What Services Does Long
Medicaid Long-Term Services & Supports can be provided in a variety of settings, but some seniors needs are best met in an institutional setting. If a senior resides in a nursing home, the Medicaid beneficiary must reside in a Medicaid-certified nursing facility for their care to be covered. States may specify the types and limitations of some services that can be provided, but federal regulations require that certified nursing homes must offer specific services at a minimum and at no charge to Medicaid residents.
All states have at least one program that allows Medicaid beneficiaries to receive medically necessary care and personal care services in their home community. Community Medicaid services are designed to help seniors stay in a home setting as long as possible. Residents can receive these services in a group residential setting, their personal home, or in the private home of someone else, such as a family caregiver. Additionally, some states allow the beneficiary to direct who provides the care services, including the selection of a family caregiver. Skilled care provided by licensed health care providers is covered by every state plan, however the additional non-medical programs covered by Community Medicaid and availability of those services varies widely by state.
New Requirement For Medicaid Effective November 2017
If you are turning age 65 within the next three months or you are age 65 or older, you may be entitled to additional medical benefits through the Medicare program. You may be required to apply for Medicare as a condition of eligibility for Medicaid.
Medicare is a federal health insurance program for people age 65 and for certain people with disabilities, regardless of income. When a person has both Medicare and Medicaid, Medicare pays first and Medicaid pays second.
You are required to apply for Medicare if:
- You have Chronic Renal Failure or Amyotrophic Lateral Sclerosis OR
- You are turning age 65 in the next three months or are already age 65 or older AND your income is below 120% of the Federal Poverty Level , or is at or below the applicable Medicaid Standard, then the Medicaid program will pay or reimburse you the cost of your Medicare premiums. If the Medicaid program can pay your premiums, you will be required to apply for Medicare as a condition of Medicaid eligibility.
If you have Medicaid and appear to be eligible for Medicare based on any of the criteria above, you must apply and show proof of Medicare application, or risk losing your Medicaid coverage.
When you apply for MEDICARE:
If you go to your local SSA office, you should bring:
- Proof of date of birth and
- Proof of U.S. citizenship or lawful residence and
- A copy of your Social Security card and your Medicaid card.
Proof of Medicare application can be:
- Social Security Administration 1-800-772-1213
Asset Income Levels Differ In Each State
Medicaid eligibility and application procedures vary from state to state.
The federal-state program was established to pay for health care for those who are unable to afford or obtain health insurance, so all states have asset and income limits that govern who can receive coverage, but it’s not one ceiling nationwide.
“Medicaid is often of importance to middle-income Americans because Medicare does not cover the costs of long-term care for illnesses such as Alzheimer’s disease or paralysis caused by a stroke. Most people who need such care for extended periods will eventually deplete their assets and become unable to pay the costs of their care, according to a brochure available online from the National Academy of Elder Law Attorneys .
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Here’s An Introduction To Medicaid’s Complicated Rules On Eligibility For Nursing Homes And Home Health Care
If you have limited assets and a low income and you need help paying for nursing home or assisted living care, Medicaid might help you pay for your care. Medicaid is a joint federal and state program, and the states have some flexibility in setting the benefits they will offer and the eligibility criteria for those benefits.
Medical And Functional Criteria For Medicaid Long
To receive institutional long-term care services paid for by Medicaid, an applicant must need a nursing home level of care. A medical specialist in the state conducts a needs assessment of the applicant and determines if they require care in a nursing home, care in an assisted living facility or if they are a candidate for home- and community-based services like in-home care services and adult day care. HCBS are a slightly different type of Medicaid program aimed at delaying or preventing applicants placement in institutional facilities like nursing homes. These services are typically provided through Medicaid waivers, which allow applicants to receive appropriate services in their own homes and communities.
Each state defines its own nursing facility level of care criteria, and the explanations are often very complex or vague. However, the requirements for meeting a nursing home level of care typically include a combination of medical, functional and cognitive components.
Medically, an applicant may need to be certified as requiring skilled nursing care from a licensed nurse . An applicants functional level is commonly determined by assessing their ability to perform activities of daily living . An evaluation is completed to identify how much assistance is needed with the following daily activities: eating, bathing, dressing, continence, toileting and transferring/mobility.
Read:Activities of Daily Living: Why This Measure Matters
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Medicaid As An Acute Care Program
As originally conceived, Medicaid was essentially patterned after health insurance available to the working population through private or employer-sponsored coverage and about to be made available to the elderly with the enactment of Medicare, that is, services would meet acute and ambulatory health care needs. The long-term care component of Medicaid grew less by purposeful design than by afterthought and reaction. Given these origins, it should not be surprising that Medicaid coverage of long-term care is often described as having gaps and being too medically oriented.
The original Medicaid legislation required States to cover services in a skilled nursing facility as part of the basic minimum package of services, however, there is no suggestion in the original legislation or in the 1971 amendment adding intermediate care facilities as an optional Medicaid service that Congress ever intended Medicaid to be the major public funding source for long-term care. Rather, the Medicaid SNF benefit, like its Medicare counterpart, seems to have been viewed as a cost-effective alternative for recipients who would otherwise spend protracted stays in more expensive acute care settings. Similarly, the inclusion of ICF services in Medicaid was motivated by a congressional reaction to safety and quality of care problems in uncovered long-term care settings it was hoped that the situation could be improved by imposing a Federal role in setting and enforcing standards.
What States Must Pay For
Federal law requires the states to provide certain services to Medicaid recipients. States must pay for nursing facilities for Medicaid recipients, and they must pay for home health care services for recipients who would qualify for nursing home care.
States have the option of using Medicaid funding to provide additional long-term care services like home health aides for those who might not qualify for a nursing home, assisted living facilities, adult foster homes, and in-home services like help with housekeeping and medication management. For information on what your state provides, see our series of articles on state-by-state eligibility for Medicaid long-term care.
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Penalty Information In South Carolina For Medicaid
If a gift of any amount is given in South Carolina during a period of 5 years before applying to Medicaid, a penalty period will be initiated. This penalty period in South Carolina is called a look-back period and it can make an individual not eligible for Medicaid. Medicaid will not pay for care until the penalty period is over. The penalty is calculated by taking the total amount of any gifts given, and dividing it by $ 6,672, which creates a number of months before Medicaid kicks in.
The average cost of Nursing home care in South Carolina is $6,596, so penalties can become very costly for a family that has not planned appropriately for Medicaid.
How And When Medicaid Can Pay For A Nursing Home
Medicaid was created in 1965 as a social healthcare program to help people with low incomes receive medical attention. Many seniors rely on Medicaid to pay for long-term nursing home care.
Most people pay out of their own pockets for long-term care until they become eligible for Medicaid. Though Medicare is an entitlement program, Medicaid is a form of welfareor at least thats how it began. So to be eligible, you must become impoverished under the programs guidelines, says Laura M. Krohn, a Rhode Island-based elder law attorney.
Let’s look at how the economics work, and how Medicaid can be used to pay for a nursing home.
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Where Nursing Facility Services Are Provided
Medicaid coverage of Nursing Facility Services is available only for services provided in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility . See NF survey and certification requirements. Medicaid NF services are available only when other payment options are unavailable and the individual is eligible for the Medicaid program.
In many cases it is not necessary to transfer to another nursing home when payment source changes to Medicaid NF. Many nursing homes are also certified as a Medicare skilled nursing facility , and most accept long-term care insurance and private payment. For example, commonly an individual will enter a Medicare SNF following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long-term care insurance they may have. If the individual exhausts assets and is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid NF benefit. If the nursing home is not Medicaid certified, he or she would have to transfer to a NF to be covered by the Medicaid NF benefit.
How Your Assets Impact Eligibility
Besides income, your assets will be counted toward meeting eligibility requirements. Countable assets include checking and savings account balances, CDs, stocks, and bonds.
In most states, you can retain up to $2,000 as an individual and $3,000 for a married couple outside of your countable assets. However, these amounts may vary depending on the state in which you live.
Your home, your car, personal belongings, or your savings for funeral expenses remain outside of countable assets. If you can prove other assets are not accessible , they too are exempt. A house must be a principal residence and does not count as long as the nursing home resident or their spouse lives there or intends to return there.
Upon becoming eligible for Medicaid, all of the applicant’s income must be used to pay for the nursing home where the applicant resides. However, you may be allowed to keep a monthly “allowance” and a deduction for medical needs, such as private health insurance. The amount of the allowance varies depending on your living arrangements, type of nursing facility, and state rules. If you are married, an allowance may be made for the spouse still living in the home.
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Medicaid Benefits And Services
The services covered by Medicaid vary from program to program and from state to state. What follows are general Medicaid benefits which are typically available in most states.
The Affordable Care Act does not significantly impact Medicaid long term care benefits for the elderly. Therefore, repeal by the Trump administration will have limited impact.
How Does The Law Impact You
Lets talk for a moment about a fictitious couple, John and Katie Elder. This Latrobe couple has been married for fifty years. They have four children. Their assets are as follows:
|
$140,000 |
|
$20,000 |
Both spouses have Social Security income and John has his monthly pension of $900 from Timken Co. Of course, they do not have any debt!!!
John Elder is now 79 years old. He has suffered a stroke and is being treated at Latrobe Hospital. The doctors have informed Katie that John will need to be discharged to a skilled nursing facility.
Since John has been in the hospital longer than three days, Medicare will pay for his nursing home stay for the first twenty days. It may also pay a small portion of the care for the next eighty days of care. After that, Katie has to figure out how to pay for Johns continued care in a skilled facility which now costs an average of $6,062 per month. From this example, it is easy to see that John and Katies monthly income is insufficient to pay for this care. Their assets are going to have to be utilized to make up the difference, unless they had previously purchased long term care insurance to help defray these expenses . Beyond that, Katie is going to need help through the Medicaid program.
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Single Person Eligibility Rules In New York State
The Medicaid resource limit for a single person in New York State for 2021 is $15,900. You will be forced to sell your investments, cash in your CDs, cash in your life insurance policies, sell your summer cottage, and sometimes even sell your home.
If you are in a Nursing Home, you will only be entitled to keep $50 of your monthly income. If you are receiving home care, you will be entitled to keep $904 of your monthly income .
When A Nursing Home Is Considered Medically Necessary In North Carolina
Medicaid will pay for a nursing home only when it is medically necessary. You must show that you “meet the nursing facility level of care,” meaning that you need the kind of care that can only be provided in a nursing home.
To show that you meet a nursing home level of care, your physician must think you need the kind of services that are only offered in a skilled nursing facility. For example, you can meet the nursing facility level of care by showing that you need the services of a registered nurse for several hours a day, or by showing that you need daily assessments of your condition by a licensed nurse, or by showing that you need medication administered frequently by a nurse. If you have a nasogastric tube, require dialysis, frequent injections, or respiratory therapy, you are more likely to meet the nursing facility level of care.
If you need only custodial care such as help with activities of daily living , you are not likely to meet the nursing home level of care.
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Let Us Help With Your Medicaid Eligibility Concerns
If you have questions about your eligibility for home health care under Medicaid in New York or need help completing your application, contact Landskind & Ricaforte Law Group, P.C. Our experienced Medicaid planning attorneys are here to answer your questions and give you the personalized legal assistance you need. We represent clients in Brooklyn, Staten Island, Queens, Manhattan, and Long Island. Call us today at 718-333-5007 to learn how we can assist you.
RELATEDEligibility Requirements For Long
The most basic and universal requirements a person must meet to qualify for Medicaid include being a U.S. citizen and meeting residency rules in the state where the applicant intends to apply.
Additionally, an applicant must:
- Be age 65 or older OR
- Have a permanent disability as defined by the Social Security Administration OR
- Be blind.
Most states automatically provide Medicaid eligibility to applicants who apply and are deemed eligible for Supplemental Security Income . However, there are a handful of states who use the same eligibility guidelines but require an applicant to file separate SSI and Medicaid applications to receive both benefits. You can learn more about SSI benefits at SSA.gov.
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Medicaid Penalties In Florida
Medicaid applicants in Florida can have their benefits delayed or denied if they willfully transferred any assets to their loved ones in the five years prior to submitting their Medicaid application. These uncompensated transfers are categorized as gifts, and they can have a major impact on a persons Medicaid eligibility.
Because Medicaid applicants are required to meet certain income and asset limits, its not uncommon for some seniors to transfer their asset in an effort to qualify for coverage. To deter this, Medicaid has established penalties for those who try.
If a person makes uncompensated transfer during their look-back period, Medicaid will not approve coverage until the persons penalty period ends. Medicaid determines a persons penalty period by dividing the number of gifts theyve given during the look-back period by $8,944, which results in the number of months Medicaid will wait before they step in.
Its important to note that there is no exception for small gifts, such as Christmas presents, when Medicaid calculates penalties. They assume all uncompensated asset transfers during the look-back period are done in an attempt to qualify for Medicaid, making it especially crucial for seniors to do careful Medicaid planning before they transfer any assets.
