Valid Reasons for an Involuntary Nursing Home Discharge One thing that strikes fear in the hearts of families caring for loved ones in a nursing home is a notice of involuntary discharge. If the nursing home accepts Medicaid or Medicaid, or both, then there are only six legal reasons for an involuntary discharge. Since virtually […]
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As of April 1, 2026, the Georgia Medicaid penalty divisor will increase from $10,798 to $11,122. This is sometimes called a transfer penalty or a gift penalty and applies where a Medicaid applicant’s resources were transferred for less than fair market value. See March 31, 2026 Memo.
How do nursing homes get paid? Sick people go to nursing homes and sick people die. According to the American Health Care Association, “Medicaid is the primary provider of coverage for nearly two out of every three (63 percent) nursing home residents,” although in Georgia the figure is 71%. One reason why residents turn to […]
Some Medicaid classes of assistance do not require verification, but most long-term care classes of assistance do. Verification documentation includes financial and non-financial information. Sometimes, tracking documentation down can be problematic. If you’re having trouble getting documentation, especially when a caseworker demands it on an unreasonable time-table, here’s what the manuals say: You are not […]
The Estate Recovery Rules vary from State to State. The federal minimum requires states to pursue recovery from the probate estate for medical assistance paid for most long-term care classes of assistance received by individuals 55 years of age and older. Federal law permits enhanced estate recovery, which would reach non-probate assets, and some states […]
Medicaid is the payer of last resort so applicants have, historically, been required to apply for all other benefits before seeking Medicaid eligibility. On March 12, 2025, Georgia issued the following Memorandum changing that rule: The purpose of this memorandum is to provide notification of the elimination of the “Application for Other Benefits” policy requirement. […]
Effective January 1, 2026, the Community Spouse Resource Allowance will increase to $162,660.00. The combined resource allowance will increase to $164,660.00. The Community Spouse income allowance will increase to $4,066.50. The SSI monthly rate in 2026 will be $994, so the 2026 Medicaid income cap will be $2,982. In general terms, all 2025 rates and […]
How the Phrase “Other Obligations” Made Special Needs Trust Invalid Christopher W. G was denied Supplemental Security Income when his conservator initially filed an application on January 25, 2022. Reconsideration was denied on August 17, 2022. The conservator requested a hearing which was conducted on June 6, 2023. After the hearing, “the ALJ issued an […]
There are a few major changes for elders in the One Big Beautiful Bill Act. First, as discussed in numerous articles cited below, it appears that reductions in funding will cause home and community-based services to be limited. This could mean more seniors are forced into nursing homes because they lack support to remain home. […]
Recent Supreme Court Medicaid Case In Medina v. Planned Parenthood South Atlantic (US 6/26/2025), the Supreme Court decided that two plaintiffs did not have a right to use 42 U.S.C. § 1983 to enforce the any-qualified-provider provision in 42 U.S.C. § 1396a(a)(23)(A). The abortion part of the case is not important for our analysis. This […]
Improper Use Spoils Trust Is it possible to spoil a trust by misusing it? The answer was “yes” in S.P. v. Division of Medical Assistance and Health Services (N.J. Super. App. Div. 2025). In that case, a brother wanted to provide housing for his sister. He did this by establishing and funding a trust that […]
2025 Georgia Medicaid Transfer Penalty If an applicant for long-term care Medicaid (e.g., nursing home Medicaid) transfers resources for less than fair market value during the 60-month look-back period, a transfer penalty is calculated. In 2024, the Georgia transfer penalty was $10,025. Effective April 1, 2025, the penalty divisor for Georgia Medicaid applicants has increased […]
Medicaid is critical for individuals with special needs. It pays for things no one else will pay for and it has recently come under fire. The Arc is working to protect Medicaid for its constituents. It is activating advocates to protect services for the disability community. It is also seeking donations to further its efforts. […]
Since 1980, Medicare pays after another responsible entity pays certain health care claims for Medicare beneficiaries. This is known as Medicare Secondary Payer (MSP). Although the issue arises in other contexts, for Elder Law Attorneys, it usually comes up when an injury claim or a worker’s compensation claim is resolved. For that reason, this post […]
The Veteran’s Administration (the VA) makes long-term care support available for qualifying veterans in several ways. VA Community Living Centers (CLCs) CLCs are VA owned and operated. Veterans can receive nursing level care, including assistance with activities of daily living. Veterans are encouraged to make their rooms feel home-like by decorating their rooms and they […]
On November 8, Medicare announced the 2025 premiums and Co-Pays. The standard monthly premium for Medicare Part B enrollees will be $185.00 for 2025, an increase of $10.30 from $174.70 in 2024. The annual deductible for all Medicare Part B beneficiaries will be $257 in 2025, an increase of $17 from the annual deductible of […]
On November 15, 2024, the Centers for Medicare and Medicaid Services posted the 2025 spousal impoverishment standards. These are the standards used to determine how the amount of income and resources that can be diverted to or retained by a Community Spouse. They also tell us the SSI rate and the Medicaid income cap. In […]
When an injured party sues someone who negligently injured him or her, one form of damages the injured party may recover are medical expenses. However, can those expenses be recovered when they have been paid by someone else? In Bennett v. Haley, 132 Ga. App. 512 (1974), the Court said they can be recovered. The […]
When the Deficit Reduction Act of 2005 changed 42 U.S.C. § 1396p, new restrictions were imposed on promissory notes. Subsection (c)(1)(I) note provides that the purchase of a promissory notes is treated as a transfer subject to the penalty rules unless the note meets the following guidelines: (I) For purposes of this paragraph with respect […]
In Lamle ex rel. Lamle v. Shropshire (W.D. Oklahoma 5/29/2024), a United States District Court upheld a denial of benefits where three Medicaid applicants refused to answer questions about promissory notes. Penelope Lamle, Marilyn Garrison and Maxine Houston each loaned money to others in exchange for a promissory note. Lamle and Garrison made loans to […]
In Hammerberg v. Department of Human Servs. (Minn. Ct. App. 4/22/2024), the State made an estate recovery claim against what appears to have been an income only trust. Very little of the trust language appears in the decision, but the “trust instrument required the trustee to pay all income derived from the trust to the” […]
The Tennessee Justice Center and its legal partners brought a class action in the U.S. District Court for the Middle District of Tennessee alleging that TennCare’s for reevaluating eligibility was defective and failed to provide notice and an opportunity for a hearing. TJC alleged that TennCare’s policies and practices caused thousands of Tennesseans to lose […]
Section 1115 of the Medicaid statute allows sates to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP). The home health waivers are designed to meet the needs of people who prefer to get long-term care services and supports in their home […]
On August 13, 2024, from 3pm to 4pm ET, the Center for Medicare Advocacy is hosting a free webinar titled: Medicare 101: Where to Begin and How to Make the Most of Medicare. Understanding Medicare is important – whether you are currently enrolled in Medicare, or you may qualify in the future. This presentation will […]
Sometimes finding Medicaid law is tough, but we hope to give you resources here. Federal and state statutes, regulations and case law is available to subscribers of LEXIS and Westlaw. The federal statute, which is Title XIX of the Social Security Act, is at 42 U.S.C. § 1396 et seq. (the “Medicaid Act”). The federal […]
At common law there is no obligation to reimburse the government for financial support and services received while impoverished. When the Medicaid Act was enacted, Congress gave States the option of pursuing estate recovery and, until 1993, estate recovery remained optional. Now, within the parameters of the federal rule, States must pursue estate recovery (1) […]
“Each participating State develops a plan containing reasonable standards . . . for determining eligibility for and the extent of medical assistance” within boundaries set by the Medicaid statute and the Secretary of Health and Human Services.” Wis. Dep’t of Health & Family Servs v. Blumer, 534 U.S. 473 (2002) (quoting Schweiker v. Gray Panthers, […]
Medicaid, as opposed to Medicare, is a health insurance program, jointly funded by the state and federal governments that pays for health care for America’s poor. See Medicaid Act (Title XIX of the Social Security Act), 42 U.S.C. § 1396 et seq. Not everyone is eligible for medical assistance; only those persons who fall within […]
In State of Idaho v. Beason, 546 P.3d 684 (2024), the Medicaid agency filed an estate recovery claim in Juanita Gilbert’s estate. she received Medicaid benefits from 1996 until her death in 2015, totaling $137,023.29 and, after she died, the State wanted its money back. Juanita and her husband, Robert, owned real property in Butts […]
Medicaid Post Eligibility Treatment of Income and Incurred Medical Expenses After Medicaid eligibility is established, 42 C.F.R. § 435.725 addresses how income is treated. For clarity, if the Medicaid recipient is married,income of the non-recipient spouse does not count toward eligibility and is not part of the patient cost share. Specifically, 42 U.S.C. § 1396r-5(b)(1) […]
Medicaid’s Refusal to Provide 24/7 Care in the Community Might be Discrimination In Harrison v. Young (5th Cir. June 6, 2024), the Fifth Circuit considered Ms. Barbara Harrison’s claim challenging Medicaid‘s denial of funding for medical services that she claimed are necessary for her survival. Harrison has severe physical and intellectual disabilities. She cannot walk […]
On June 11, 2024, the Gerontologist published an article on Medicaid enrollment and Intergenerational transfers of wealth among older adults. The article was based on a review of data from 2008 through 2018 analyzing estate planning and family wealth transfers of older adults aged 65 and older who became Medicaid recipients. There were 8,347 respondents […]
Medicaid’s “Any Circumstance” Test for Trusts In case you missed the memo, Medicaid doesn’t like trusts. The rules relating to trusts you create with your money or property are found at 42 U.S.C. § 1396p(d). To put this discussion in context, we’ll begin with the sections relevant to the “any circumstances” test, but the full […]
SNT Trustee Ordered to Reimburse Some Conservator Expenses In Weidner v. Stevenson (Cal. App. 2nd Dist. May 13, 2024), Roberta Davis established a special needs trust inside her living trust for her disabled adult son, Daniel. Daniel was under a conservatorship. Daniel’s aunt, Charlyne, was the successor trustee of the trust after Roberta’s death, while […]
In Agency for Health Care Administration v. Spence (Fla. App. 3rd Dist May 22, 2024) the Court of Appeals reversed a probate court order authorizing distributions from a special needs trust without first reimbursing the Medicaid agency. Ryan Spence was a disabled child adopted by Kathleen Spence. After Spence was killed, a settlement agreement allocated […]
Long-Term Care Partnership Policies One example of good planning is purchasing long-term care insurance. The greatest risk to non-taxable estates (those under $12.9 million) is the cost of long-term care. With long-term care insurance, you can shift that risk to an insurance company. A partnership policy is a special long-term care insurance policy that protects […]
In ____ v. Brock, Judge Schwall, Fulton County Superior Court), affirmed an administrative law judge’s Final Decision as supported by the administrative record. Here, the most interesting portion is the language discussing how a Superior Court reviews the appeal of an ALJ decision. The case began when DHS found suspicious transactions on a food stamp […]
In a Texas case decided on May 3, 2024, the Texas Supreme Court reversed the Court of Appeals and trial court, siding with the Medicaid agency on whether a home purchased after admission to a nursing home was exempt. Clyde and Dorothy Burt sold their home to their daughter and moved into a rental property. […]
In Parker v. Louisiana Department of Health (April 30, 2024), the U.S. District Court for the Eastern District of Louisiana granted a motion for preliminary injunction prohibiting the State from terminating a grandmother’s QI Medicaid based on the State’s determination of family size. The Plaintiff, a 71 year old widow who was raising her grandchild, […]
The federal Medicaid statute authorizes the use of individual self-settled special needs trusts for individuals under the age of 65. See 42 U.S.C. § 1396p(d)(4)(A). It also authorizes any applicant, regardless of age, to establish a self-settled pooled special needs trust sub-account. 42 U.S.C. § 1396p(d)(4)(C). An open question not addressed in (d)(4)(C) is whether […]
If someone is receiving Medicaid and was injured through the negligence of others, Medicaid asserts a third-party claim against any recovery, whether by settlement or verdict. This is sometimes known as a Medicaid lien. The form shown below is one currently used by Georgia Medicaid when investigating whether a third-party claim exists.
Effective April 1, 2024, the statewide averaged nursing facility private pay rate used in determining the penalty period for institutionalized individuals (nursing facility and home and community-based waiver programs) who transfer assets for less than the fair market value will increase from $9,584.00 to $10,025.00.
Recently we received a document we haven’t seen before which informs Medicaid recipients that their special needs trust accounting was approved. Obviously, there is probably a different form telling some individuals that their accounting was not approved, but we haven’t seen that form yet. The new form is below:
On March 27, 2024, the Social Security Administration published a final rule in the Federal Register which changes its calculation of In-Kind Support and Maintenance (ISM). Under the prior rule, if food and/or shelter is provided to a recipient of Supplemental Security Income (SSI), the income is deemed to the recipient, reducing his or her […]
