the LIFE programs are often more medical in nature than maybe you would be getting under the waiver programs. And that's because it's a medical managed care program. You'll have your adult day services, okay? Audiology services, dental services, emergency care, your end of life services, hospital and nursing facility services, in home supportive care, your lab and x-ray services, meals, medical and non-medical transportation. 

So something that sets this program apart from maybe your traditional adult day program is the transportation. So the little van's are gonna come to your loved one's house in the morning, they're gonna get them up, help them get into the van, take them to the center. So they'll transport them to the center. They'll be at the center during the day, and then they'll transport them home later in the day. So that transportation is provided as part of this program. The transportation is helpful too. And the center in and of itself, one of the great things about these programs is that they become the medical home for the individual. So if you have a loved one who is missing doctor's appointments, either because they're forgetting, or they're calling to cancel, because they don't wanna have to pay a co-pay. Or if you are maybe the adult child and you're working and you have to constantly be taking off of work to run mom or dad to the doctors. This can be helpful because it allows for a little bit of independence there that you're not gonna be dependent, or they're not gonna be dependent on you to get to these appointments. You know, the transportation's provided by the center and the doctors come to them. So it cuts down on the missed appointments and missed time from work. So that's a great program. 

Additionally, so your eye services, nursing and medical coverage, nursing care. So if the person would need to move into a nursing home that actually will continue to be covered by the life provider. Unless the individual disenrolls from the program. So we see that sometimes again, because we have multiple providers and they contract with different nursing homes. So if the client selects a nursing home that their life provider does not participate with, they will need to disenroll from their life program and just go on traditional Medicaid so that they can go to the nursing home of their choice. Personal care services, their prescriptions, I think that's one of the greatest benefits about these programs. So many clients have medication problems where they're taking them incorrectly. They're not taking them. They're mixing medications that they shouldn't. One person is prescribing something that the other one doesn't know about. 

So because you're gonna have one medical home and all of the doctors are gonna be writing out of the same office and the same pharmacy, really cuts down on those difficulties. And somebody's going to be administering the medications, that they're getting them appropriately. Physical therapy, speech therapy, occupational therapy, recreational, and socialization activities. So that's a great benefit. You know, there's reading clubs and gardening clubs and just playing bingo, playing cards, getting an opportunity to get people out of the house who otherwise wouldn't be able to. You know, that was really a challenge for these programs during the pandemic that they weren't permitted to be bringing the residents in. And when we first reopened and they were permitted to bring 20% capacity back or 30% capacity back, they were trying to pinpoint those individuals that truly were isolated and alone. And didn't have other family supports at home to get them back to social socialization, and seeing other individuals again. So either of these programs, whether it's the Medicaid waiver at home, or your LIFE or PACE programs for the medical home type layout, the rules are the same, okay? We wanna be able to apply for Medicaid so that Medicaid will pay. 

The rules with regard to Medicaid are in four different areas. We have rules about assets, we have rules about income, rules about gifts, and rules about estate recovery. So we wanna cover those to make sure that we are helping our clients become eligible for Medicaid, so that they can take advantage of these programs. So I'm gonna start with our married couples. It's a little more cut and dry when it's a single person, you either medically qualify or you don't. The general rule is $2,400 in countable assets. Where I practice in Pennsylvania, there is a disregard amount for low income individuals, where they can keep up to $8,000. But general rule, 2,400 for Medicaid eligibility. When we have a married couple, there is a division of assets, okay? We can't impoverish our spouse who's in the community, because if we did, they could become dependent on the system as well. So the federal government, and by way of the states, they don't want that. They don't want more people dependent on the system. So they are going to permit our spouses who are not our applicants to keep some degree of assets and net worth. So they're called the community spouse because traditionally, when you're talking about Medicaid, you have an institutional spouse who's in the institution, and you have the community spouse who lives in the community. 

Obviously, when we're applying for home and community based benefits, everybody's living in the community. But we're gonna still refer to them, our applicant spouse is going to be our institutionalized spouse. And then our non applicant spouse is going to be our community spouse. So they're gonna pull the assets, okay? This is gonna vary from state to state, but in Pennsylvania, the date that the state uses is the date of the assessment. So as part of enrolling in this waiver program, there's three in-home visits that come from the, we have an independent enrollment broker who enrolls individuals in the program. And there are three separate visits that are set up to assess the individual medically to make sure that they're appropriate for the program. And all the way up through final service plan meeting. So, coming up with what kind of services the individual's going to receive. But we use the date of the assessment, okay? As our financial snapshot. So that's the date that the assets are going to be pooled together, husband and wife, and we're looking at what the couple has as a whole. Now, our community spouse resource allowance is gonna be one half of the countable assets with a ceiling of 137,400 and a floor of 27,480. Now, the numbers are gonna change every January 1st. So this is what it is for 2022, note that the numbers will change every year, but the methodology is gonna stay the same. So, we're gonna take one half of the assets with a ceiling and a floor. So if we have a couple with 300,000 in countable assets, our community spouse is gonna keep that ceiling of 137,400. If we have a family with $100,000 in assets, our community spouse is going to keep one half or 50,000. And if we have a family with $30,000 in countable assets, our community spouse is going to keep 27,480 or that floor. 

So what goes into the countable assets, all right? So, it's easier to start with what's non-countable, okay? 'Cause it's a much shorter list. So the primary residence is not countable, which is often surprising because just people walking around in the community, they always hear, oh, somebody applies for Medicaid, they lose their home. Or they went to the nursing home and the nursing home took their house, okay? Which isn't really accurate as to what happened. But estate recovery is an issue which we're gonna talk about, but that's where you need to be concerned about the house. It doesn't have any countable value at the time that we apply. Your household belongings, one car, jewelry, clothing, things in your house. Prepaid irrevocable burial funds and burial plots, okay? The way that that's administered in Pennsylvania is every county has a different limit, based on the average cost of funerals. That list is published by the department of human services each January. And that's the amount that we are permitted to use for our prepaid irrevocable burial accounts, for what's exempt for the year. Any property essential to self support. 

So if you have income producing property, you operate a business, you have rental properties, anything that is providing you with income, the state will permit you to keep, okay? They don't wanna take away your income. They want you to be able to continue to support yourself to the extent that you can, okay? Any term life insurance, group life insurance, any life insurance that doesn't have cash value, and life insurance policies with a very small amount of cash value. So, a combined face value of less than $1,500. That's really just not that common. Most of our clients are going to have more than $1,500 of life insurance. But every once in a while, you'll have that client who their parents took out a $500 policy for them when they were born. So they have a small policy, the cash value in that would be exempted, okay? But for the most part, our cash value life insurance is gonna count as a countable asset. Now, also in Pennsylvania, we have another exception with regard to tax qualified retirement accounts of our community spouse. So this is not everywhere. If you know anything about Medicaid, so Medicaid's a federal program. In order to participate in Medicaid, your state has to give a certain amount of benefit or follow a certain number of rules to participate. 

However, states can be more generous than what the federal law requires. So this is an area in which the federal law is, oh I'm sorry, the Commonwealth of Pennsylvania is more generous than what the federal law requires. So in Pennsylvania, the tax qualified retirement accounts, 401ks, 403Bs, thrift savings plans, IRAs, of the non applicant spouse are exempt regardless of value, okay? So my client can have a million dollars in their IRA, if their spouse needs nursing home care, if their spouse wants to apply for Medicaid home and community based services or the LIFE program, that does not count. That that million dollars is gone, okay? It just doesn't go into the pot. So that's a great exception for a lot of my clients. All right, and then what is countable is everything else. So, secondary real estate, savings bonds, time shares, CDs, investment accounts, non-qualified annuities, other types of brokerage accounts. It all counts. Anything else that you can convert to cash is going to count. So if you have too much money, when that's normally a good problem to have, but not when you're applying for Medicaid. If you have too much money, what can you spend it on? What can you do, okay? So, obviously you can spend it on care. So if we have sometimes nursing home bills, we're paying for home care, paying off outstanding debt. So car loans, credit cards, prepaying income taxes. So, although I didn't draw it out specifically when I was covering the previous slide. Although the tax qualified retirement accounts of the person who's not applying for the benefit, don't count, those accounts for the applicant spouse do, okay? 

So if I have a single person, or if I have my applicant spouse has an IRA or 401k, that is going to be a countable resource. So if we have to spend it down, we're going to have to surrender it. And the income taxes are gonna come due. So we're gonna prepay those income taxes, so we don't have any problems come tax time next year, okay? So as I said, pay off the mortgage, prepay taxes, home repairs or furnishings, prepaying for funeral burial arrangements, clothing, travel, legal or medical bills, okay? That's how we get paid. So we have clients who have too much money. They can't get eligible for Medicaid. So a good use of that money is to hire a lawyer, to help advise them on what are some things that they can do to protect as much as possible. New car, okay? That's another one that clients use often, just because we try to think about what are the things that might be coming down the line, okay? We have that little old lady who's driving the giant boat of a car that's 13 years old and has 10,000 miles on it. And she says, "Oh, I don't need a new car." 

But the problem is is that this money is going to, something's gonna have to happen with it in order to qualify for Medicaid. And so if you've spent it on other things or even heaven forbid, you've spent it on nursing home bills or spent it on Medicaid, or spent it on home care, trying to get eligible for Medicaid, that money's gone. You're not going to get it back. And so if you need to apply or need to get a new car down the road, it's not gonna be as easy, 'cause you don't have as much money laying around. So we try to anticipate those needs. As long as the item that was purchased was purchased for the benefit of the applicant or their spouse, there will be no problem with gifting, okay? We don't wanna go out and buy cars for other people, or buying homes for other people, paying off other people's mortgages. But if the debt or obligation is that of the applicant or their spouse, that is going to be a permittable expense. For married couples. If nursing home care is contemplated or Medicaid home care is contemplated. We wanna actually hold off on any expenditures if we want them to count towards the spend down, okay? And timing is critical because if you spend too soon, you'll have to spend down again. 

So what I mentioned was the financial snapshot date for our programs here, are gonna be the date of the assessment. If the person goes into the nursing home, it's the date of admission to the nursing home. That's the date of the financial snapshot. If you start trying to spend assets down in anticipation of somebody applying for benefits or going into a nursing home and the money's already gone, there's still gonna be a 50, 50 split. But the 50, 50 split is going to be of a smaller amount because the money is already gone. So we don't want to spend down too soon, okay? So as I mentioned that snapshot date, the date of financial assessment for the married couples for home and community based services, is gonna be our date of, they call it the functional eligibility determination. So the date that they assess the individual. Okay so, that covers our assets. 

How about gifts? So if you have made gifts in the last five years, it does not mean that you're not eligible for medical assistance for five years. So there's a calculation that's performed. I think that's a big misconception that people think that the five year look back means that you can't apply for five years, but it doesn't. The five year look back is an audit period to determine, did you give anything away within the last five years? And if you did the department of human services here, they're going to take the amount of money that you gave away and divide it by the average cost of nursing home care in the state. So in Pennsylvania, our average cost of nursing home care this year is $482.50 a day. So we take the value of what was given away, divided by $482.50 a day. And that gives us the number of days the person is ineligible for Medicaid. 

For example, Mary gives away $100,000 to her grandson in 2020 for his education. In 2022, she suffers a stroke and moves into the nursing home. Once her other assets have been depleted to $8,000, okay? 'Cause that's her limit. She will have an additional 207 days of ineligibility for medical assistance. So we take the $100,000 divided by $482.50, and that gives us 207 days, Okay, we don't have partial days, 207 days of ineligibility, okay? And I do note that we wanna make sure all appeal options have been exhausted. Just what that means is that the presumption is going to be that you gave away this money in contemplation of needing care. And that often is not the case. I mean, in this example here, we showed that Mary gave the money to her grandson for his education. And so we may have an opportunity to rebut the presumption and prove that at the time that Mary made this gift, she was healthy, she couldn't have contemplated needing nursing home care, she had a lot of other assets that she could have used, and that it was reasonable. 

Now, on the flip side, let's say Mary already has had a dementia diagnosis for two years. And that this $100,000 is every penny that she had to her name. Well, you're not gonna have a strong argument to say that she didn't contemplate needing nursing home care, or she didn't think she might need this money to pay for her care in the future, okay? You're probably gonna lose an appeal on that end. But if you have a good fact pattern, you might be able to appeal. Now, there is no period of ineligibility, or for asset transfers made to your spouse, okay? A blind or disabled child, a trust for the benefit of a blind or disabled child, or a trust for the benefit of another disabled person under the age of 65. So, if you have disabled grandchildren or disabled siblings, you can make gifts to those individuals via a trust. But if it's your actual child, then it can be a straight gift. Now, we wanna be careful just in case that blind or disabled child is also on their own benefits. 'Cause we don't wanna upset anything that they already have. So we need to be careful. But we can make straight gifts to a blind or disabled child, okay? And just actually, as a note, along those lines, the blind or disabled child, they don't have to have been blind or disabled from birth. So they could be somebody who was 50 years old and got hurt at work, and now they're on SSD, okay? So it can, any disabled child, it doesn't mean that they were your disabled child when they were minors, okay?

Okay so, now let's talk about a crisis plan, okay? A Medicaid crisis plan. We have Bob and Mary Jones and they're going to start looking into care. So Bob, something has happened, maybe his dementia's progressing, or he's becoming frail and having a hard time getting around the house. And we're gonna seek out Medicaid home and community based services, okay? Now his wife, Mary, we're gonna call her healthy, okay? She may or may not be, but she's not applying for home and community based services at this time. They have $350,000 in countable resources. Plus Mary's $225,000 IRA, okay? So again, in Pennsylvania, that's not gonna be countable. So we get to just take that off the top and put that aside. We have the family home valued at $250,000, which is also non-countable, and how are we gonna solve this case? 

So we're gonna transfer the home to Mary. We're gonna create a new will for Mary disinheriting Bob. This will is gonna protect the home and other protected assets if Mary unexpectedly dies before Bob, okay? So if you've been in this line of work for any period of time, you know that we never know. It's a flip of a coin. We have our quote-unquote unhealthy spouse and our quote-unquote healthy spouse. And our healthy spouse often passes away before our non-healthy spouse. And either it's something sudden or they've neglected their own healthcare needs for so long that now something has occurred in their life. They've got an opportunity to get a break and now their own health starts to crumble. So, if they pass away first, everything that they got to protect, if their will says, "All to my spouse," or they still hold assets jointly. The spouse who's our institutional spouse, either in the nursing home or applying for home care benefits, they're going to lose their Medicaid, 'cause now they have had a sudden net worth increase, okay? 

So we wanna make sure that we take steps to create a new estate plan for our healthy spouse. That's going to allow for them to disinherit, to the extent permitted by law, their institutionalized spouse or their applicant spouse, okay? We're gonna change the beneficiary on the IRA to the children, okay? Again, for the same reasons, we don't want Bob to inherit Mary's IRA. That's money that he would get and have to liquidate and spend down to keep his Medicaid eligibility. We're going to identify Mary's protected assets, and spend down the rest, and preserve our remaining assets, okay? So we have our $350,000 of total countable assets. Mary's protected share is gonna be that maximum community spouse resource allowance of 137,400, Bob's protected share is gonna be $8,000, okay? He gets to he's one of those individuals that gets to keep a little bit more because of his income, the way that the rules work here in Pennsylvania. And their spend down is gonna be $212,600, okay? We're gonna prepay funerals for both spouses at about $40,000. We can do home improvements, purchase a new car, pay off their mortgage, or credit cards, or other debts. They're going to hire our law firm to represent them. And we're going to take with what's left and purchase a Medicaid qualifying annuity for Mary, which is gonna preserve our remaining assets from spend down. 

So Medicaid qualifying annuity is a specific type of annuity. It's not an investment, okay? It's a specific annuity that permits the countable resources of a married couple, to be converted into an income stream in the name of the community spouse, okay? When we apply for Medicaid, the income of the community spouse does not count towards the eligibility of the institutionalized spouse. An annuity can be an asset, okay? Or it can be income. If it has been annuitized, then there is no cash value and it is purely income. So if we convert the excess assets that otherwise would have to be spent down into a stream of income, by purchasing the Medicaid compliant annuity with the excess resources, that will be for the benefit of the community spouse. As a result, the resources converted to an annuity are exempt, because there's no cash value to them anymore. They're just purely an income stream. They're gonna be returned to the community spouse via a monthly income payment. And we're gonna try to do that as quickly as we can. And by structuring the annuity to pay out quickly, we're decreasing the likelihood that the healthy spouse will pass away before receiving all of their income. So, what that means is that the reason you're permitted to do this, is that the requirement is that the state be the beneficiary in the first position of this Medicaid qualifying annuity. So, the government says, "Okay, sure, community spouse, you need money to live off of. We'll let you have this. But if you pass away before all this money is returned to you, if there's anything left in it, it's going to go to pay back the state for the care that they provided to your spouse." 

All right, so, here we go. Mary and John have $350,000 in countable resources. John enters the nursing home, okay? Or maybe in our, we're talking about home and community based services today. So John's going to apply for Medicaid home and community based services. And we have our financial snapshot, okay? Mary gets to keep the maximum of 137,400 and 212,600 is subject to spend down, okay? So our numbers that we just talked about. John's gonna get to keep his disregard amount and they have $204,600, okay? We're going to purchase an immediate annuity for $204,000, Okay? That's just making the math easy for me. There's no magic to that, but we're gonna purchase the Medicaid annuity for $204,000. And we're going to have that pay out in equal installments to Mary, of $11,333.33, each month for 18 months, okay? So they are required to be equal payments. To be a Medicaid qualifying annuity, it has to provide for equal payments, okay? So we have to take whatever amount we put it in and divide it up in equal shares. At the end of the 18 months, Mary has her entire $204,000 back. John's been eligible for Medicaid payment for the entire time, all right? 

So, everybody's state might be a little bit different with regard to what they deem as reasonable. Here in Pennsylvania or not even just in Pennsylvania, but in my own practice, my clients wanna know what to expect. What they're paying for to a certain extent is some comfort with the process. That they can be told what to expect. They know what's gonna happen next. They know what the outcome's gonna be and what it's gonna look like. So to that end, most of my clients are not interested in trying to, I guess, be crazy, so to speak and see what we can get away with. They wanna know what what's going to happen. So, we know that the state is not really going to blink. If the annuity payments are 10, $11,000 a month, that they're going to consider that to be a reasonable amount of money. We don't wanna put $500,000 into a two month annuity and take two income payments of $250,000. That that's gonna be challenged, okay? That's that's not reasonable. So, it may be different where you are when you go to apply. But those are the numbers that we use just as a rule of thumb. Because again, we can know that we're not gonna be challenged and our clients can know what to expect, okay? So, that's married couple, as you can see, we can get somebody eligible for Medicaid, fairly easily protecting almost 100% of their net worth, okay? In that situation, Mary's probably out, her legal fee that she paid to us and the company that we purchased the annuities through charges a fee for their service, because they don't really get any opportunity to make money off of your money when they're returning it to you so quickly. So, that's pretty much all she's out of pocket and everything else, they got to keep. And they were eligible for Medicaid home care almost immediately. 

Let's talk about, now Mary's a single person, okay? So she's no longer married, her husband's predeceased her. She's living at home with her daughter, Carol, okay? Mary's needs are beginning to increase, but Carol is still able to meet them. If Mary were living alone, she would require extensive in-home care or placement in a facility. But right now she's okay 'cause she has her daughter. So what do we do about protecting Mary's home, and $250,000 in savings, and getting her eligible for Medicaid home care? Okay so, while traditionally giving your house away to your child would be considered to be a gift for which you would be penalized. There's a few exceptions, okay? One is going to be that disabled child that we talked about previously, but the other is the caretaker child exception, okay? So if you have a child who has lived with you for two years or more prior to you entering the home, okay? Or prior to applying for Medicaid home and community based services, you are permitted to give that child the home and it's not considered to be a gift, okay? Now, depending on, as I mentioned before, some jurisdictions are more generous than others. So I do happen to know that for instance, Florida is more generous with regard to the estate recovery against the family home, okay? Estate recovery does not extend to the family home in Florida. So you might not need to do this type of planning for the family home if that was your jurisdiction. In Pennsylvania, it does. So estate recovery does extend to the family home. There is no homestead exemption for it. 

So we do wanna often do planning for the home. We wanna try to make sure that we're protecting it from Medicaid estate recovery. So here we're going to take advantage of the caretaker child exception, and we are going to give Carol the home, okay? That takes it out of Medicaid estate recovery. And we don't need to worry about it anymore, okay? We're gonna consider maybe a couple of home improvements to help make the home safer, making it easier for her to age in place. Pre-planning funerals, hiring a lawyer, and we're gonna consider a gifting plan for the remaining assets. All right, so, oftentimes we're going to use an irrevocable trust. Occasionally we'll make a straight gift to a child, but in this case, we're going to do an irrevocable trust. She had $218,000 in excess resources, okay? After the other things that we spent her money on. That's gonna create a 14.8 month penalty period, okay? So if I use the daily rate before the monthly rate for Pennsylvania, $14,676 a month is the monthly rate average cost of nursing home care. So the $218,000 divided by the average cost of care, 14.8 months. 

After the expiration of the penalty period, Mary is gonna be eligible for home and community based services, and or eligible for Medicaid payment for nursing home care and any subsequent move to a nursing facility. So here's an example of maybe one of two things. So either, yes, we're trying to get Mary care at home, okay? Or we are trying to accelerate her eligibility for Medicaid so that in the event that she does need nursing home care down the road, she's already through her ineligibility period. So, the way that it works here is that the state is not going to send anybody. If you're not eligible for Medicaid, because you're in a penalty period, the state's not gonna send anybody to pay for the, or send anybody to take care of you. And therefore, because they're not sending anybody, there's no bill. So if you're able to be cared for by family supports, it actually allows your penalty period to run almost for free, okay? So you're not paying anything out. Whereas, if you were in a nursing home and you were not eligible for Medicaid, you would be paying for every single day that you were in your penalty, okay? So, we will sometimes use the fact that the Medicaid home and community based services follow the same rules to intentionally toll the penalty period, okay? 

So, we know that Mary's health will be declining. She's doing okay right now. We can give her daughter this money and apply for Medicaid home care benefits, and let this 14 months run. And maybe she'll get through all 14 months before she needs nursing home care. Maybe she'll only get through six months before she needs nursing home care. But she's going to be able to get through some period of time that she's not paying for, which is going to allow them to protect more assets, okay? So we were able to protect those assets, she spent money hiring a lawyer, making handicap accessible bathroom, adding a stair-lift in. So we were able to take care of that. Now, the only difference in Medicaid eligibility rules here in Pennsylvania, have to do with the income. So we do have an income limit 25 to 23, for 2022. If your income is above that amount, gross monthly income, you are not eligible to take advantage of Medicaid home care benefits, okay? So you can't get Medicaid payment for the LIFE program. You can't have Medicaid payment for home and community based waiver services. We do have a couple of options. So, now this could be different in your jurisdiction if you are permitted to use Miller income trusts, we cannot in Pennsylvania. So that's not permitted. So we can't do anything with the excess income to get back under the threshold, to utilize home community based services. However, we do have a process by which as long as the person's income is only slightly over the limit, okay? That would be less than $500 a month. We are permitted to do a gift to a special needs trust because Medicaid doesn't penalize anything that's less than $500 in a month, as far as a gift is concerned, we're permitted to make an excluded gift of up to $500 a month to a special needs trust. And they will permit that individual to be eligible for Medicaid home and community based services. So, that's a great exception that we can utilize. If somebody's just slightly over. In the last year, I actually had somebody who was only over by $2.36. And he otherwise would not have been able to take advantage of Medicaid home care. We have to round up, but we put $3 a month into a special needs trust for him. And he was able to get eligible for services, okay? 

So I touched on it, but Medicaid estate recovery, okay? That's the program by which the state's required by federal law to try to get paid back out of the assets of somebody who has taken advantage of Medicaid during their lifetime. In Pennsylvania, our estate recovery is limited to the probate assets or the probate estate of the individual. So if we haven't done all of our appropriate planning, it's a possibility that the home, or maybe some group or term life insurance, might be part of what goes back in estate recovery. So we do wanna try to plan for the home. You know, sometimes it's adding a joint owner. A lot of times it's putting the home into an irrevocable trust, sometimes gifting to a blind or disabled child, or to that caretaker child, doing something with the home to try to protect the equity or net worth. And the group life insurance, often we see that the individual was working, they were 25 years old, they put their spouse on the policy, and 50 years later the spouse died. They never went back to their prior employer and asked to change the beneficiary on the life insurance. The life insurance becomes payable to the estate of the individual at their death. And that money is lost in estate recovery. So, we want to try to plan for estate recovery as best we can. So, there are some exceptions undue hardship waivers for disabled children or caretaker children. So, those exceptions still do exist. Even if the individual did not exercise them during their lifetime. 

So, what would happen is if we have a caretaker child who would otherwise have qualified, and we did not transfer the home to the individual during their lifetime. When there's an estate recovery claim against the probate asset of the home, we can file what's called an undue hardship waiver showing that this child lives there, that's their primary residence, they don't have another place to go, and they would've qualified. So, they will, they being the state, will consider that an exception and they will waive their claim against the house. It's also possible if maybe the child isn't a caretaker child, maybe they only just moved in after mom went into the nursing home. If they can show that they have nowhere else to go, the state will postpone the claim. Now this is the only time, although everybody says, "Oh, the state puts a lien against your house." They don't. But this is the only time that they actually do put a lien against the house. They would put a lien against the home that is recorded so that if that other child or whoever's living in the home, if they sell it, vacate it, then the state does get paid back on their Medicaid estate recovery claim, okay? All right, So that's Medicaid. They're gonna be, like I said, one of our larger payers of long term care, and that's usually just because we get more bang for our buck. Home care is very expensive and we're gonna talk about VA benefits next, but VA is just a cash benefit. And so, it doesn't go as far as the Medicaid benefit goes, but still very important. 

So, we're gonna talk about VA pension benefits. The term pension is often misleading because it's not really based on your term of service, but it's a needs based cash pension program for eligible wartime veterans, or they're surviving dependents. So surviving spouses or surviving dependent child. If you are the veteran, it is called, The Improved Pension. If you are the surviving spouse or dependent child, it's called, The Survivor's Pension. They used to call it Death Pension, but that sounds kind of yucky. So they, a few years back changed it to Survivor's Pension. And aid and attendance and housebound, are additional rates that are paid on top of the basic pension rate, okay? If you cannot get aid and attendance, you can still qualify for increased benefits by being housebound. And housebound is basically what it sounds like, that you can't leave your home without the help of somebody else. It's a practice point though. I have never gotten a housebound rating for any of my clients, because if you can't leave the home without the help of somebody else, you often can't do other things without the help of somebody else. So, aid and attendance is again the highest rating. And it's for individuals who need help with their activities of daily living, that they need the aid and attendance of another person to be able to do their dressing, bathing, toileting, medication management. They need to live in a protective environment because they can't appreciate the dangers in their environment. You know, they've dementia would leave the stove on, or they would leave the house and not be able to find their way home, okay? 

So what are we talking about? Well, it's as I mentioned, it's just a cash benefit. If you're applying for the straight pension, the monthly maximum award amount is gonna be 1,610 a month for the veteran and their surviving spouse. So it's for a married veteran. Single veteran is 1,229. And a surviving spouse is gonna be 824 a month. Now these are the maximum amounts when I say maximum it's because the VA pays this benefit on a sliding scale based on what the individual needs, okay? We'll show how they determine what you need, but those are the maximum amounts. For housebound benefits, our monthly maximum award amount, okay? Is gonna be 1,883 a month for the veteran and their surviving spouse, 1,502 a month for single veterans, and $1,007 a month for the surviving spouse. And aid and attendance, our highest rate, 2,431 a month for the married veteran, 2,050 for the single veteran, 1,318 for the surviving spouse. 

So, as I mentioned before, or I'm sorry, as I didn't mention before, though, the benefit is only paid to the veteran as long as the veteran is alive, okay? Regardless of who the individual is, who needs the help in the family, as long as the veteran is alive, our veteran has to be our applicant. The surviving spouse can only apply once the veteran has passed away, okay? The veteran has to have been discharged from service under other than dishonorable conditions. So honorable discharge, general discharge, medical discharge. They had to serve 90 days of active duty. And one of those 90 days fell during a period of war time. They meet the income and net worth requirements. They are permanently disabled, so 100% disability rating, or they're 65 or older, okay? So how many veterans are walking around out there that are 65 or older with 90 days of active duty, and one day fell during a period of war time, okay? That's a lot. 

Now veterans who enlisted after September 7th, 1980, actually do have additional service requirements. They actually have to have served 24 months or their full period to which they were called, okay? And one of those days has to fall during war time, the war time service periods, okay? World war two, December 7th, 1941 through December 31st of '46, Korean war, June 27th, 1950 through January 31st of '55, Vietnam era, August 5th of '64 through May 7th of '75. Now, for this benefit, there is no requirement that you served overseas, that you had boots on the ground, that you served in combat. However, the Vietnam war, if you actually did serve in Vietnam, they will back that date up to February 28th, 1961. So it gives you an extra window of opportunity to claim this benefit if you actually served in Vietnam. Otherwise it does not matter whether you even ever left the United States. If you were on active duty, and there was a war going on, you qualify, okay? For our Gulf war veterans, August 2nd 1990 through present. So there actually hasn't been any congressional, or presidential proclamation, or declaration that the Gulf war has ended. So we have to assume everybody, August 2nd, 1990 through present is a wartime veteran. However, depending on when they enlisted, they may have fallen under that two year requirement instead of just the 90 days. 

Okay, So the VA has a net worth threshold that they establish each year. For 2022, it's $138,489, okay? The countable assets are going to be similar to Medicaid. They're going to look at the assets of both couple or both individuals and a couple, if it's a married couple, all right? Now, the VA actually didn't used to have a net worth requirement. And they changed a lot of rules on October 18th of 2018. So one is that they established this hard and fast net worth rule, which makes it easier for us to apply 'cause we know if somebody's financially eligible or not, ahead of time. And they also impose a look back period, similar to Medicaid, to deter veterans from intentionally divesting themselves of their resources to try to get benefits sooner, okay? So, before that time we could meet with the family, set up an irrevocable trust, divest all of our assets to an irrevocable trust, and apply for Medicaid benefits the next month. And we were totally permitted to do that because there was no look back period, Okay? There is now. 

So when you make your claim, you're required to disclose any gifts and you'll be penalized for any gifts that you made, after October 18th, 2018, okay? And we are now three years out from the change in the law, so it is a full three year look back period. The penalty is calculated similarly to the penalty as we described for Medicaid, there's just a different advisor. They use the married couple maximum aid and attendance rate, okay? So which this year is 2,431. So if we've made a gift of $10,000, we have a five month ineligibility period, $50,000, 21 month ineligibility period, gift of $100,000, we have a 42 month ineligibility period, okay? So note that the penalty can be longer than the look back, okay? A gift of $150,000 would be the maximum. So the penalty will max out at 60 months, but the penalty can be longer than the look back period. So we wanna be really careful when we're applying for benefits to make sure that we're not making somebody ineligible for two extra years, when we should just be waiting out the rest of the 36 months, okay? So, it might be cheaper to just to wait the three year period rather than apply and take the penalty. The penalty runs a little bit differently than it does for Medicaid. Where Medicaid, the penalty starts to run at the time that you're eligible, for the VA, the penalty starts to run at the time that you made the gift, okay? So the penalty may have already run before you even apply for VA benefits. 

So, an analysis always needs to be done with the VA to determine when's the appropriate time to apply. So, this is where it can get dangerous when people are told by a facility social worker, or just a friend like, "Oh, just apply for VA benefits and see what you get." Well, no, 'cause you might have screwed yourself up and lost two whole years of benefits, if you would've just waited, okay? So, we don't wanna just apply and see what sticks. So the way VA looks at income is they look at your income and relationship to your unreimbursed medical expenses, okay? So if your income is too high, you can't call up social security and say, "Send me less money." If your income's too high, you can pay it down by, or offset it by showing increased unreimbursed medical expenses. So, we can intentionally increase those expenses, hiring a caregiver, paying a family caregiver, making a move to personal care. Those can all increase somebody's costs and then drive their income down. 

The income limits for aid and attendance. We have our married veteran, your income has to be less than 2,431. Single veteran, less than 2,050. Surviving spouse, less than 1,318. Now you might be saying, "I recognize these numbers, I've seen these before," and they are also the maximum benefits. So when I said the maximum, or the benefits paid on a sliding scale, okay? This is the maximum benefit that you can get. So what the VA's going to do is they're going to look at your income for VA purposes. So the income, less the medical expenses, and see what is your actual income and how does it relate to the maximum benefit amount. And then you'll get the difference, okay? So if our income is totally consumed by outgoing medical expenses, so we have a negative or zero for our IVAP or income for VA purposes, we're gonna get the maximum amount, okay? So if my income was 23, if I'm a married veteran, okay? My income is 2,430 a month, I'm gonna get $1 a month of VA benefit. If I wanna get that maximum VA benefit, I wanna have zero income, okay? So those are income for aid and attendance. 

So, while aid and attendance is a financial benefit, okay? So that's gonna be that cash benefit that you use to pay for care. If you're enrolled with VA healthcare, you fill out the 1010EZ. You can also receive long term care services provided by the VA. Now, this payment towards the cost of your services is gonna be based on your priority level, which is gonna take into consideration your service connection, your assets, your income. So, sometimes veterans maybe cannot get long-term care services provided by VA healthcare because they don't have a service connection, and they have too many assets in income, okay? Some can get it for free. Some will have to pay a co-pay for services. What I can tell you though, is that if you do go back and qualify for the VA pension program, it will change your priority level. So if you've been turned away from VA healthcare before, and then you get eligible for aid and attendance or other VA pension programs, go back and reapply for VA healthcare, 'cause it'll change your priority level and you will be eligible. Now, the VA will provide adult daycare, home health aids, hospice and palliative care, assisted living, and nursing home care. So if you qualify for VA healthcare, you can get these services provided by the VA, okay? So this is different. So the VA pension benefit is gonna be, you're gonna get cash, and you're gonna pay your own providers, okay? The VA healthcare program is the VA's gonna pay the providers directly, all right? 

Another VA home care program that's available is the VA family caregiver assistance program, all right? This is the program of comprehensive assistance for family caregivers. It will pay for the son, daughter, parent, or extended family member of a veteran, or somebody who lives full time with the veteran. The veteran must have had a service connected disability of 70% or higher. Their disability must have been caused or made worse by their service, that was either before May 7th of '75 or after September 11th of 2001. Okay, so our Vietnam era, veterans and older, okay? Or somebody who their service was September 11th, 2001 and forward. And they're gonna need continuous services for at least six months, okay? So this isn't a program I can use that often with my clients because most of my clients don't have a service connection of 70% or higher. I'm dealing with a lot of folks who have no service connection, okay? So the VA pension program is a non-service connected disability pension. That's just as a result of your service. If you have a service connection, you can get VA compensation. So that's a different monetary benefit for people who have a service connection. And this program is available to those with a service connection of 70% or higher. If these conditions are met, the family member can be paid a stipend and receive health insurance through the VA, because they're caring for a family member. So this is huge. The stipend's gonna be between 26,000 and $29,000 depending on the care needs. So you're essentially becoming a government employee, okay? And you're given a pay grade. This income is tax free, you don't pay any income taxes on it and you get health insurance. So that can be huge, again for a family caregiver. It takes about 45 to 90 days to get enrolled. And this can be paid in addition to compensation and aid and attendance. So, if you are already getting a VA compensation because of your service connection, this benefit is paid to your caregiver. So it's separate. So you still get your money. And then the VA pays that family caregiver as well, okay? 

I just wanna take a few moments here at the end of our presentation to talk about some of the considerations, things we wanna talk about. And this is more along the lines of just the conversations to have with your clients about entering into these arrangements, more so than educating a client on what they should be doing. But these are things that you wanna just bring up. You know, there's going to be some sort of living arrangement. So whether the care is gonna be provided to the individual in the individual's home, or child is bringing parent into their own home, or maybe they're living in an independent living facility or in an apartment, and somebody's going in to see them. We wanna talk about cohabitation arrangements. When we enter into these agreements, they might not be thinking about applying for government benefits down the road, but they very well may be. And so we wanna make sure that we're not running into trouble applying for government benefits because of maybe financial arrangements that were made when individuals enter into these arrangements. 

So, here's an example, parent moves into child's home, they're eating food, utilizing utilities, and just overall increasing the costs and expenditures of the house. You know, they wanna start contributing to the bills and they start transferring money to their kid, or they're taking out withdrawals of cash and giving them cash. And those can be considered to be gifts for Medicaid purposes. Similarly, the child maybe quits their job or cuts back on work hours to begin taking care of parents, and maybe parent's going to give them money to make up for those hours. Again, that could be penalized as a gift for Medicaid purposes. So we wanna make sure that the elder's always getting fair consideration. We wanna have lease agreements. We want to have family caregiver agreements, or even just, if it's not a family member, a contract in place. We wanna make sure that there's a substantiation that that elder has a responsibility to pay those bills so that they're not gonna be treated as gifts. And they will be transactions in which the elder received fair consideration. 

Sometimes people wanna buy a new home together, okay? So parent and child are both gonna sell their homes and they're gonna buy a house together, because they're gonna have an in-law suite and it'll be one level living, and it's gonna work out better for everybody. We wanna be careful about how we're titling the house, so that there's gonna be fair consideration. So we wanna make sure that if mom or dad's putting their money in, that they're getting some sort of equity interest in the house in return. But we also wanna make sure we're protecting from estate recoveries. We wanna use joint tenants with right of survivorship or other designations, so that we're not going to have estate recovery against the house in the future, okay? Sometimes too, if there's even gonna be a large addition, that's gonna be added on maybe to child's home and mom or dad's gonna pay for it because it's gonna be their residence, that's where they're gonna live. We may want to give them an interest in the home so that they're actually buying something, okay? And they're not just increasing the value of their child's home. That's how the department of human services is gonna view it. That you gave $50,000 for an addition to your child's home. Well, yeah, that person's gonna live there, but your child is gonna be the one who reaps the benefit in the future. So by giving you an equity interest in the home, we've satisfied the fair consideration transfer position. 

Caregiver duties, we wanna make sure that we are clearly outlining what the caregiver's responsibilities are, what they're going to do, what they're not going to be expected to do. What's the hourly rate going to be? Is there gonna be a cost differential for overnights or weekends? What are the terms under which that can be terminated? These are the things that you would be dealing with at agency, you'd be discussing those. What's the rate? What's the difference on overnights or weekends? You know, how do we pay? What's that, when can we cancel the agreement? But sometimes those things are not considered on a family caregiver arrangement. So we want to make sure that we are putting those things in writing, because those questions will come up. Those concerns will be there. You know, we wanna make sure that our caregiver is providing for the social needs and transportation of the person that they're taking care of. 

Let's address that in the agreement, not just the personal care needs, but companionship needs, religious needs. Are they gonna take the individual to church? Are they gonna take them to a card club that they've always been a member of? Are they gonna make sure that they still see their friends for lunch? We don't wanna have the individual in this position where now they feel like they're totally dependent on the caregiver, and the caregiver's not allowing them to see their friends, or do the things that they used to do. Is the caregiver gonna provide care in, well, not provide care, but provide transportation in their own vehicle? In the care recipients vehicle. What about car insurance? Rearranging for public transportation, medical assistance provided transportation. There's considerations with all of that. 

You know, I see problems too, and this is again, a more of a Medicaid application problem. Mom or dad's gonna buy a car for child to drive them in, or they're going to give them money to put towards the purchase of a car because child has to get a new car that makes it easier for mom or dad to get in and out of. We wanna make sure that we're trying to think about those things, or at least plan for them. If we know we have done them, if we need to apply for Medicaid in the future, that we're going to potentially have some sort of transfer penalty. So let's get that in writing. Many individuals entering into these arrangements might also be applying for veterans pension or aid attendance in the future. We need to make sure that those caregivers are providing assistance with activities of daily living in order for the caregiver expense to be treated as a medical deduction. So we wanna write into our family caregiver agreements that the caregiver is providing assistance with activities of daily living, because that's gonna be necessary in order to get VA benefits. Even if they're not necessarily contemplated, originally when you enter into this arrangement, it might be something you wanna take advantage of down the line. 

Most of our family caregivers are gonna be non-medical caregivers, or even if they're not family members, if we're using a neighbor or a friend, and we wanna address the agreement as such. That it's not gonna be expected that they're gonna oversee medication administration. They're not gonna be responsible for the nutritional needs of the individual, that those things are not going to be part of their responsibility. And you wanna put a plan in place for if there is a medical emergency. You know, who to call, who the treating physicians are, what hospital to go to. If there is gonna be the need in the future for IV medications, feeding tubes. What's our plan to bring in medical support, like a registered nurse to that situation? Because the caregiver's not gonna be medical in nature. 

Unique considerations and common pitfalls in family caregiver arrangements. Payment's gonna be one, one of them, okay? So we talked about, for fair consideration purposes, but the caregivers quitting their job. They're cutting back at work. They're taking on this additional burden on top of their other employment or responsibilities. You know, family care can be paid for care. It doesn't have to be for free, but there can be issues with family dynamics. So the child who is maybe not the primary caregiver is gonna see this as a windfall to the child who's being paid for care. They say that it's unfair. And that's just another reason why we wanna have it in writing. Showing what the hourly wage is and that the person is just providing care that otherwise you would be paying the same amount for, by hiring an agency. We wanna have contingencies in place. You know, we never think about what happens if our caregiver is sick. You know, with an agency, they just send somebody else's backup. But with a family arrangement who is gonna be that backup, who's gonna cover vacations or weekends? If we are providing family paid care, who is paying the taxes? Is the caregiver starting their own caregiving company and taking care of the taxes? Is the elder paying them as an employee of the household and withholding. What if the caregiver is hurt in their duties? Is there worker's compensation? Does it fall under homeowner's insurance? What if the caregiver in inadvertently hurts their parent taking care of them? So, we sometimes want to have the family caregiver employed by an agency. Often the agencies will permit that caregiver to only provide care to their own parent or to their brother or sister if they want to, but that will permit all of those things. You'll have insurance, you'll have the taxes withheld, and you don't need to worry about it. 

Now, the flip side of that is that most people don't wanna go that route because they want cash under the table. They're willing to work for less because they're taking cash. But it's so important to legitimize this as actual employment for government benefit reasons, and for taxation, and insurance reasons. So as we wrap up here, I did provide in the materials, just a sample caregiver agreement, how I write my agreements up, just addressing some of these things that we talked about. The services performed, the transportation, what are the services that the individual is going to provide, the hourly rate. It's just so important. Many of these situations can be rectified or even avoid any sort of problems when they're just written out in advance. And these are, when we're entering the family caregiver agreements, we're taking care of our family members out of love and respect, and that's still why we're doing it. But unfortunately just with applying for government benefits down the road, and maybe the need to replace lost income. If we are choosing to step back at work to take care of a family member, it needs to be done. There's gonna be money changing hands. And we just wanna put things in writing to make sure that we don't have any problems down the road. 

So I thank you so much for your time and attention today. And I hope that you learn something about options for taking care of your clients who maybe want to receive care at home and utilizing what government benefits do exist out there, to help pay for that very expensive and very valuable care.