Medicaid does not help everyone who needs assistance paying for healthcare. Coverage is limited to individuals who meet eligibility criteria for specific classes of assistance. The classes of assistance most often sought by elderly and disabled individuals relate to nursing home coverage or home health care.
To many, Medicaid is an enigma. Even the Court have been less than kind describing it. The program’s complexity surrounding who can become eligible, what services are paid for, and how those services are reimbursed and delivered is one source of this confusion. Variability across State Medicaid programs is the rule, not the exception.
In recent years, more States have implemented a variety of major program changes using special waiver authority. Income eligibility levels, services covered, and the method for and amount of reimbursement for services differ from State to State. Furthermore, Medicaid is a program that is targeted at individuals with low income. However, not all of the poor are eligible, and not all those covered are poor. For populations like children and families, primary and acute care often are delivered through managed care, while the elderly and disabled typically obtain such care on a fee-for-service basis. Nationwide, Medicaid finances the majority of long-term care services. Those services include, for example, nursing home care and community-based services designed to support the elderly and disabled in their homes. Recently, some States have begun to integrate Medicare and Medicaid financing and/or coordinate acute and long-term care services for these populations.
Like SSI, to gain or maintain eligibility for Medicaid, an applicant must be poor enough under the program eligibility rules. An applicants’ income and resources must be within certain limits. The specific income and resource limitations that apply to each eligibility group are set through a combination of Federal parameters and State definitions. Consequently, those standards vary considerably among States, and different standards apply to different population groups within a State. For many of those groups, States have permission under a special provision, Section 1902(r)(2), to use more liberal standards for computing income and resources than are specified within each of the groups’ definitions. Most States use Section 1902(r)(2) to ignore or disregard certain types or amounts of income or assets, thereby extending Medicaid to individuals with earnings or assets too high to otherwise qualify under the specified rules for that eligibility pathway.
Income vs. Resources
Medicaid always treats things of value (assets) as either income or resources. ” An asset cannot be considered income and a resource during the same month.” See Section 2300-1 of the Georgia ABD Manual. It is one or the other. See also POMS SI 01110.600 B.3. We illustrate how the income and resource eligibility rules work separately in the post linked here.
Income is anything of value you receive during a particular month. At this time, income is subject to a monthly income cap. The income cap changes each year, but in 2023, it is gross income of $2,742. Resources are everything else you already had on the first moment of the first day of the month. Resources are not limited to property you own. Under the POMS, a resource is any property you (1) own; (2) have the right, authority, or power to convert to cash (if not already cash); and (3) you are not legally restricted from using for your support and maintenance. See POMS SI 01110.100 B.1
A single Medicaid applicant can only have $2,000 in countable resources. In 2023, the Community Spouse in a maximum-maximum State can keep $148,620 in countable resources. Exempt resources do not count toward these limits. In 2023, the minimum Community Spouse Resource Allowance is $29,724.
Medicare versus Medicaid
Medicare is health insurance for those who paid into the system and who are aged, blind or disabled. “Paid into the system” means the Medicare worked at least 40 quarters paying Medicare taxes, or qualifies as an eligible dependent of someone who worked 40 quarters. Medicare eligibility is an entitlement; it is not means-tested.
Like traditional health insurance, Medicare focuses on acute care. Coverage is weighted toward face-to-face visits with a health care professional such as hospitalization, doctor visits, and therapy. Medicare does have a nursing home component, but it is limited to a maximum of 100 days following a qualifying hospital stay. Days 1 through 20 (if skilled therapy is needed) are covered at 100%. Days 21 through 100 (if skilled care is needed) have a $194.50 co-pay (in 2022 and 2023). Coverage terminates on the earlier of (i) the date skilled care is no longer needed; or (ii) after 100 days.
Medicaid, on the other hand, is a welfare program that pays health care bills for certain aged, blind and disabled individuals. Although applicants have a right to due process and a right to demand that the rules be followed, not everyone who needs care is eligible for Medicaid. Only those individuals who fall within a class of assistance are eligible. Medicaid planning is a process elder law attorneys use to assist individuals in accelerating Medicaid eligibility, usually with the goal of preserving resources.
Many Medicaid classes of assistance are “waivers” which means the State can limit the number of eligible individuals, or can cap the amount of funds for a specific waiver. In February 2018, it was reported that the Trump Administration was considering lifetime caps for Medicaid coverage. It is unknown whether future administrations will revisit the issue, but overt rationing already occurs in some States, and less obvious forms of rationing can be found in the coverage rules.
Most Common Classes of Assistance
Qualified Medicare Beneficiary (QMB)
QMC pays the monthly Medicaid Part A premium for individuals who must pay a premium. It pays the monthly Medicare Part B premium. It also pays all Medicare co-pays and deductibles for eligible individuals. In 2022, a qualifying individual must have less than $1,094 per month of gross income, and less than $7,970 in countable resources. More information about QMB Medicaid is available at Benefits.gov.
Nursing Home Medicaid
Nursing home Medicaid pays the cost of a nursing home stay after the resident contributes his or her patient liability amount (PLA), also known as a cost-share. As discussed elsewhere, the PLA is that portion of the resident’s monthly income that must be applied toward the nursing home cost before Medicaid pays the balance of the bill. In other words, Medicaid is a cost-share program. Countable resources for an individual cannot exceed $2,000. A more generous allowance is available for the health spouse of a nursing home resident (known as the “Community Spouse”).
Community Care Services Program (CCSP)
CCSP is designed to provide home and community based services for qualifying individuals. The financial eligibility criteria are identical to those for nursing home Medicaid. Georgia CCSP will generally provide up to a maximum of up to 35 hours of care per week in the home. Alternatively, it can pay for adult day care, placement in a personal care home, respite care, or other services. The local Area Agency on Aging served as the gatekeeper for this program, but in many counties it is now administered by Legacy Link.
Independent Care Waiver Services Program (ICWP)
The ICWP is a home and community based waver intended to help adult Medicaid recipients with physical disabilities live in their own homes or in the community instead of a hospital or nursing facility. ICWP services may also be available for persons with traumatic brain injuries (TBI). This program is generally available for recipients between the ages of 21 and 64. Eligibility criteria appear in Section 2139 of the Georgia ABD Manual.
NOW and COMP Waivers
The New Options Waiver (NOW) and the Comprehensive Supports Waiver Program (COMP) are intended to provide home and community-based services for people with intellectual disabilities or developmental disabilities. A diagnosis of developmental disability includes intellectual disability or other related developmental conditions such as cerebral palsy, epilepsy, autism or neurological problems that require a level of care provided in an ICF/ID. Eligibility criteria appear in Section 2132 of the Georgia ABD Manual.
Georgia Pediatric Program Waiver (GAPP)
The GAPP is a service-delivery model for providing nursing care in the home to medically fragile children. Children must be under the age of 20 years, 11 months and must be medically eligible. The GAPP Waiver program may provide services in medical daycare settings to medically fragile children with multiple system diagnoses who require continuous skilled nursing care, or skilled nursing care in shifts. Children receive services in their homes, communities, and in ‘medical’ day care settings rather than placing children in a nursing facility or hospital.
We have posted an unofficial version of the Georgia Medicaid Manual on EZ Elder Law. The Official version is MAN3480 on ODIS. This is the manual caseworkers follow as they evaluate your Medicaid application. Don’t worry. We don’t expect you to know what’s in it. We’re just making you aware so you can look at it if you choose to do so.
MEDICAID BLOG POSTS
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Preliminary injunction granted barring state from terminating QI Medicaid
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