Medicaid is a public benefits program, administered by each state and co-funded by the federal government. Medicaid eligibility varies from state to state, but the overall eligibility is based on specific financial, medical, and age criteria. For you to qualify for Medicaid, you must be older than 65, disabled, and have, at most, $2,000 in assets.

Coverage for Medicaid includes community-based health care, as well as long-term care or nursing home care for individuals who qualify.

To prevent someone with significant assets from benefiting from the financial eligibility of Medicaid, each individual’s resources are closely examined. If there have been asset transfers at below value within a five-year period before Medicaid benefits begin, there may be a “divestment penalty.” This does not mean that all resources are counted; there are asset exemptions, but the requirements for Medicaid qualification can be extensive.

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Long-term care, such as care provided by a nursing home or other residence facility, must be paid for either privately, via long-term care insurance, or through Medicaid. If it is determined that an individual needs custodial long-term care and that individual is eligible for Medicaid, Medicaid will cover the costs of the nursing facility, as well as ancillary services that are needed.

You may have heard of the Medicaid Waiver Program. The Medicaid Waiver is a benefits program which is offered to qualified Medicaid applicants as an alternative to long-term custodial nursing home care. The Waiver Program is a way to allow an eligible individual to stay in their own home while receiving support services provided for and paid for by Medicaid. The Waiver program may cost less for the Medicaid system than paying for a custodial care nursing home; there are specific rules of eligibility and implementation for the Waiver Program to be approved. If considering the Waiver Program, consult with an elder law attorney at Hook Law Center.

What should I know about Medicaid medical and financial eligibility?

The medical eligibility for Medicaid long-term care is determined on an individual basis. The groups covered include people over age 65 who demonstrate difficulties in daily living activities, such as the ability to safely transfer from a bed to a chair, self-dressing, preparing food and eating, toileting, etc., and who also require some level of skilled nursing care. The other group eligible for Medicaid long-term care is the disabled. Each individual is assessed for eligibility either in their home or in a facility, depending on where they reside.

The rules for Medicaid’s financial eligibility have been designed to take into account individuals who are married. The person applying for long-term custodial care is called the “institutionalized spouse (IS);” the partner residing at home is the called “community spouse (CS).” The combined resources of the couple are counted for the purpose of Medicaid eligibility, including resources that are titled jointly with a third-party, including children.

All the resources are identified and then divided into two groups of assets: countable and exempt. Exempt assets generally include personal property, the marital home (if the Community Spouse is living there), any pre-paid funeral and burial plans, and any automobiles. All resources which are not considered exempt assets are considered countable assets. The Community Spouse may keep 50 percent of the couple’s countable resources, to a maximum amount.

For detailed calculations and assistance in determining countable resources, consult with a Hook Law Center attorney.

The qualifying and eligibility rules for Medicaid can be quite extensive; you need an experienced attorney assist you as you navigate the complex system of long-term care coverage. If you have questions about your eligibility or denial of eligibility for Medicaid, the attorneys at Hook Law Center can help you determine your next steps.

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