As with the income rules, the resource defaults may be changed. First, if all of the Applicant’s income has been diverted to the Community Spouse and the monthly income available to the Community Spouse still does not reach the minimum monthly maintenance needs allowance, then 42 U.S. Code § 1396r–5(e)(2)(C) provides an administrative remedy for […]
A Community Spouse is entitled to a resource allowance in addition to the income allowance. 42 U.S. Code § 1396r–5(f)(1) and (2) provide: (1) In general An institutionalized spouse may, without regard to section 1396p(c)(1) of this title, transfer an amount equal to the community spouse resource allowance (as defined in paragraph (2)), but only […]
The SSI regulations describe deeming as the process of considering another person’s income or resources to be your own. See 20 CFR § 416.1160 (income) and 20 CFR § 416.1202 (Resources). Prior to the time Medicaid is approved, all marital resources are deemed available to the Applicant. See 42 U.S. Code § 1396r–5(c)(2)(A). However, 42 […]
As a general rule, all countable resources owned by the Institutionalized Spouse are considered available to pay his or her nursing home bills. It does not matter whether the resource is co-owned with someone else unless co-ownership makes it impossible to liquidate the resource. Georgia ABD Manual § 2300 states that resources include cash, other […]
The law protects a Community Spouse with low income. It does this by diverting a portion of the applicant’s income to the Community Spouse. The rules are different in each state so we’re giving you the law. In 2023, states that allow a maximum income allowance say that a Community Spouse with less than $3,715.50 […]
On the income side, there are three pathways to Medicaid eligibility for nursing home residents. First, SSI recipients are almost always eligible. Second, in most States, if the resident’s income does not exceed 300% of the federal poverty level ($2,742 in 2023), then he or she qualifies for Medicaid under a “special income level.” Third, […]
In evaluating financial eligibility for Medicaid, both monthly income and resources must be considered. The basic rule is everything having value is an asset. 42 U.S.C. § 1396p(h)(1). This includes monthly income and resources. Income includes both earned and unearned income. 42 U.S.C. § 1396p(h)(2) incorporates by reference the definition of income found at 42 […]
Categorical and medical eligibility is covered in Chapter 2. Here we begin an aerial fly-over of financial eligibility. In this chapter we are painting with a broad brush. Subsequent chapters will examine financial eligibility and planning techniques in more detail. In reviewing financial eligibility, it is important to know which class of assistance the applicant […]
Only those persons with a medical need are eligible for Medicaid and not all persons needing help receive Medicaid. In Georgia, medical eligibility determinations for nursing home facility care are performed by the facility using Form DMA-59. Determinations for CCSP (HCBS) are made by the CCSP RN Care coordinator. 2240 – Level of Care As […]
With few exceptions (such as the existence of an interstate compact), a Medicaid applicant must be a resident of the State where benefits are provided. 42 CFR § 435.403. [Note 10]. The “duration” of residence cannot be a condition of eligibility. See 42 CFR § 435.403(j)(1); Shapiro v. Thompson, 394 U.S. 618 (1969). HCFA 64 […]
An applicant must be a U.S. Citizen or a legally admitted alien to receive Medicaid. 42 CFR § 435.406. In that regard, HCFA 64 provides as follows: 3210.1 General Requirements.–The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) significantly changed Medicaid eligibility for individuals who are not citizens of the United States. […]
In addition, to establish technical eligibility for nursing home Medicaid, an applicant must be (i) a U.S. Citizen or lawfully admitted alien, (ii) a resident of the State where benefits are sought and (iii) have been treated for a continuous period of 30 days in a medical facility. 42 C.F.R. § 435.211. [Note 7]. By […]
Individuals who are aged (age 65 or older), blind or disabled may be entitled to Medicaid if they are medically eligible and financially needy. In Georgia and Tennessee, SSI recipients are immediately eligible. See 42 U.S.C. § 1396a(a)(10)(A)(i)(II). Although the focus here is on long term care Medicaid, other classes of assistance make Medicaid available […]
The Rule 42 U.S. Code § 1382c(a)(3)(A) states: “an individual shall be considered to be disabled for purposes of this subchapter if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or […]
The remainder of this book focuses on long-term care Medicaid. Long-term care refers to a wide range of supportive and health services for persons who have lost the capacity for self-care due to illness, frailty, or a disabling condition. It differs from acute care in that the goal of long-term care is not to cure […]
States may extend Medicaid to certain individuals with incomes too high to qualify for SSI, and who are eligible for nursing facility or other institutional care. Under the special income rule, also referred to as “the 300 percent rule,” such persons must (1) require care provided by a nursing home or other medical institution for […]
The enactment of the Omnibus Budget Reconciliation Act of 1986 (OBRA 86) offered States an option for covering persons whose income exceeds SSI or 209(b) levels. (CRS Report, How Medicaid Works: Program Basics, January 4, 2006). This option allows States to cover aged and disabled individuals with incomes up to 100 percent of FPL. In […]
Many States provide SSP benefits with State-only dollars on a monthly basis. These payments are intended to cover such items as food, shelter, clothing, utilities, and other daily necessities. The amount of the benefit is determined by the individual States. States may provide supplemental payments to all persons who receive SSI, and/or to individuals who […]
With one important exception, States are required to provide Medicaid coverage to recipients of SSI. SSI, authorized under Title XVI of the Social Security Act, is a means-tested cash assistance program for aged, blind, and disabled individuals whose income falls below the Federal maximum monthly SSI benefit and whose resources are limited. To qualify for […]
The Federal Medicaid statute defines over 50 distinct population groups as being potentially eligible for States’ programs. Some groups (classes of assistance) are mandatory, meaning that all States that participate in the Medicaid program must cover them; others are optional. Prior to the 1980s, Medicaid eligibility was limited to very low-income families with dependent children, […]
Medicaid was enacted in 1965, in the same legislation that created the Medicare program, the Social Security amendments of 1965 (P.L. 89-97). [Note 2]. A history of Medicaid’s evoluation is recounted in Wilbur Cohen’s article Reflections on the enactment of Medicare and Medicaid. “The program is designed to provide medical assistance to persons whose income […]
The Medicare program (Title XVIII of the Social Security Act) provides hospital insurance (HI), also known as Part A coverage, and supplementary medical insurance (SMI), also known as Part B coverage. Free HI coverage (a/k/a Premium-free Part A) is automatic for persons with insured status (those eligible for Social Security benefits) aged 65 and older […]
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
One strategy used when planning for Medicaid eligibility is called “spousal refusal.” It is authorized under 42 U.S.C. § 1396r-5(c)(3). There, the federal statute provides: (3) Assignment of support rights The institutionalized spouse shall not be ineligible by reason of resources determined under paragraph (2) to be available for the cost of care where— (A) the […]
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
If you care about making sure the application is filed correctly and processed swiftly, the you should consult with an elder law attorney and probably hire him or her. Attorney assistance in completing the application is advised if any of the following are concerns: (1) the applicant made significant gifts within the look-back period; (2) […]
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
We reached out to Medicaid caseworkers to see whether they had any advice for law firms helping Medicaid applicants. Not surprisingly, they did have some advice, so here it is: Be honest and don’t hide the ball. It only takes one act of dishonesty to lose trust. File “complete” applications. If they are completed from […]
We regularly scour the internet looking for information relating to elder care, special needs and elder law. Although we review a number of sources collecting information, many of the articles listed here were found using Google Scholar Alerts. If a link you need has gone missing, try pasting the link into the Wayback Machine (Internet […]
There are numerous ways to contact Georgia Medicaid. We will list a few here: Online How to Apply (Georgia.gov) Georgia Gateway Customer Portal How to Apply for Medicaid and CHIP (USA.gov) Once you apply for Medicaid your Medicaid application will be assigned to a Medicaid Eligibility Specialist to complete and make an eligibility determination. You […]
There is no automatic right to appeal from the Superior Court to the Court of Appeals. An application for the right to file an appeal is necessary. If it is granted, then appeals follow the typical appeal process. O.C.G.A. § 5-6-35 provides the rule for discretionary appeals: (a) Appeals in the following cases shall be taken […]
After exhausting all administrative remedies, the Applicant may file a Petition for Review in Superior Court. See O.C.G.A. § 49-4-153(c); O.C.G.A. § 50-13-19. The petition may be filed in the Superior Court of Fulton County or in the superior court of the county of residence of the petitioner. O.C.G.A. § 49-4-153(c). O.C.G.A. § 49-4-153(c) provides: […]
After entry of an initial decision, the Clerk must certify the record, including the Initial Decision and any tapes or other recordings of the hearing, to the the parties upon request. Ga. R. & Regs. § 616-1-2-.33. The Applicant or the Department may appeal. In Georgia, the OSAH decision is an initial decision. O.C.G.A. § […]
Medicaid eligibility determinations must be based on “ascertainable standards.” See J. Perkins, Issue brief: Appeal Rights and Medicaid Benefits citing Holmes v. New York City Hous. Auth., 398 F.2d 262, 265 (2d Cir. 1968). In Holmes, in the context of housing authority decisions, the Court said “due process requires that selections among applicants be made […]
A record must be kept in all contested cases. 42 C.F.R. § 431.244 provides: (b) The record must consist only of— (1) The transcript or recording of testimony and exhibits, or an official report containing the substance of what happened at the hearing; (2) All papers and requests filed in the proceeding; and (3) The […]
In preparing the original version of these materials several years ago, I spoke with one of the Administrative Law Judges (the Hon. Patrick Woodard) regarding what Judges want advocates to know about hearings. Make copies. Although you may presume your judge knows Medicaid law, don’t presume your judge is a Medicaid expert. Make copies of […]
Same rules as non-jury civil cases The rules of evidence applicable in civil nonjury trials apply in administrative hearings. O.C.G.A. § 24-1-2(d)(4); Ga. R. & Regs. § 616-1-2-.18(1)(a). Irrelevant, immaterial, or unduly repetitious evidence shall be excluded. When necessary to ascertain facts not reasonably susceptible of proof under such rules, evidence not admissible thereunder may […]
The Applicant and DFCS have the right to the following: 1. Bring and/or subpoena witnesses; 2. Establish all pertinent facts and circumstances; 3. Present arguments without undue interference; 4. Question or refute any testimony or evidence, including the opportunity to question and cross-examine adverse witnesses. 42 C.F.R. § 431.242(b) through (e). DFCS has the responsibility […]
The fair hearing or the appeal from agency review must give the applicant a de novo hearing if requested. 42 C.F.R. § 431.232(c). A de novo hearing means it starts over from the beginning. 42 C.F.R. § 431.201. The hearing includes consideration of the following: 1. Any agency action, including the following: a. Denial or […]
As a general rule, discovery is not permitted in any proceeding before an ALJ, except to the extent specifically authorized by law. Ga. R. & Regs. § 616-1-2-.38. In Bd. of Dental Examiners v. Daniels, 137 Ga. App. 706 (1976). Appellant/defendant contends that the Civil Practice Act is not applicable to proceedings under the Georgia […]
Form All requests made to the Administrative Law Judge shall be made by motion. Unless made during the hearing, motions shall be in writing, shall state specifically the grounds therefor, and shall describe the action or order sought. A copy of all written motions shall be served in accordance with Rule 11. Ga. R. & […]
Form; timing A Motion for Summary Determination may be filed no later than thirty days prior to the date a case is set for hearing. The motion may be based on supporting affidavits or other probative evidence, for summary determination in its favor on any of the issues being adjudicated on the basis that there […]
An ALJ may order a prehearing conference to simplify the issues being presented. Conferences may be held in person or by telephone. Ga. R. & Regs. § 616-1-2-.14 is analogous to O.C.G.A. § 9-11-16(a) because it allows ALJs to clear up evidentiary and procedural matters before the hearing. Specifically, Rule 14 provides: (1) Conferences. The […]
Minimum Federal Requirements for Medicaid Fair Hearings Each State must give Medicaid applicants the right to a fair hearing when applications are denied, improperly approved, or simply not acted in a timely manner. 42 U.S.C. § 1396a(a)(3); 42 C.F.R. §§ 431.200-431.250; 42 C.F.R. § part 438. The State’s hearing system must provide for a hearing […]
All applications for ABD Medicaid require that the applicant’s basic eligibility be verified. See ABD Manual Section 2201-4. Applications for long-term care Medicaid also require verification of income and resources, but caseworkers are instructed to “For ABD Medicaid verification requirements, see the sections pertaining to the specific COA and the Income and Resource Chapters.” ABD […]
If benefits are being terminated or reduced, the applicant/recipient may request that benefits continue while the appeal is pending. A request for continuation of benefits must be made within ten days following issuance of the notice. See 42 C.F.R. § 431.231(c)(2). Allowance should be made in the event the Applicant’s reports late receipt of notification […]
Right to a Hearing The right to a hearing is a property right and belongs to the applicant. See Bd. of Regents v. Roth, 408 U.S. 564 (1972) (“Property interests, of course, are not created by the Constitution. Rather, they are created and their dimensions are defined by existing rules or understandings that stem from […]
Theoretically, Medicaid should be simple. It’s anything but simple. Also, theoretically, the Medicaid program should be administered in the best interests of Medicaid recipients. 42 C.F.R. § 435.902. Anyone who has worked on more than a few Medicaid applications knows otherwise. Still that’s what federal law requires. 42 U.S.C. § 1396a(a)(19) must “provide that State […]
Taking over a case started by someone else is never my preference. It’s far easier to do something correctly the first time. So what do you do when you’re brought in to fix a case. You pray! First, if someone hires you and no decision has been made, review the file. If there is an […]
We regularly post links to news articles and other resources related to Elder Law and Special Needs Law. We focus on general news, health and healthcare news, special needs news, events, government sources, financial and retirement news and legal news. Some cited resources are for professionals, but most are news or other helpful articles we […]
Enter your name and email address to keep up with what’s new at EZ Elder Law!
P.O. Box 2023
Dalton, Georgia 30722
+1-800-241-8755EzElderLaw is an online service providing legal forms and information. We are not a law firm and we do not provide legal advice.
