The Medicaid Application Process for Long Term Care & Assisted Living

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Medicaid application process tips to

facilitate approval I'm Benjamin pierce

this presentation is intended to expose

you to the Medicaid application process

to increase your overall awareness it is

not intended to provide legal or

financial advice I encourage you to seek

professional help in applying for any

state or federal financial assistance

from qualified and experienced sources

what is Medicaid the Medicaid program

title 19 of the Social Security Act is a

state administrated health insurance

program that is jointly funded by

federal and state governments the states

operate individual Medicaid programs

within broad federal guidelines it

provides care after financial resources

have been exhausted in contrast Medicare

is a federal health insurance program

that covers most hospital and other

health care services for people aged 65

and older individuals may still incur

significant out-of-pocket expenses for

Medicare premiums deductibles and

co-payments Medicare does not pay for

custodial care or room and board

the scope of the Medicaid program

Medicaid is the largest health insurance

program in the United States it

comprises fifteen point nine percent of

the nation's total health spending which

is approximately one point nine trillion

dollars fifty eight million people

participate in the program Medicaid

expenditures are increasing at a faster

rate than private insurance and medicare

covers twenty-six percent of all

children in the United States 8% of all

non-elderly adults and comprises nearly

22% of the average state budget Medicaid

is the highest spender in most states

federal poverty level the federal

poverty level

FPL is the amount of income to provide a

bare minimum for food clothing

transportation shelter and other

necessities it's updated annually by HHS

and varies according to family size

hundred percent of the FPL is twenty

three thousand eight hundred

50 for a family of four in 2014

medically needy Medicaid serves many

people who have extreme medical costs

that can completely deplete their income

and assets such as nursing home or high

hospital expenses eligibility is

calculated by deducting medical costs

from income it allows individuals to

spend down to Medicaid eligibility 39

states have elected to cover medically

needy individuals each one of them

different so when you've seen one

Medicaid program you've seen one

Medicaid program who is eligible

Medicaid is only available to people

with limited income you must meet

certain requirements in order to be

eligible for Medicaid Medicaid does not

pay money directly to you instead it

sends payments to your healthcare

provider depending on your state's rule

you may also be asked to pay a small

part of the costs a co-payment for some

medical services eligibility unlike

Medicare Medicaid is an entitlement

program based on income and asset

guidelines the State Department of

Social Services administers the program

through the county offices monthly

program must be eligible on the first

day of the month of requested

eligibility applicants resources must be

at or below the Medicaid resource level

filing an application during a period of

ineligibility could potentially cause a

significant delay in the applicants

eligibility approval status physical

criteria qualifying for Medicaid

involves not only financial but also

physical requirements applicants must

demonstrate through a physical exam that

he or she is unable to perform the

activities of daily living including

feeding dressing bathing toileting and

continence if it cannot be shown to

Medicaid that the care is medically

necessary the Medicaid application will

be denied Medicaid income and resource

levels you meet financial eligibility by

either qualifying for Supplemental

Security Income SSI in the community or

qualifying for instance

no Medicaid you have to have a grossly

month income at or below 2022 per month

and resources at or below 2000 there are

exempt transfers the house to a spouse

to a primary caregiver a child that is

lived with the parent and kept them out

of a nursing home for two years siblings

with an equity interest who have lived

together for one year disabled children

of any age or children under 21 also

assets can be exempt to spouse and

disabled child of any age and the home

equity limit is seven hundred and fifty

thousand dollars the community spouse

now this is the spouse that's not

institutionalized the community spouse

resource allowance CSRA

is currently seventy four thousand eight

hundred twenty or one-half the total

value of the countable resources of both

spouses as of the date of the

institutionalization of the hill spouse

and it's not to exceed the maximum CSRA

which is a hundred and four thousand

four hundred and forty it does not

include the ill spouses allowance of

4350 the family home a car of any value

$1500 face value of the life insurance

policy or any prepaid burial items the

community spouse minimum monthly needs

allowance mmm and a the allowance right

now is twenty seven thirty nine if the

income of the community spouse is less

than mmm na they will be allowed to keep

enough of the ill spouses income to

bring them up to the Mme if the income

of the community spouse is more than the

Mme they will be asked to make a

contribution towards the care of the ill

spouse normally 25 percent of the excess

over the mmm a now there are look back

and penalty periods there are two

different time periods look back is

simply how far back Medicaid can examine

your records to see what you've done

with your money the penalty period is

how long you are ineligible for Medicaid

if they see that you have made gifts of

your money within the look-back period

the look-back period before February 8


his 36 months look-back for transfers to

individuals and 60-month looked back for

transfers to a trust after February 8th

of 2006 as a result of the deficit

reduction Act of 2005 a 60-month looked

back for all transfers the five year

look-back went into effect on February

2011 the longer look-back period was

phased in gradually as an only effected

transfers after February 8th 2006

penalty periods if the transfer appears

in the look-back period divided the

amount transferred by the average

regional rate for a nursing home in your

region before February 8 2006 the

transfer penalty began the month after

the transfer was made after February 8th

2006 the transfer began the month the

person is institutionalized and

otherwise eligible for Medicaid

retroactive eligibility if you are

determined eligible for Medicaid and you

have unpaid medical bills from the

three-month period immediately before

the month of your Medicaid application

the state will pay for those services if

you were eligible for Medicaid at the

time of the service this is called

retroactive eligibility and you must

apply for this coverage within six

months of the date of your Medicaid

application assisted living or al al is

a Medicaid Waiver program that enables

individuals at risk of placement in a

nursing facility and who meet income and

resource requirements to receive a broad

array of supportive and health services

by residing in an assisted living

facility there is limited availability

for this program and it has long waiting

lists the services that are provided in

Al include homemaker chores attendant

care medication administration social

activities skilled nursing ongoing

assessment health monitoring and

transportation availability of ale

enrollment and the AL Medicaid Waiver is

available in many states the

availability of al services is

determined by the number of vacancies in

the provider facilities and the

availability of medic

waiver slots distribution of these slots

has managed to the State Department of

Health and Senior Services the service

package provided is based on an

assessment of the individuals needs

unique care plan and availability of

services and funding who is eligible for

Medicaid Services in Hale

you must meet the following clinical

requirements at least 65 years old or 21

to 64 and determined disabled by the

Social Security Administration or by the

disability review section of the state

division of medical assistance and

health services and have been assessed

by the staff of the State Department of

Health and Senior Services and found to

be in need of nursing facility level of

care who is eligible for al Medicaid

Waiver well you must meet financial

eligibility by qualifying as before for

Supplemental Security Income SSI in the

community or for qualifying for

institutional Medicaid qualifying for

state-sponsored care must have a grossly

month gross monthly income that's no

more than a hundred percent of the

federal poverty level and have resources

at or below four thousand the AL program

participants may pay the provider a cost

share in addition to any room and board

fees depending on his or her income and

allowable deductions the care manager

calculates the cost share these are the

documents you will need to support your

Medicaid application birth or baptismal

certificate Medicare card and Social

Security card

health insurance card copy the front and

back and current premiums verification

of marital status using a marriage

certificate divorce papers death

certificate of spouse veteran discharge

papers if applicable verification of

income for current year so you can use a

pension check and stub Social Security

award letter or a copy of your most

recent check all estate planning

documents are required power of attorney

will trust agreements as applicable

statements or pass books on all bank

accounts open or closed for the past 36


or 60 months to a trust all checks are

receipts for any withdrawal $1,000 are

over for the past 36 months or to the

creation of a trust within 60 months any

other resource owned in the past 30

months or 60 months to a trust stocks

bonds mutual funds etc certificate of

title to any motor vehicle including a

car or mobile home verification of

income from all sources stock dividends

interest income or other sources they

need a copy of your latest income tax

return and for the past three years for

with all the 1099 residency verification

deeds and tax bills to home residents or

any lease or rental agreement deed and

tax bills for any other property that

you may own contract of sale for any

property sold in the last three years a

burial plot deed life insurance policies

including the face and cash values

substantiating the data each Medicaid

office has a computer program to verify

Social Security numbers employment

history and other personal information

if any financial information is not

disclosed to a county welfare office the

office may deny the application based on

information that it periodically

receives from the Internal Revenue

Service intentional failure to disclose

relevant financial data is considered

medicaid fraud even in cases where

Medicaid eligibility has initially been

granted the county welfare office may

revoke the approval upon receiving the

IRS records warning the following acts

are crimes under the federal and state

law and persons found guilty of these

acts can be fined up to $10,000 or put

into prison for up to three years or

both lending your Medicaid card giving

any information known to be false in

order to gain medicaid benefits hiding

any information about the occurrence of

an event that you know will bear on your

right to Medicaid benefits or the right

of another person for whom you applied

and who is receiving Medicaid coverage

applying for Medicaid for another person

and using the benefits for yourself or

someone else who is not eligible what

services are covered inpatient and

outpatient hospital services physician

services medical and surgical dental

services nursing facility services for

individuals aged 21 and older home

health care for persons eligible for

nursing facility services family

planning services and supplies health

clinic services and any other ambulatory

services offered by a health clinic that

are otherwise covered in the state plan

laboratory and x-ray services pediatric

and family nurse practitioner services

midwife services to the extent

authorized by state law early and

periodic screening diagnosis and

treatment EP STD services for

individuals under the age of 21 well how

long does it take well the federal

rights ensure a prompt disposition of

your application enforcing the federally

mandated deadline of 90 days found in

the Code of Federal Regulations and the

state can be done through a fair hearing

which is informal proceeding before an

administrative law judge these hearings

are often used to expedite the decision

making process of the county and state

welfare agencies individuals who do not

exercise their federal and state rights

to a prompt decision on their Medicaid

applications might otherwise find

themselves waiting for over a year to

learn whether their nursing home bills

which have been accruing will be covered

by the benefits program highly encourage

anyone undergoing this process to seek

legal advice mishandled Medicaid

applications can cause families

thousands of dollars do not apply to

early strategies for Medicaid planning

off include triggering a penalty period

for Medicaid eligibility purposes it's

imperative to have ownership of assets

evaluated using the DSS rules before a

spend-down plan is created may require

individuals to complete a plan of

liquidation of assets in certain

situations there is much more to filing

a medicaid application than just

gathering documents you will need

competent representation

this has been medicaid application

process tips to facilitate your approval

I'm Benjamin pierce for more information

visit my website at Planet Benja com