When it comes to Medicaid in NY State, the first thing that one needs to determine is the applicant’s budgeting category. People in different age groups and circumstances are subject to different eligibility rules, and the services available in each category may also vary. In this section we will be discussing eligibility and services for the aged, blind, and disabled. This category includes people who are 65 and above, certified blind by the Commission for the Blind and Visually Handicapped, and certified disabled by Social Security or NY State (the official title for this category is “SSI-Related”). There are three levels of Medicaid for this category:
- Community Medicaid
- Community Medicaid with Long-Term Care
- Nursing Home Medicaid
The following is an overview of Community Medicaid and Community Medicaid with Long-Term Care:
What is Covered?
What are the Eligibility Requirements?
What if your income or resources exceed the Medicaid limit?
Common ways people with income above the Medicaid limit can qualify
Common ways people with resources above the Medicaid limit can qualify
Community Medicaid is standard health insurance and covers most healthcare such as doctor visits, hospital visits, lab tests, and prescription drugs. Most people in the aged, disabled, and blind category also have Medicare. For them, Medicare functions as their primary health insurance and Medicaid acts as a supplement – covering gaps in Medicare coverage as well as providing coverage for services not covered by Medicare. If someone has a Medicare supplement (Medigap) policy as well, the policy will first pay it’s share and Medicaid will provide coverage for things that remain.
While Medicaid covers prescription drugs, people with Medicare will not have their prescription drugs paid for by Medicaid directly. Rather, Medicaid will pay Medicare to provide a free Medicare Part D prescription drug plan for these beneficiaries. Click here to learn more about this.
Community Medicaid with Long-Term Care provides everything that Community Medicaid does with the addition of community based long-term care services such as home care, adult day care, and assisted living.
Medicaid is a means-tested program designed for people with low income and limited resources. Medicaid will look at two financial categories when determining an applicant’s eligibility – income and resources. Income is any money that is coming in on a timely basis such as Social Security, a pension, or an IRA that is in distribution. Resources are any assets that the applicant has such as savings, stocks, bonds, real estate, or an IRA that is not in distribution.
The current Medicaid income limits for Community Medicaid are $825/month for an individual and $1209/month for a couple. Applicants in the aged, disabled, and blind category are entitled to a $20 disregard. Therefore, practically speaking, the income limits are $845/month for an individual and $1,229/month for a couple (a couple only gets one $20 disregard).
The current resource limits for Community Medicaid are $14,850 for an individual and $21,750 for a couple. Applicants who are not seeking coverage for long-term care are allowed to declare their assets and are not required to document them. Applicants that are seeking coverage for long-term care are required to document their resources. The documentation of resources is the only difference between qualifying for standard Community Medicaid and Community Medicaid with Long-Term Care. An applicant that may at some point need long-term care should strongly consider documenting their resources at the time of application and applying for the higher level of coverage.
Don’t be discouraged if your income and/or resources are above the Medicaid limit. There are many ways that people who have income and/or resources above the Medicaid limit can qualify.
The following are some common ways that people with income above the Medicaid limit can qualify:
Health Insurance Premiums
Money being paid toward a health insurance premium is exempt and is disregarded when Medicaid budgets an applicant’s income.
Pay-In and Spend-Down
One can pay to Medicaid the amount that he is above the income limit and receive Medicaid benefits. A similar way to get Medicaid coverage is through “spending down”. This means that the Medicaid beneficiary “spends down” their excess income by paying medical bills. Once they have paid the amount of their excess income towards the cost of medical bills, Medicaid will provide coverage for any additional costs. Paying in or spending down can be good options for someone who is only slightly above the income limit.
Earned income receives very favorable budgeting for the aged, disabled, and blind category. All earned income first gets a $65 disregard. Then, the remaining income is divided by two. The following is an example:
Sally works part-time at a local grocery and earns $1,065/month. For the purpose of her Medicaid budgeting, Medicaid will first deduct $65 from the total. This will leave $1,000. Then, Medicaid will divide $1,000 by 2. Her budgeted earned income will only be $500.
Pooled Income Trust
Sheltering excess income in a pooled-income trust is one of the most popular ways for someone above the income limit to qualify for Medicaid. NY State policy is that excess income placed in a pooled income trust (the name comes from the way the money is held by the trust, but each beneficiary has their own account) by a disabled individual be disregarded for Community Medicaid budgeting. Disability is almost never difficult to prove for someone who requires long-term care. Money placed into a pooled income trust can never be withdrawn as cash. Rather, the trust can pay bills in the name of the beneficiary.
To learn more, see: Pooled Income Trusts
Holocaust Restitution Payments
Holocaust restitution payments are exempt and are disregarded when Medicaid budgets an applicant’s income.
Spousal Impoverishment Allowance
Spouses of Medicaid recipients enrolled in Managed Long-Term Care (MLTC) plans are entitled to a portion of their spouse’s income up to a total combined income between them and their spouse of $2,980.50/month. This is called a Minimum Monthly Maintenance Needs Allowance (MMMNA). Additionally, the Medicaid recipient enrolled in MLTC is entitled to a Personal Needs Allowance (PNA) of $384/month. Combined, a couple can have a monthly income of up to $3,364.50 and still be within the Medicaid limit if one of them is enrolled in a Managed Long-Term Care (MLTC) plan.
The following are some common ways that people with resources above the Medicaid limit can qualify:
Generally, real estate is considered a countable resource. However, an applicant’s primary residence is exempt if the value of his equity in the residence is within $828,000. That being said, Medicaid does have the right to recover from a recipient’s equity in his residence after his death. Therefore, many people take measures to protect their residence from Medicaid estate recovery. It is often necessary to obtain the services of an attorney to implement these measures. Applicants whose spouse, or child who is under the age of twenty-one, blind, or disabled reside in the home, are not subject to the $828,000 limitation.
Holocaust Restitution Payments
Holocaust restitution payments are exempt resources. This means that even if someone has been receiving payments for decades, if he can document the total amount of payments received, he may keep that entire sum and still qualify for Medicaid.
Spousal Impoverishment Allowance
Spouses of Medicaid recipients enrolled in Managed Long-Term Care (MLTC) plans are entitled to a resource allowance the greater of $74,820 or one-half of the couple’s total combined assets up to $119,220. This is in addition to the recipient’s resource allowance of $14,850.
Please note: this article covers basic eligibility guidelines and does not address more advanced techniques such as transferring assets or spousal refusal.
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