1. Quad City Estate Planning Council March 21, Iowa Medicaid Estate Recovery Ben Chatman, Estate Recovery Program Iowa Department of Human Services Iowa Medicaid Enterprise, Revenue Collections Unit Health Management Systems th Avenue, Suite 600 Des Moines IA   Phone: 515/ Fax: 515/ Toll-free

2. Introductory Comments
Estate Recovery mandated in early 1990’s for all states
Administering the law to recover correctly paid Medicaid, not just collecting money -- Four examples of typical estate recovery cases
Review files regularly to maintain constant active number of files
Only about 35% of total cases (10,000/yr) have any recovery
Over 60% of recoverable cases are less than $2,000
Waivers (deferrals) in about 11% of all cases.
Average time each file is open is five months.
Average Iowa recoveries for last 3 years is $26 million per year
Authorized by 42 USC 1396(p)(b) and Iowa Code 249A.53(2)

3. Processes Outreach and Referrals Obtaining debt information
Contacts with personal representatives
Probate (mandatory online notice, claims, and EDMS)
Iowa Code ; A, , and
Non-probate (letters and small estate affidavits)
Probate administration (nominated PR by DHS)
TEFRA liens – not available in Iowa
Responses and Follow-up
Consistent monthly deposits

4. What Amount to Collect
As authorized under 42 USC 1396p(b), all Medicaid assistance provided, as limited by Medicaid Improvement for Patients and Providers Act (MIPPA) for Medicare Cost Sharing aka Medicare Savings Program
Fee for service
Affordable Care Act (ACA), Managed Care Organizations (MCO’s), and capitation fees
Buy-in (Medicare premiums)
Interest

5. From Which Estates? “Estate” includes whether probated or not
Age requirement – 55 and over
Long term care requirement (under 55)
Liability for personal representatives who distribute funds without paying medical assistance debt

6. Waivers and Exemptions
Spouse, disabled children, minor children
Hardship waivers
Homestead exemption not applicable per se (See Iowa Code ), but hardship waiver may apply

7. Probate Assets Bank accounts Real estate
Excess burial funds and life insurance
Household goods and personal effects
Litigation
Vehicles
Stocks, bonds, and mineral interests

8. Expanded Probate Assets
Jointly held property
Estate of Kirk, 591 NW2d 630 (Iowa 1999)
Estate of Serovy, 711 NW2d 290 (Iowa 2006)
Life estates
Estate of Laughead, 696 NW2d 312 (Iowa 2005)
Interests in trusts
In re Barkema Trust, 690 N.W.2d 50 (Iowa 2004)
Estate of Gist, 763 N.W. 2d 561 (Iowa 2009)
Estate of Melby, 841 N.W. 2d 867 (Iowa 2014)
Beneficiary designations (annuities, etc.)

9. Higher Priority Expenses
Court costs and costs of administration
Funeral expenses
Medical bills of last illness
Taxes and other debts to federal and state
Examples of other expenses with lower priority
Bankruptcy issues
Medicaid Trusts – DHS is a beneficiary, only costs of administration are paid before Medicaid

10. Medicaid Trusts Iowa Code Chapter 633C
Medical assistance income trusts (MAIT’s)
aka Miller trusts, income assignment trusts or qualified income trusts
Special needs trusts
Pooled trusts
Balance in trust at death to pay Medicaid

11. Final Comments
All states are required to have a Medicaid Estate Recovery Program, but the laws, the resources devoted to the program, and political climates vary greatly.
Estate recovery is merely a matter of fairness. Assets that could have been used to pay for medical bills before death are used instead after death to replenish Medicaid, similar to a line of credit that comes due in full at death.
Estate recovery is for correctly paid Medicaid. However, referrals can be made to other agencies if there are issues with how the Medicaid benefits were obtained.
Thank you for having me speak to your group.