Medicaid

Medicaid is a joint federal/state program operated by the Pennsylvania Department of Public Welfare through its local County Assistance offices. Medicaid helps to pay for long-term care if someone is in a nursing home or the individual needs medical help at home. Currently, Medicaid in Pennsylvania does not pay for assisted living. Eligibility is based on medical need as well as financial need.

In Delaware County, all applications for Medicaid and Long Term Care benefits are handled through the Delaware County Assistance office at 701 Crosby Street, Chester, Pennsylvania 19013. However, the in-home benefits under Medicaid are channeled through the County Office on Service for Aging (COSA), 206 Eddystone Avenue, 2nd Floor, Eddystone, PA 19022; telephone 610-490-1300.

Eligibility for Nursing Home Benefits

Medicaid benefits are available under the following eligibility standards:

General Eligibility:

The Applicant must be 65 years or older or disabled. The Applicant must be a citizen of the United States (or equivalent) to apply in Pennsylvania. The Applicant must be a resident of Pennsylvania.

WARNING: Please note, both the Commonwealth of Pennsylvania and the federal government have recently enacted substantial changes to the Medicaid eligibility rules. The implementation of these changes will require further modifications of the Pennsylvania Medicaid rules within the next year. The following information should be used as only a general guide, and you should be sure to consult with an attorney who is an experienced practitioner in the area of elder law to be sure that the current rules are correctly applied to your situation.

Medical Eligibility:

An Applicant for Medicaid benefits must actually need long term care in a skilled nursing facility (or, if at home, require a similar level of care). A Medical assessment, an MA-51 Options Assessment, should be completed by the treating physician.

Financial Eligibility:

Assets:

As a general rule someone is eligible for Medicaid in a nursing home if the assets (generally cash, stocks, bonds and real estate) of the nursing home resident are below $2,400; however, there are a number of exemptions or excluded assets. For someone whose income is under $1,809 per month in 2006, there is a disregard of $6,000 of assets so that the nursing home applicant may have up to $8,000 in assets.

Asset Exceptions (single or married):

Assets that are not counted for purposes of the above calculation and which may be protected include, but are not limited to, the family residence (however, special rules apply as to possible estate recovery), one motor vehicle, property used in a trade or business, term insurance, life insurance with a face value of a maximum of $1,500, an irrevocable burial reserve, household goods and personal effects.

Income:

The income of the individual receiving benefits (both earned and unearned income such as social security or pension) must be contributed towards the care of the individual except he or she is allowed to keep $40 per month for personal needs. If Applicant’s income is insufficient to meet nursing home expenses, then the Applicant is eligible.

Example:

applicant’s income is $3,000 per month. Nursing home cost is $5,000 per month. The Applicant’s income will not make the Applicant ineligible because income ($3,000) is insufficient to meet medical needs. Note however, that the income indicated will be applied toward nursing home care on qualification for the program.

Special Rules for Husband and Wife:

Assets:

For married couples, the Applicant’s spouse can keep $19,908 in 2006 as a minimum or one-half of the combined countable assets of both spouses up to a maximum amount, which in 2006 is $99,540 (the CSRA or “spousal share”). Available assets consist of assets owned by the applicant in his/her own name and also assets titled jointly and assets titled in the name of the applicant’s spouse (except for the community spouse’s IRA or pension type savings which, in Pennsylvania is completely exempt). The value of assets in order to determine the CSRA is calculated based on completion of a Resource Assessment Form with values on the date of the admission to the nursing home.

Income:

For husband and wife, the income of the spouse who remains at home is not counted. The spouse who remains at home is called the community spouse. However, in 2006, if the community spouse’s income is below the range of $1,604 to $2,489 per month, then it may be possible for the community spouse to keep some of the institutionalized spouse’s income. Also, if the spouse who remains at home has extraordinary needs, such as pharmacy bills, then it is possible to receive more than the limit.

Disqualification (single or married)

As part of the Deficit Reduction Act of 2005, many Medicaid eligibility rules were changed. Several of the most important and confusing changes to these rules relate to the treatment of gifts (which includes any transfers for less than fair market value).

Under the prior gifting rules, gifts made the applicant temporarily ineligible for Medicaid benefits even if all of the other eligibility criteria had been satisfied. Under the prior rules, a person who made a gift transfer, would be ineligible from the date of the gift going forward for the number of months that the gifted funds could have been used to fund his or her care. The actual length of time that a person was ineligible varied on the size of the gift, but the starting point for the penalty period began during the month that a gift was made. Under these rules, an individual would have to supply financial information for the 36 months prior to the Medicaid application date, but that actual period of ineligibility could be shorter or longer depending on the size of the gift.

Under the new and more confusing rules, an individual who applies for Medicaid must provide financial information for the 60 months prior to the date of his or her Medicaid application. This Application must establish that the individual is medically and otherwise financially eligible for Medicaid. Then, as part of the Application process, the County Assistance Office will review the financial records of the Applicant to see what, if any, gift transfers were made during the past 60 months. The value of all of the gifts occurring within that 60 months will be added together, and then there will be a calculation to see how many months these gifts could have funded the person’s care. What is critical here is that the penalty period will then be applied from that date of the Medicaid Application for the number of months the applicant is found ineligible. It is quite likely under these new rules that many sick and poor individuals may find that they are not eligible for Medicaid due to gifts made to family members, friends, churches, etc. if made within the 60 months prior to their Medicaid application.

The advice of an experienced elder law attorney may be required to resolve many of the expected issues that will arise from the changes to the Medicaid eligibility rules.

Estate Recovery

Upon the death of a person who has received Medicaid benefits, the state must seek recovery of the amounts paid to a nursing home from the deceased’s estate. At this time, Pennsylvania limits such recovery to an individual’s probate estate, that is, any assets titled in the individual’s name alone at the time of death that are or could have been transferred by a Will.

There are also provisions for a person or family to request waiver of the recovery due to hardship or to request postponement of the recovery. For information contact the Estate Recovery Program Hotline at 800-528-3708 or Legal Aid of Southeastern Pennsylvania – Delaware County Division at 610-874-8421.

Home and Community Based Benefits

PA WAIVER PROGRAM

The Medicaid PDA 60+ Program is an alternative to the nursing home placement for individuals who qualify and wish to receive long term care services in their home or community.

Benefits will be paid by Medicaid if the individual qualifies both medically and financially, with a resource limit of $8,000 ($2,000 plus disregard of $6,000) and income limit of 300% ($1,809) of SSI. Under this program, there is no income contribution on the part of the applicant.

In 2005, Pennsylvania enacted legislation that now requires the inclusion of a spouse’s resources in the computation of available resources. However, as of the writing of this book, it is unclear whether the enactment of the new legislation will be delayed until formal regulations are adopted.

The Estate Recovery Program does apply to Pennsylvania Waiver Benefits received.

The provision of services is coordinated by the area agency on aging and includes:

Bridge Program

The “Bridge” program was abolished in Pennsylvania in 2005. Those already in the program will continue to receive those benefits.

Options Program

For more information on the Options Program, contact COSA at 610-490-1300.