MEDICAID: BEYOND THE BASICS

Todd W. BartimoleBartimole Greene25550 Chagrin Blvd. Suite 103Beachwood OH 44122216-464-9999todd@bartimolegreene.com

Medicaid Eligibility Requirements, Benefits, and Application Process

Session I

Overview

Medicaid was created by the Social Security Amendments of 1965 which added Title XIX to the Social Security Act

It si a Federal program administered by states to provide medical coverage to aged, blind, and disabled; low income children and mothers, pregnant mothers

Must be financially eligible On Federal level administered by the

Centers for Medicare and Medicaid Services (CMS)

Ohio Medicaid

Administered by the Ohio Department of Job and Family Services

Locally administered by County Departments of Job and Family Services

Additional administration for waiver programs may come from Area Agencies on Aging for some Medicaid Waiver Programs

See, 42 U.S.C. § 1396n(c); 42 C.F.R. § 441.300 et seq. 

Medicaid Law & Rules

Where to find it: Federal: USC Chapter 7, Subchapter XIX

Grants to States for Medical Assistance Programs

Chapter CFR §42, Chapter IV, Subchapter C, Section 435 (Eligibility)

ORC §5111 OAC §5101 (mostly 5101:3-1 and

5101:3-3)

Note on Citizenship § 435.406   Citizenship and alienage. (a) The agency must provide Medicaid to otherwise

eligible residents of the United States who are— (1) Citizens: (i) Under a declaration required by section

1137(d) of the Act that the individual is a citizen or national of the United States; and

(ii) The individual has provided satisfactory documentary evidence of citizenship or national status, as described in § 435.407.

(v) The following groups of individuals are exempt from the requirements in paragraph (a)(1)(ii) of this section: (A) Individuals receiving SSI benefits under title XVI of the

Act. (B) Individuals entitled to or enrolled in any part of Medicare. (C) Individuals receiving disability insurance benefits

Qualified Aliens

A qualified alien who enters the United States on or after August 22, 1996 does not meet the citizenship requirement for Medicaid for a period of five years beginning on the date of the alien's entry into the United States with a status of "qualified alien.“

See OAC §5101:1-38-02.3 Medicaid: Qualified Aliens

General Medicaid Eligibility for Long Term Care Three general Areas:

1. Health Eligibility 2. Income Eligibility 3. Asset Eligibility

Other Considerations:Citizenship, improper transfers, etc.

Health

Requirement: Intermediate Level Of Care Skilled Level of Care

Preadmission Screening PASRR (Pre-Admission Screening and

Resident Review 42 CFR 483.100 to 483.138 Attempt to ensure MR/DD people are not put

in nursing home for non medical reasons Two stages of screen, if first is tripped, second

will outline recommendations for treatment OAC 5101:3-3-15.1

PASRRPreadmission Screening and Resident Review

Applies to anyone entering a Medicaid certified NF

PAS: No level II screen unless there is indication of serious mental illness, mental retardation or Developmental disability

If level II is required, there will be recommendations for specialized services

Placement in NF may not be appropriate

Intermediate Level of Care To require an intermediate level of

care the resident must require: Two activities of daily living require

hands on assistance One activity of daily living and hands on

assistance with medication administration

24 hour support in order to prevent harm due to a cognitive impairment

Income

What is income? Cash, income in kind, or something of

value received and available and attributable to an individual.

all income must be considered in determining the need of an individual by the agency.

All potential income must be explored by the agency.

Non utilization will be seen as an attempt to obtain benefits

Duties to apply

Is it best practice to apply for benefits for clients who may be entitled to VA or other benefits?

Non application may be grounds for denial.

Ohio so far has not taken this stance, but other states have required a VA application before an application will be approved.

Court Ordered Support

When an individual has been court-ordered to pay child support and/or spousal support to a former spouse, these payments must not be deducted from countable income to the individual.

Court ordered income deductions must be considered available income to the medical assistance individual.

Exemptions from Income

non-cash benefits from personal services non-cash benefits from medical or social services Income Tax refunds Bill paid directly to a creditor An arrearage of child support paid to the Medicaid

recipient 9 months of interest on assistance received (such

as fire, flood, hurricane, etc. disaster relief) Proceeds from casualty insurance due to loss Whole list of disregards on pages 6-8 of the outline

What are income limits?

Nursing facilities: Single Person: Must have income that is

less than the cost of care of the nursing facility.

Married Person: Same, although institutionalized spouse may have to provide assets to community spouse under spousal impoverishment rules

Waiver Limits Income cap of 300% of poverty level, or

$2130.00 per month

Resources

Resources are cash, personal property, and real property an individual and/or the individual's spouse has an ownership interest in, has the legal ability to access in order to convert to cash (if not already cash), and is not legally prohibited from using for support and maintenance.

"Countable resources" are those resources remaining after all exemptions are applied.

Trusts Trusts may be resources. Something that looks like a trust is a trust,

even if it isn’t. "Trust” means any arrangement in which a

grantor transfers property (real or personal) to a trust with the intention that it be held, managed, or administered by a trustee(s) for the benefit of the grantor or certain designated individuals (beneficiaries). In this rule, the term trust includes any legal instrument or device that is similar to a trust.

Trusts are addressed at OAC 5101:1-39-27.1

The Five Trust Categories

Self Settled Trusts prior to 8/11/1993 Self Settled Trusts post 8/10/1993 Exempt Trusts

Special Needs Trusts Qualified Income Trusts Pooled Trusts Supplemental Services Trusts

Third party Trusts Testamentary Trusts

The Five Trust Categories Trust Category #1 :Self Settled trusts

prior to 8/11/1993 Established by the individual, where the

individual may become a beneficiary of the trust, and payment is determined by trustees

Resources in the trust are available to the extent the trustees have discretion to distribute to the beneficiary

Amounts actually distributed to the beneficiary are considered income

Assets transferred to the trust which cannot be removed from the trust are improper transfers

The Five Trust Categories

Trust Category #2 – Self Settled Trusts established on or after 8/11/1993

Trust established by the individual or the spouse or court and the individual’s assets were used to create the trust.

Revocable trust assets are always available

Payments to the individual are income

Payments to third parties are improper transfers

Self Settled Trusts post 1993 continued…

For irrevocable trusts: when some or all of the trust can be disbursed to, or for the benefit of, the individual, any payment that is made to another person is an improper transfer. The transfer is considered to have been made as of the date of payment to another person.

The Five Trust Categories

Trust Category #3, Exempt Trusts, Medicaid Payback Trusts

The principal or income is exempt as a resource.

1. A trust established for a disabled individual aged under 65, established by a court, parent, grandparent or guardian, where corpus of trust must be used to repay medicaid.

Distributions are unearned income

Five Trusts: QIT’s

Category #3, Exempt Trusts, Qualified Income Trusts

Comprised only of income of the individual

Income received by the individual, then transferred into the trust by the individual

Those funds transferred are not considered income

Funds in trust still are counted for patient liabilty.

Five Trust Categories

Category #3, Exempt Trusts, Pooled Trusts Disabled individual Trust maintains separate accounts pooled

together Established by the individual, parent,

grandparent, or guardian trust pays to the state the amount

remaining in the account equal to the total amount of medical assistance paid on behalf of the beneficiary. 

Five Trusts

Category #3, Exempt Trusts: Supplemental Services Trust

meets the requirements of section 1339.51 of the Revised Code.

person who is eligible to receive services through one of the following agencies: the department of mental retardation and developmental disabilities; a county board of mental retardation and developmental disabilities; the department of mental health; or a board of alcohol, drug addiction, and mental health services.

The Five Trusts

Category #4: trusts established by someone else for the benefit of the individual. (Third Party Trusts)

Created by third party, individual is a beneficiary, funded by third party’s assets

Trust is unavailable unless the trust permits beneficiary access.

Five trusts

Category 4 continued… If the trust contains a clear

statement requiring the trustee to terminate the trust if it is counted as an available resource, then it is not counted as an available resource. 

Can file suit against trustee to have a court declare funds are not distributable.

The Five Trusts

Category #5: trusts established by will for the benefit of a surviving spouse.

Testamentary trusts which permit payments to an institutionalized spouse, the assets which are available to the spouse are available assets.

Payments to or for benefit of spouse are income.

Payments made to 3rd parties are improper transfers

No penalties are applied if the surviving spouse elects to take against the will

Annuities

OAC 5101:1-39-22.8  Important dates:

Date of purchase Date of annuity “Transaction” which

means any action taken by the individual or community spouse that changes the treatment of the income or principal of the annuity.

After DRA, any annuity transaction is considered an improper transfer unless exemptions apply.

Annuities

Exemptions: State of Ohio must be remainder

beneficiary in first position, or second position after spouse or disabled child.

Annuities created from assets of certain qualified funds

Must be irrevocable, non assignable, and actuarially sound (payable in equal installments within life expectancy), without balloon payments

Private annuities are not permitted

Exempt Resources

Household goods and personal effects of reasonable value

Automobiles One is exempt for married couple One is exempt if it is

Necessary for employment Necessary for the treatment of medical problems Modified for handicapped person

$4500 in value of one automobile is excluded Equity does not come into the equation.

Exempt Resources

Life insurance where: Face value is 1500 or less Cash value is exempt, even if over $1500 Dividend accumulations are also exempt

Example: $1,500 face value policy

$2500 Cash Value plus $1000 Dividend accumulation $3,500 is exempt

Exempt Resources

The Home Single Person: first $500,000 is exempt

for 13 months post eligibility Exempt if spouse, minor child, blind or

disabled child, child over 65 who is dependent, sibling with equity interest and has been in house for over a year.

Value of house is equity value, not value of the house itself.

Exempt Resources

Real or personal property essential to the means of self-support

Burial plots (usually will exempt multiple plots if it is for family use)

Irrevocable burial contracts Accumulation of reparation and other

special accounts Must be segregated

Retirement accounts which require a working person to quit their job

Exempt Resources

Legally restricted accounts a legal restriction against the

property's use for the owner's own support and maintenance means the property is not a resource.

Shared Ownership

Assets of a husband and wife are not distinguished in Medicaid applications.

If a co-owner blocks access, the individual is required to pursue legal action.

If cost of action is prohibitive, or individual is unsuccessful, the asset is not counted.

Evidence can be proffered to show percentage of ownership.

Resources

Property that has not been sold If real property, listed for sale, the asset is

not counted Property must be listed at an amount equal

to the county assessed value If there is an offer to purchase at 90% of said

value it may not be rejected. If it appears that the stated value is incorrect,

either the individual or the administrative agency may obtain an appraisal from a second source to set a more accurate value.

Newly Discovered Resources Any individual alleging lack of knowledge of

an ownership interest in a resource must provide a signed statement attesting to the lack of knowledge and explaining the circumstances resulting in its discovery.

If the signed statement and adequate supporting documentation is provided, the department should not count an individual's ownership interest as an available resource during any period in which the individual was unaware of the ownership interest.

Spousal Impoverishment Rules FCPI Spousal resources are divided in half,

however: Community Spouse max is $115,920 Community Spouse min is $23,184

Can be increased through state hearing

Medicaid Benefits

LTCF Dental Medical Equipment

Waiver Programs Passport Assisted living waiver

Medicaid Application Fraud No person shall make or cause to be

made a false or misleading statement

Conceal an interest in property Penalties

Restitution can be draconian

Coordination of Benefits

Session II

Veteran’s Benefits

Coordination The VA pension will pay monthly

benefits to those who have served in time of war.

Homebound or Aid and Attendance

Planning for VA benefits, No lookback period (yet)

Medicare Savings Programs

QMB A and B premiums, deductibles Income $987 per month or $1,313 for a

couple Assets $7,080 or $10,620 couple

SLMB Part B premiums $1,169 a month or $1,571 a couple

QI1 Part B Premiums $1,313 per month or $1,765 for a couple

Long Term Care Insurance

Partnership Program - Partnership insurance offers a way for people to buy long-term care insurance, receive policy benefits and protect a matching amount of assets if they need to apply for Medicaid.

Benefits are counted as income

Break