for Long Term Care
Medicaid is a Federal Insurance Program for people of limited meas. In addition to general Medical coverage, Medicaid also covers long term care costs under the OSIP Medicaid program.
For long term care coverage under Medicaid, an individual must two financial and one needs based criteria.
1) Assets below $2,000 for a single person.
2) Income below 300% of SSI ($2,199 in 2017).
3) Need Assistance with Activities of Daily Living.
Qualification 1 - Assets
All a person’s assets are evaluated for Medicaid. Certain assets are excluded from the $2,000 maximum. Anything not explicitly excluded in the rules is included.
Excluded assets include:
1) Certain real property.
a. Up to $552,000 of a person’s residence if they are living there.
b. The home of applicant’s spouse or disabled child so long as they are currently living there.
c. Real property for which there is a good faith attempt to sell
d. Real property held jointly and not able to sell due to joint owner’s unwillingness, domestic violence, or incapability.
2) Vehicle. One car used by or for the Medicaid applicant or spouse.
3) Personal household items. Items of nominal value in the home or care community.
4) Medical equipment.
5) Funeral Services
a. An irrevocable burial plan and burial merchandise.
b. Up to $1,500 in a burial savings account.
6) Up to $119,220 in assets for the spouse. See Spousal Impoverishment section below.
7) Have ownership in property but not able to access.
8) Pensions and Retirement Plans that only allow for periodic payments so long as there is no way to change the payment terms and the payment terms start immediately and are actuarially sound.
9) Medicaid compliant annuities.
10) Term Life Insurance. So long as there is with no cash value.
11) Whole Life Insurance. With a cash surrender value of $1,500 or less.
Unless specifically excluded by statute, all other assets held individually or jointly are considered available to the Medicaid applicant and would count toward the asset limit.
Giving away assets for less than the fair market value is not a good idea as it will disqualify a person from Medicaid benefits for up to five years from when they would otherwise have been eligible to receive the benefits. If you have a too many assets to qualify, an attorney at NW Estate Law, LLC can help you determine the best course of action.
Qualification 2 - Income
A person’s income must be below 300% of SSI which is currently $2,199 per month from all sources. However, an Income Cap Trust is an allowable remedy to bring income down below the limit. Certain expenses can come out of the Income Cap Trust such as room and board costs, certain medical expenses, some home maintenance expenses, child support obligations, and spousal income based on the Spousal Impoverishment Rules. If there is more money left each month, it is transferred to the state to reimburse a person’s care.
Qualification 3 - Activities of Daily Living (ADL)
ADL’s measure a person’s ability to function independently during the day. Medicaid considers if a person is Independent, In Need of Stand By Assistance, or Fully Dependent in the following Activities; bathing, eating, incontinent care (bathroom), dressing, grooming, transferring and mobility.
Each applicant is interviewed by a caseworker and placed in a service priority level between one and seventeen. Currently persons falling in priority level thirteen and higher will meet the ADL requirement for Medicaid.
Spousal Impoverishment Rules
For a married couple when one needs care and one does not, certain rules help ensure the healthy spouse (known as the “community spouse”) does not reach poverty levels before Medicaid will cover care costs for the Medicaid Spouse.
Income. The Community Spouse can keep the following income:
1) All the income in his/her name.
2) A portion of the Medicaid Spouse’s income if the Community Spouse’s income is not enough to reach the Minimum Monthly Needs Allowance or MMNA which is currently set at $2,003 minimum and $2,980.50 maximum. The amount a person can keep is dependent on a few factors including certain expenses and the community spouse’s income.
Assets. The Community Spouse can keep certain excluded assets as well as the greater of $23,884 one-half of the couple’s total countable assets at the time care is initiated, not to exceed $119,220.
If these amounts are not enough to cover the Community Spouse’s Expenses, there may me an option to increase the assets, income, or both the Community Spouse can keep.
Service Providers and Medicaid
Medicaid covers care in Nursing Homes, Assisted Living, Memory Care Facility Adult Care Homes, Residential Care Facilities, and certain Home Based Care. A service provider choses to contract with Medicaid. Medicaid will not cover services or care at non-Medicaid contracted places. If a person lives in a long-term care facility that is not contracted with Medicaid, they must move to a Medicaid certified facility. More options may be available for people who are not currently on Medicaid so it is a good idea to move while still paying privately in anticipation of future Medicaid payment.
Medicaid recipients are responsible for their room and board plus pay any extra income toward the cost of their care. Room and Board is currently set at $590 per month. The Medicaid recipient gets to keep a personal needs allowance ranting from $60 per month to $163 per month depending on what type of care they are in.
The State of Oregon (and any other states where a person receives Medicaid) will seek repayment from the Medicaid recipient’s estate for all costs spent on care. However, the state cannot collect until the recipients, spouse or child (who is disabled or a minor) is still living.
Applying for Medicaid
An Attorney at NW Estate Law, LLC can help navigate the system – this is especially a good idea for couples with a Community Spouse. The Application starts ate the Area Agency on Aging in the County the Medicaid recipient lives. The Medicaid Eligibility Worker ca help. There is also an application online at: https://apps.state.or.us/Forms/Served/se0539a.pdf.
If an application is denied, benefits are reduced, or terminated, there is an appeals process that will be outlined I the notice.
How an Elder Law Attorney Can Help
Navigating long term care and Medicaid can be difficult. An Elder Law Attorney can help by:
- Finding options to protect the Community Spouse through:
+ preservation of assets;
+ transitioning countable assets into excluded assets; and
+ petitioning for a higher level of income, assets, or both.
- Providing a summary of costs and a best approach for paying for long term care.
- Assisting with the Medicaid Application.
- Providing guidance regarding transfers and penalties.
- Providing connections to other service providers.
- Helping families through a difficult and confusing time.