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Medicaid 101

Medicaid 101. Helping VICAP Clients Apply for Medicaid. The Basics. Part I. Medicaid Eligibility. 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:

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Medicaid 101

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  1. Medicaid 101 Helping VICAP Clients Apply for Medicaid VDSS

  2. The Basics Part I Medicaid Eligibility 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. 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. VDSS

  5. How Does Someone Apply for Medicaid? • Complete the application • The applicant may have assistance with completing the application. • The applicant or authorized representative must sign the application. VDSS

  6. How Does Someone Apply for Medicaid? • Submit the application to the LDSS in the locality in which the applicant resides: • In person • By mail • By fax • Coming soon: submit on-lineA face-to-face interview is not required when applying only for Medicaid. 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. 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) VDSS

  9. How is Eligibility Determined? • 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 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. 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. 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) 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. VDSS

  14. The applicant must meet all non-financial criteria: Legal Presence Citizenship/Alien Status Virginia residence Social Security Number Assignment of rights to medical support Application for other benefits Institutional status Health Insurance Premium Payment (HIPP) requirements How is Eligibility Determined? 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. 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). 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. VDSS

  18. How is Eligibility Determined? • 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. VDSS

  19. How is Eligibility Determined? • 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. 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. 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 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 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 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. 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. VDSS

  26. MedicaidLong-term Care (LTC) Part II Nursing Facility (NF), Community-based Care (CBC) & PACE 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. 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. 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. 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? 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. VDSS

  32. Substantial Home Equity • 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. VDSS

  33. Substantial Home Equity • 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. 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. 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. 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. 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. VDSS

  38. Transfer of Assets • Policy for transfers on or after 2/8/06changed: • 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. VDSS

  39. 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. Look-back PeriodApplication Date… VDSS

  40. Transfers That Do Not Impact Medicaid Payment for LTC • Transfers that have a cumulative value < $1,000 per calendar year. 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). 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. 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. 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. VDSS

  45. 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 Penalty PeriodTransfer Made… VDSS

  46. 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. Partial Month Penalty Period Transfer Made… 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). 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. 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. 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. VDSS

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