Institutional Medicaid §1634 Changes - Pro Seniors

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Institutional Medicaid §1634 Changes (8/25/2016 Edit) To: All Staff From: Managing Attorney

__________________________ General

1) For ODM QIT forms see http://medicaid.ohio.gov/INITIATIVES/DisabilityDeterminationRedesign.aspx

2) Ohio Medicaid eligibility must have the same criteria as SSI eligibility. [EN1]

3) As of September 1st, 2016, the average private pay rate for nursing facilities, used to calculate Medicaid penalty periods for improper transfers, increases to $6,570 from $6,327. See Medicaid Eligibility Procedure Letter No. 118, at http://medicaid.ohio.gov/RESOURCES/Publications/ODMGuidance.aspx#1535541-medicaid-policy.

Resources

Retirement Funds

4) For Community Medicaid only, the Community Spouse’s retirement funds are exempt.

Exempt Resources 5) Exempt resources increased from $1,500 to $2,000 for an individual, $3,000 for a

couple. The Home

6) When I go into a nursing facility, my home is exempt as long as I intend to return to it.

7) A home in a living trust is treated the same as a home not in a trust.

8) A home that is no longer the individual’s principal place of residence is still an excluded

resource so long as a spouse or dependent relative of the individual continues to live there while the individual is institutionalized.

9) A home that is no longer the individual’s principal place of residence is still an excluded resource if its sale would cause undue hardship for a co-owner of the property, due to loss of housing.

10) If the individual leaves the home with no intentions of returning due to domestic abuse, the home can still be an excluded resource.

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11) A home that is no longer the individual’s principal place of residence can still be an excluded resource if the property satisfies the provisions governing the treatment of property essential for self-support.

12) An individual is not eligible for LTCF services, a HCBS waiver or PACE if the individual's

equity interest in the individual's home exceeds the home equity limit ($552,000 for 2016), but there is an undue hardship exception to this rule.

13) Note that more homes will end up in Medicaid Estate Recovery because the Medicaid recipient will still own the home at death.

The Car

14) When I go into a nursing facility, one automobile is excluded for me or a member of my household, regardless of value, if it is used for transportation.

Annuities

15) Medicaid will now permit a community spouse to place assets in excess of the community spouse resource allowance (CSRA) into a single premium immediate annuity which follows certain criteria as set forth by Medicaid. However, consumers should be aware that such annuities are not appropriate in every case.

Medicaid Planning

16) The Medicaid Planning strategy of “reverse half-a-loaf” for transferring assets has been eliminated.

17) What are ABLE (STABLE) accounts and how are they used?

18) UPME (Unpaid Past Medical Expenses) is still available (the old ACT 52) and more useful than ever due to lack of retroactive coverage for higher incomes without a QIT.

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1) Under § 1634 must Ohio Medicaid eligibility have the same criteria as SSI eligibility? Yes. Starting August 2016, the State of Ohio is switching to a "1634" state and will no longer be a "209(B)" state. Under Section 1634 of the Social Security Act, states enter into an agreement with the federal government to use the Social Security Administration (SSA) to determine Medicaid eligibility for its aged, blind and disabled population. The State of Ohio is switching to a system where Medicaid will accept the Social Security Administration's decision that a person is eligible for SSI, which will automatically enroll an SSI beneficiary in Medicaid. Therefore, all eligibility criteria (income, resources, etc.) for both programs must align. For more information, see http://www.hannah.com/DesktopDefaultPublic.aspx?type=hns&id=202792. For a list of SSI resource exclusions see POMS - SI 01110.210 Excluded Resources.

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2) Are the Community Spouse’s pension funds exempt?

Yes. SSI holds exempt, the spouses’ “pension funds” defined as funds held in individual retirement accounts (IRA) or in work-related pension plans (including such plans for self-employed persons, sometimes referred to as Keogh plans.) Medicaid refers to them as “retirement funds” and defines them in the broadest way possible as all plans designed to provide unearned income to supplant or supplement earned income. ___________________________________ 20 CFR § 416.1202. Deeming of resources. (a) Married individual. In the case of an individual who is living with a person not eligible under this part and who is considered to be the husband or wife of such individual under the criteria in §§ 416.1802 through 416.1835 of this part, such individual's resources shall be deemed to include any resources, not otherwise excluded under this subpart, of such spouse whether or not such resources are available to such individual. In addition to the exclusions listed in § 416.1210, we also exclude the following items: (1) Pension funds that the ineligible spouse may have. Pension funds are defined as funds held in individual

retirement accounts (IRA), as described by the Internal Revenue Code, or in work-related pension plans (including such plans for self-employed persons, sometimes referred to as Keogh plans);

See also POMS - SI 01330.120 Deeming - Spouse-to- Spouse Exclusions from Resources at https://secure.ssa.gov/poms.nsf/lnx/0501330120. ___________________________________ OAC § 5160:1-3-05.20 - Medicaid: deeming of resources (E) Spouse to spouse deeming

(1) When an eligible individual and their spouse live together, all resources are combined and the couple is permitted resources in the amount described in rule 5160:1-3-05.1 of the Administrative Code in addition to what is described in rule 5160:1-3-05.14 of the Administrative Code. Retirement funds, described in rule 5160:1-3-03.10 of the Administrative Code, owned by an ineligible spouse are excluded from resources for deeming purposes.

OAC § 5160:1-3-03.10 Medicaid: retirement funds (D) Retirement funds treated as a resource

(2) A retirement fund is a countable resource if the individual or the individual's spouse has an ownership interest in the retirement fund and the legal ability to convert it to cash.

[But] (5) A retirement fund determined to be a resource in accordance with paragraph (D) of this rule, which is owned by an ineligible spouse or parent or spouse of an ineligible parent, shall not be considered for deeming purposes described in rule 5160:1-3-03.20 of the Administrative Code.

[And, “retirement funds” are defined very broadly by Medicaid]

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(B) Definition. "Retirement funds" are plans designed to provide unearned income to supplant or supplement earned income. Retirement funds may include, but are not limited to such plans as: public and private pension, disability, or retirement plans; defined benefit employer pension plans, profit sharing pension plans, 403(b) pension plans, money purchase pension plans, employee stock ownership plans, individual retirement accounts (IRA); KEOGH pension plans, Roth IRAs, simplified employee pension plans (SEP-IRA), and 401k pension plans; or any other pension or retirement plans authorized under 401, 403, 408 of the Internal Revenue Code (IRC) as outlined in 26 U.S.C. (as in effect on February 1, 2016), or any other enacted IRC provisions providing for a pension or retirement plan or any other similar financial vehicles administered by an individual, employer, or union.

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3) When I go into a nursing facility, my home is exempt as long as I intend to return to it. The definition of home remains the same. The principal place of residence remains exempt. Moving into a nursing facility has always been considered a temporary absence from the principal place of residence. But instead of that temporary absence turning into a permanent absence after 13 months, the temporary absence continues so long as the individual intends to return home, evidenced by a signed statement, and so long as she has not established permanent residence elsewhere. § OAC § 5160:1-3-05.13 Medicaid: treatment of the home (C) The home lived in, owned by, and considered the principal place of residence by the individual, the couple, or the parents with whom the eligible child is living is an excluded resource, regardless of value.

(1) For the value of the home to be excluded: (a) The home must be the individual's or the individual's spouse principal place of residence; and (b) The deed to the home must be in the individual's or individual's spouse's name; or (c) The home must be deeded to a revocable trust so long as the principal of the trust remains a resource

of the individual or the individual's spouse. (2) The home is no longer considered to be the principal place of residence and shall be treated as a countable

resource if the individual does not intend to return to the home. (3) A temporary absence from the home does not affect the principal place of residence exclusion so long as

the individual provides a signed statement of his or her intentions to return to the home and has not established permanent residence elsewhere.

20 CFR § 416.1212. Exclusion of the home. (a) Defined. A home is any property in which an individual (and spouse, if any) has an ownership interest and which serves as the individual's principal place of residence. This property includes the shelter in which an individual resides, the land on which the shelter is located and related outbuildings. (b) Home not counted. We do not count a home regardless of its value. However, see §§ 416.1220 through 416.1224 when there is an income-producing property located on the home property that does not qualify under the home exclusion. (c) If an individual changes principal place of residence. If an individual (and spouse, if any) moves out of his or her home without the intent to return, the home becomes a countable resource because it is no longer the individual's principal place of residence. See also POMS: SI 01130.100 The Home Exclusion.

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4) A home in a living trust is treated the same as a home not in a trust.

To retain the exemption, the home must be deeded to a revocable trust, so long as the principal of the trust remains a resource of the individual or the individual's spouse.

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OAC § 5160:1-3-05.13 Medicaid: treatment of the home

(1) For the value of the home to be excluded: (c) The home must be deeded to a revocable trust so long as the principal of the trust remains a resource

of the individual or the individual's spouse.

MEPL 108 re OAC § 5160:1-3-6.2 (February 16, 2016) Medicaid Resource Assessment - calculation of the Community Spouse Resource Allowance (CSRA)

New Policy: When excludable resources are put into a revocable trust the placement of that resource into the trust does not change the excludable nature of the resource. Because federal law excludes the value of the home from the CSRA calculation, the value of the home shall be excluded in the calculation of the CSRA even if the home is deeded in a revocable trust. If the home is transferred from the revocable trust to one or both spouse’s names that transfer is not improper.

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5) A home that is no longer the individual’s principal place of residence is still an excluded resource so long as a spouse or dependent relative of the individual continues to live there while the individual is institutionalized. Any type of dependency will suffice and the definition of a relative is very broad. Note that resources excluded for Medicaid eligibility purposes are generally not excluded from Medicaid Estate Recovery. OAC § 5160:1-3-05.13 Medicaid: treatment of the home (C)(4) If the individual leaves the home with no intentions of returning, the home remains an excluded resource for as long as:

(a) A spouse or dependent relative of the individual continues to live there while the individual is institutionalized.

(i) Dependency may be of any kind (e.g. financial, medical, etc.). (ii) Relative means:

(a) Child, stepchild, or grandchild; (b) Parent, stepparent, or grandparent; (c) Aunt, uncle, niece, or nephew; (d) brother, sister, stepbrother or stepsister, half-brother or half-sister; (e) cousin; or (f) in-law.

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6) A home that is no longer the individual’s principal place of residence is still an excluded resource if its sale would cause undue hardship for a co-owner of the property, due to loss of housing. The co-owner must provide a signed statement that she uses the property as her principal place of residence, would have to move if the property were sold and has no other living quarter readily available. OAC § 5160:1-3-05.13 Medicaid: treatment of the home (C)(4)(b) Its sale would cause undue hardship, due to loss of housing for co-owner of the property and the co-owner provides a signed statement whether he or she:

(i) Uses the property as his or her principal place of residence; and (ii) Would have to move if the property were sold; and (iii) Has no other living quarter readily available.

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7) If the individual leaves the home with no intentions of returning due to domestic abuse, the home can still be an excluded resource. The individual cannot have established a new principal place of residence nor taken action to render the home no longer excludable. OAC § 5160:1-3-05.13 Medicaid: treatment of the home (C)(4)(c) The individual leaves his or her home due to domestic abuse and has not established a new principal place of residence, or has taken action to render the home no longer excludable.

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8) A home that is no longer the individual’s principal place of residence can still be an excluded resource if the property satisfies the provisions governing the treatment of property essential for self-support. See OAC § 5160:1-3-05.19 re the provisions governing the treatment of property essential for self-support. OAC § 5160:1-3-05.13 Medicaid: treatment of the home (C)(4)(d) The property satisfies the provisions governing the treatment of property essential for self-support described in rule 5160:1-3-05.19 of the Administrative Code.

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9) An individual is not eligible for LTCF services, a HCBS waiver or PACE if the individual's equity interest in the individual's home exceeds the home equity limit, but there is an undue hardship exception to this rule. The home equity limit of five hundred thousand dollars will increase annually beginning January 1, 2011, as established by § 5163.32 of the Revised Code. OAC § 5160:1-3-05.13 Medicaid: treatment of the home

(D) The property satisfies the provisions governing the treatment of property essential for self-support

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10) When I go into a nursing facility, one automobile is excluded for me or a member of my household, regardless of value, if it is used for transportation. Any automobile an individual owns in addition to the one wholly or partly excluded and which cannot be excluded under another rule (e.g., property essential for self-support) is a resource in the amount of its equity value. The current market value of an automobile is determined by the average trade-in value shown for the vehicle in the most recently published "National Automobile Dealers Association (NADA) Guide". OAC § 5160:1-3-05.11 Medicaid: automobiles and other modes of transportation as resources

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(B) Definition. "Automobile", for the purpose of this rule, means any vehicle used for transportation. It can include, in addition to cars and trucks: boats, snowmobiles, animal-drawn vehicles, and even animals. (C) One automobile is excluded for the individual or a member of the individual's household regardless of value if it is used for transportation.: necessary for employment; necessary for the treatment of specific or regular medical problems; modified for operation by, or the transportation of, a handicapped person; or necessary, because of climate, terrain, distance or similar factors, for the performance of essential daily activities.

(1) For the purposes of determining the resource assessment for couples when one spouse is institutionalized, one automobile is considered totally excluded, regardless of its use and value in accordance with rule 5160:1-3-06.2 of the Administrative Code.

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11) Medicaid will now permit a community spouse to place assets in excess of the community

spouse resource allowance (CSRA) into a single premium immediate annuity which follows certain criteria as set forth by Medicaid. However, consumers should be aware that such annuities are not appropriate in every case. Medicaid Eligibility Procedure Letter No. 112 (February 26, 2016 ) Treatment of Annuities

New Policy: Effective immediately, the purchase of annuity by an individual or the individual’s spouse after the date of institutionalization, but before the eligibility determination date, in an amount above the CSRA shall not be determined improper if the purchase of the annuity meets the requirements listed in Ohio Administrative Code 5160:1-3-05.3. Those requirements include, that the State of Ohio be named as a remainder beneficiary in the correct position

OAC § 5160:1-3-05.3 Medicaid: the disclosure and treatment of annuities for medical assistance programs

(C) Treatment of annunities for eligibility for medical assistance.

(1) Any annuity not providing fixed, monthly payments shall be treated as a countable resource. Once annuitized, the annuity shall be considered an excluded resource.

(2) Once the annuity is annuitized, any fixed, monthly payment received from the annuity shall be considered as unearned income to the named annuitant.

(D) Treatment of annunities for long term care services.

(1) Treatment of annuities purchased or transactions on or after February 8, 2006. (a) Any purchase or annuity transaction, including annuities purchased by a spouse, shall be treated as

the disposal of an asset for less than fair market value as outlined in rule 5160:1-3-07.2 of the Administrative Code unless: (i) The state of Ohio is named as the remainder beneficiary in the first position for the total amount of

medical assistance furnished to the individual; or

(ii) The state of Ohio is named as such a beneficiary in the second position for the total amount of medical assistance furnished to the individual after the community spouse or minor or disabled child, and is named in the first position for the total amount of medical assistance furnished to the individual if such spouse or a representative of such child disposes of any such remainder for less than fair market value; except that

(b) If the annuity is purchased by or on behalf of an annuitant who has applied for medical assistance, the purchase of the annuity will be deemed an improper transfer even if the beneficiary naming

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requirements in paragraph (D)(1) are met, unless: (i) The annuity is an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue

Code of 1986 (as in effect on February 1, 2016); or

(ii) The annuity was purchased with proceeds from: (a) An account or trust described in subsection (a), (c), or (p) of section 408 of such code; or (b) A simplified employee pension (within the meaning of section 408(k) of such code); or (c) A Roth IRA described in section 408A of such code; or

(iii) The annuity meets the following requirements: (a) Irrevocable and non-assignable; and (b) Actuarially sound as determined by the life expectancy tables published by the office of the

actuary of the social security administration in accordance with 26 C.F.R. 20.2031-7 (as in effect on February 1, 2016). For an annuity to be considered actuarially sound, the total amount of proceeds shall be designed to be dispersed in equal monthly payments with no anticipated lump sum payment. The only allowable lump sum payment is the refund provided when the annuitant dies prior to the end of the guaranteed period and paid to the remainder beneficiary; and

(c) Provides for payments in equal amounts during the term of the annuity with no deferral and no balloon payments made. The purchased annuity shall not have a balloon payment provision unless the balloon payment designation is for the community spouse.

12) .

13) What are ABLE accounts and how are they used?

The federal Achieving a Better Life Experience (ABLE) Act became law in December 2014. The law allows states to create tax-free accounts for individuals with disabilities. The creation of these ABLE accounts will allow individuals with disabilities to save up to $14,000 a year without losing their eligibility for certain public benefits programs, like Medicaid or SSI. The “Eligible Individual” is someone who developed their disability before the age of 26.

The Ohio ABLE statutes can be found at ORC §§ 113.50 to 113.56. The Treasurer of State is coordinating the program (with assistance from the Dept. of Developmental Disabilities). They have selected Intuition ABLE Solutions to be the ABLE Service Provider. Intuition will run the program. The Treasurer of State will select an Ohio financial institution to be the account custodian. They are testing the program in March and will probably go live within a couple of months after that. Ohio is one of about 5 states to move forward quickly to implement ABLE Treasurer of State has an FAQ at http://www.tos.ohio.gov/Documents/CMS/ABLE/Ohio%20ABLE%20FAQs%206.14.pdf

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Am I correct that there is not a transfer penalty imposed for eligibility for the Medicare Premium Assistance (MPAP) programs?

May 20, 2016 9:23 AM

Michelle Baumeister , Esq

Below are the questions I sent to attorneys in 1634 states and below that are their responses (the last question was not answered so far). Michelle Baumeister Gentle People; Ohio is changing from a 209(b) state to a 1634 state. So we have a lot of changes to get used to. Perhaps you can help us attorneys figure out how your state handles certain details.

1) Instead of applying for SSI and Medicaid separately, applicant applies only for SSI and, if approved, will automatically qualify for Medicaid. However, most nursing home residents are already receiving SS retirement benefits, so they will not be applying for SSI; thus, won't all these Medicaid applicants still have to apply for Medicaid alone?

2) What is the point of "extra" income going to the applicant who then puts it into a QIT to be sent to the nursing home along with the rest of their patient liability amount due to the nursing home? I'm not seeing the benefit to the state or the nursing home. Why the extra steps (and expense)?

If anyone wants to warn us Ohioans about other surprises when one is a 1634 state, we'd love to know about them. [email protected]

Michelle L. Baumeister, Esq. 3495 Woodhaven Lane

Lima, Ohio 45806 419-999-1256 www.liondoglaw.com Michelle:

1) YES. Clients ineligible for SSI must apply for MAO ("Medical Assistance Only") Medicaid

2) GA switched to QITs in 2004. At the time, a handful of us in the eldercare community asked this very same question … and implored the state to recognize that there would be no "savings" considering the patient liability budget is identical whether income flows through a QIT or not. The state ignored us and moved forward with converting from a Spend Down state to a Cap state. At the time, GA had somewhere around 2000 NH residents on Medicaid whose income necessitated a QIT. As a consequence, the Elder Law Section of the State Bar and various other attorneys banded together and made sure that 100% of those residents ended up with a QIT. Most were done pro bono. Some even required a conservatorship because there was inadequate POA authority / no capacity. It was a massive undertaking for a whole lot of nothing. Fast forward 12 years and the state has figured out that requiring QITs not only results in no reduction of Medicaid expenditures. Instead, it actually increases them by dragging down DFCS productivity. Accordingly, the state has been trying to figure out how to get rid of QITs for 1-2 year now. My understanding is that being a 1634 state does not = QIT requirement. Rather, I believe that states can adapt their

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State Medicaid Plan to be a Spend Down state such that there is a unique NH AMN COA for people in NH with excess income. As long as they pass all other tests, then these states ignore failure of the income test without the need for a QIT.

Dan The Elder Law Practice of Daniel D. Munster 5855 Sandy Springs Circle Suite 270 Atlanta, GA 30328 (404) 920-0521 Direct Dial (404) 420-2614 Fax www.georgiaelderlaw.net

A QIT is required if the state does not choose to cover long term care through a medically needy Medicaid program. Conversely, fed law prohibits QITs in states with ltc coverage through MN Medicaid.

Lawrence A. Friedman, [email protected]

908-704-1900 FriedmanLaw 12 Cushing Dr., Bridgewater, NJ 08807 NJ, NY & U.S. Tax Court Bars; LL.M. Tax (NYU Law) NJ State Bar Assn- Former Chair Elder & Disabilities Law Section, Former Member Board of Consultors Real Property Trusts & Estates Law Section, Distinguished Legislative Service Award- for drafting special needs trust law Certified Elder Law Attorney by A.B.A. accredited National Elder Law Foundation Vice Chair NAELA Special Needs Section ============================================================= So, e.g., an unmarried SSI recipient can exempt one car of any value but a non SSI older adult is limited to one not exceeding $4,500 in value? David A. Myers, Esq. Certified Elder Law Attorney

Fauver, Keyse-Walker & Donovan

5333 Meadow Lane Court Sheffield Village, OH 44035

(440) 934-3700 [email protected]

Correct. At least in GA, this distinction is made with the terms:

FBR A/R è Federal Benefit Rate Applicant/Recipient (SSI) Non-FBR A/R è Non-Federal Benefit Rate Applicant/Recipient

Our policy manual accounts for both FBR and Non-FBR treatment of income and resources. If you would like to take a gander, go here… odis.dhs.ga.gov/ChooseCategory.aspx?cid=813 … and select MAN3480 … then scroll down to Chapter 2101 for a summary of the COAs. You can then

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review each individual asset/income section to observe how treatment differs between FBR and Non-FBR. DDM The Elder Law Practice of Daniel D. Munster ================================================================================================================================================== Larry, Is the Medically Needy program the reason for a state to be an income-cap state rather than having an effective income limit of the private pay nursing rate? Marty

Martin C. Womer, Esq. Maine Center for Elder Law, LLC 3 Webhannet Pl., Suite 1 Kennebunk, ME 04043 Phone: 207-467-3301 Fax: 207-467-3305 [email protected] www.mainecenterforelderlaw.com

Members: Could someone share with me the life estate table used by Bob Byrne to calculate the value of a life estate? Thanks

Mea, culpa. Bob Byrne replies: "I actually use and have shared with outside counsel the following link that is very user friendly. I happened upon it a number of years ago. " http://www.revenue.nebraska.gov/PAD/doc_stamp/int_table.html ROBERT J. BYRNE (#0040299) Principal Assistant Attorney General Collections Enforcement Section 150 E Gay Street, 21st Floor Columbus, Ohio 43215 (614) 466-8459 (614) 752-9070 fax

In my experience Bob and his private attorney agents DO NOT use that table in the OAC which does not comply with federal law. They properly use the IRS tables that value a life estate at much lower value in estate recovery cases.

Computation of the life estate value under Medicaid law is determined by application of the “Section 7520 interest rate” applicable at the date of death. That percentage governs which

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table in IRS Table S is to be used to determine the life estate valuation. T [These tables are available on-line. The Section 7520 interest rate is found: www.irs.gov/businesses/small-

businesses-self-employed/.... Table S is at www.irs.gov/pub/irs-tege/sec_1_table_s_2009.xls.

[the link Table S isn't working for me today, but you can get there from: www.irs.gov/retirement-plans/actuarial-tables]

e.g. current Section 7520 interest rate is 1.8%

use the 1.8% interest table in Table S. For an 80-year old the value is 13.5% for a 90-year old it's 7.5%

------------------------------ Elliot Legow Elliot P. Legow, Atty. at Law Youngstown OH ------------------------------

Just an FYI for Promissory Notes - 5160:1-3-05.5(C)(2)(c): They added the line:

For the restricted medicaid coverage period to be recalculated, the note must be repaid in full and in accordance with rule 5160:1-3-07.2 of the Administrative Code.

I would assert that the Medicaid qualified promissory note is not affected by 5160:1-3-07.2(M) since it is a

transfer for fair market value (just as an Medicaid qualified annuity would be exempt).

"5160:1-3-07.2 (M) When assets transferred for less than fair market value are returned to the individual."

Also, none of the examples at the RMCP Update included a Medicaid qualified promissory note. I have been

advising families for years to not spend the "gift" money until full Medicaid eligibility is obtained in case

there needs to be a reconveyance. If the Agency insists on not accepting the reconveyance of the Medicaid

qualified promissory note, then there will be no alternative but to use short term Medicaid qualified

annuities. Just my observation.

Dennis G. Mille, CELA* Phillips & Mille Co., L.P.A., 7530 Lucerne Dr Ste 200, Middleburg Hts OH 44130, (440) 243-2800 FX: (440) 243-2852 [email protected] www.pmlawyers.com *Certified Elder Law Attorney by the National Elder Law Foundation and the Ohio State Bar Association and approved by the Commission on Specialization of the Supreme Court of Ohio

In light of the new stance on partial reconveyances, I had a question about promissory notes. Is the use of a promissory note to pay for a restricted coverage period still a viable strategy for achieving Medicaid eligibility and protecting assets? Do they need to be paid in full? If so, what does that

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mean? Does that mean they should be paid in full before an applicant is deemed eligible or does it mean that the obligation cannot be cancelled if the Medicaid applicant dies before it is fully paid back?