Medicaid does not help everyone who needs assistance paying for healthcare. Coverage is limited to individuals who meet eligibility criteria for specific classes of assistance. The classes of assistance most often sought by elderly and disabled individuals relate to nursing home coverage or home health care.
To many, Medicaid is an enigma. Even the Court have been less than kind describing it. The program’s complexity surrounding who can become eligible, what services are paid for, and how those services are reimbursed and delivered is one source of this confusion. Variability across State Medicaid programs is the rule, not the exception.
In recent years, more States have implemented a variety of major program changes using special waiver authority. Income eligibility levels, services covered, and the method for and amount of reimbursement for services differ from State to State. Furthermore, Medicaid is a program that is targeted at individuals with low income. However, not all of the poor are eligible, and not all those covered are poor. For populations like children and families, primary and acute care often are delivered through managed care, while the elderly and disabled typically obtain such care on a fee-for-service basis. Nationwide, Medicaid finances the majority of long-term care services. Those services include, for example, nursing home care and community-based services designed to support the elderly and disabled in their homes. Recently, some States have begun to integrate Medicare and Medicaid financing and/or coordinate acute and long-term care services for these populations.
Like SSI, to gain or maintain eligibility for Medicaid, an applicant must be poor enough under the program eligibility rules. An applicants’ income and resources must be within certain limits. The specific income and resource limitations that apply to each eligibility group are set through a combination of Federal parameters and State definitions. Consequently, those standards vary considerably among States, and different standards apply to different population groups within a State. For many of those groups, States have permission under a special provision, Section 1902(r)(2), to use more liberal standards for computing income and resources than are specified within each of the groups’ definitions. Most States use Section 1902(r)(2) to ignore or disregard certain types or amounts of income or assets, thereby extending Medicaid to individuals with earnings or assets too high to otherwise qualify under the specified rules for that eligibility pathway.
Income vs. Resources
Medicaid always treats things of value (assets) as either income or resources. ” An asset cannot be considered income and a resource during the same month.” See Section 2300-1 of the Georgia ABD Manual. It is one or the other. See also POMS SI 01110.600 B.3. We illustrate how the income and resource eligibility rules work separately in the post linked here.
Income is anything of value you receive during a particular month. At this time, income is subject to a monthly income cap. The income cap changes each year, but in 2023, it is gross income of $2,742. Resources are everything else you already had on the first moment of the first day of the month. Resources are not limited to property you own. Under the POMS, a resource is any property you (1) own; (2) have the right, authority, or power to convert to cash (if not already cash); and (3) you are not legally restricted from using for your support and maintenance. See POMS SI 01110.100 B.1
A single Medicaid applicant can only have $2,000 in countable resources. In 2023, the Community Spouse in a maximum-maximum State can keep $148,620 in countable resources. Exempt resources do not count toward these limits. In 2023, the minimum Community Spouse Resource Allowance is $29,724.
Medicare versus Medicaid
Medicare is health insurance for those who paid into the system and who are aged, blind or disabled. “Paid into the system” means the Medicare worked at least 40 quarters paying Medicare taxes, or qualifies as an eligible dependent of someone who worked 40 quarters. Medicare eligibility is an entitlement; it is not means-tested.
Like traditional health insurance, Medicare focuses on acute care. Coverage is weighted toward face-to-face visits with a health care professional such as hospitalization, doctor visits, and therapy. Medicare does have a nursing home component, but it is limited to a maximum of 100 days following a qualifying hospital stay. Days 1 through 20 (if skilled therapy is needed) are covered at 100%. Days 21 through 100 (if skilled care is needed) have a $194.50 co-pay (in 2022 and 2023). Coverage terminates on the earlier of (i) the date skilled care is no longer needed; or (ii) after 100 days.
Medicaid, on the other hand, is a welfare program that pays health care bills for certain aged, blind and disabled individuals. Although applicants have a right to due process and a right to demand that the rules be followed, not everyone who needs care is eligible for Medicaid. Only those individuals who fall within a class of assistance are eligible. Medicaid planning is a process elder law attorneys use to assist individuals in accelerating Medicaid eligibility, usually with the goal of preserving resources.
Many Medicaid classes of assistance are “waivers” which means the State can limit the number of eligible individuals, or can cap the amount of funds for a specific waiver. In February 2018, it was reported that the Trump Administration was considering lifetime caps for Medicaid coverage. It is unknown whether future administrations will revisit the issue, but overt rationing already occurs in some States, and less obvious forms of rationing can be found in the coverage rules.
Most Common Classes of Assistance
Qualified Medicare Beneficiary (QMB)
QMC pays the monthly Medicaid Part A premium for individuals who must pay a premium. It pays the monthly Medicare Part B premium. It also pays all Medicare co-pays and deductibles for eligible individuals. In 2022, a qualifying individual must have less than $1,094 per month of gross income, and less than $7,970 in countable resources. More information about QMB Medicaid is available at Benefits.gov.
Nursing Home Medicaid
Nursing home Medicaid pays the cost of a nursing home stay after the resident contributes his or her patient liability amount (PLA), also known as a cost-share. As discussed elsewhere, the PLA is that portion of the resident’s monthly income that must be applied toward the nursing home cost before Medicaid pays the balance of the bill. In other words, Medicaid is a cost-share program. Countable resources for an individual cannot exceed $2,000. A more generous allowance is available for the health spouse of a nursing home resident (known as the “Community Spouse”).
Community Care Services Program (CCSP)
CCSP is designed to provide home and community based services for qualifying individuals. The financial eligibility criteria are identical to those for nursing home Medicaid. Georgia CCSP will generally provide up to a maximum of up to 35 hours of care per week in the home. Alternatively, it can pay for adult day care, placement in a personal care home, respite care, or other services. The local Area Agency on Aging served as the gatekeeper for this program, but in many counties it is now administered by Legacy Link.
Independent Care Waiver Services Program (ICWP)
The ICWP is a home and community based waver intended to help adult Medicaid recipients with physical disabilities live in their own homes or in the community instead of a hospital or nursing facility. ICWP services may also be available for persons with traumatic brain injuries (TBI). This program is generally available for recipients between the ages of 21 and 64. Eligibility criteria appear in Section 2139 of the Georgia ABD Manual.
NOW and COMP Waivers
The New Options Waiver (NOW) and the Comprehensive Supports Waiver Program (COMP) are intended to provide home and community-based services for people with intellectual disabilities or developmental disabilities. A diagnosis of developmental disability includes intellectual disability or other related developmental conditions such as cerebral palsy, epilepsy, autism or neurological problems that require a level of care provided in an ICF/ID. Eligibility criteria appear in Section 2132 of the Georgia ABD Manual.
Georgia Pediatric Program Waiver (GAPP)
The GAPP is a service-delivery model for providing nursing care in the home to medically fragile children. Children must be under the age of 20 years, 11 months and must be medically eligible. The GAPP Waiver program may provide services in medical daycare settings to medically fragile children with multiple system diagnoses who require continuous skilled nursing care, or skilled nursing care in shifts. Children receive services in their homes, communities, and in ‘medical’ day care settings rather than placing children in a nursing facility or hospital.
We have posted an unofficial version of the Georgia Medicaid Manual on EZ Elder Law. The Official version is MAN3480 on ODIS. This is the manual caseworkers follow as they evaluate your Medicaid application. Don’t worry. We don’t expect you to know what’s in it. We’re just making you aware so you can look at it if you choose to do so.
MEDICAID BLOG POSTS
Medicaid Fair Hearing Dismissed Where Estate was Not Opened
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 […]
Medicaid Verification: When the Agency is Required to Help
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 […]
Medicaid Estate Recovery – 50 States
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 […]
Georgia Medicaid Applicants No Longer Required to Apply for Other Benefits
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. […]
2026 Community Spouse Income and Resource Allowances
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 […]
Medicaid Changes for Seniors in the One Big Beautiful Bill Act
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 Does Not Change the Law
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
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
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 […]
The ARC Fights to Protect Medicaid
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. […]
2025 Spousal Impoverishment Standards
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 […]
Social Security Disability versus Veteran’s Disability
The word disability doesn’t have the same meaning in all contexts. If you have a disability insurance policy, you could qualify for benefits if you have a covered condition even if you could still work. If you are a veteran, you might qualify for disability if you have specific conditions. Social Security disability, however, requires […]
Social Security Announces 2.5 Percent Benefit Increase for 2025
On October 10, 2024, the Social Security Administration announced that Americans will increase a 2.5 percent cost of living increase in 2025. A fact sheet linked to the preset release shows that the monthly SSI rate for an individual will increase from $943 to $967. This COLA means the following (estimates) should apply beginning January […]
Medicaid’s payment of medical bills does not bar recovery from negligent party
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 […]
Promissory Notes
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 […]
Refusal to Answer Medicaid’s Questions Justified Denial of Eligibility
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 […]
How much protection does a Medicaid Asset Protection Trust really provide?
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” […]
TennCare’s Medicaid Renewal Process was Illegal and Flawed
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 […]
Georgia Medicaid Waiver Programs
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 […]
Locating Medicaid Law
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 […]
Medicaid Estate Recovery is Required
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) […]
Structure of the Medicaid Program
“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, […]
Introduction to Medicaid Estate Recovery
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 […]
Idaho Medicaid Agency Sets Aside Deeds to Grandchildren in Estate Recovery Action
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
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
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 […]
New Article Discussing Medicaid Enrollment and Wealth Transfers
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
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
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 […]
SNT Payback Provision Enforced
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
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 […]
Superior Court Review of Georgia ALJ Decision
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 […]
Home purchased after nursing home admission was not an exempt homeplace
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. […]
Preliminary injunction granted barring state from terminating QI Medicaid
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, […]
SSI Decisions finding no penalty where beneficiary over 65 funds a pooled trust sub-account
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 […]
Example of Georgia Medicaid Lien Inquiry
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.
Updated Georgia Penalty Divisor Effective April 1, 2024
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.
New Form Approving Special Needs Trust Accounting
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:
SSI to Remove Food as In-Kind Support and Maintenance
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 […]
Is a Community Spouse required to name the State as remainder beneficiary of an annuity?
A Petition for writ of certiorari in the case of Dermody v. Massachusetts Executive Office of Health and Human Services is pending in the U.S. Supreme Court. The issue is “Whether an annuity that satisfies the condition in 42 U.S.C. § 1396p(c)(2)(B)(i) determining the Medicaid eligibility of a married institutionalized person must name the state […]
Georgia Medicaid Manual Updated with Transmittal 71
On November 17, 2023, Georgia issued Manual Transmittal 71, updating its Medicaid Manual, making technical changes to the following sections. The following sections were updated: 2054 – Emergency Medical Assistance 2060 – ABD Medicaid Application Processing 2101 – ABD Medicaid Classes of Assistance Overview 2111 – SSI Medicaid 2135 – Hospice Medicaid 2143 – QMB […]
Cost of Long-Term Care
For many years, Genworth has produced a Cost of Care Survey tracking the cost of long-term care in America. According to the survey, the projected national monthly median costs will be as follows: Homemaker Services: $5,417 Home Health Aide: $5,625 Adult Day Health Care: $1,847 Assisted Living Facility: $4,917 Nursing Home Semi-Private Room: $8,641 Nursing […]
2024 SSI and Spousal Impoverishment Standards Announced
On November 14, 2023, the Centers for Medicare and Medicaid Services announced the 2024 SSI and Spousal Impoverishment Standards. The SSI rate for 2024, which was previously announced by the Social Security Administration, will rise to $943. The Medicaid Income Cap will rise to $2,829. The minimum MMMNA will be $2,465 and the maximum MMMNA […]
2024 SSI Amounts and Estimated Impact on Medicaid
Effective January 1, 2024, the federal Supplemental Security Income payment amount will increase by 3.2 percent. The amounts paid to individuals and couples are below: Recipient Unrounded annual amounts for— Monthly amounts for 2024 2023 2024 a Eligible individual $10,970.44 $11,321.49 $943 Eligible couple 16,453.84 16,980.36 1,415 Essential person 5,497.80 5,673.73 472 Impact on Medicaid This […]
Medicaid Questions: Am I Eligible?
Am I Eligible for Medicaid? Recently we were asked about the following fact pattern. Parent had multiple properties in different counties. More than 60 months ago, parent gave these properties to children reserving a life estate. The question, initially, was whether parent is eligible for nursing home Medicaid. The follow-up question was whether the property […]
Medicaid Trust Case Remanded for Further Proceedings
Harves V. Rusyniak In Harves v. Rusyniak, 23A-PL-671 (9/26/2023), the Indiana Court of Appeals found that the Family and Social Services Administration (FSSA) missed a step in finding that a trust rendered Natalie Harves ineligible for Medicaid. Harnes and her children signed a number of documents in January 2019 when she was 91 years old. […]
Social Security Announces 2024 Increase
On October 12, 2023, the Social Security Administration announced that Social Security and SSI payments will increase by 3.2% in 2024. Federal benefit rates increase when the cost-of-living rises, as measured by the Department of Labor’s Consumer Price Index (CPI-W). The 2024 SSI rate will be $943 for individuals and $1,415 for eligible couples. This […]
Sometimes You Must Say No
Sometimes you just have to say No “No” isn’t a four-letter word. Saying “no” isn’t necessarily bad and you shouldn’t feel bad when you say it. Part of saying no means taking a stand. It can mean standing up to injustice. For example, our legal system is, for the most part, dependent on people saying […]
Tennessee Justice Center Presents Medicaid Eligibility Boot Camp
On October 24th and 25th, 2023, the Tennessee Justice Center will present its annual two day virtual training event on Medicaid eligibility. This event is designed for health care providers and advocates. Information regarding what’s covered and how to register is below: Medicaid Eligibility Boot Camp – A Virtual Training Event Navigating the Red Tape […]
NEW VIDEO: Medicaid – 2023 Financial Eligibility
We’re just getting to the point where we’re producing videos for EZ Elder Law. There are, after all, only so many hours in the day. This video published on September 17, 2023, runs through basic Medicaid eligibility in Georgia under the 2023 rules. It focuses on nursing home Medicaid and home health Medicaid. Slides for […]
