Income and resources are treated differently. Unlike resources, income is not pooled in determining eligibility; the Community Spouse’s separate income is never considered available to the Institutionalized Spouse. Thus, the standard income eligibility process for one person applies. First, all income earned by the Community Spouse is always unavailable to pay nursing home bills, regardless […]
In Dullard v. Minnesota Department of Human Services, 529 N.W.2d 438, 443 (Minn. App. 1995), Minnesota was allowed to reevaluate eligibility after a couple moved from Illinois to Minnesota. There, Illinois (like Georgia) allowed the Community Spouse to keep the maximum CSRA, while Minnesota (like Tennessee) applied a formula resulting in a lower CSRA. The […]
Some couples might consider reducing the size of the marital estate by giving their resources away. Frequently this is the result when the plan is “home-made.” However, transfers for less than fair market value, including complete and partial gifts) trigger a period of ineligibility. 42 U.S.C. 1396p(c). It does not matter whether the applicant or […]
Federal law protects the healthy (or healthier) spouse of a nursing home resident. The healthier spouse is known in Medicaidland as the Community Spouse. The protections, known as the Spousal Impoverishment Rule (but logically be called the anti-impoverishment rule) were passed as part of the Medicare Catastrophic Coverage Act of 1988, P.ub. L. No. 100-360 […]
The following the committe report for the Medicare Catastrophic Coverage Act of 1988 (MCCA): The leading cause of financial catastrophe among the elderly is the need for long-term care, especially the need for nursing home placement. The expense of nursing home care–which can range from $2,000 to $3,000 per month or more–has the potential for […]
While nursing home bills accrue, the healthy or well spouse, known as the “Community Spouse,” [Note 1] struggles to identify and keep income and resources that are necessary to support herself. [Note 2]. To remedy this situation, Congress enacted spousal impoverishment provisions as part of the Medicare Catastrophic Coverage Act of 1988 (“MCCA”). [Note 3]. […]
If you agree to file a client’s Medicaid application as part of your representation, here are a few practical considerations. Keep in mind, these suggestions are how we handle matters in our office. If you have a different approach, that’s fine. If you have suggestions on other ways to approach applications, we’d love to hear […]
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 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 […]
In States where Medicaid disability determinations are performed by the Social Security Administration, the eligibility rules cannot be more restrictive than the SSI eligibility Rules. Section 1902(r)(2) [42 U.S.C. § 1396a] indicates a State’s Medicaid eligibility criteria can be no more restrictive than the SSI program. Specifically it states: (2) (A) The methodology to be employed […]
Medicare is a nationwide health insurance program for individuals aged 65 and over and certain disabled individuals. The basic Medicare benefit package (termed “original Medicare” in this report) provides broad protection against the costs of many health care services. However, Medicare beneficiaries may still have significant additional costs, including copayments, coinsurance, deductibles, and the full […]
On December 8, 2003, the President signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. 108-173. On November 22, 2003, the House of Representatives voted 220 to 215 to approve H.R. 1, the Medicare prescription drug and modernization conference agreement. The Senate voted 54 to 44 to approve the conference agreement on […]
The Children’s Health Insurance Program (CHIP) was created in 1997 to give health insurance and preventive care to nearly 11 million, or 1 in 7, uninsured American children. Many of these children came from uninsured working families that earned too much to be eligible for Medicaid. All 50 states, the District of Columbia, and the […]
The 2010 Affordable Care Act (ACA) brought the Health Insurance Marketplace, a single place where consumers can apply for and enroll in private health insurance plans. It also made new ways for us to design and test how to pay for and deliver health care. Medicare and Medicaid have also been better coordinated to make […]
There are five levels in the Medicare claims appeal process: Level 1: Your Health Plan. If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim. Level 2: An Independent Organization. If you disagree with the decision in Level 1, you may request a reconsideration by an independent […]
For more programmatic information, please see reports published by the Congressional Research Service. CRS works exclusively for the United States Congress, providing policy and legal analysis to Committees and Members of both the House and Senate, regardless of party affiliation. Legislative History The following provides a brief legislative history for Medicare from the prior Green Book […]
Initial Enrollment Period If you are receiving Social Security or Railroad Retirement Benefits, then you will automatically get Medicare Part A starting the first day of the month you turn 65. You have the option of enrolling in Part B, with the Initial Enrollment Period beginning three months prior to the month when you turn […]
Medicare Part D was created as part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, with an effective date of January 1, 2006. It is designed to subsidize the cost of prescription drugs for Medicare beneficiaries in the United States. Medicare Part D was estabilshed as part of the Medicare Prescription Drug […]
Medicare Advantage replaced prior programs, alternatively called Medicare+Choice or Part C, which originated in the Balanced Budget Act of 1997. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 altered those programs and renamed them as Medicare Advantage. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care […]
Medicare part B is voluntary. All persons over age 65 and all persons enrolled in part A may enroll in part B by paying a monthly premium. The 2022 monthly premium is $170.10 (0r higher depending on your income). Part B covers medically necessary doctor’s services, outpatient care, home health services (those not covered by […]
Part A provides most of your institutional coverage. It covers inpatient care in hospitals, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care services, home health care services and inpatient care in a religious nonmedical health care institution. Part A also covers blood. If the hospital uses a blood bank, […]
On September 27, 2022, the Centers for Medicare & Medicaid Services (CMS) released the 2023 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2023 Medicare Part D income-related monthly adjustment amounts. Medicare Part B Premium and Deductible Medicare Part B covers physician services, outpatient hospital services, certain […]
On September 29, 2022, CMS issued the following press release regarding 2023 premiums for Medicare Advantage and Prescription Drug Plans: The Biden-Harris Administration has made expanding access to health insurance and lowering health care costs for America’s families a top priority, and today, the Administration is announcing that people with Medicare will see lower premiums […]
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 […]
In our August 26, 2022, News Roundup, we reported that Talevski v. Health and Hospital Corporation of Marion County (HHC) was headed to the Supreme Court. The case concerns the rights of nursing home residents. The Plaintiff argued the nursing home violated his rights under the Federal Nursing Home Reform Act (FNHRA). The nursing home […]
The Centers for Medicare and Medicaid Services (CMS) regularly records and posts informational workshops on a variety of subjects. For example, the workshop recorded on August 2, 2022, regarding Social Security addresses a range of retirement issues for students. To participate live, or to hear a previously recorded program, you will need to create a […]
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 […]
Medicaid beneficiaries cannot “fix” eligibility by giving away resources. A transfer of resources without receipt of fair market value will trigger calculation of a transfer penalty. “The penalty for an institutionalized individual consists of ineligibility for certain services for a period or periods of ineligibility that equal the number of months calculated by taking the […]
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 […]
42 U.S. Code § 1382c(a)(2) states: An individual shall be considered to be blind for purposes of this subchapter if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that […]
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 […]
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