April 2009VDSS1 Medicaid 101 Helping VICAP Clients Apply for Medicaid.

April 2009 VDSS 1

Medicaid 101

Helping VICAP Clients Apply for Medicaid

April 2009 VDSS 2

The Basics

Medicaid Eligibility

Part I

April 2009 VDSS 3

What is Medicaid?• Medicaid is a needs-based medical assistance

program that is jointly funded by federal and state funds. To be eligible for Medicaid, individuals must: – Be in one of the groups covered by Medicaid

AND– Have limited income and resources

• Due to the joint funding, Medicaid is subject to both State and Federal regulations.

April 2009 VDSS 4

How Does Someone Apply for Medicaid?

Obtain an application:

– Call the local Department of Social Services (LDSS) office

– Pick up an application at the LDSS office

– Print an application from the VDSS web site at www.dss.virginia.gov.

– Coming soon – The web-based online Application for Adult Medical Assistance.

April 2009 VDSS 5


Complete the application

– The applicant may have assistance with completing the application.

– The applicant or authorized representative must sign the application.

April 2009 VDSS 6


Submit the application to the LDSS in the locality in which the applicant resides:– In person– By mail– By fax– Coming soon: submit on-line

A face-to-face interview is not required when applying only for Medicaid.

April 2009 VDSS 7

Application Processing• The applicant will receive a letter

requesting any required verifications.

• The eligibility worker (EW) must process applications within a specified time period.– 45 days– 90 days if a disability determination is required

• The applicant will receive a “Notice of Action on Medicaid and FAMIS Programs” form explaining the action taken, the type of coverage, and the appeal process.

April 2009 VDSS 8

How is Eligibility Determined?

• The applicant must be in a covered group.

• All covered groups fall into one of two broad groups, each with its own set of policies: – Aged, Blind and Disabled (ABD)– Families and Children (F&C)

April 2009 VDSS 9


• Medicaid coverage for older adults and adults with disabilities is under the ABD group– Aged = 65 years or older – Blind = SSI definition (having best corrected

central visual acuity of 20/200 or less in the better eye)

– Disabled = Social Security Administration (SSA) definition

April 2009 VDSS 10

Applicants with Disabilities

• The disabled or blind covered groups include individuals who:– receive Social Security Disability

benefits – receive SSI based on blindness or

disability – have been determined to be blind by Va.

Dept. for the Blind and Vision Impaired– receive Railroad Retirement benefits

due to a disability.

April 2009 VDSS 11

What if There Has Not Been a Disability Determination

from SSA?

• If an applicant with blindness or a disability has not been denied disability by SSA within the past 12 months, the EW makes a referral to Disability Determination Services (DDS) for a disability determination.

April 2009 VDSS 12

Referral to DDS

• The applicant must complete the Disability Report (SSA-3368-BK)

• The applicant must sign several copies of the Authorization to Disclose Information to the Social Security Administration (SSA-827-02-2003)

April 2009 VDSS 13

Referral to DDS• Eligibility Worker (EW) completes DDS

Referral Form and forwards to DDS along with Disability Referral Cover Sheet and Authorizations.

• DDS obtains necessary medical records.• DDS advises EW of the applicant’s

disability status as soon as it is determined.

• DDS provides EW with a notice to be sent to the applicant advising him/her of the outcome of the disability determination.

April 2009 VDSS 14

How is Eligibility Determined?• The applicant must

meet all non-financial criteria:

Legal PresenceCitizenship/Alien

StatusVirginia residenceSocial Security

NumberAssignment of

rights to medical support

Application for other benefits

Institutional statusHealth Insurance

Premium Payment (HIPP) requirements

April 2009 VDSS 15

Citizenship and Identity Documentation Requirements

• Effective 7/1/06, States are required to obtain documentation of citizenship and identity from all Medicaid applicants and recipients who claim to be U.S. citizens.

• Once satisfactory evidence is obtained, no further requirement to obtain additional documentation.

April 2009 VDSS 16

Citizenship and Identity Documentation Exemptions

for Adults• Current SSI recipients • Individuals entitled to or receiving

Medicare.• Individuals receiving Social

Security benefits on the basis of a disability (not retirement).

April 2009 VDSS 17

How Does Eligibility for Other Benefits Affect Medicaid Eligibility?

• The applicant must apply for any benefits he or she has earned the right to receive, such as:– Social Security Benefits– VA Pensions and Compensation– Worker’s Compensation

• The applicant is not required to apply for Supplemental Security Income (SSI) in order to be eligible for Medicaid.

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• The applicant is first evaluated for full coverage, which includes:– hospital care, doctor’s visits,

prescriptions for those not entitled to Medicare, and transportation to receive covered services.

– payment of Medicare premiums, deductibles, and copayments for Medicare beneficiaries.

April 2009 VDSS 19


• If the applicant is not eligible for full coverage and has Medicare, may be eligible for limited coverage under a Medicare Savings Program.

– Qualified Medicare Beneficiary (QMB): Medicaid pays Medicare Part B premiums, co-payments, and deductibles. Will pay Part A premiums if person has a premium.

– Special Low-Income Medicare Beneficiary (SLMB) and Qualified Individuals (QI): Medicaid pays Medicare Part B premiums only.

April 2009 VDSS 20

Medicaid & Medicare Prescription Drug Coverage• Medicaid cannot cover prescriptions for

individuals who are enrolled in/entitled to Medicare.

• Dual Eligibles (full Medicaid & Medicare), QMBs, SLMBs, and QIs are deemed eligible for Extra Help subsidy for out-of-pocket costs associated with Medicare Part D Prescription Drug Coverage.– Are auto-enrolled or facilitated with

enrollment in prescription drug plan.

April 2009 VDSS 21

What Determines Full or Limited Coverage?

Full Coverage:• Resource Limit: $2,000 for an

individual or $3,000 for a couple

• Countable Income (after allowable deductions): less than or equal to 80% of Federal Poverty Level– In 2009, $722 for individual; $972 for

couple

April 2009 VDSS 22

What Determines Full or Limited Coverage?

Medicare Savings Programs (QMB, SLMB, QI):

• Resource Limit: $4,000 for an individual or $6,000 for a couple

• Countable Income (after allowable deductions): must be within limit for covered group

April 2009 VDSS 23

2009 Medicare Savings Program

Income Limits • QMB: < 100% FPL

– $903 for individual; $1,215 for couple

• SLMB: > 100%FPL but < 120 FPL– $1,083; $1,457

• QI: > 120% FPL but < 135%FPL– $1,219; $1,640

April 2009 VDSS 24

Medicaid & Supplemental Security Income (SSI)

• In Virginia, an SSI recipient who wishes to receive Medicaid must also apply for Medicaid--enrollment is not automatic!

• The real property eligibility requirements for Medicaid in Virginia are different than the real property eligibility requirements for SSI.

April 2009 VDSS 25

Medically-Needy (MN) Spenddown

• Applicants who meet all Medicaid requirements for full coverage except income are placed on a MN spenddown and may be able to receive a period of full coverage. When the period is up, the spenddown must be met again.

• The income limit for MN is based on the applicant’s locality and is lower than other ABD covered groups’ income limits.

April 2009 VDSS 26

MedicaidLong-term Care (LTC)

Nursing Facility (NF), Community-based Care

(CBC)& PACE

Part II

April 2009 VDSS 27

Community-based Care

• Most older adults in CBC receive services under the Elderly and Disabled with Consumer-direction (EDCD) Waiver:– Personal care, – Respite care, and/or – Adult day health care– Personal Emergency Response System

(PERS)

• Other Waivers have different admission processes.

April 2009 VDSS 28

PACE

• The Program for All-inclusive Care for the Elderly (PACE) is a community-based managed-care model for integrating acute and LTC.

• Open or due to open in areas throughout Virginia.

• Individuals receive in lieu of EDCD Waiver services.

April 2009 VDSS 29

Pre-Admission Screening

• Completed by local DSS Social Worker and Health Department RN or hospital staff.

• Universal Assessment Instrument (UAI) is used.

• Not required when person is in nursing facility at time of application or has been in nursing facility for at least 30 consecutive days.

April 2009 VDSS 30

Eligibility for LTC Services

• Must meet regular eligibility rules + special LTC rules– Substantial home equity – Non-financial, resources, income– Asset transfer

• Resource eligibility considerations– Single or married? – Is spouse living in the community in a

home couple owns?

April 2009 VDSS 31

Substantial Home Equity

• Individuals with equity in excess of $500,000 are not eligible for Medicaid payment for LTC services unless home is occupied by:– Spouse– Dependent child under age 21– Blind or disabled child of any age.

April 2009 VDSS 32


• Applies to nursing facility and CBC patients who meet the requirements for LTC on or after 1/1/06.

• Does not apply to recipients approved for LTC prior to 1/1/06, who maintain continuous eligibility. Applies to all applications and renewals for cases approved on or after 1/1/06.

April 2009 VDSS 33


• Home equity does not impact Medicaid coverage for other services, only LTC.

• There is an undue hardship provision for individuals denied Medicaid payment for LTC services due to substantial home equity.

April 2009 VDSS 34

Resource Assessment (RA)

• Is a determination of spousal share of couple’s resources.

• Only for institutionalized applicant with a community spouse and who had the first continuous period of institutionalization (>30 days) on or after 9/30/1989.

• Can request RA prior to application for Medicaid.

April 2009 VDSS 35

Continuous Care Retirement Center (CCRC) Entrance Fees

– Countable resource when individual• can use fee to pay for care if other resources or income

is insufficient to pay for care;• is eligible for a refund at death or when leaving the

CCRC; and• does not receive an ownership interest in CCRC.

– Countable amount is amount that could be refunded; no requirement to seek refund.

– Payment of CCRC entrance fees are not subject to transfer of assets evaluation.

April 2009 VDSS 36

LTC Income Eligibility

• Income limit < 300 % of SSI payment for one person.– In 2008, $2,022 per month.

• If income exceeds limit, spenddown is available.

April 2009 VDSS 37

Transfer of Assets

• When an asset is transferred for less than fair market value, Medicaid will not cover the cost of LCC services for a period of time, based on the uncompensated amount.

• Asset transfers that occurred before 2/8/06 are evaluated under the rules in place at the time of the transfer.

April 2009 VDSS 38

Transfer of Assets

• Policy for transfers on or after 2/8/06 changed:

• Treatment of promissory notes, loans, mortgages, purchases of life estates and annuities

• Look-back period• Period of ineligibility

– Begin date of penalty – Partial months ineligibility

• Undue hardship may be claimed.

April 2009 VDSS 39

Look-back PeriodApplication Date…

Prior to 2/8/06

• For trusts, 60 months before the first date

the individual is both an institutionalized individual and has applied for Medicaid to cover his LTC services.

• For all other transfers, 36 months.

On or after 2/8/06

• For all transfers, 60 months before the first date the individual is both an institutionalized individual and has applied for Medicaid to cover his LTC services.

April 2009 VDSS 40

Transfers That Do Not Impact Medicaid Payment for LTC

• Transfers that have a cumulative value < $1,000 per calendar year.

April 2009 VDSS 41

Transfers That Might Not Impact Medicaid Payment for LTC

• Transfers that have a cumulative value of > $1,000, but < $4,000 per calendar year, if documentation establishes that pattern existed for at least 3 years prior to requesting Medicaid for payment of LTC services.

• Examples include:• Gifts (holiday, birthday, wedding,

graduation, etc).

April 2009 VDSS 42

Undue Hardship Claim

– All individuals who have transferred assets without receiving adequate compensation must be notified that• Undue hardship can be claimed and

given the process for requesting an undue hardship.

• Written information must document that the resources transferred cannot be recovered and why.

• Documentation must clearly substantiate the immediate adverse impact of the denial of Medicaid coverage of LTC services.

April 2009 VDSS 43

Undue Hardship Claim• Requests for undue hardship must

be sent by local DSS to DMAS for an evaluation.– Individual or authorized

representative (including nursing facility if authorized by individual) can file an undue hardship request.

– DMAS will evaluate and provide local DSS with a decision.

– Denial of a claim for undue hardship may be appealed.

April 2009 VDSS 44

Undue Hardship Claim

• Undue Hardship – Exists when applying transfer of

assets penalty would deprive the individual of medical care such that his health or life would be endangered.

– Also exists when applying transfer of assets penalty would deprive the individual of food, clothing, shelter, or other necessities of life.

April 2009 VDSS 45

Penalty PeriodTransfer Made…

Prior to 2/8/06

• For Applicants: – Begins on first day

of month of transfer

• For Recipients: – begins month

following month of transfer

On or after 2/8/06

• For Applicants: – Begins first day of the month the

institutionalized individual would be eligible for Medicaid payment of LTC services except for imposition of the penalty

• For Recipients: – begins month following month of

transfer

April 2009 VDSS 46

Partial Month Penalty Period Transfer Made…

Prior to 2/8/06

• No partial month penalty period.

• Once penalty period is calculated, drop any fractional portions.

On or after 2/8/06

• There can be a partial month penalty period.

• Penalty period is calculated without dropping fractional portion of the month.

April 2009 VDSS 47

Penalty Period Calculation for Transfers Made On or After February 8, 2006

• To calculate a penalty period for an uncompensated transfer that occurred on or after February 8, 2006, the amount of the uncompensated transfer is divided by the average private nursing facility monthly rate at the time of the individual’s application for Medicaid, and the remainder is divided by the daily rate (monthly rate divided by 31).

April 2009 VDSS 48

Penalty Period Calculation for Transfers Made On or After February 8, 2006

• The penalty period begins with the month the applicant is both institutionalized and eligible for Medicaid. Individuals are responsible for paying the cost of care until their penalty period expires.

• Medicaid begins paying for long-term

care services after the penalty period expires.

April 2009 VDSS 49

Penalty Period - Example

• An individual makes an uncompensated transfer of $30,534 in April 2009, the same month he applies for Medicaid.

• The uncompensated transfer amount of $30,534 is divided by the average monthly rate of $4,060 and equals 7.52 months.

April 2009 VDSS 50

Example - Continued

• The full 7-month penalty period runs from April 2009, the month he applies for Medicaid as an institutionalized individual and meets the requirements, through October 2009 with a partial month penalty calculated for November 2009.

• The partial month penalty for November is calculated by dividing the partial month penalty amount by the daily rate.

April 2009 VDSS 51

Example - ContinuedThe calculations are as follows:

Step #1 $30,534.00 uncompensated transfer amount

÷ 4,060.00average monthly nursing facility rate at time of application

= 7.52 penalty period

Step #2 $4,060.00 average monthly nursing facility rate at time of application

× 7seven-month penalty period $28,420.00 penalty amount for seven full

months

April 2009 VDSS 52

Example - Continued

Step #3 $30,534.00 uncompensated amount- 28,420.00 penalty for seven full months

$ 2,114.00 partial month penalty amount

Step #4 $ 2,114.00 partial month penalty amount÷ 130.97daily rate ($4,060 ÷ 31)= 16.14 number of days for partial

month penalty

• For November 2009, the partial month penalty of 16 days would be added to the seven (7) month penalty period. This means Medicaid would authorize payment for LTC services beginning November 17, 2009.

April 2009 VDSS 53

Post-Eligibility-Patient Pay

• Patient Pay = gross income – allowances• Allowances differ for nursing facility and CBC

patients– NF = $40 personal needs allowance– CBC & PACE = $1,112 personal

maintenance allowance• Other allowances include health insurance

premiums, non-covered medical expenses, community spouse and dependent child allowances, guardianship fee, earned income.

April 2009 VDSS 54

For Additional Information…• Contact the Local Department of Social

Services office in the city or county where the individual lives:

• For questions about applying for Medicaid and to request applications and Fact Sheets about Medicaid eligibility

• To report changes in income or resources and for questions about continuing eligibility

• Local DSS contact information available online at www.dss.virginia.gov.

April 2009 VDSS 55

VDSS Medical Assistance Unit Staff

Stephanie Sivert, Program Manager(804) 726-7660

• VDSS Home Office :

– Diane Drummond (804) 726-7390

– Sandy Gilbert (804) 726-7397

– Susan Hart (804) 726-7363

– Glenn Rainey(804) 726-7377

• Regional Field Offices:

– Central - Sherry Sinkler-Crawley (804) 662-9756

– Eastern - Lynn Brodnax (757) 491-3980

– Northern - Donald McBride(540) 347-6326

– Piedmont - Judy Ferrell(540) 857-7972

– Western - Sharon Craft(276) 676-5639

April 2009 VDSS 56

April 2009 VDSS 57

From VDSS to VICAP Volunteers and Staff…for all you do,

April 2009VDSS1 Medicaid 101 Helping VICAP Clients Apply for Medicaid.

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