Moved into CCRC today

[harllee]

Some of the more established CCRCs in NC are Medicaid certified and thus have Medicaid residents. You can peruse the CCRCs in NC that have Medicaid certified status from this official NC Guide on CCRCs. https://www.ncdoi.gov/documents/continuing-care-retirement-communities/ccrc-reference-guide/open

There are nuanced reasons for some CCRCs to have Medicaid certified facilities. And perhaps some CCRCs initially created, when first operating, far too many nursing beds it needed to accomodate initial entry classes of CCRC residents and thus permitted "direct admits" in the skilled nursing facility wing of the CCRC to offset the cost of having too many bed vacancies; thus, these CCRCs were willing to take on Medicaid residents.

For those CCRCs that are not Medicaid certified, they seem to walk a careful tightrope of having enough nursing beds to accomodate current and projected needs of the CCRC residents. If a CCRC has too many vacant and unused nursing beds, it could be a drain on its financial resources -- I'd imagine state health regulations might require certain staffing requirements based on number of beds available. On the other hand, if it slowly builds and expands bed capacity, it might result in demand exceeding bed capacity with the result that many CCRC residents have their skilled nursing care outsourced to another SNF, off the campus of the CCRC. One should carefully look at occupancy levels and expansion plans for all wings at a CCRC, especially the skilled nursing wing.

Frankly, we haven't been viewing older CCRCs that have Medicaid certified status. But we are very concerned that a CCRC has Medicare certified status. It's important to us that the skilled nursing wing of a CCRC (and the nomenclature they use around here is "health center" as in Stewart Health Center, Embrace Health Center, or Asbury Health Center -- all part of the CCRCs down here) has Medicare certified status so that it can serve as a rehabilitation facility for Medicare purposes. If you're in a CCRC and have knee or hip replacement surgery, I'd want to be able to do rehab and PT on the CCRC campus and not have to go to another rehab facility.

For sure you would want your CCRC to be MEDICARE certified. The Medicaid certification issue is confusing to me. I know that my CCRC is Medicare certified and not Medicaid certified. In looking at the NC list I see there are some fee for services CCRCs listed as taking Medicaid but I don't think that list as accurate. For example, my mother is in a CCRC that is fee for services. The list shows that CCRC takes Medicaid but I have been told they do not and in fact they have a trust fund for people who run out of money. I was told that one of the reasons they do not take Medicaid is that they would have to open their skilled nursing units to the general public and would not be able to limit skilled nursing to just those coming from independent living.

If a CCRC says they take Medicaid I would take that with a grain of salt and do some independent investigation.

 

[harllee]

CCRCs and Medicare. My CCRC takes Medicare. When DH has his upcoming second knee replacement he will be able to do his rehab at the CCRC and Medicare will pay for it. One of the questions we had to answer when we moved in was what type of Medicare we had and what type of medicare supplement (and we had to give them copies of our cards). They wanted us to have traditional Medicare and a supplement, which we had. Not sure what would have happened if we had Medicare Advantage--I got the impression they did not accept Medicare Advantage in their rehab department.

 

[Koolau]

Unless your QCD giving is approaching $100K per taxpayer and you still want to give more (rare, but possible), it is generally strictly better to do giving through QCDs rather than Schedule A itemized donations.

There are a few reasons for this:

1. Schedule A deductions are reduced in impact because you get the standard deduction (maybe $27K or so in your case, since I'm pretty sure you're MFJ and at least one of you is over 65 maybe?) for free. If you know you'll be itemizing due to the medical deductions anyway, this is less of a concern but it's still less than optimal. If you're close to itemizing, you could consider a strategy of giving every other year ("bunching") and alternating itemizing and taking the standard deduction. Remember too that the medical percentage from the CCRC will have 7.5% of your AGI subtracted before it starts adding to your Schedule A deductions. That, plus the ~$27K standard deduction makes itemizing a very high bar these days.

2. QCDs reduce AGI; itemized deductions do not. Many other things key off AGI, including state income taxes usually, ACA subsidies (not a concern in your case I'm guessing), eligibility for a number of tax benefits, and IRMAA tiers. It also looks like QCDs would reduce SS provisional income, which would reduce the amount of your SS benefits subject to taxation.

3. A minor issue, but in some cases significant generosity can be limited on Schedule A. As far as I know, those limitations do not apply to QCDs.



Ditto my Dad.

I'm sure I could look this up (and this is getting off topic) Are you saying that using a QCD does not affect your MAGI toward IRMAA? Thanks.

 

[ChrisC]

For sure you would want your CCRC to be MEDICARE certified. The Medicaid certification issue is confusing to me. I know that my CCRC is Medicare certified and not Medicaid certified. In looking at the NC list I see there are some fee for services CCRCs listed as taking Medicaid but I don't think that list as accurate. For example, my mother is in a CCRC that is fee for services. The list shows that CCRC takes Medicaid but I have been told they do not and in fact they have a trust fund for people who run out of money. I was told that one of the reasons they do not take Medicaid is that they would have to open their skilled nursing units to the general public and would not be able to limit skilled nursing to just those coming from independent living.

If a CCRC says they take Medicaid I would take that with a grain of salt and do some independent investigation.

It could be that a CCRC that is Medicaid certified no longer takes new Medicaid residents and is transitioning out of being a Medicaid facility. I don’t know if that’s the case with your mother’s CCRC, but it seems the case with one of the oldest and largest CCRCs in Charlotte.

 

[RunningBum]

There are tax benefits to being in a CCRC. The CCRC will give us a letter at the end of the year specifying the percentage of our entrance fee and monthly fees that are deductible as a medical expense for income tax purposes. I have not been able to itemize deductions for many years so this will be a tax benefit to me. One thing I have to think through is our charitable giving. We have been doing all our charitable giving through our IRAs as a QCD but maybe it will be better for us to take out RMD distributions from our IRAs and then give to the charity so we can itemize our charitable deductions. I do my taxes myself using Turbotax, will have to run some numbers.

As already stated, QCDs have advantages over donating the same amount with RMD funds withdrawn, but there is another possibility.

If you find you will already be itemizing, you might look at donating assets with high unrealized gains rather than simple funds taken from an RMD. If you want to give $100,000, and have a holding with 50% gains, you could donate those funds and take a $100,000 tax deduction, while shedding a $50K unrealized gain.

The easiest way to do this is through a DAF, which has no issue with taking your funds. An individual charity, especially a small one, might not be so well equipped to do so. A DAF also allows anonymous grants, which is good if you don't want to be pestered in future years. It also lets you make a large lump sum donation which you can dole out in grants over many years.

There are limits on how much you can deduct. For stock or fund shares, it was 20% of AGI when I did this a few years back. I think that's still it but couldn't immediately verify it.

If you want to keep it simple, a QCD is best. It might even be better if IRMAA is a factor, since it reduces your AGI. I'm just pointing out another possibility.

 

[Koolau]

If you want to keep it simple, a QCD is best. It might even be better if IRMAA is a factor, since it reduces your AGI. I'm just pointing out another possibility.

Sorry! Once again, QCD lowers AGI but does it lower MAGI? Thanks.

 

[SecondCor521]

I'm sure I could look this up (and this is getting off topic) Are you saying that using a QCD does not affect your MAGI toward IRMAA? Thanks.

No, exactly the opposite. QCDs reduce AGI, which in turn reduces MAGI, which in turn can help reduce or avoid IRMAA.

Sorry! Once again, QCD lowers AGI but does it lower MAGI? Thanks.

Yes, QCD lowers AGI, which lowers MAGI.

 

[Alex The Great]

They wanted us to have traditional Medicare and a supplement, which we had. Not sure what would have happened if we had Medicare Advantage--I got the impression they did not accept Medicare Advantage in their rehab department.

It looks like a trap. In our local network in Northern California called Sutter Health (PAMF) all doctors accept Medicare Advantage only. They clearly state it on their web site. I assume there could be similar situation in North Carolina or anywhere else? Does your doctor work with Medicare Advantage or Supplement? Or both? If some CCRCs accept Advantage and some Supplement I do see it as a potential trouble.

 

[harllee]

It looks like a trap. In our local network in Northern California called Sutter Health (PAMF) all doctors accept Medicare Advantage only. They clearly state it on their web site. I assume there could be similar situation in North Carolina or anywhere else? Does your doctor work with Medicare Advantage or Supplement? Or both? If some CCRCs accept Advantage and some Supplement I do see it as a potential trouble.

Probably very different in every state. Here in NC I don't know of any doctors that take Medicare Advantage but not traditional Medicare. Almost all doctors in NC take traditional Medicare but it appears to me that only a few take Advantage plans and then only certain advantage plans.

Suggestion--for anyone considering a CCRC, check with them to see if they take Medicare Advantage plans and if so which ones if you are considering a Medicare Advantage plan.

 

[ChrisC]

Probably very different in every state. Here in NC I don't know of any doctors that take Medicare Advantage but not traditional Medicare. Almost all doctors in NC take traditional Medicare but it appears to me that only a few take Advantage plans and then only certain advantage plans.

Suggestion--for anyone considering a CCRC, check with them to see if they take Medicare Advantage plans and if so which ones if you are considering a Medicare Advantage plan.

I think the stated requirement for CCRCs that they only take traditional Medicare plus a Medicare Supplemental Policy stems from their familarity with this coverage and the fact that it's fairly comprehensive (and I note I haven't heard of any CCRC requiring Medicare Part D drug coverage). Moreover, the likelihood that the CCRC operating as a Medicare certified facility, with their team of Medicare providers, would not be at payment risk for services also might be a factor. The problem with Medicare Advantage is the HMO nature of coverage, with possible insurance delays in treatment plans, and quite frankly, some coverage for PT and OT is quite limited and hospice care might be difficult to navigate (as opposed to coverage under traditional Medicare).

My wife has traditional Medicare, Parts A and B, and we use my Federal retiree health insurance coverage (GEHA, plus 1) to cover her medical care like a Medicare supplemental plan. I only have Medicare Part A and the GEHA, plus 1 coverage. The CCRCs we've been researching and visiting all say our coverage would be sufficient for their medical insurance requirements and, of course, they appear to salivate over our LTCi coverage, as we only consider CCRCs that are Type C, pay-as-you-go into LTC,

 

[Koolau]

No, exactly the opposite. QCDs reduce AGI, which in turn reduces MAGI, which in turn can help reduce or avoid IRMAA.



Yes, QCD lowers AGI, which lowers MAGI.

Thanks!

I was afraid it was one of those items you had to "add back in" to your AGI to MAGI. BUT, if it lowers AGI, then, you are correct. That would lower MAGI as it's based on AGI plus some stuff possibly added back in.

Thanks again!

 

[SecondCor521]

Thanks!

I was afraid it was one of those items you had to "add back in" to your AGI to MAGI. BUT, if it lowers AGI, then, you are correct. That would lower MAGI as it's based on AGI plus some stuff possibly added back in.

Thanks again!

You're welcome.

QCDs reduce AGI in the sense that they're never included in the first place when reported properly. Any QCD dollars are *not* reported on line 4b, which is what goes into AGI (and provisional income for SS taxability).

Good point about the add backs though with regards to MAGI. There are several different versions of MAGI, so you'd have to be specific about which one you meant, but AFAIK none of them add back QCDs.

 

[harllee]

Regarding Medicare Part D--I don't remember if our CCRC required it but they did ask for a copy of our part D card (along with our Medicare card and Supplement card). They suggested we use a nearby pharmacy that delivers to the CCRC on a daily basis. We will probably switch our prescriptions to the pharmacy that delivers but we may have to wait until January when we can change our Part D, will have to look into that.

 

[Scuba]

No I don't think any true CCRCs accept Medicaid. Most only accept people to skilled nursing, assisted living etc who have lived in independent living apts at that CCRC. But some, like my CCRC, have trust funds that will pay your expenses at the CCRC if you run out of money.

Many CCRC’s I’m familiar with accept Medicaid, particularly those with large SNF’s. They prioritize the CCRC residents first, but it doesn’t make sense for them to leave a substantial number of SNF beds open. They definitely take Medicare/Medicaid admissions for short-term stays, for example. And they may take a certain number of Medicaid admissions just to help cover their overhead.

 

[Scuba]

Probably very different in every state. Here in NC I don't know of any doctors that take Medicare Advantage but not traditional Medicare. Almost all doctors in NC take traditional Medicare but it appears to me that only a few take Advantage plans and then only certain advantage plans.



Suggestion--for anyone considering a CCRC, check with them to see if they take Medicare Advantage plans and if so which ones if you are considering a Medicare Advantage plan.

Good suggestion. I think generally most SNF’s are far more likely to prefer traditional Medicare vs Advantage. I know the chain of senior living communities I worked for did not accept Kaiser in their SNF’s for example due to low reimbursement rates. It was very upsetting to some of our CCRC residents to realize that their insurance wasn’t accepted at the SNF at their community. Definitely best to ask these questions up front.

 

[harllee]

Many CCRC’s I’m familiar with accept Medicaid, particularly those with large SNF’s. They prioritize the CCRC residents first, but it doesn’t make sense for them to leave a substantial number of SNF beds open. They definitely take Medicare/Medicaid admissions for short-term stays, for example. And they may take a certain number of Medicaid admissions just to help cover their overhead.

My CCRC takes Medicare but not Medicaid. None of the Class A CCRCs in North Carolina take Medicaid.

 

[Huston55]

I don't think you are missing anything, I am sure that most people in CCRCs have children. I think a CCRC is a good option for anyone. But a number of our friends who do have children and grandchildren say that they do not need to move into a CCRC because their children/grandchildren will take care of them. I wonder what the children/grandchildren have to say about this.

You aren't missing anything. Far too many folks think they'll need only the occasional pop in and help with a doctor visit - and can call upon the kids for that. They don't anticipate 24/7 care, or the kind of burden that can place on their children...or, they think they deserve it in return for raising them....

Absolutely agree with these sentiments. At the risk of sounding a bit harsh, I think many people resort to 'lazy' or worse ('magical') thinking when it comes to this subject, as alluded to by Aerides. I know this from personal experience in my own family. Below are some stats on how "family member care" impacts the caregiver; it's not pretty.

https://www.ncbi.nlm.nih.gov/books/NBK396398/
Go to section on: THE IMPACT OF CAREGIVING ON THE CAREGIVER

https://www.cdc.gov/aging/caregiving/caregiver-brief.html

 

[Koolau]

Absolutely agree with these sentiments. At the risk of sounding a bit harsh, I think many people resort to 'lazy' or worse ('magical') thinking when it comes to this subject, as alluded to by Aerides. I know this from personal experience in my own family. Below are some stats on how "family member care" impacts the caregiver; it's not pretty.
https://www.ncbi.nlm.nih.gov/books/NBK396398/
Go to section on: THE IMPACT OF CAREGIVING ON THE CAREGIVER

https://www.cdc.gov/aging/caregiving/caregiver-brief.html

Thanks for the web sites. These should be read and understood by all who are or are considering care giving. I was the primary care giver for my mom (auxiliary care giver for my dad - mom was primary.) Each in turn had Alz. Eventually, I couldn't handle the situation and each went into memory care - which was a real blessing (to them and to me.)



At first, it was simply setting up pill boxes and keeping the heating/AC running etc. Eventually, it became much more involved. In each case, mom and dad, there was a crisis that took it out of my hands and forced one then the other into memory care.



I would warn anyone in this situation NOT to feel guilty because the loved one is forced into memory care. My "relief" at no longer being care giver caused me some guilt. I had to w*rk through that. It's similar to the relief (and subsequent possible guilt) when a loved one dies.



It's not anyone's fault. You did what you could do. Life goes on.



YMMV

 

[oldphd]

On the subject of Medicare Advantage...

DW has a Medicare Advantage plan through her state retirement. The documentation states that it is accepted as "in network" by anyone who takes medicare. We have lived in two different states, the one where she is retired from and now another. We have found it to be excellent coverage, always accepted as described, and she has (unfortunately) used it more than she would like. Open heart surgery, cancer surgery, chemo, broken bones, multiple rounds of PT, etc.

Based on my limited experience, I believe there are many medicare advantage plans, and don't think that one can paint them all with a broad brush. Perhaps I'm missing something...

 

[ChrisC]

On the subject of Medicare Advantage...

DW has a Medicare Advantage plan through her state retirement. The documentation states that it is accepted as "in network" by anyone who takes medicare. We have lived in two different states, the one where she is retired from and now another. We have found it to be excellent coverage, always accepted as described, and she has (unfortunately) used it more than she would like. Open heart surgery, cancer surgery, chemo, broken bones, multiple rounds of PT, etc.

Based on my limited experience, I believe there are many medicare advantage plans, and don't think that one can paint them all with a broad brush. Perhaps I'm missing something...

I don’t think anyone is painting with a broad brush about the coverage regarding Medicare Advantage plans, but posts here point out that some (and maybe all) CCRCs want their residents to have traditional Medicare plus Supplemental Plan or some other retiree health insurance coverage not wedded to a HMO or in-network coverage because as I suspect the CCRC certified Medicare facility is not in-network for Medicare Advantage plans (and may not go through the trouble of achieving in-network status for a number of reasons).

If someone is already in a CCRC and that CCRC, whether Medicare certified or not, and the facility or its providers accept Medicare Advantage plan, it would be helpful for someone to post and confirm!

 

[harllee]

My point is that if you are interested in a CCRC and you have Medicare Advantage or are considering Medicare Advantage you should ask the CCRC is they take that Medicare Advantage policy.

To change the subject, tomorrow is the day at my CCRC to sign up for August Activities and there are tons of things to choose from, everything from dance lessons to museums to overnight trips to bourbon tastings to classical music, foreign films, etc etc etc. I think we are really going to like this place!

 

[youbet]

Many CCRC’s I’m familiar with accept Medicaid, particularly those with large SNF’s. They prioritize the CCRC residents first, but it doesn’t make sense for them to leave a substantial number of SNF beds open. They definitely take Medicare/Medicaid admissions for short-term stays, for example. And they may take a certain number of Medicaid admissions just to help cover their overhead.

We're familiar with five Type A CCRC's here in NE Illinois. Have attended numerous presentations and one-on-ones. All five emphasize "No Medicaid." They don't seem to have any issues filling any SNF beds not occupied by residents with private pay patients. In fact, four of the five don't even accept private pay non-residents into their SNF.

There must be substantial variation in this policy from region to region. I guess that is not a surprise.

I'm really finding a lot of value in this thread and learning lots of new things to inquire about as we check out places.

 

[youbet]

To change the subject, tomorrow is the day at my CCRC to sign up for August Activities and there are tons of things to choose from, everything from dance lessons to museums to overnight trips to bourbon tastings to classical music, foreign films, etc etc etc. I think we are really going to like this place!

Sign me up for the bourbon tastings please.

 

[harllee]

Sign me up for the bourbon tastings please.

I am told that activity (as well as the Martini making class) fills up quickly.

 

[Koolau]

I am told that activity (as well as the Martini making class) fills up quickly.

Bring your own shaker.