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Medicaid for Older Adults and Adults with Disabilities. Cindy Olson Department of Medical Assistance Services March 23, 2005. What is Medicaid?. Medicaid is an assistance program that helps pay for medical care. To be eligible for Medicaid, individuals must:

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medicaid for older adults and adults with disabilities

Medicaid for Older Adults and Adults with Disabilities

Cindy Olson

Department of Medical Assistance Services

March 23, 2005

what is medicaid
What is Medicaid?
  • Medicaid is an assistance program that helps pay for medical care. To be eligible for Medicaid, individuals must:
    • Be in one of the groups covered by Medicaid
    • Have limited income and resources
  • Since Medicaid is funded by the State and Federal governments, it is subject to both State and Federal regulations
applying for medicaid
Applying for Medicaid
  • Obtain an application by:
    • Calling the local Department of Social Services (LDSS) office
    • Picking up an application at the (LDSS) office
    • Downloading and printing an application from the DSS web site at www.dss.state.va.us
applying for medicaid4
Applying for Medicaid
  • Complete the application
    • The applicant may have assistance with completing the application
    • The applicant or authorized representative must sign the application
applying for medicaid5
Applying for Medicaid
  • Submit the application to the LDSS in the locality in which the applicant lives:
    • In person
    • By mail
  • A face-to-face interview is NOT required when applying only for Medicaid
application processing
Application Processing
  • The applicant will receive a letter requesting any required verification or documentation
  • The eligibility worker (EW) must process the 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
how is eligibility determined
The applicant must meet all non-financial criteria:

Citizenship/Alien status

Virginia residence

Social Security number

Assignment of rights

Pursuit of support

Application for other benefits

Institutional status

Health Insurance Premium Payment (HIPP) requirements

How is Eligibility Determined?
how does eligibility for other benefits affect medicaid eligibility
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 Disability
    • VA Pensions and Compensation
    • Worker’s Compensation
  • The applicant is NOT required to apply for SSI in order to be eligible for Medicaid
how is eligibility determined9
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)
how is eligibility determined10
How is Eligibility Determined?
  • Medicaid coverage for older adults and adults with disabilities is under the ABD group
    • Aged=Age 65 or older
    • Blind=SSI definition (having best corrected central visual acuity of 20/200 or less in the better eye)
    • Disabled=SSA definition (inability to do any substantial, gainful activity because of a severe, medically determinable physical or mental impairment which has lasted or is expected to last for a continuous period of not less than 12 continuous months, or which is expected to result in death)
applicants with disabilities
Applicants with Disabilities
  • The disabled or blind covered groups include:
    • Those who receive Social Security Disability benefits
    • Those who receive Supplemental Security Income (SSI) based on blindness or disability
    • Those who have been determined to be blind by the Virginia Dept. for the Visually Handicapped
    • Thos who receive Railroad Retirement benefits due to a disability
what if there has not been a disability determination from ssa
What if There Has Not Been a Disability Determination from SSA?
  • If an applicant claims to be blind or disabled, but has not already had a disability determination completed, the EW in the local office will make a referral to the Medicaid Disability Determination Services Unit (DDS)
how is eligibility determined13
How is Eligibility Determined?
  • The applicant is first evaluated for full coverage
    • Includes hospital care, doctor’s visits, prescriptions and transportation to receive covered services
    • Also includes payment of Medicare premiums, deductibles and co-payments for Medicare beneficiaries
how is eligibility determined14
How is Eligibility Determined?
  • If the applicant is not eligible for full coverage, he or she may receive limited coverage
    • Qualified Medicare Beneficiary (QMB): Medicaid pays for Medicare Part A and B premiums, co-payments and deductibles
    • Special Low-Income Medicare Beneficiary (SLMB) and Qualified Individuals (QI): Medicaid pays for Medicare Part B premiums only
what determines full or limited coverage
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): must be under limit for the covered group
what determines full or limited coverage16
What Determines Full or Limited Coverage?
  • Limited Coverage (QMB, SLMB, QI):
    • Resource Limit: $4,000 for an individual or $6,000 for a couple
    • Countable Income (After Allowable Deductions): must be under limit for the covered group
medically needy mn spenddown
Medically Needy (MN) Spenddown
  • Applicants who meet the resource limit for full coverage but have income in excess of the limit, may be able to meet a MN spenddown and receive a limited period of full coverage. When the period is up, the spenddown must be met again in order to receive Medicaid
  • The income limit for MN is based on the locality where the individual lives and is lower than for other ABD covered groups
medicaid and supplemental security income ssi
Medicaid and Supplemental Security Income (SSI)
  • In Virginia, an SSI recipient who wishes to receive Medicaid must also apply for Medicaid -- enrollment is not automatic!
medicaid and supplemental security income ssi19
Medicaid and Supplemental Security Income (SSI)
  • An individual who receives SSI meets the income eligibility for Medicaid

- but-

  • The real property eligibility requirements for Medicaid in Virginia are different than the real property eligibility requirements for SSI
medicaid covered long term care services
Medicaid Covered Long-Term Care Services
  • Medicaid covers long-term care services for individuals who meet covered group requirements and are in need of a greater level of service
  • Services can be provided in a nursing facility or through one of 5 Home and Community Based Waivers
eligibility for long term care
Eligibility for Long-Term Care
  • Individuals must first be screened to determine if they meet the level of care requirements for care in a facility or through a waiver
    • Screening completed by a DSS Social Worker and Health Department Nurse or Hospital Staff
      • Use Universal Assessment Instrument (UAI)
eligibility for long term care22
Eligibility for Long-Term Care
  • In addition to meeting the level of care requirements, individuals must meet a Medicaid covered group and meet the special rules for long-term care
    • Income, resources
    • Asset transfer
resource eligibility for long term care
Resource Eligibility for Long-Term Care
  • Must determine if individual is single or married.
    • If married, must determine if spouse is living in the community
  • Must complete a resource assessment for married individuals with a community spouse
    • Only for institutionalized individuals with a community spouse whose first continuous period of institutionalization (>30 days) occurred on or after 9/30/89
    • Can request a resource assessment prior to application for Medicaid
    • Only one resource assessment is completed
resource assessment
Resource Assessment
  • Is a compilation of all resources in his name, her name and their names together
    • Is used to determine the spousal resource allowance, or the amount of resources the community spouse may keep
    • Transfers of resources between a married couple are allowed
    • Resource assessment can be waived if applicant meets Undue Hardship requirements
asset transfer
Asset Transfer
  • Must evaluate asset transfer at the time of application for Medicaid long-term care services
    • “Look-back” period of 36 months for real property and 60 months for trust property
    • Individuals who transfer assets without receiving adequate compensation (fair market value for the resource) will be penalized for a period of time and will not be able to receive Medicaid payment of their long-term care services
      • Hardship exemptions apply
income eligibility
Income Eligibility
  • Income limits are higher for those individuals needing long-term care services
    • Up to 300% of the SSI payment
      • $1737 per month for 2005
  • Individuals with income in excess of 300% of SSI can be placed on a spenddown for nursing facility care and some waiver services
patient pay
Patient Pay
  • Is a federal requirement
    • Medicaid eligible recipients must share in the cost of their long-term care services
  • Income-allowances=patient pay
patient pay28
Patient Pay
  • Allowances specified in federal regulations
  • Allowances differ for nursing facility and CBC patients
    • NF: $30 personal needs allowance guardianship fee, community spouse and dependent child allowances, health insurance premiums, non-covered medical expenses
patient pay29
Patient Pay
  • CBC: $579 basic personal maintenance allowance ($1737 for AIDS waiver), guardianship fees, community spouse and dependent family member allowance, health insurance premiums and non-covered medical expenses
  • Certain waivers have additional allowances for earned income:
    • Mental Retardation (MR) waiver
    • Individuals and Family Developmental Disabilities Support (DD) waiver
    • Elderly or Disabled with Consumer Direction (EDCD) waiver
who can you contact for more information
Who Can You Contact for More Information?
  • Contact the Local Department of Social Services 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
  • This information is available in the blue pages of the telephone book or online at www.dss.state.va.us