Are You Applying For Medicaid Coverage?

Getting Started

There are three types of Medicaid: (1) Community Health Insurance (2) Custodial Long-Term Care and (3) Home Care Waiver Programs. Most likely, you are interested in information about Custodial Long-Term Care or the Waiver Programs offered in the applicant's home state.

Medicaid is a public benefits program. The rules are very complicated, and for you or your loved one, there is a lot at stake. The costs of long-term custodial care are going nowhere but up, quickly approaching $120,000 per year. There are only three ways to pay for long-term custodial care: (1) private pay (2) long-term care insurance; or (3) Medicaid. If you are in a crisis situation, it is recommended that you consult with an Elder Law attorney familiar with Medicaid eligibility rules before you apply for Medicaid.

The Medicaid Program

Medicaid is a welfare program jointly administered by the federal government and the states. Each state administers the program subject to its own state agencies and Medicaid regulations. An applicant has to satisfy three eligibility criteria to qualify for long-term care Medicaid: first, the applicant must be aged (over 65) or disabled; second, the applicant must require a nursing home level of care; and third, the applicant must have less than $2,000 in countable resources in Virginia ($2,500 in Maryland and $4,000 in D.C.). If determined eligible, long-term care Medicaid will pay the nursing care facility the costs for custodial long-term care of the eligible individual. In addition, Medicaid will pay the facility, or a third-party provider, for the cost for ancillary services provided to the individual.

Medicaid Waiver

Medicaid Waiver is a Medicaid benefits program offered to qualified applicants as an alternative to long-term custodial care in a nursing home. The eligibility criteria are essentially the same as those of long-term custodial care, with some variation by jurisdiction.

The Waiver Program allows an eligible individual to continue to reside at home, with support services provided and paid for by Medicaid. The concept of the Waiver Program is to allow an eligible individual to stay at home, rather than enter a nursing home if the costs to Medicaid are less than the costs of custodial long-term care. There are a variety of Waiver Programs. The Waiver Program has specific rules of eligibility and implementation. It is best to consult with an elder law attorney if you are considering the Waiver Program.

Eligibility: Medical

Medical eligibility for long-term care is determined on a case-by-case basis. Covered groups are the aged (over 65), blind, and/or disabled. In most jurisdictions, the aged applicant must also be deficient in a number of activities of daily living (transferring from bed to chair, dressing, toileting, eating, etc.) and require skilled nursing care. If your loved one is at home, the county social services office will do an assessment for eligibility. If he or she is in a nursing home, the facility will conduct the assessment.

Eligibility: Financial

Medicaid's financial eligibility rules were designed with the married couple in mind. The individual in (or applying for) long-term custodial care is identified as the "institutionalized spouse (IS)" and the spouse at home is the "community spouse (CS)." All of their resources, regardless of whose name is on the title, are counted for purposes of Medicaid eligibility. This includes resources titled jointly with any third party, including children.

Once all resources are identified, they are divided into two groups: countable assets and exempt assets. Exempt assets include the marital home, provided the CS is living in it, personal property, pre-paid funeral and burial, and automobile. All resources that are not exempt assets are countable.

Community Spouse Resource Allowance

In very basic terms, the CS is allowed to keep a Community Spouse Resource Allowance in an amount between $24,180 and $120,900 (2017). The amount of the Community Spouse Resource Allowance will depend on the value of the couples' total countable resources when the IS first became institutionalized for a period of thirty days or more.

Income

The general rule, subject to variations among jurisdictions, is that if the applicant's income is less than the private pay rate of the nursing home and he/she is resource qualified, then he/she is financially qualified.

For couples, Medicaid follows the "name on the check rule;" that is, there is no mingling of income between spouses.

Medicaid eligibility rules provide for a shifting of income from the IS to the CS to assure that the CS has a base income. The maximum base income guaranteed the CS is $3,022.50 (2017). The minimum guaranteed amount, known as the Minimum Monthly Maintenance Needs Allowance (MMMNA), is $2,030.00 (2017).

The Application Process

Each jurisdiction has its own application process and specific requirements for documentation. See your state's Medicaid Web site to find out more about local procedures. The first step is to obtain and review a copy of the application of the jurisdiction where your loved one is in a long-term care facility. Eligibility rules are different for each jurisdiction, and eligibility strategies, resource preservation, planning and documentation will vary from jurisdiction to jurisdiction, so it is very important to identify the correct jurisdiction. Contact an elder law attorney prior to attempting to navigate the application process.

Lastly, please familiarize yourself with the Medicaid Myths to avoid any misinformation. For more information and skilled assistance, contact The Elder & Disability Law Center by calling us toll free at 866-399-4324 or locally at 202-452-0000. You may also send us an email.