Medicaid is a means-tested health insurance program.  It has two main pieces:

  1. The general health insurance program that is more based on low income
  2. The Long Term Care benefit that has both income and asset limitations (as well as a clinical requirement)

Unlike Medicare, Medicaid, under the right circumstances, will pay for long-term care services in a nursing home or at home.  Medicare does not pay for long-term care services. It will, however, pay for limited rehabilitation services in a nursing home environment. This post will focus on Medicaid’s long-term care services and not its general health insurance program.

Often, older or disabled individuals need assistance with performing activities of daily living (ADLs).  These activities typically include independently and safely dressing, bathing, ambulating, toileting, meal preparation and other tasks people normally perform without assistance when they are unimpaired.  As people age (or as a result of a medical or cognitive condition, injury or other cause) they often can no longer perform these normal tasks without assistance. When those same people reach a certain stage of dependence on others they can be assessed as Nursing Facility Clinically Eligible (NFCE).  This is a term used (currently as a new assessment tool is going to be introduced soon) to classify someone who is in need of a level of care typically provided in a nursing home long-term care unit. While almost all Pennsylvania nursing homes have Skilled Nursing units, those units are designed and staffed to provide rehabilitation services and discharge patients rather than provide long-term care and support to permanent residents.

So, if you are NFCE, Medicaid will pay for your care in a nursing home or, under certain circumstances, more limited services in the community.  However, you need to financially qualify to receive this care. To qualify you need to have assets below $2,000.00 (or, in PA, $8,000.00 if your monthly gross income is below $2,250.00).  For care in a nursing home there is no income limit unless your income is above the private pay rate the nursing home charges (which is a very rare occurrence). To receive services in the community through the Waiver program (home and community-based care) there is an income cap of $2,250.00 per month of gross income (before taxes and other deductions like Medicare Part B).  So if your income is above that limit and you need Medicaid paid services, you are limited to receiving them in a nursing home.

If you are married, there are asset and income provisions to protect the healthy spouse (Community Spouse or CS) that is not receiving care from becoming destitute.  First, there are rules to allow certain dollar amounts of assets to be protected for the spouse (maximum is $123,600.00 today which is adjusted annually). Additionally, if the CS lacks enough income to support his or herself, there are also rules to allow income to be shifted from the ill spouse to the CS to allow that CS to get the calculated shelter cost (maximum of $3,090.00).

If you are unmarried, you need to have assets below $8,000.00 or $2,400.00, depending on your income.  There are protected resources which do not need to be spent to get care and there are available resources and you need to spend them down to the previously mentioned limits to get care.  A skilled, experienced elder care attorney can help you maximize the financial resources you can retain so that the maximum value can be protected for the CS. Often with a spouse or disabled child in the community a skilled elder care attorney can assist preserving far more assets than you would without one.

The application process seeks financial records for five years prior to the date you are seeking services.  This process is complicated and some Medicaid caseworkers can take an aggressive stance on approving cases and be very particular in questioning you about information regarding the application.  If the application is not approved, you will owe the nursing home for the care of your loved one at the private pay rate for the entire period your loved one resides there. Nursing homes in southeastern PA charge between $10-15,000.00 per month for care.

Planning ahead to deal with the devastating costs of long-term care will ultimately save stress, time and money.

If you would like to speak with an experienced Elder Care Attorney for help with Medicaid applications in Montgomery County, Chester County, and the surrounding areas, call Slutsky Elder Law at (610) 940-0650

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