Presents

Medicaid OverviewWith

Attorney Sharon L. Pope

Sponsored by:

January 21,2014

Traditional Medicaid Coverage

(this is not the ACA which is also known as “extended Medicaid”)

What is Traditional Medicaid?

• A jointly funded, Federal-State health insurance program for low-income, needy people, and persons with disabilities.

• The law establishing Medicaid can be found in Title XIX of the federal social security statute; sometimes Medicaid is referred to as, “Title XIX”.

• Each state then has it’s own statutes and regulations as the program is administered by the states.

• Each state has a department that administers the program, typically the Department of Human or Social Services. These departments likewise have program manuals which state the policies and procedures the Department uses to administer the Medicaid programs.

What Services Does Medicaid Provide?

Medicaid Services(States do vary in the services offered)

• Inpatient and Outpatient Hospital and Clinics

• Physicians, Nurses, Dentists, Vision care

• Pediatrics

• Laboratory and X-Rays Dialysis

• Long Term Care (Nursing Home, Home and Community-Based Care)

• Prescription Medications

• Medical supplies, equipment, and appliances (wheelchairs, etc.)

• Non-Emergency medical transportation

• Hearing aids/prosthetic eyes

Who is Eligible for Medicaid?

Who is Eligible for Medicaid?

• US citizens

• Permanent residents

• Pregnant Women (without regard to citizenship or legal status)

• Immigrants who entered the US illegally (only in case of medical emergency)

• Must be a resident of the State in which Medicaid is sought

Who is Eligible for Medicaid?

• Supplemental Security Income (SSI) Recipients

• Persons who are blind, disabled, or aged (defined as 65 years or better) and who meet certain income and resource limitations; these income and resource limits will be discussed in greater detail

• Pregnant women with family income less than 200% of the Federal Poverty Level

• Children under age 6 with family incomes less than 133% of the Federal Poverty Level

• Children ages 6 – 19 with family income up to 100% of the Federal Poverty Level

Who is Eligible for Medicaid?

Definition of “Blind or Disabled”Under 18: The individual must have a medically determinable physical or mental impairment which results in marked and severe functional limitations and can be expected to result in death or last for a continuous period of not less than 12 months

18 and Over: The individual must have a medically determinable physical or mental impairment which results in the inability to engage in any substantial gainful activity and can be expected to result in death or can be expected to last for a continuous period of not less than 12 months

Blindness defined: see www.ssa.gov

Who is Eligible for Medicaid?

Substantial Gainful Activity (SGA)

• “Substantial Gainful Activity” is measured by level of work activity and earnings.

• Work is “substantial” if it involves doing significant physical or mental activities, or a combination of both.

• “Gainful” work activity is either of the following: • Work performed for pay or profit; • Work of a nature generally performed for pay or profit; or• Work intended for profit, whether or not a profit is realized.

• 2014 income level for SGA –• Blind: $1,800 per month• Disabled: $1,070 per month

Medicaid Counted Resources

• Cash

• Bank Accounts

• Stocks

• U.S. savings bond

• Land

• Life insurance

• Personal property

• Automobiles

“Resources” also sometimes referred to as “assets”

are things an individual owns such as:

• and anything else which could be changed to cash and used for food or shelter, subject to certain exclusions.

• The resource limit for most of these programs is $2,000.00 for a single individual.

Examples of Excluded Resources

• Home in which the beneficiary resides

• One automobile, there may be an equity limit

• Household goods

• Personal effects

• Burial Space

• Irrevocable Prepaid Burial Contract- may be limits on the amount

• Life Insurance (face value and the face value of any other life insurance policies total $1,500 or less)

• Joint Ownership in Residence

• Real Property Unable to be Sold

• Food Stamps

• School Lunch Programs

• Child Nutrition Programs

• Grants, Scholarships, Fellowships, or Gifts Set Aside to Pay Educational Expenses

• Resources and income in a special needs trust

Medicaid – Counted Income

Income is any item an individual receives in cash or in-kind that can be used to meet his or her need for food or shelter, including the receipt of anything which can be applied, either directly or by sale or conversion, to meet basic needs of food or shelter, subject to certain exclusions.

Examples of Excluded Income

• First $20 per Month. However state may vary in these rules if the recipient is not also an SSI recipient.

• Infrequent or irregular income: $60 per quarter of infrequent or irregular unearned income and $30 per quarter of infrequent or irregular earned income

• Other items if not food or shelter and cannot be used to obtain food or shelter

• Certain Medical and Social Services• Food and shelter received during medical confinement• Personal services performed for an individual• Income Tax refunds• Rebates and Refunds or other return of money he or she has already

paid• Loan proceeds

CAUTION: an item may not be countable income, but if held past the month’s end, it could become a countable resource!!

Pathways to Medicaid

Pathway Income Eligibility Asset Limit Medicaid

(Individual/Couple) Benefits

SSI < 74% of poverty $2,000 Y

$3,000

Medicaid Criteria are essentially the same as SSI in most states, except applicant does not wish to receive SSI payments

Medically Spend-down $2,000+Y

Needy income $3,000+

Pathways to MedicaidPathway Income Eligibility Asset Limit Medicaid Medicare Premiums

(Individual/Couple) Benefits & Cost-Sharing

NH Res. < 300% of SSI level $2,000 Y

$3,000

Home-Based < 300% of SSI level* $2,163 Y Waivers

QMB < 100% of poverty $4,000 N Y** $6,000

*Will vary among states

**Qualified Medicare Beneficiary; eligibility will vary among states.

Transfer of Asset Rules

For long term care Medicaid programs, such as skilled nursing home placement or long term home and community-based services, there are transfer of asset rules in addition to the resource and income rules. This is known as the 5 year look-back. If the applicant has given away assets, there may be a period of ineligibility.

Medicaid ServicesSome Other State Options

Home and Community Based Waiver Programs (HCBW)

• Must meet regular Medicaid requirements

• Programs vary from State to State

• States can use federal Medicaid funds for Medicaid services to persons needing institutional levels of care which can be provided at home or in the community

Katie Beckett Option (children with special needs)

• Home care for the child must be appropriate

• Estimated cost of community services may not exceed the cost of institutional care

• The child must require the level of care normally provided in an institution

Medicaid ServicesSome Other State Options

Ticket to Work

• Meets the increased income and resource requirements established by the State (for example, CT allows an individual to earn up to $75,000 per year and have up to $10,000 in resources under CT’s Employed Disabled Program)

• Must be “disabled” and otherwise (SSI) but for his or her earnings

• A person is not required to be receiving SSI in order to be eligible under the Medicaid provision

• The fact that the individual is working will not be considered when making the disability decision for this law

• Some modest co-payments may be required

Health Care Reform – 1/1/14Patient Protection and Affordable Care Act (P.L.

111-148)

There is no resource test for the expanded Medicaid program.

• Medicaid will expand to include most persons with income up to 133% of the federal poverty level plus a 5% disregard. Those individuals currently covered by traditional Medicaid will not be able to qualify for the ACA, Affordable Care Act coverage.

• ACA does not cover individuals age 65 +

• ACA does not cover long term care in a nursing home or in the home

• Requires States to expand Medicaid to include childless adults

• Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016

• Expansion of States’ ability to use HCBW funds

Medicaid Liens

If Medicaid pays for injury-related expenses for a person injured as the result of a tort, Medicaid is entitled to recover all or some portion of the monies it spent on injury-related medical expenses from the settlement or judgment. 42 U.S.C. § 1396k

However, Medicaid can only collect from that portion of the settlement or award that compensates for injury-related medical expenses. Arkansas Department of Health and Human Services et al. v. Ahlborn, 547 U. S. 268 (2006)

But . . . Tristani V. Richman, 609 F. Supp. 2d 423, (W.D., Pa., 2009)

Medicaid Liens

Source of Funds Medicaid Payback

InheritanceNo

GiftsNo

WindfallsNo

Personal Injury Damages Yes

Estate Recovery

States must pursue recovering costs for medical assistance consisting of:

• Nursing home or other long-term institutional services;

• Home- and community-based services;

• Hospital and prescription drug services provided while the recipient was receiving nursing facility or home- and community-based services; and

• At State option, any other items covered by the Medicaid State Plan.

Estate Recovery

Estates from which recovery can be made:

• Estates of deceased Medicaid recipients who were 55 or older (65 for some States) when they received benefits

• Estates of Medicaid recipients who were permanently institutionalized, regardless of age

States may exempt recipients whose only Medicaid benefit is payment of Medicare cost sharing (Medicare Part B premiums)

Estate Recovery

Estates from which recovery can be made:

• Probate Estate

• Non-probate assets (passing outside the estate), such as interests passing through joint property, revocable trusts and annuities – at the option of the State

Preservation of Medicaid

• Proper Estate Planning: Third-party Special Needs Trusts

• Use of Self-Settled Special Needs Trusts

Websites

Centers for Medicare & Medicaid Services (CMS)

• Medicaid Website: http://www.medicaid.gov

• CMS Programs & Information Guide: http://www.cms.gov

Social Security Administration

• Summary Guide to Employment Support for Individuals with Disabilities (Red Book): http://www.ssa.gov/redbook/eng/main.htm

• General Information: http://ssa.gov/

• Benefits Eligibility Screening Test (B.E.S.T.): https://www.benefit.gov/ssa

• State SSI Supplements: http://www.ssa.gov/pubs/

Support(866) 296-5509

support@specialneedsplanners.com

Attorney Sharon L. Pope, Esq.

CZEPIGADALYPOPEBerlin • Hartford • Simsbury • Vernon,

CTsharon@ctseniorlaw.com

www.ctseniorlaw.com