Category: General Medicaid

Medicaid will not pay medical bills that you incur before you are eligible. However, Medicaid may begin your 6 month Period of Consideration (POC) for eligibility as much as 3 months before you apply to determine your eligibility. So, if you apply for Medicaid shortly after you incur the bills, you may be able to get Medicaid to pay for them. 

If your income is above the Medically Needy Income Limit (MNIL), you can use old unpaid medical bills toward your spend down. Medicaid will not pay the old bills, but you may not have to pay for additional medical expenses that you incur. You can also use your spouse’s or dependents’ medical bills to meet the spend down if they live in your home. 

For example, say you have $5,000 worth of medical bills and you decide to apply for Medicaid. Let’s further say that you have a spend down limit of $1,000. You can use $1,000 worth of the old medical bills toward your spend down amount. By doing this, you will not have to pay anything for your medical expenses during the six-month period, starting with the date of your application for Medicaid; Medicaid pays it all. However, you are still responsible for paying the old medical bills. 

Medicaid reassesses your eligibility every six months. Each time, Medicaid will set your spend down amount. You can keep using the old bills toward your spend down amount, as long as you do not use the same portion twice. That means that if your spend down amount was $1,000, and you had a single old unpaid medical bill for $5,000, you could use $1,000 of the $5,000 bill five times as your spend down amount. After that, you would pay the spend down amount yourself for bills you incur, or those for which you must pay, as needed. 

In terms of getting Medicaid coverage with your upcoming medical expenses, old unpaid medical bills can help you. However, Medicaid will not actually pay any of these bills. 

Also, Medicaid will not pay for any medical expense that is eligible for coverage by any other insurance such as Medicare or a private insurer. Likewise, Medicaid will not use any medical expense that is covered or eligible for coverage by Medicare or other insurance to meet the spend down. 

For more information, see: West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§ 1.22(M), 10.22(D)(11), http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 26, 2015).

Medicaid is a need-based program for people who cannot afford to pay for their medical care. You must meet income and asset requirements to be eligible. 

When you set up a trust, technically you do not own the money and assets in the trust unless you are the trustee. The trustee owns it and gives out the assets according to the arrangements of the trust. The interest you receive from the trust is income, but you do not have access to the rest, or principal, of the trust.  

Previously, people would escape the asset limit for Medicaid by putting their money into trusts. However, that loophole has been largely closed. Now, when you set up a revocable trust, the income is counted toward your income limit, and the principal will probably be counted as an asset. It is unlikely that you will be able to exclude any income you receive, and you cannot exclude the principal as an asset except in limited circumstances. 

Another type of trust is called an irrevocable trust. A trust is irrevocable when there are restrictions on your access to the principal. In the past, some irrevocable trusts were not counted as an asset. However, now, if there is any chance that the principal of the trust can be used for your benefit, the principal will be counted as an asset. For example, say you have a trust worth $50,000. The trust states that $50 per month is to go to you. Also, the trust states that if you have a heart attack, you can have the rest. Unless you have a heart attack, you cannot get to that $50,000. But, because there is some possible way for the money to be used for your benefit, it will be counted as an asset. Likewise, the $50 per month will be counted as income. If there were no way the principal could be used for your benefit, then and only then would it not be counted as an asset. 

If you set up an irrevocable trust that cannot be used for your benefit, be aware of a few things. First, if you do create and title assets such a trust, you may have a period of disqualification from long-term care Medicaid, which acts as a penalty. Medicaid will not allow you to just take your money and give it to someone else so that you can apply for Medicaid. This practice is called an uncompensated transfer of assets. 

Medicaid will penalize you for any uncompensated transfers of assets you make within a certain time period directly prior to the time you apply for long-term care Medicaid benefits. That period of time is called the “look-back period” and the Deficit Reduction Act of 2005 (DRA) required state Medicaid programs to change the look-back period to 60 months for transfers made after February 8, 2006. In March 2009, West Virginia implemented this change and the look-back period is now 60 months for any resource transfer, whether or not a trust was involved. The penalty period begins when you are both eligible for and receiving long-term care that would be covered if not for the penalty, and after any other penalty periods imposed have expired.  

The penalty is disqualification from long-term care Medicaid coverage (nursing home care or Medicaid waiver program) for a period of time. If you transferred your assets into an irrevocable trust that could not be used in any way for your benefit, you would be penalized. If you were trying to obtain nursing home care, you would be disqualified for as many months as it would take for you to use up the assets you placed in the trust toward your care. Your penalty period will not begin until you need the benefits and you no longer have more than $2,000 in assets. 

Some transfers may not result in penalties. Transfers made before the beginning of the look-back period are not penalized as uncompensated transfers of assets. A hardship provision also exists. This provision allows the exclusion of a trust when counting it would result in undue hardship for the client. Decisions about undue hardship are made by the Director of the Office of Family Support. 

It is also important to remember that if you are unable to get to the money in a trust, you cannot use it, so it may not be to your advantage to set up an irrevocable trust. You may benefit more from the use of your money even though you are not able to get Medicaid. Before setting up a trust, you may want to examine these issues. Medicaid laws and trusts in general can be very complicated. Consequently, if you are interested in setting up a trust, you should consult an attorney who is experienced in Medicaid planning. 

For more information, see: 42 U.S.C. §§ 1396p, 1396a (2015); West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§11.4(TT), 17.10(B)(3), 17.10(B)(12), http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 26, 2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging §§ 11.29, 11.42-.46 (2nd ed. 1993).

he Aged & Disabled Medicaid Waiver Program is an alternative to nursing home care. It provides services in your own home to help take care of you and assist you with activities of daily living. This program is also called home and community-based care.  

Under this waiver program you can receive services that enable you to remain living independently in the community rather than having to move to a nursing home. However, one significant difference between in-home care on the waiver and nursing home care is that the care received on the waiver is not around-the-clock. This arrangement can be ideal for you if you do not need constant medical care or if you have a relative or spouse or informal support who can care for you when the home care provider is absent.  

Eligibility for this Medicaid waiver program is similar in many ways to nursing home Medicaid eligibility. In order to qualify for the Medicaid waiver program you must be both medically and financially eligible. Your medical eligibility is assessed by a company called West Virginia Medical Institute (WVMI) using the same assessment tool (the PAS 2000) and standard required for nursing home medical eligibility. 

The Medicaid waiver program requirements are different in some ways from nursing home Medicaid. The Medicaid waiver program may be better for you financially. For one thing, the Medicaid waiver program does not count the income or assets of your spouse in determining your eligibility. Since you are not penalized for transferring assets to your spouse, you could put everything into your spouse’s name and those assets would not be counted for the Medicaid waiver program. The asset limit for the Medicaid waiver program is the same as the asset limit for nursing home Medicaid. Under the Medicaid waiver program, the covered individual may have up to $2,000 in assets. 

The income requirement for the Medicaid waiver program is the same as the income requirement for nursing home Medicaid. Your monthly income must be equal to or below 300% of the monthly SSI payment. For nursing home Medicaid a single individual often must spend all but $50 per month on care. However, under the Medicaid waiver program, you do not have to contribute any of your income if you meet the income requirement. 

Before you decide to move to a nursing home you may consider participating in the Medicaid waiver program. However, funding for the Medicaid waiver program is limited, and even if you are found medically eligible you still may have a waiting period before you can receive any benefits.  

If you are considering applying for the Medicaid waiver program, contact your local West Virginia Department of Health and Human Resources (DHHR) office. In addition, you can contact: 

WV Bureau of Senior Services  Phone: 1 (877) 987-3646 or  

Medicaid Waiver Staff 1 (304) 558-3317 

Mailing Address: 1900 Kanawha Boulevard, East Fax: 1-304-558-5609 

Charleston, WV 25305 http://www.wvseniorservices.gov

Physical Address: Town Center Mall, 3rd Level, Charleston WV     

Table Comparing Aged and Disabled Medicaid Waiver Program to Nursing Home Medicaid

	Aged & Disabled Medicaid Waiver Program	Nursing Home Medicaid
Location of services	C provides services in your own home to assist you with daily living	C provides services in a nursing home
Amount of care	C care is available for a set number of hours per week	C care is available 24/7
Eligibility requirements	requires that you meet eligibility standards to become eligible for this program	requires that you meet eligibility standards to become eligible for this program
Impact of spouse’s income on eligibility	does not count the income or assets of your spouse in determining eligibility for the program	counts the income and assets of your spouse in determining your eligibility for the program
Contribution of income to care	you do not have to contribute any of your income to your care	you must make some contribution to your care based on your income
Program funding and receipt of benefits	funding is limited, and so even those who are eligible for the program may have to wait before receiving benefits	C this program is well funded, and there is generally no wait time to receive benefits

For more information, see: 42 U.S.C. §§ 1396u, 1396d (2015); 42 C.F.R. §§ 440.180, 441.300-.365 (2014); West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§ 17.9-.11, 17.17-.31, Chapter 2, Appendix B, http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 26, 2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging § 11.86 (2nd ed. 1993).

You may be able to receive Medicaid assistance. Medicaid is need-based, so you must meet an income and possibly an asset requirement to qualify. There are several different kinds of Medicaid, each with different eligibility requirements. The following information applies to people who are low-income and Medically needy. 

Income Requirement

In West Virginia, if you are eligible for SSI, you also meet the income requirement for Medicaid. However, you do not have to receive SSI to be eligible. If you are at least 65 years old, Medicaid allows you to spend down some of your income to meet the Medicaid income requirement. 

Spend down works very much like a deductible. Medicaid will calculate your spend down amount every six months. This six-month period is called the Period of Consideration (POC). Medicaid pays everything after the date the spend down amount has been met during the POC. You are responsible for the spend down amount. 

To calculate the spend down amount, Medicaid uses a Medically Needy Income Limit (MNIL). The MNIL for one person is $200 per month. The MNIL for a couple is $275 per month. The MNIL represents the amount of income needed for monthly living expenses. 

Next, Medicaid subtracts the MNIL, or $200, from your countable income. Medicaid then multiplies that number by six. This amount is your spend down amount. Medicaid will pay your medical bills that exceed this amount. You can also use your spouse’s or dependents’ medical bills to meet the spend down, provided that they live in your home. The idea is that you should spend, or incur and be responsible for paying, all of your income above the $200 MNIL on your medical bills before you receive Medicaid benefits. 

For example, say you have a countable income of $500 per month. This is $300 more than the $200 MNIL. Multiply the $300 by six months. This gives you a total of $1,800. This is your spend down amount for the POC. 

Let’s also say that you pay or incur $5,000 of medical bills during the POC. Medicaid will then pay your medical expenses after your $1,800 spend down amount has been met. That means that Medicaid will pay $3,200 of your medical bills. You are responsible for the spend down amount, or $1,800. In essence, you are responsible for the first $1,800 before Medicaid pays. This is why the spend down is like a deductible. 

However, spend down is unlike a deductible in that you do not have to actually pay the total spend down amount before Medicaid pays your medical bills, you only have to incur medical expenses equal to or greater than the spend down amount and be responsible for them. You may not use old medical bills twice to count toward your spend down amount. If you use an old medical bill toward your spend down amount you may not use it again, regardless of whether you actually pay it. 

Asset Requirement

Once you meet the income requirement, you must also meet the asset requirement. There is no asset test or Medically needy test for eligibility for the Medicaid expansion created under the Affordable Care Act, only income is considered. 

For more information, see: West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§10.22(D)(11), 16.9, Chapter 10, Appendix A, http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 26, 2015).

 

 

Medicaid is a health coverage program for certain low-income people. If you receive Medicaid, this means that the program pays your health care provider for certain health care costs. Although Medicaid may cover most of your costs, you may still be required to assist in paying for the medical services by paying a co-pay. Because of the Affordable Care Act, more preventative services are available such as yearly wellness checks.

Each state administers Medicaid through its own state law according to federal law. To qualify to receive Medicaid, you must satisfy certain requirements set forth in both state and federal law. If you are eligible to receive Supplemental Security Income (SSI), you are likely also eligible to receive Medicaid.

If you are married, you and your spouse may apply for Medicaid individually or jointly. Since 2015, all states permit same-sex spouses to apply for Medicaid jointly. Currently, legally married couples, including same sex-couples, will have both individuals’ assets and financial need considered when applying for Medicaid.

For more information, see: Centers for Medicare and Medicaid Services, Overview Medicaid Program, https://www.medicaid.gov/medicaid/index (last visited June 10, 2019)