Circle of Friends Issue 11

When we lose someone we love – whether to an unexpected event or a prolonged illness – we don’t always get the chance to say the words we wish we had. And for some, the loss is harder to process because of the things left unsaid. But there is hope. Taking time to write these thoughts down is an excellent and proven method for helping people heal from emotionally stressful events. By writing a letter to your lost loved one, you can give expression to the thoughts and feelings rolling around inside your mind and heart, so that you can move forward in the healing journey. By writing a letter, you give yourself time to think through all the questions in your mind. You can be honest and reflect on your true feelings. Do you wish you’d shared something with them, whether good or bad? Are you struggling with “why” questions? Do you simply miss them and want to feel connected again? All of these are good reasons to take time to write a letter addressed to your loved one, allowing yourself the opportunity to release your emotions and unburden yourself.

A Few Tips

1. This is an exercise for you, so there’s no time frame. Take all the time you need.
2. You may need to write more than one letter. That’s perfectly fine. Write to your loved one as often as you need. In the beginning, you may write more often.
3. Write down EVERYTHING you want to say. Don’t hold anything back, even if it’s something negative.
4. If you’d like, after you’ve written the letter, you can read it aloud. Perhaps you can go to your loved one’s gravesite or another significant place to read it so that you feel close to them.

To Get Started

First, choose a medium. Do you want to write a series of letters? Perhaps a notebook or journal would be appropriate. Would you prefer to write a traditional letter on stationery? Or would you prefer to type on a computer or smart device? Take a look at a few examples, and choose whatever medium best fits your needs. Second, find a comfortable place to write, knowing that this may be an emotional process. For some, coffee shops are appealing, and for others, a quiet room at home is preferred. Alternatively, you can find a beautiful spot outdoors or visit a special place to begin your letter. Third, write. There’s no instruction manual, so there’s no way you can do this the wrong way. Just write openly and from the heart. Tell your loved one all the things you didn’t say. Allow yourself to really enter into the exercise and put it all out there. Maybe you need to ask their forgiveness. Or, you just wish you’d said, “I love you” one more time. Maybe they hurt you deeply and you need to put that pain into words. No matter what you feel, tell them.

Different Approaches & Prompts

Again, there’s no wrong way to do this, but if you’d like a place to start, here are some tips and prompts to help.

• Share what has happened in your life since their death.
• How do you feel?
• What do you miss about them?
• Is there something you regret not doing or saying?
• Were there unresolved issues that you need to get off your chest?
• Talk about ways that you’ve grown and changed.
• Tell them how you plan to honor their memory.

Write to them as if they are still alive, and make sure to say everything you need to.

What Do I Do Once It’s Written?

There are a number of things you can do with your letter. It will all depend on what is most satisfactory to you. This is not a comprehensive list, so feel free to come up with another option that may work better for you.

• Destroy the letter – burn it, rip it up, shred it, or some other method.
• Seal it in an envelope and keep it in a special place.
• Keep it in a place where you can see it often, like on a bedside table.
• Save it on your hard drive for reference later (if you used an electronic device).
• Send it to someone you trust, who will take care of it until you want it back.
• Share your letter with others through email, social media or a blog.

No matter what you decide, writing a letter to your loved one and saying everything that’s on your heart and in your mind is a step toward greater acceptance and reconciliation to the loss you’ve suffered. This exercise will not miraculously remove your grief. In fact, grief isn’t really something we can “get over.” But we can give our grief a voice, and you will find that the more you express your feelings of grief, the easier it becomes to deal with those emotions. Sharing your heart and giving expression to all the emotions – good, bad, tender, destructive – is an important step on the journey toward healing.  

When a person you love passes away Look to the night sky on a clear day. The star that to you, appears to be bright Will be your loved one, Looking upon you during the night

The lights of heaven are what shows through As your loved one watches all that you do. When you feel lonely for the one that you love, Look to the Heavens in the night sky above.

Author Unknown

If you need to qualify for Medicaid coverage for long term care, you may be trying to think of smart ways to spend down your assets. Burial plans can be set up as exempt assets so that they are not counted when applying for Medicaid coverage. This way, you are able to preserve some assets that your family will need one day.

What is Medicaid?

First of all, let’s discuss what Medicaid does. Medicaid is a state and federally funded health insurance program serving low income families and individuals and those in critical need for medical care. Medicaid covers over 72.5 million Americans including seniors, disabled individuals, children, parents, and pregnant women. Disabled individuals and those age 65 and older are not affected by the new modified adjusted gross income (MAGI) qualification rules established by the Affordable Care Act. Those who are determined to be “medically needy,” but whose income is too high to qualify for Medicaid may be able to qualify by “spending down” their assets to a level that makes them eligible for the state’s medically needy qualification standards.

What does “spend down” mean?

Spend down is the process of divesting an individual’s assets down to the amount that makes him or her eligible for Medicaid coverage for long term care. Spend down usually occurs as the individual pays for nursing home care expenses out of pocket until their assets have dwindled to the allowable limit. Because of the high cost of nursing home care, which is usually between $6,000 to $7,000 per month, careful planning is essential before spending down.

Do government stimulus checks affect Medicaid eligibility?

When the federal government issues stimulus checks, you may wonder how these checks affect your Medicaid eligibility. Stimulus checks do not count as income, and therefore, do not impact Medicaid beneficiaries or applicants if you spend the funds within 12 months of receiving them. However, if the money isn’t spent within 12 months, it will be counted as an asset and could impact Medicaid eligibility for the year ahead. That said, if you are preparing to plan ahead for funeral wishes, consider using your stimulus checks as a down payment toward a prepaid funeral plan. This will not only help you finance your funeral wishes, removing a financial burden from your family members, but it will also protect your Medicaid eligibility.

How can I protect my assets from being spent on nursing home costs?

Most state Medicaid programs allow certain assets to be exempt from consideration, and thus protected from being spent out of pocket on nursing home costs. Before spending down, understand which assets are considered exempt, which are non-exempt, and how much you can preserve for your family. Depending on the type of assets you are trying to preserve, the transfer of assets may need to be done up to 5 years before you apply for Medicaid coverage. Application for long-term services and supports (LTSS) will be denied if an individual’s assets have been transferred for less than fair market value within a five-year period before applying for Medicaid assistance. Planning ahead is essential if you wish to protect as many assets for your family as possible. Most states follow the Social Security Administration’s (SSA) Supplemental Security Income (SSI) guidelines to establish Medicaid eligibility for seniors over 65 and for disabled individuals. The following states use their own rules to establish eligibility for Medicaid which are different from SSA’s SSI rules: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia. For specific information about your state’s Medicaid qualification and spend down rules, click here, select your state, and scroll down to “State Medical Assistance Office.” You can then visit your state’s health services website and/or contact your health services department for more information.

Will my spouse be affected by Medicaid spend down?

The spouse of the person in long term care is afforded some measure of protection from spousal impoverishment. As of 2016, here are Medicaid’s published Spousal Impoverishment Standards.

In general, what kinds of assets are exempt from being counted for Medicaid qualification?

Other than the income that your spouse is allowed, you can also set up certain assets as exempt from being counted, at least for the time-being, for Medicaid qualification. The following is by no means an exhaustive list, but gives you an idea of the types of assets that generally are excluded by the state’s Medicaid program. Every state has the ability to set its own qualification rules, but in general:

Exempt Assets

• Your principal residence (subject to equity limits in some states) if you, your spouse, or dependent child still live in the house, or if you intend to return to the house.
• Personal property and effects, such as furnishings, belongings, appliances, and household goods. Some states place a cap on the allowable amount.
• Life insurance with a cash value up to $1,500. Term life insurance is generally excluded as an asset.
• A designated revocable account for burial funds with a value of up to $1,500 per spouse. Other burial funds, irrevocable burial contracts, and cash surrender value from life insurance will reduce this allowable amount.
• An irrevocable contract for burial space items (with no limitation on the amount) for you and your immediate family members including your spouse, your children (including adoptive and stepchildren), their spouses, your siblings and their spouses, and your parents. Burial space items include caskets, urns, vaults, burial plots, cremation niches, headstones, opening and closing of the grave, and perpetual care. Burial space items are counted as separate from burial funds.
• A larger irrevocable contract for burial funds for you and your spouse only that includes funeral service costs such as transportation of the body, embalming, cremation, flowers, clothing, services of the funeral director and staff, etc.
• One automobile (in some cases there is a limit on the market value) for spouse or child if used to visit the person who is ill.
• One wedding and engagement ring.
• A married couple can keep considerably more if one spouse is still well, and does not need Medicaid; in most cases half the assets up to a certain amount.

Non-exempt Assets

Non-exempt assets are those that Medicaid considers as part of your accessible, countable assets when you apply for assistance. You will be expected to liquidate these types of assets to help you pay for long term care costs. Non-exempt assets will be considered as available to you to use toward paying the cost of your medical care. This includes money and a variety of real and personal property which can be valued and turned into cash. These include (but are not limited to):

• Cash
• Checking and savings accounts
• CDs, stocks, bonds, or mutual funds
• Retirement accounts including IRAs, 401(k)s, 403(b)s
• Prepaid funeral contracts that are not irrevocable (can be cancelled)
• Trusts (depending on how they are set up and your access to them)
• Property other than the primary residence
• Jewelry and valuable art or collections
• More than one vehicle, boats, RVs, etc.
• Cash surrender of life insurance with a face value of $1,500 or more

What is the difference between burial funds and burial space items?

These terms may sound similar, but they mean different things when it comes to Medicaid spend down rules. Both burial funds and burial space items can be placed into irrevocable contracts. The term “irrevocable” signifies that you cannot cancel or liquidate your assets within the contract for cash value. This irrevocable status excludes the contract from being considered as a countable asset for your state’s Medicaid program. “Burial funds” is a term that designates the services provided by a funeral home. “Burial space items” is a term that designates the merchandise and items associated with the burial of a body. Burial funds may be purchased for both the Medicaid applicant and his or her spouse. Burial funds include any funeral goods and services sold by a funeral home. For example, burial funds may be set aside in an irrevocable contract to cover expenses such as embalming, burial clothing, preparation of the body for burial, cremation fees, transportation of the remains, limousines, honorariums, flowers, police escort, etc. The burial funds must be placed in an irrevocable prepaid funeral contract (maximum value determined by state), or they must be less than $1,500 if the funds are in a revocable account. An irrevocable contract allows more funds to be preserved from being spent on nursing home costs so that your family does not have to cover funeral and burial expenses. Burial space items can be purchased for most of the applicant’s family members, including the applicant, his or her spouse, and their immediate family members along with their spouses. This is one of the few ways you can legally set aside some of your assets for your children. Burial space items must also be irrevocable contracts to be considered exempt. Burial space items include any merchandise or items associated with burial such as cemetery plots, vaults, caskets, urns, opening & closing of grave, cremation niches, headstones, grave markers, family estates or crypts, and perpetual care. Properly structured burial space contracts may be excluded as an asset regardless of value. Be sure to consult an experienced prearrangement specialist or licensed funeral director to ensure that your contract meets all of your state’s requirements for Medicaid spend down.

Important Notice about Medicaid Eligibility Rules

Please be aware that Medicaid rules vary greatly from state to state and are constantly changing. The listed examples of exempt and non-exempt assets may vary from state to state and will often depend on a variety of individual factors. Most states follow the Social Security Administration’s (SSA) Supplemental Security Income (SSI) guidelines to establish Medicaid eligibility. The following states use their own rules to establish eligibility for Medicaid which are different from SSA’s SSI rules: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia. An attorney can assist you in designing a Medicaid plan that preserves as many assets as possible under the laws and eligibility requirements of your state. Always speak to a qualified attorney who is knowledgeable in elder law before spending down or transferring assets to qualify for Medicaid. The purchase of a prepaid funeral contract is an important part of your complete Medicaid plan, so be sure to consult a licensed funeral prearrangement specialist or licensed funeral director who can assist you in creating a properly structured prepaid funeral plan.