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Medicaid Financial Eligibility Rules For Nursing Home Care In New York State Books Pdf File [UPDATED]

To understand Spousal Refusal as a Medicaid planning tool, we need to back up; Medicaid has both income and asset limits in order for a senior to qualify for long-term care. While these income and asset limits vary based on the state and the marital status of an applicant, generally speaking, the income limit for a married long-term care Medicaid applicant in 2023 is $2,742 / month and the asset limit is $2,000. Two exceptions are New York, where applicant spouses can keep up to $30,180 in assets, and California, where applicant spouses can keep $130,000. See state-by-state financial eligibility criteria.

Medicaid Financial Eligibility Rules for Nursing Home Care in New York State books pdf file

Second, LTSS is a major part of the Medicaid program, accounting for about a third of total expenditures, although the percentage has been declining steadily over time. Although the number of Medicaid beneficiaries who are younger people with disabilities has grown substantially over time, the number of elderly Medicaid beneficiaries has barely increased since the early 1990s, despite the growth in the number of older people in the general population. Because people using LTSS have high medical needs and because many younger people with disabilities do not qualify for Medicare, users of LTSS account for 42 percent of total Medicaid medical and LTSS expenditures; older people and younger persons with disabilities account for 56 percent of expenditures. Also, because states have considerable latitude over financial eligibility, covered services and reimbursement, the percentage of total Medicaid spending on LTSS varies widely among states, from 18 percent in Arizona to 61 percent in North Dakota.

Third, Medicaid is the dominant payer for LTSS; for example, 62 percent of nursing home residents have their care paid by Medicaid. Although Medicaid historically has primarily financed institutional services, such as nursing homes and institutions for people with intellectual and developmental disabilities (IDD), federal and state policies have fostered a greater emphasis on home and community-based services (HCBS). This trend has been especially notable for people with IDD and less so for older people and younger persons with physical disabilities.

Thirty-two states included older adults and younger adults with disabilities in their "medically needy" option, which covers individuals whose incomes do not meet standard eligibility criteria but who have high medical expenses. This is a common eligibility pathway for people in nursing homes.

Seventeen states made state plan amendments for Section 1915(i) services, allowing coverage for individuals who receive state plan HCBS and who do not have a nursing home level of care. (Section 1915(i), which allows states to offer HCBS as part of the state plan benefits package, was modified by the ACA; Watts, Cornachione & Musumeci, 2016).

Medicaid covers a wide range of LTSS, but coverage varies across states. All states are required to provide coverage for nursing facility services and home health services. States may also offer optional services, including intermediate care facilities for IDD, state plan personal care services, Community First Choice state plan option (Section 1915(k)), and the HCBS state plan option (Section 1915(j)). Services provided through the Medicaid state plan must be provided on an entitlement basis; waiting lists are not permitted, although states have wide authority to limit the amount of services and the functional eligibility that is required.

In addition, there are also two waiver programs through which states can provide HCBS: Section 1915(c) and Section 1115. Section 1915(c) (commonly known as Medicaid HCBS waivers) allows states to waive regular Medicaid program income and resource limits and provide HCBS to beneficiaries who would otherwise need institutional care. In FY 2014, Medicaid HCBS waivers accounted for 51.5 percent of total Medicaid spending for HCBS (Eiken, Sredl, Saucier & Burwell, 2016). There are 290 1915(c) waivers nationwide distributed across every state (except those that have research and demonstration waivers) (Kaiser Family Foundation, 2015). Under Section 1915(c), states can use higher financial eligibility criteria and provide coverage for a wide range of medical and non-medical services that are often not otherwise covered (including case management, respite, home health, personal care, residential care, habilitation and day care, nursing, therapy, and respite care). States are also required to target people meeting an institutional level of care criteria and to limit the number of people who receive services to a number approved by the Centers for Medicare and Medicaid Services (CMS). In some states, there are more individuals who need services than the maximum number of waiver slots available. States may establish waiting lists when waiver slots are filled or when there is limited state funding to cover waiver services, something not normally permitted in Medicaid. The number of people on HCBS waiver waiting lists has steadily increased over the past decade, increasing from 260,916 individuals in 2005 to 641,841 individuals in 2015 (Ng, Harrington, Musumeci & Ubri, 2016). There is great variation in the use and size of wait lists. Some states have none at all while others have wait lists of many years. Most people on waiting lists (67 percent in 2015) are persons with IDD.

As evident in expenditure data, LTSS for these populations can be very costly. Older adults and people with disabilities who rely on Medicaid to finance their care often "spend down" to Medicaid eligibility, meaning that they have exhausted their personal savings by paying out-of-pocket for care. Spending down is common among people using LTSS, particularly among those who require nursing home care. From 1996-1998 to 2008, nearly 10 percent of adults aged 50 and older spent down to Medicaid eligibility; more than half of these beneficiaries utilized personal care services, nursing home services, or both (Wiener, Anderson, Khatutsky, Kaganova & O'Keeffe, 2013).

Not only does LTSS represent a large proportion of Medicaid outlays, but Medicaid plays an important role in the LTSS system, accounting for about 51 percent of LTSS (O'Shaughnessy, 2014; Reaves & Musumeci, 2015). Private spending, including private long-term care insurance and out-of-pocket payments, make up 27 percent of LTSS expenditures. Approximately two-thirds of private spending is for nursing home care2 (Colello et al., 2012). Medicare and other public programs (e.g., Veterans Health Administration, State CHIP, general assistance programs, and state and local programs) make up the remaining public share of LTSS expenditures (21 percent) (Figure 5).

Through Medicaid, the LTSS delivery system is also introducing more managed care options for eligible beneficiaries. Managed LTSS provide an opportunity to improve care coordination and access to HCBS for beneficiaries, as well as achieve cost savings or improved health outcomes (Reaves & Musumeci, 2015). As of 2016, 11 states were operating Section 1115 Medicaid managed LTSS waivers and had enrolled nearly 900,000 beneficiaries, most of whom were seniors, people with physical disabilities, and to a smaller extent, people with IDD (Watts, Musumeci & Ubri, 2017). These waivers require health plans to provide comprehensive benefit packages, including coverage of nursing home services, HCBS, acute and primary care, and behavioral health services. The waivers also incentivize plans to increase community integration, HCBS access, and self-direction of services for beneficiaries, and develop innovative initiatives to increase nursing home diversion and transitions (Watts et al., 2017).

Payments by Medicaid beneficiaries receiving nursing home services toward their cost of care are considered out-of-pocket payment rather than Medicaid payment. Thus, these estimates understate the role of Medicaid in financing the LTSS system.

Chronic Care Medicaid is a health care coverage for those who reside in a nursing home type setting. The intent of the program is to assist those aging and disabled residents who cannot afford to pay for their own medical care. Eligibility for the program is determined through a means test that reviews the income and resources of the individual and/or spouse applying for coverage. A five year review of all financial transactions is required.

Medicaid provides comprehensive coverage and financial protection for millions of Americans, most of whom are in working families. Despite their low income, Medicaid enrollees experience rates of access to care comparable to those among people with private coverage. In addition to acute health care, Medicaid covers costly long-term care for millions of seniors and people of all ages with disabilities, in both nursing homes and the community. Medicaid bolsters the private insurance market by acting as a high-risk pool providing coverage for many uninsured people who were excluded from the private, largely employment-based health insurance system because of low income, poor health status, or disability. Medicaid also supports Medicare by helping low-income Medicare beneficiaries pay for premiums and cost-sharing and providing long-term services and supports that are not covered by Medicare.

Accounting for one-fifth of health care spending, Medicaid funding is a major source of support for hospitals and physicians, nursing homes, and jobs in the health care sector. The guarantee of federal matching funds on an open-ended basis allows states the flexibility to use Medicaid to address health priorities such as addressing the opioid epidemic. The financing structure also provides support for states to allow Medicaid to operate as safety net when economic shifts and other dynamics cause coverage needs to grow.

Older adults and individuals with disabilities are more likely to require LTSS due to chronic disabling conditions or other functional or cognitive impairments (e.g., extended nursing facility care, personal care, and other home and community-based services). Federal policymakers have an interest in understanding Medicaid eligibility pathways for these populations, as Medicaid plays a key role in providing LTSS coverage. Generally, LTSS is not covered by Medicare or major health insurance plans in the private market. In fact, Medicaid is the largest single payer of LTSS in the United States, accounting for 42% of all LTSS expenditures in 2016 (or $154 billion). Individuals eligible for or enrolled in Medicaid who are in need of Medicaid-covered LTSS must demonstrate the need for long-term care by meeting state-based level-of-care criteria. They may also be subject to a separate set of Medicaid financial eligibility rules.


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