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Medicaid & Long-Term Care Costs
–MSU Extension MontGuide 199511
Updated March 2013
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MontGuide Co-authors
Marsha A. Goetting • MSU Professor & Extension Family Economics Specialist
Nancy Clark & Barb Flamand• Dept. of Public Health & Human Services
Joel Schumacher• MSU Extension Economics Associate Specialist
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PowerPoint Developer
Keri Hayes •MSU Extension Economics Publications Assistant
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Major Concern of Families
• Will costs for long-term care exceed my/our savings?
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Research
•43% of those age 65 and over will spend time in nursing home
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Average Stay • 55%
– At least one year• 21%
– 5 or more years
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Nursing Home Care Costs 2013
•Montana Average $ 5,955* monthly $ 71,456 yearly
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*Rounded
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Who Pays????
•Residents & Families 32%•Medicaid 61%•Medicare 7%
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4 Ways to Provide for Long-term Care CO$T$
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Way…….#1• Use Personal Resources
Current income Savings/Investments Sale of assets
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Way.……...#2
• Purchase “regular” long-term care insurance
• Purchase Long-Term Care Partnership Insurance Policy
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Long-Term Care Partnership Insurance Program
•MontGuide• www.montana.edu
Search by title
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Example Policy Costs
Age Cost Yearly
Cost Monthly
40 $1,320 $110
50 $1,920 $160
60 $2,760 $230
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Montana Insurance Dept. Montana Insurance Dept.
•Montana Consumer’s Guide to Long-Term Care– 1-800-332-6148
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Senior & Long Term Care Division-DPHHS Senior & Long Term Care Division-DPHHS
•Montana Legal Guide to Long Term Care Planning– 1-800-332-2272
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Way……...#3
• Depend on relatives to pay nursing home costs
Most families say no way
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Way……….#4
•Medicaid60% of Montanans in nursing homes receive assistance
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Eligibility Requirements
FEDERAL
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Montana Eligibility Tests
•Circumstances•Assets•Income
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Circumstances Test
• 65 or older• Permanent U.S. resident• Montana resident• Have a Social Security Number
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Assets Test
•Resources–Countable –Excluded
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Countable Resources:
• Non-home real estate• Vehicles• Checking & savings accounts• U.S. Savings Bonds
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Countable Resources:
•Investments–Stocks–Bonds–Mutual funds
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Countable Resources:
• Retirement PlansKeogh accountsIRAs (Roth, Traditional)SEPsSIMPLES 24
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Countable Resources:
•Retirement Plans (con’d.)
401 (k) plans403 (b) plans457 plans
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Countable Resources
• Life estates• Oil & mineral rights• Assets in living (revocable)
trusts26
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Countable Resources Summary
•Any asset over which individual has control are counted
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ExcludedResources
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Excluded Resources
• Home (Single Person)–If applicant was living in it &
expects to return to it within 6 months
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Excluded Resources
• Home (value less than $500,000)– If used as primary residence by
• Spouse• Other dependents
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Excluded Resources
•Personal Effects•Ordinary
Household Goods
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Excluded Resources
•Cash value of life insurance –Total value of $1,500 or less
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Excluded Resources
•Burial plot•Burial fund– $1,500
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Excluded Resources
•Irrevocable burial contract–On Montana approved form with
funeral home34
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Excluded resources
• Income producing property –Up to $6,000 of equity value
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Excluded resources
• Livestock, if:•Used to produce income•Raised for home consumption•Used as pets
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Marital Assets
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Marital Assets
•Assets of both spouses are included–Regardless of whose name
appears on titles
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Marital Assets • Includes all
separately & jointly owned real & personal property
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Joint Tenancy Property
• All included–Even if children or
grandchildren’s names are on document
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Solely Owned
• Includes all property titled in separate names of spouses
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Premarital Agreement Between Andy & Nancy
• Doesn’t matter• All property is countable
resource for Medicaid Eligibility test
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Andy &Nancy
• Each had wills bequesting separate property to their respective children
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Nancy & Andy6 months later
• Andy is diagnosed with Alzheimer’s disease
• All property of BOTH are countable resources
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Assets: Couple with children from prior marriage
•Andy = $100,000•Nancy = $800,000 $900,000
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Community Spouse Protection
• Can keep up to one-half of value of countable assets (2013)– Minimum $23,184– Maximum $115,920
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Nancy Keeps
• Maximum: $115,920• Remainder: $784,080
Must be “spent down” to $2,000 before Andy is eligible
for Medicaid Can use for nursing home
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Bonnie & Sam
•Assets = $25,000•Bonnie can keep minimum
$23,184 if Sam goes in nursing home
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Betsy & Bill
•Assets = $70,000•Bill can keep one-half $35,000 if Betsy goes in
nursing home 49
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Budd & Sara
• Assets = $314,000• Sara can keep maximum$115,920 if Budd goes in
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Amounts over limit: Spend-down amount
•Available resources must be “spent down” to $2,000 for nursing home spouse 51
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Frank & Catherine •Assets = $300,000
Catherine can keep $115,920
Remainder of $184,080 must be spent down to $2,000 before Frank is eligible for Medicaid
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Assets Test Summary
•Countable Resources •Excluded Resources
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Income Test for Medicaid Eligibility
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• Most income received in name of Medicaid applicant is countable
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Countable Income Examples
•Social Security•Retirement pensions•Railroad retirement•VA benefits
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Countable IncomeExamples (con’d.)
•Lease & rental income•Dividends• Interest earnings
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Countable IncomeExamples
•Trust income•Annuity
payments
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Personal Needs Allowance
•Institutionalized personal allowed–$50 per month
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Health Insurance
•Can pay monthly premium cost from income
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Income Rule
• Income of an individual in a nursing home must be used to pay for care
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Medicaid eligibility
• If applicant’s cost of nursing home care is greater than income, income test is met
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Bruce: $2,000 income $50 personal care allowance $550 health insurance $600 total allowance
$2,000 income - $600 allowances
$1,400 available income for nursing home cost
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Available Medicaid Payment
Cost of Bruce’s Care $5,818Available Income $1,400Balance
$4,418
• $4,418 Paid by Medicaid 63
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Marital Income
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•Community Spouse• Institutionalized Spouse
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Community Spouse
•Can keep all income paid solely in his or her name
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Institutionalized Spouse
•All income in nursing home spouse’s name is counted for the income test
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•1/2 institutionalized spouse•1/2 community spouse
Income in names of both spouses will usually be attributed:
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Community Spouse
•Monthly Allowance up to maximum– $2,898 (2013)
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• Home maintenance costs: Rent or MortgageInsurance TaxesUtility Charges
Calculation for monthly allowance
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Community Spouse
• If he/she has sufficient income no monthly allowance is granted
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Application Process for Medicaid Eligibility
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Forms • Resource Assessment• Pre-screening Medical
Determination• Application for
Assistance 72
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Resource Assessment
•Based on first day of the month that an individual entered nursing home
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Resource Assessment
•DPHHS Form– HCS 457 – HCS 245
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Pre-screening determination
• Is the applicant in need of long term care services?
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Pre-screening
•Mountain Pacific Quality Health Care Foundation–1-800-219-7035
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Application
• Montana – County Office of Public Assistance
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Decision on Eligibility
•45 days from date of application
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Denial
• Request hearing–Must make written request
within 90 days of denial
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Approved • Issued a one-time permanent
card• Used to access eligibility data
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Front of Card
• Individual’s Name• Date of birth• Client I.D. number
– No Social Security Number
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Summary Eligibility Requirements
•Medical Need•Assets•Income
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Transfer of Property Rules
Become “impoverished” to qualify for Medicaid Assistance
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Consequences
• Legal• Tax• Emotional
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Look-Back Rules
• Assets transferred on or after February 7, 2006 Has 5-year back rule
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Period of ineligibility
• Depends on:– Value of gift or
transfer– When it was made
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Period of ineligibility
• Number of months that would otherwise be required to spend the uncompensated value on nursing home care
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Value based on average cost per month of nursing home care in Montana
• $ 5,955 average –2013
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Example: John gifted stocks valued at $182,000 in 2013
• Adult children & spouses • Grandchildren• No gift tax• Annual Exclusion (Federal) $14,000 for each donee
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Ineligibility Calculation
• Value of Gifs $182,000 –Nursing Home Cost $5,955 = 30.56
months–Ineligible for about 2 ½ years
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Transfers made before the look back period:
• Do not affect Medicaid eligibility
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Excluded Transfers
• Home; if lived in by– Community spouse– Child less than age 21– Adult child
• Blind or permanently disabled92
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Excluded Transfers
• Home, if– Child lived in home– Child Provided care to
parent for at least 2 years– Care allowed parent to
remain at home 93
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Excluded Transfers
•Home, if –A sibling owns an interest
& has lived there for one year
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Role of Trusts in the Protection of Assets
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What is a Trust??•Legal arrangement whereby an individual transfers assets into the name a trust
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Beneficiary?
•Person(s) or organization(s) to whom the trustee distributes trust income or principal
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Revocable Living Trust•Created during owner’s lifetime
•Can be changed anytime•Funds used to cover nursing home costs
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Irrevocable Trust•Person who established trust has no power to:
Amend Cancel Remove 99
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Trusts
•Contact an attorney to obtain legal advice
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Emotional Consequences of “going on Medicaid”?
•Feelings of older adults of being on “welfare”
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Medicaid patients •Often more difficult to place in nursing home • Move more often
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Tax Consequences
•Federal Estate Tax•Federal Gift Tax• Income Tax
– Capital Gain 103
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Basis in Property
• Stepped up Basis at death of owner
• Carryover Basis when gifted during life of owner
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Present Law•Real & Personal Property
receives stepped-up basis in value at death of owner
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Stepped-up basis
• Fair Market Value • Date of death of
owner
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Larry’s Ranch •Purchased
–$ 40,000 in 1950
•Value in 2013–$2 million
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Ranch Given to GrandsonDuring Larry’s Lifetime
•Grandson assumes Larry’s basis of $40,000 in the property
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If grandson sells ranch for $2 million
• Capital Gain$ 2,000,000 Selling price$ 40,000 Basis$ 1,960,000 Capital Gain
x .15 Tax Rate294.000 Tax 109
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Federal Gift Tax
•No federal gift tax paid because•Up to $5.25 million can be gifted without a federal gift tax (2013)
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Ineligible
• Larry is ineligible for Medicaid either case Because the value of property exceeds $2,000
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Gift
•Property received as gift receives carryover basis in value
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Federal Gift Tax •Gifts are subject to federal
gift tax if above $14,000•Fair market value at date of
gift
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Marie• Owns home valued at $40,000 40 years ago Fair market value (2013) $400,000
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Gives home to her granddaughter
•Granddaughter assumes Marie’s basis of $40,000 in the property
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Granddaughter sells
• $400,000 Sale Price - 40,000 Basis $360,000 Capital Gain for Granddaughter
X .15 (2013) $54,000 potential
Capital Gain Tax for Granddaughter
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Marie bequeathed in a will her home to her granddaughter
• There would be NO capital gain tax
• No federal estate tax Applicable exclusion amount is less than $5.25 million (2013)
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Results
•From a tax savings perspective, bequests save more money for heirs than gifts
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Summary Tax Consequences
• Federal Estate Tax• Federal Gift Tax• Income tax
– Capital Gain 119
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Medicaid Lien & Estate Recovery Program
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Federal Mandate •States are required to:
–Recuperate costs for Medicaid recipients who pass away
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LienLien
•Must be paid before title to property can be sold or transferred
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• Creditors–Medicaid $24,000–Funeral + 10,000–Probate + $2,000 Total $34,000 Expenses
Robert: House valued at $75,000
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Son InheritsSon Inherits
$75,000- $34,000
$41,000
Estate ValueExpensesLeft for Son
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Recovery procedures while Medicaid recipient living
Recovery procedures while Medicaid recipient living
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MontanaMontana•Files lien on
real property owned by Medicaid recipient
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Medicaid Lien and Estate Recovery Program
•1-800-694-3084127
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Senior & Long Term Care Division
• Questions about Medicaid• 1-800-332-2272• www.dphhs.mt.gov
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Medicaid Recipient HotlineMedicaid Recipient Hotline
•1-800-362-8312
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Public Assistance Office
• Medicaid Eligibility Specialist• Telephone book
–Name of county
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Medicaid & Long-Term Care Costs–MontGuide 199511
Updated March 2013