On July 30, 2015 we celebrated the 50th anniversary of Medicaid, the medical insurance program for children, the poor, the elderly and persons with disabilities. Some facts about Medicaid are well-documented: All state Medicaid programs cover a set of standard health benefits ranging from physician services to inpatient hospital care. Having access to preventive care is associated with better health. In 2014, adults who had Medicaid for a full year reported having access to recommended preventive services at a rate on par with individuals with private insurance. And they were much more likely to have access to preventive care than people who were uninsured. In 2014, 95 percent of adults who had Medicaid for a full year reported having a regular doctor. That’s comparable to the percent of people with private insurance (94 percent), and it’s much better than the rate for people without insurance (77 percent).
Individuals with Medicaid report receiving excellent or very good care at the same rate as those with private insurance. A large-scale study of states that extended Medicaid before 2014 found that broader Medicaid coverage was associated with reductions in mortality, increased access to care, and improved reported health status. Children account for nearly half of all Medicaid enrollees. Medicaid helps them get a good start in life and succeed years later. Studies show that individuals who had Medicaid when they were young not only experienced better health while they were enrolled, but that they actually earned more as adults than children who were uninsured.
Medicaid keeps out-of-pocket costs (like copayments) low so that enrollees can use the coverage they have. Compared to people who are uninsured, Medicaid enrollees are less likely to incur catastrophic health care costs, and they report feeling less financial strain. People with Medicaid report receiving same-day return calls from physician offices and getting same-day appointments when sick at roughly the same rate as people with private insurance. (FamiliesUSA Fact Sheet)
The Mississippi Medicaid program is a broad range of services provided to many different “coverage groups”. A summary of these groups that apply to adults follows, along with statements for each group regarding: (1) the “income limit” for that group (i.e., the maximum countable income a person can have to be eligible); (2) the “resources limit” (i.e., the maximum cumulative value of countable resources a person can own to be eligible); and (3) whether there is a “transfer penalty” for eligibility (i.e., whether transfer of assets by the applicant will result in any period of ineligibility):
SSI-Eligible. Any Mississippi resident who receives any payment of SSI benefits is automatically eligible for Medicaid services. The income and resource limits of the SSI program apply.
Qualified Medicare Beneficiary (QMB). An individual who is Medicare-eligible and whose income is below 100% of the federal poverty level + $50 ($1,022 individual / $1,361 couple) is eligible for this Medicaid program. Medicaid will act like supplemental insurance to Medicare, paying the monthly Medicare Part B premium as well as other Medicare deductibles and co-payments for the individual. There is no resource (asset) limit for this coverage.
Specified Low-Income Medicare Beneficiary (SLMB). An individual who is Medicare-eligible and whose income is below 120% of the federal poverty level + $50 ($1,217 individual / $1,623 couple) is eligible for this Medicaid program. Medicaid will pay the monthly Medicare Part B premium only for the individual.
Healthier Mississippi Waiver. The individual cannot be covered by Medicare and the individual must be age 65 or over, or if under age 65, must be disabled using SSI program rules; and total monthly income can be no more than 135% of the federal poverty level ($1,363 for an individual / $1,820 for a couple using income of both members of the couple, even if only one member is applying). Countable assets may not exceed $4,000 ($6,000 for couple). No doctor’s certification of disability is required. If any household income is from wages, the allowable income limit is higher. Disabled children can qualify for this program. The income limit is based on the parents’ income and the number of other children in the family. Only 5,500 recipients state-wide are authorized for this coverage group.
Working Disabled. An individual who is disabled and working at least 40 hours per month may be eligible for Medicaid assistance if his earned income is below $4,853 single / $6,529 couple and unearned income is below $1,343 single / $1,795 couple, and if countable assets are less than $24,000 single / $26,000 couple. If gross earned income is greater than $2,939 single / $3,943 couple, the recipient must pay a monthly premium in the amount of five percent (5%) of “countable earnings” (1/2 gross earnings – $32). There is no transfer penalty applied to this program and the “spousal impoverishment” rules (see Long-Term Care group below) do not apply.
Home and Community-Based Services (HCBS) Waiver Programs. Mississippi has obtained federal waivers to use Medicaid funds to offer services in “home and community-based” programs designed to help recipients avoid institutionalization. These include: (1) Elderly and Disabled Waiver, which provides respite, adult day care, meals, homemaker and other services for older persons with deficits in at least 3 of the activities of daily living; (2) Independent Living Waiver, which provides personal care attendant services to physically disabled persons; (3) Intellectually Disabled/Developmentally Disabled (ID/DD) Waiver, which provides “day-habilitation”, respite care, attendant care, and speech/physical/occupational therapies to persons who would, without such services, require the level of care in an Intermediate Care Facility for the Mentally Retarded; (4) Assisted Living Waiver, which provides homemaker, attendant care, medication supervision, social and recreational therapies, transportation and other services to residents of certain personal care homes and other congregate living facilities who would otherwise require placement in a nursing facility; and (5) Traumatic Brain Injury/Spinal Cord Waiver, which provides services to persons with traumatic brain or spinal cord injuries necessary to help them avoid institutionalization. There are other eligibility criteria, services and population limitations on these groups. The monthly income limit for these groups is generally the nursing home income limit ($2,199 in 2015) for an individual. The resource limit is $4,000 and liberalized resource and “spousal impoverishment” rules apply (see following section). There is a Medicaid transfer penalty for these groups.
Long Term Care (or Nursing Home) Group. This coverage pays nursing home costs in excess of the Medicaid recipient’s monthly share of cost. A single Medicaid applicant may have monthly countable income of up to $2,199 (2015) and countable assets of up to $4,000 to qualify for Medicaid for LTC. Under “spousal impoverishment” rules for married applicants, the at-home spouse (“community spouse” or CS) may keep all of his/her own separate income, plus enough of the applicant’s income to get the CS’s income up to $2,981 per month (the “monthly maintenance needs allowance”) (2015) if the CS’s separate income is less than this amount. The CS may own separate countable resources of up to $119,220 (the “community spouse resource allowance”). Assets may be assigned from the nursing home spouse to the community spouse to achieve these levels. In addition, the applicant (nursing home spouse) may have separate income of up to $2,199 and separate countable assets of up to $4,000. The separate income (Social Security, etc.) of the applicant spouse that is not assigned to the CS as part of the monthly maintenance needs allowance must be applied to pay nursing home cost as the applicant’s “share of cost”, but the community spouse’s income and assets need not be spent for this care. Medicaid transfer penalties are imposed for uncompensated transfers of resources by the applicant or the applicant’s spouse.
There are many misconceptions about Medicaid eligibility for nursing home care. Medicaid will pay nursing home costs for persons who are disabled and whose “countable” income and assets are under certain limits. While these limits are low, a number of assets are excluded in determining “countable” assets and income.
(1) Excluded Assets: A number of assets are not counted when determining eligibility for Medicaid. These include: the entire value of the residence (unless it is in a revocable living trust); all household furnishings; up to two automobiles, based on use; certain life estate or inherited interests in property; some income producing property; property used in trade or business for self-support; certain mineral and timber rights; certain life insurance policies; prepaid or designated funeral contracts and burial plots; and certain retirement or annuity accounts in pay-out mode.
(2) The “Look-back Rule”: Many people have heard: “You have to wait 3 years after giving anything away to get Medicaid.” The Truth: The look-back for gifts made before February 8, 2006 was 3 years, and in some cases there was no disqualification at all. The Deficit Reduction Act of 2005 (“DRA”) changed the look-back for transfers made on or after February 8, 2006, the effective date of DRA. The new law requires disclosure of all transfers made within five (5) years prior to Medicaid application, whether they were transferred to a trust or otherwise. Medicaid may refuse to pay nursing home benefits for a period of time based on the amounts and dates of such gifts made during the look-back period. (See Transfer Penalty below.) However, the rules penalizing transfers do not apply to all transfers.
(3) Transfer Penalty. If assets were given away (that is, without any value in return) to persons other than a spouse or disabled child after February 8, 2006, and if the giver applies for Medicaid within 60 months after such gift, Medicaid will impose the following penalty on such gifts: Medicaid will refuse to pay the giver’s nursing home care for a number of months based on the state average nursing home cost ($5,700 since January 2011). Under the DRA, the penalty period for gifts does not begin to run until the Medicaid Applicant has both entered a nursing home and is otherwise financially eligible for Medicaid. Therefore, if the applicant gave away $57,000 on February 1, 2012 and goes into a nursing home and applies for Medicaid February 1, 2016, there would be a 10-month ineligibility period ($57,000 divided by $5,700 average cost in 2012) before Medicaid will begin. Even though his assets are below the Medicaid eligibility limit ($4,000) when he applies for Medicaid, he must private pay for his nursing home for the additional 10 months of ineligibility.
The DRA has dramatically changed the Medicaid eligibility rules. Therefore, it is imperative that, if substantial gifts have been made, a Medicaid application must NOT be filed prematurely. Consult an experienced elder law attorney about any gifts and their effect on Medicaid eligibility.
(4) Estate Recovery: Federal law requires that each state Medicaid agency seek to recover reimbursement from the estate of each deceased Medicaid recipient for nursing home or home and community based waiver services paid by Medicaid after the recipient was 55 years of age. This claim will be waived by Medicaid (a) if there is a surviving spouse; or (b) if there is a surviving dependent who is under the age of twenty-one (21) years or who is blind or disabled; or (c) as provided by federal law and regulation, if it is determined by Medicaid or by court order that there is undue hardship. Estate recovery against a residence may also be waived if the property value is less than $75,000 and there is a surviving spouse, child or grandchild.
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