Long Term Care

Medi-Cal Resource Limits for Long Term Care

http://www.canhr.org/factsheets/medi-cal_fs/html/fs_medcal_limits.htm

Spousal Impoverishment: Protects the spouse of a Medicaid applicant or beneficiary who needs coverage for long-term services and supports (LTSS), in either an institution or a home or other community-based setting, from becoming impoverished in order for the spouse in need of LTSS to attain Medicaid coverage for such services.

Treatment of Trusts: When an individual, their spouse, or anyone acting on the individual’s behalf establishes a trust using at least some of the individual’s funds, that trust can be considered available to the individual for purposes of determining eligibility for Medicaid.

Transfers of Assets for Less Than Fair Market Value: Medicaid beneficiaries who need LTSS will be denied LTSS coverage if they have transferred assets for less than fair market value during the five-year period preceding their Medicaid application.  This rule applies when assets are transferred, sold, or gifted for less than they are worth by individuals (or their spouses) who need LTSS in a long-term care facility or wish to receive home and community-based waiver services.

The following property is generally exempt and therefore not counted in determining Long Term Care Medi-Cal eligibility:

• The home: totally excluded, if it is the principal residence. The applicant must state an “intent to return to the home.” Includes mobile home, houseboat, or an entire multi-unit dwelling as long as any portion serves as the principal residence of the applicant. (See “Your Home & Medi-Cal” for more information)
• Other real property: may be excluded if it is used in whole or in part as a business or means of self-support (you should see an attorney if you have other real property).
• Household goods and personal effects: totally exempt.
• Jewelry: for a single person, wedding, engagement rings and heirlooms, and items of jewelry with a net market value of $100 or less are totally exempt; for spouses, there is no limit on exempt jewelry for determining the institutionalized spouse’s eligibility.
• One car is generally exempt if used for the benefit of the applicant or if needed for medical reasons.
• Whole life insurance policies with a total face value (also called “combined death benefit”) of $1,500 or less.
• Term life insurance: totally excluded.
• Burial plots: totally excluded, includes headstone, crypts, etc.
• Prepaid irrevocable burial plan of any amount and $1,500 in designated burial funds. These designated funds must be kept separate from all other accounts.
• IRAs and work-related pensions: if in applicant’s name, the balance of the IRA or the pension is considered unavailable if the applicant is receiving periodic payments of interest and principal. If in the spouse’s name, the balance of the IRA or pension is totally exempt.
• Non-work related annuities: the balanceofcertain types of annuities may be exempt (see CANHR’s fact sheet, “Medi-Cal for Long Term Care” for more information.) You should see an attorney if you are considering buying an annuity – call CANHR for a referral.
• Up to $2,000 in cash reserve, e.g. in savings, checking, etc., for the Medi-Cal applicant.
• Community Spouse Resource Allowance (CSRA) for 2016: the spouse at home can keep the first $119,220 in assets, and may be able to keep more if his/her income is below the Minimum Monthly Maintenance Needs Allowance (MMMNA). For 2016 this amount is $2,981. Average Private Pay Rate (APPR) for 2016 is $8,189.

For more information, contact CANHR at 800-474-1116 (consumers only)

Limits on Home Equity

When determining eligibility for Medicaid your home, regardless of its value, is exempt from being counted as a resource as long as it is your principal place of residence.  But, your home can affect whether Medicaid will pay for your long-term care services, including nursing home care and home and community-based waiver services.

If your equity interest in the home exceeds a certain level, Medicaid cannot pay for your long-term care.  The equity value of your home is the fair market value (that is, what you could sell it for on the open market) minus any debts secured by the home, such as a mortgage or a home equity loan.  For example, if your home has a fair market value of $300,000 and an outstanding mortgage of $100,000, the equity value is $200,000.

But your equity interest, which is what is important, depends on whether you own the home by yourself or with someone else.  In our example, if you own the home by yourself, your equity interest is the entire equity value of $200,000.  If you own your home jointly with your spouse or someone else, though, your equity interest is only half of the home’s equity value, or $100,000.

In 2013, the minimum home equity limit is $536,000.  In other words, your must have more than $536,000 in equity interest in your home before Medicaid must deny payment for your long-term care services.  However, states have the option of using a higher limit, which can be as high as $802,000 in 2013.  Most states have chosen to use the lower limit but some states, especially in parts of the country where housing is expensive, use the higher amount.  These limits are adjusted each year to account for inflation.

There are some exceptions to this rule.  If your spouse or your child who is under 21 or blind or disabled lives in the home, this rule does not apply.  Also, the state can choose not to apply this rule if it determines that applying the rule would be an undue hardship.

Long Term Care   LONG TERM CARE

What is Long Term Care Medi-Cal?

Long Term care (LTC) is a specialized Medi-Cal program that provides benefits for paying all or part of the medical expenses incurred by an individual who has been in a hospital (receiving acute care) or a Skilled Nursing Facility (SNF) for over 30 days and is expected to remain at least 30 more days.

Who is eligible for Long Term Care Medi-Cal?

• Single individual with property/resources of $2000 and under are eligible.
• • For a married individual with a spouse still living at home, the spouse at home may keep a predetermined amount of community property/resources. This amount is established by the State and it is referred to as the Community Spouse Resource Allowance (CSRA). Although the Community Spouse Resource Allowance may change annually, the only time the property/resources would be reevaluated is if the person leaves the facility and then reenters. The Community Spouse Resource Allowance may be increased by an Administrative Law Judge through the appeals process. The institutionalized spouse may keep up to $2000 of the countable property in their name.
• • Individuals under age 65 receiving Modified Adjusted Gross Income (MAGI) Medi-Cal are also eligible for Long Term Care services. See the Children and Adults section for information regarding MAGI Medi-Cal.

Income of Long Term Care Medi-Cal Beneficiary

When determining if the long term care beneficiary will be responsible for any medical expenses each month, a long term care maintenance need of $35.00 is deducted from the gross monthly income of the individual residing in the facility. The remainder of the income is considered the Medi-cal Share of Cost (SOC), which, like a deductible, is paid to the facility monthly. The facility bills Medi-Cal for the balance. A married individual can allocate all or part of their monthly income to the spouse at home. The allocation amount is based on the Minimum Monthly Maintenance Needs Allowance (MMMNA) which is an amount predetermined by the State, and reevaluated annually to reflect increases in income. The Spouse at homes gross income is subtracted from this amount to determine how much can be allocated to them.

Estate Recovery

The Medi-Cal program pays for medical care for some persons whose savings and income are too low for them to be able to pay for their own care. In turn, the person or their estate may be required to pay the medical care costs back to Medi-Cal. When notification of a Medi-Cal recipient’s death is received, the Department of Health Services will determine whether or not the cost of services must be repaid. This decision will be based on how much was paid by Medi-Cal and what is left in the estate of the deceased Medi-Cal beneficiary. Regardless of what is owed, the Department will never collect more that the value of the assets owned by the person who received Medi-Cal at the time of his/her death. The Department of Health Services cannot require reimbursement under the following circumstances:

• During the lifetime of a surviving spouse.
• For Medi-Cal services provided before the beneficiary’s 55th birthday, unless the beneficiary is institutionalized.
• If the Medi-Cal beneficiary is survived by a child under 21 years old.
• If the Medi-Cal beneficiary is survived by a child who is blind or disabled (as defined by the Federal Social Security Act).
• Beneficiaries receiving assistance through a Medicare Savings Program only are exempt from Estate Recovery.

A Resident’s Rights In A Nursing Home

When you are admitted to a nursing home, you keep all your basic human and civil rights and liberties. Federal and State regulations list nursing home residents’ rights in detail, and require the Department of Health Services’ staff that inspects your nursing home to decide whether this home is protecting and promoting your rights.
For additional information about your rights as a resident in a nursing home or for a list of the Licensing and Certification District Offices in Orange County, please click here. Orange County Social Services Agency does not make any recommendations or referrals for long term care facilities.

Information for Long Term Care Facilities & Providers

The Medi-Cal Long Term Care Facility Admission and Discharge Notification form (MC 171 ) can be faxed to 714-645-3483 or mailed to:

OC SSA/OCPC
P.O. Box 70003
Anaheim, CA 92825-9922