FAQs

Medicaid covers the remaining monthly expenses of the Nursing Facility (NF), including prescription costs, once the resident’s income liability and any necessary “spend-down” of assets have been subtracted. Medicaid coverage includes six haircuts per year, provided by the NF, but does not extend to cover TV, cable, or telephone expenses.

MA eligibility hinges on two criteria: Medical Need and Financial Need.

For Medical Need qualification, applicants must undergo assessment by the Department of Aging and Adult Services (AAA) to be deemed “medically needy” for either short-term or long-term care. This involves completing a medical evaluation endorsed by the resident’s primary care physician, which is then scrutinized and approved by a AAA caseworker. The nursing facility will coordinate this assessment.

In terms of Financial Need, applicants must be verified as “financially needy” by the County. This determination is based on income, assets, and is subject to a five-year financial history review mandated by the County Assistance Office.

The permissible asset limit is determined by your gross income:

If the monthly gross income is $2,742 or less [2023], the maximum asset limit is $8,000.
If the monthly gross income is $2,743 or more [2023], the maximum asset limit is $2,400.

To qualify, a qualified spend-down must be carried out until the maximum asset limit is attained.
For example:

If there is $50,000 in savings and the asset limit is $8,000, a $42,000 spend-down is required.
Note: In cases where there is a spouse in the community, additional determining factors may come into play to protect a significant portion of assets and income, if necessary.

Certainly, both spouses’ assets are revealed, but only the community (at home) spouse’s IRA accounts are excluded from the asset division. The community spouse is allowed to retain a minimum of $29,724 [2023] or 50% of total assets (whichever is greater), up to a maximum of $148,620 [2023]. Any amount exceeding $148,620 [2023] for the spouse’s share of assets is subject to the MA spend-down requirement; nevertheless, there might be alternative options for the community spouse to retain the majority of the assets.

Expenditure post the “need date” (retroactive Medicaid start date) is restricted to medically related expenses, nursing facility costs, or placement in an irrevocable burial trust.

However, preceding the “need date,” you have the flexibility to pay any legitimate expense if there is a spouse at home or if you have intentions to return home. Gifting, however, is not allowed. This implies that as long as Medicaid coverage is not required during the spending period, you can continue to cover any valid expenses incurred. During this timeframe, there might be additional opportunities to preserve assets, but careful adherence to regulations is crucial, particularly within the 5-year look-back period preceding Medicaid qualification. Seeking advice from a professional well-versed in LTC MA regulations is recommended.

Certainly, but only the “cash surrender value” applies if the face value is over $1,500. This implies that if the face value is $1,500 or less, it will not be considered part of your total assets. However, any life policy with a face value exceeding $1,500 and a cash value surpassing $1,000 would be included in your “total assets.”

It’s important to note that the cash value differs from the face value of the policy and is usually lower. This represents the amount you would receive if you discontinued coverage and closed the policy, distinct from the amount payable upon death. For example, a $20,000 Life Policy with a $5,000 cash value would count as $5,000 towards your total assets.

In case of unverifiable or inadequately explained large withdrawals (amounting to $500 or more) or any transactions involving investments, title transfers, or deeds without receiving fair market value, the State may impose a penalty period. During this period, the State will not cover Long-Term Care (LTC) expenses, equivalent to the duration the “gifted” funds would have covered. Consequently, you will be responsible for paying the full private pay amount incurred during this timeframe.

If it is determined that you cannot afford the private pay rate to the Nursing Facility (NF) for covering the penalty period, there is a risk of the resident being discharged from the nursing facility, and collection proceedings will commence.

The determination of acceptance might take a few months. Following the completion of the initial application review and the signing of all necessary forms and consents by the resident or Power of Attorney (POA), it may take several weeks to gather all the required documentation. Obtaining support documentation is the responsibility of the resident, POA, or family.

Upon submission of the application, the County has a 30-day period to review and verify financial information. Based on their findings, they may request additional documentation for specific items before making a final acceptance decision.

In the event of a denial of your application, the County will provide a list of reasons. Denials usually result from either missing support documentation or the identification of newly discovered assets not reported in the original application.

Upon receiving a denial, you have the option to file an appeal, allowing the application to remain open until the issues are resolved. Support documentation must be submitted to the County for each item mentioned in their denial, in anticipation of the scheduled hearing. During the hearing, the Judge will determine the next course of action.

Your coverage will persist as long as you are in a Long-Term Care (LTC) facility and remain financially in need of coverage. It is possible to transfer this coverage to another nursing facility, provided the resident was not discharged home. However, the County mandates an annual renewal (also known as redetermination) of financial need on the anniversary of your coverage.

To ensure compliance with the maximum asset limit, current statements for all financial/investment accounts, including pension and annuities (unless previously documented as “fixed, lifetime” income), must be submitted. Additionally, disclosure of any liquidated assets is required. If the resident is discharged home, LTC Medicaid coverage will terminate, or it can be transferred to a LTC Waiver program (Aging Waiver) for part-time care at home.

After determining the effective date (commencement of coverage) for Medicaid, any valid expense may be paid before that date (refer to #9 above); however, payments of $500 or more will necessitate verification. Subsequent to the initiation of the Medicaid effective date, which might be retroactive, any expense paid that doesn’t qualify as part of the spend-down (#9 above) will be subtracted from your allowable asset balance ($8,000 or $2,400 balance, as outlined in #5).