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VA Medicaid Long-Term Care

Medicaid will cover part of the cost of care for an eligible individual receiving long-term care services in a facility (medical institution) or in a community-based care setting when an eligible individual has mental or physical conditions requiring nursing supervision and assistance with activities of daily living.

There are different eligibility rules and requirements that apply to individuals who need Medicaid coverage of long-term care services:

·             Pre-admission screening;

·             Asset transfer restrictions;

·             Patient pay requirements; and

·             Special income and resource rules for married institutionalized individuals who have a spouse who lives in the community. (Spousal Impoverishment provisions.)

Pre-Admission Screening

Pre-admission screening provides the authorization for Medicaid payment of facility (medical institution) and community-based care long-term care services. The screening determines whether an individual meets the level of care criteria for long-term care services.

Pre-admission screenings are completed by the following:

·             For nursing facility care - local teams composed of health and social service agencies or staff of acute care hospitals.

·             For community-based care - local and hospital screening committees, Community Services Boards (CSBs), the Department of Rehabilitative Services (DRS) and other entities are authorized to complete the screening.

Asset Transfer Restrictions

Institutionalized applicants for Medicaid may be ineligible for a period of time if assets were transferred (sold, given away or disposed of). You will be asked about any assets you transferred in the last 36 months -- or 60 months if you set up a trust fund.

A transfer of assets without adequate compensation can result in ineligibility for Medicaid payment of long-term care services for a period of time. The length of time depends on the value of the asset that is transferred, when it was transferred, and whether more than one transfer took place.

Some asset transfers may not result in a period of ineligibility depending on the circumstances and if the Medicaid Program determines that the denial of Medicaid eligibility would cause an undue hardship.

Because the asset transfer policy is very complex, contact your local Department of Social Services if you have further questions regarding the impact of property transfer upon Medicaid eligibility. Department of Social Services staff will not advise an individual to take any specific course of action to achieve Medicaid eligibility.

Patient Pay Requirements

The amount of a long-term care patient's income, which must be paid as a share of the cost of long-term care services, is called patient pay. The amount is based on an individual's total monthly income with allowances made for some expenses such as, personal needs, the cost of medical insurance and the amount needed for the maintenance needs of a spouse or minor dependent child in the community.

When patient pay has been determined, the local department of social services sends a Notice of Obligation for Long-Term Care Cost form to the patient and the patient's representative. This form notifies the patient of the amount of patient pay that is due to the provider of Long-Term Care services.

Special Income and Resource Rules for Married Institutionalized Individuals

Medicaid law requires the use of special rules when determining Medicaid eligibility for a married institutionalized individual with a community spouse.

NOTE: A "community spouse" is a spouse of an institutionalized spouse who is not in medical institution or nursing facility. A community spouse can be living outside an institution or in a residential institution such as an adult care residence. A spouse living in the couple's home who is also receiving Medicaid CBC Waiver services is a community spouse.

These rules are referred to as spousal impoverishment protections. The income eligibility rules do not permit income of community spouses to be used in determining the nursing home or waiver recipient spouse's eligibility unless the income is actually made available.

The resource eligibility rules require a resource assessment of the couple's combined resources so that an amount can be protected for the spouse remaining in the community.

See Also:

VA Medicaid Income Limits

VA Medicaid Resource Limits

Back to:

VA Medicaid Eligibility

VA Medicaid Covered Groups

VA Medicaid Overview

VA Benefit Information System Welcome and Introduction

Source:

Information for this topic was drawn from the Department of Medical Assistance Services (DMAS) Medicaid Handbook.

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