Medicaid for Older Adults and Adults with Disabilities

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Medicaid for Older Adults and Adults with
Disabilities

• Cindy Olson
• Department of Medical Assistance Services
• March 23, 2005

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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

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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

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Applying for Medicaid

• Complete the application
• The applicant may have assistance with completing
  the application
• The applicant or authorized representative must
  sign the application

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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

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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

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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

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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
• Workers Compensation
• The applicant is NOT required to apply for SSI in
  order to be eligible for Medicaid

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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 (FC)

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How is Eligibility Determined?

• Medicaid coverage for older adults and adults
  with disabilities is under the ABD group
• AgedAge 65 or older
• BlindSSI definition (having best corrected
  central visual acuity of 20/200 or less in the
  better eye)
• DisabledSSA 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)

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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

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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)

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How is Eligibility Determined?

• The applicant is first evaluated for full
  coverage
• Includes hospital care, doctors visits,
  prescriptions and transportation to receive
  covered services
• Also includes payment of Medicare premiums,
  deductibles and co-payments for Medicare
  beneficiaries

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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

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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

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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

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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

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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!

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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

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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
  

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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)

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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

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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

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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

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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

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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

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Patient Pay

• Is a federal requirement
• Medicaid eligible recipients must share in the
  cost of their long-term care services
• Income-allowancespatient pay

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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

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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

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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