How Medicaid Works
You may not qualify for or be able to afford long term care insurance. If you meet financial eligibility requirements, you will qualify for Medicaid. Medicaid will pay for the long term care needs of a resident in a skilled or intermediate care facility. The Pennsylvania Waiver program may also pay for certain other care costs in the home or elsewhere if you are eligible. The Pennsylvania Waiver program is part of Medicaid so you will need to have met similar eligibility requirements. To be eligible for the Pennsylvania Waiver program you must:
- Be 60 years of age or older;
- Have no more than $8000.00 in liquid assets (does not include exempt resources);
- Have income of less than 300% of SSI (Supplemental Security Income, currently $2199.00 per month).
Medicaid is a combination state and federal program that helps pay for long-term care. Once an applicant successfully completes the eligibility process, Medicaid will pay for nursing home costs, and certain home and community-based (Waiver) services. In most nursing home cases, the individual receiving Medicaid benefits must pay his or her income to the facility, less a $45 allowance for personal needs, and less an allowance for the community spouse. A short-term resident in a nursing home, certified for 6 months or less, may also be allowed a housing allowance to pay some of the expenses of maintaining a home.
Benefits are available only to individuals who meet these Medicaid eligibility standards. An applicant for Medicaid benefits must prove medical and financial eligibility. The main challenge is verifying financial eligibility. All income and resources must be disclosed to the Medicaid caseworker. The applicant’s non-excluded, available resources must not exceed the applicable limit. Single applicants with income over $2199.00 must have total resources under $2,400. Single applicants with income less than $2199.00 have a resource limit of $8,000.
The eligibility rules for married Medicaid applicants are much more complicated. An elder law attorney familiar with Medicaid planning should be consulted in order to make sure you do not spend-down more money on nursing home costs than is required under Medicaid rules. Medicaid rules provide that the person in the nursing home will have the $2,400 or $8,000 limit described above. The spouse of the nursing home resident (community spouse) must also meet certain resource limits.
Certain gifts or transfers for less than fair market value will make the applicant temporarily ineligible for Medicaid long-term care benefits even if all of the other eligibility requirements have been satisfied. Transfer penalties can be severe and devastating.
Pennsylvania is required by federal law to seek reimbursement from the estates of certain deceased Medicaid recipients, including those over age 55 who received nursing home care or home and community-based long-term care services through the PDA 60+ Waiver Program. In some cases, advance Medicaid planning with an elder law attorney can reduce or avoid estate recovery.
Under certain circumstances, Pennsylvania law allows individuals or their spouses to keep their homes and much of their money without becoming ineligible for Medicaid benefits.
VERY IMPORTANT NOTE:
Qualifying for Medicaid or the Waiver program is complex.
The tools that can be used to preserve assets for the healthy spouse or your loved ones are complex. Qualification for public benefits while preserving assets has risk and should be done only with the advice of an experienced Elder Law attorney. The consequences of poor planning or no planning can be devastating.