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Medicaid (Title XIX of the Social Security Act)
Medicaid
Medicaid is a joint federal and state welfare program that was enacted by Congress in 1965. Under the Medicaid program, the federal government makes annual appropriations to states to provide medical assistance, rehabilitation, and other sources to the aged, blind, or disabled individuals whose income are insufficient to pay for necessary services.
Medicaid covers the costs of items not provided by Medicare for poor seniors. One of these major costs is long-term support and services. Long-term support and services includes nursing home care, and home and community based long-term support.
States are not required to participate in the Medicaid program, but all of the states have chosen to do so. These programs are jointly funded by both state and federal tax revenue.
The federal Medicaid statutes were enacted as an amendment to the Social Security Act, beginning at 42 U.S.C. § 1396 (Title XIX of the SSA). The Centers for Medicare and Medicaid Services within the Department of Health and Human Services is the agency that oversees the program. The federal Medicaid statutes provides the lists of benefits for the elderly poor that must or may be covered by a state plan.
Eligibility and Coverage
Under 42 U.S.C. § 1396b, a state cannot impose a resident requirement that excludes from eligibility an individual residing in the state, regardless of whether the individual’s residence is maintained permanently or at a fixed address. The state Medicaid agency is responsible for making individual decisions concerning eligibility. Federal regulations preclude an agency from imposing an age requirement of more than sixty-five years when the program provisions are for the aged.
Eligibility
Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to over 72.5 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities. Medicaid is the single largest source of health coverage in the United States.
To participate in Medicaid, federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible.
The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time.
Determining Eligibility for Medicaid
Financial Eligibility
The Affordable Care Act established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions available through the health insurance marketplace. By using one set of income counting rules and a single application across programs, the Affordable Care Act made it easier for people to apply and enroll in the appropriate program.
MAGI is the basis for determining Medicaid income eligibility for most children, pregnant women, parents, and adults. The MAGI-based methodology considers taxable income and tax filing relationships to determine financial eligibility for Medicaid. MAGI replaced the former process for calculating Medicaid eligibility, which was based on the methodologies of the Aid to Families with Dependent Children program that ended in 1996. The MAGI-based methodology does not allow for income disregards that vary by state or by eligibility group and does not allow for an asset or resource test.
Some individuals are exempt from the MAGI-based income counting rules, including those whose eligibility is based on blindness, disability, or age (65 and older). Medicaid eligibility for individuals 65 and older or who have blindness or a disability is generally determined using the income methodologies of the SSI program administered by the Social Security Administration (some states, known as 209(b) states, use certain more restrictive eligibility criteria than SSI, but still largely apply SSI methodologies). Eligibility for the Medicare Savings Programs, through which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries eligible for both programs is determined using SSI methodologies..
Certain Medicaid eligibility groups do not require a determination of income by the Medicaid agency. This coverage may be based on enrollment in another program, such as SSI or the breast and cervical cancer treatment and prevention program. Children for whom an adoption assistance agreement is in effect under title IV-E of the Social Security Act are automatically eligible. Young adults who meet the requirements for eligibility as a former foster care recipient are also eligible at any income level.
Non-Financial Eligibility
To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
Effective Date of Coverage
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application, if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
Medically Needy
States have the option to establish a “medically needy program” for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by “spending down” the amount of income that is above a state’s medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance. Once an individual’s incurred expenses exceed the difference between the individual’s income and the state’s medically needy income level (the “spenddown” amount), the person can be eligible for Medicaid. The Medicaid program then pays the cost of services that exceeds the expenses the individual had to incur to become eligible.
In addition to states with medically needy programs, 209(b) states also must allow a spenddown to the income eligibility levels eligibility groups based on blindness, disability, or age (65 and older), even if the state also has a medically needy program. Thirty-six states and the District of Columbia use spenddown programs, either as medically needy programs or as 209(b) states.
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, his or her 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 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 individuals (or their spouses) who need LTSS in a long-term care facility or wish to receive home and community-based waiver services have transferred, sold, or gifted assets for less than they are worth.
Medicaid Denial Reasons
There are a variety of reasons why an applicant may be denied Medicaid coverage, assuming that they qualify.
An application for Medicaid benefits may be denied due to missing documentation, such as bank statements, tax returns, or other important documents pertaining to income or other criteria. Since the person reviewing the application will need these documents to verify eligibility, omitting these documents (whether intentionally or unintentionally) can result in a denial.
There may be times when an applicant includes all requested documents but still receives a denial. For example, they may have been lost or misinterpreted by the person reviewing the application.
In some instances, the applicant’s behavior can also result in a denial. If a person transfers their assets to someone else (such as a family member) or puts the assets in a trust in order to meet the income requirements for Medicaid coverage, then their application can be denied.
The Appeals Process
The process for appealing a denial will vary depending on the state, but there are some basic federal rules that states must follow.
Written Notice of Denial.
The state Medicaid agency is required to send written denial notice to the applicant. The written notice must explain why the Medicaid application was denied, the fact that the applicant has a right to appeal, how to request a hearing, and the deadline to appeal the decision. As per federal law, the state must issue the denial notice:
45 days from the application date, if the application was based on something other than a disability.
90 days from the application date, if the application was based on a disability.
Requesting an Appeal
Whether an applicant is required to request the appeal in writing or not will depend on state rules (and should be included in the notice). However, it is a good idea to file a written request, even if it’s not required, so that there’s proof that it was done within the deadline.
Appeals Hearing
The state Medicaid agency will set a date for the appeals hearing and provide information about how the hearing will be conducted. It is important for the applicant to attend the hearing because failure to appear will result in the appeal being dismissed. Under federal rules, an applicant is permitted to view the state’s file on them to better prepare for the hearing.
Result of the Hearing
After the hearing, the applicant will receive a written notice of the hearing officer’s decision. If the appeal is unsuccessful, the notice will explain how to appeal the hearing officer’s decision. If on the other hand the appeal is successful, the applicant will be enrolled in the Medicaid program and will also receive retroactive coverage in most cases.
Long-term Care Insurance
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Long-Term Care (LTC) Insurance
Long-term care policies are private insurance policies. Among the important choices are the king of coverage to be provided, the amount of coverage, the duration of coverage, premium payment options, the age at which to purchase a policy, and whether the policy is tax qualified or is a state partnership policy.
The phrase “long-term care” refers to the help that people with chronic illnesses, disabilities or other conditions need on a daily basis over an extended period of time. The type of help needed can range from assistance with simple activities (such as bathing, dressing and eating) to skilled care that’s provided by nurses, therapists or other professionals.
Employer-based health coverage will not pay for daily, extended care services. Medicare will cover a short stay in a nursing home, or a limited amount of at-home care, but only under very strict conditions. To help cover potential long-term care expenses, some people choose to buy long-term care insurance.
Policies offer many different coverage options. Since you can’t predict what your future long-term care needs will be, you may want to buy a policy with flexible options. Depending on the policy options you select, long-term care insurance can help you pay for the care you need, whether you are living at home or in an assisted living facility or nursing home. The insurance might also pay expenses for adult day care, care coordination and other services. Some policies will even help pay costs associated with modifying your home so you can keep living in it safely.
Factors to consider:
Age and Health: Policies cost less if purchased when a person is younger and in good health. If individuals are older or have a serious health condition, they may not be able to get coverage and if they do, they may have to spend considerably more.
Premiums: Premiums often increase over time, and income may go down. If people find themselves unable to afford the premiums, they could lose all the money they invested in a policy.
Income: If individuals’ income is low and have few assets when care is needed, they might be qualified for Medicaid. (Medicaid pays for nursing home care; in most states it will also cover a limited amount of at-home care.) In order to qualify for Medicaid, individuals must first exhaust almost all their resources and meet Medicaid’s other eligibility requirements. Some individuals may have family and friends who can provide some of their long-term care should you need it.
Savings and Investments: A financial adviser or a lawyer who specializes in elder law or estate planning can advise on ways to save for future long-term care expenses and the pros and cons of purchasing long-term care insurance.
Taxes: The benefits paid out through a long-term care policy are generally not taxed as income. Also, most policies sold today are “tax-qualified” by federal standards. This means if the deductions are itemized and medical costs are in excess of 7.5 percent of one’s adjusted gross income, the value of the premiums can be deducted from one’s federal income taxes. The amount of the federal deduction depends on the age of the individual. Many states also offer limited tax deductions or credits.
Long-term care policy sources
Individual plans: Most people buy long-term care policies through an insurance agent or broker. It is important for an individual to check with their state’s insurance department to confirm that the person is licensed to sell insurance in the individual’s state.
Employer-sponsored plans: Some employers offer group long-term care policies or make individual policies available at discounted group rates. A number of group plans don’t include underwriting, which means you may not have to meet medical requirements to qualify, at least initially. Benefits may also be available to family members, who must pay premiums and might need to pass medical screenings. In most cases, if individuals leave the employer or the employer stops providing the benefit, they may be able to retain the policy or receive a similar offering if they continue to pay the premiums.
Plans offered by organizations: A professional or service organization individuals belong to might offer group-rate long-term care insurance policies to its members.
State partnership programs: If individuals purchase a long-term care insurance policy that qualifies for the State Partnership Program, they can keep a specified amount of assets and still qualify for Medicaid.
Joint policies: These plans let one buy a single policy that covers more than one person. The policy can be used by a husband and wife, two partners, or two related adults. However, there is usually a total or maximum benefit that applies to everyone insured under the policy. For instance, if a couple has a policy with a $100,000 maximum benefit and one person uses $40,000, the other person would have $60,000 left for his or her own services. With such a joint policy, there is a risk of one person depleting funds that the other partner might need.
Long-term care policies and preexisting conditions
Insurers often turn down applicants due to preexisting conditions. If a company does sell a policy to someone with preexisting conditions, it often withholds payment for care related to those conditions for a specified period of time after the policy is sold. If an individual fails to notify a company of a previous condition, the company may not pay for care related to that condition. Most companies will provide an informal review to determine whether one is eligible for the policy.
Covered Services
Some insurance companies require a person to use services from a certified home care agency or a licensed professional, while others allow the hiring of an independent or non-licensed providers or family members. Companies may place certain qualifications such as licensure, if available in one’s state or restrictions on facilities or programs used.
Policies may cover the following care arrangements:
Nursing home: A facility that provides a full range of skilled health care, rehabilitation care, personal care and daily activities in a 24/7 setting.
Assisted living: A residence with apartment-style units that makes personal care and other individualized services (such as meal delivery) available when needed.
Adult day care services: A program outside the home that provides health, social and other support services in a supervised setting for adults who need some degree of help during the day.
Home care: An agency or individual who performs services, such as bathing, grooming and help with chores and housework.
Home modification: Adaptations, such as installing ramps or grab bars to make your home safer and more accessible.
Care coordination: Services provided by a trained or licensed professional who assists with determining needs, locating services and arranging for care. The policy may also cover the monitoring of care providers.
Future service options: If a new type of long-term care service is developed after a person purchases the insurance, some policies have the flexibility to cover the new services. The “future service” option may be available if the policy contains specific language about alternative options.
Policy coverage amounts and limits
Long-term care policies can pay different amounts for different services (such as $50 a day for home care and $100 a day for nursing home care), or they may pay one rate for any service. Most policies have some type of limit to the amount of benefits one can receive, such as a specific number of years or a total-dollar amount. When purchasing a policy, it is best to select the benefit amount and duration to fit one’s budget and anticipated needs.
“Pooled benefits” allow one to use a total-dollar amount of benefits for different types of services. With this coverage option individuals can combine services that meet their particular needs.
Qualifying for benefits
“Benefit triggers” are the conditions that must occur before receiving benefits. Most companies look to individuals’ inability to perform certain “activities of daily living” (ADLs) to figure out when they can start to receive benefits.
Generally, benefits begin when a person needs help with two or three ADLs. Requiring assistance with bathing, eating, dressing, using the toilet, walking and remaining continent are the most common ADLs used. A person with Alzheimer’s may be physically able to perform activities but is no longer capable of doing them without help. Mental-function tests are commonly substituted as benefit triggers for cognitive impairments. Coverage exclusions for drug and alcohol abuse, mental disorders and self-inflicted injuries are common.
Waiting and elimination periods
Most policies include a waiting or elimination period before the insurance company begins to pay. This period is expressed in the number of days after individuals are certified as “eligible for benefits,” once they can no longer perform the required number of ADLs. One can typically choose from zero up to 100 days. The shorter the period, the higher the price of the policy. Many policies allow individuals to stop paying their premiums after they have started receiving benefits. Some companies waive premiums immediately while others waive them after a certain number of days.
Long-term care benefits and inflation
Since many people purchase long-term care insurance 10, 20 or 30 years before receiving benefits, inflation protection is an important option to consider. Indexing to inflation allows the daily benefit one chooses to keep up with the rising cost of care.
Some policies offer “future-purchase options” or “guaranteed-purchase options.” These policies often start out with more limited coverage and a corresponding lower premium. At a later, designated time, individuals have the option of increasing their coverage at a substantially increased premium.
The National Association of State Insurance Commissioners has established rate-setting standards and about half of the states, along with several of the large insurance companies, have adopted these measures.
Long-term care policies are “guaranteed renewable,” which means that they cannot be canceled or terminated because of the policyholder’s age, physical condition or mental health. This guarantee ensures that a policy will not expire unless it has used up the benefits or individuals have not made their premium payments.
Problems paying the premiums
If individuals stop paying their premiums or drop their benefit, a “nonforfeiture option” will allow individuals to receive a reduced amount of benefits based on the amount of money they already paid. Some states require policies to offer nonforfeiture benefits, including benefit options with different premiums.
References:
Brashier, Ralph C. (2016) Mastering Elder Law. 2nd Edition Carolina Academic Press
Medicaid Denial Reasons and the Appeals Process
https://www.findlaw.com/healthcare/medicare.
https://www.aarp.org › health-insurance › info-06-2012
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Understanding Long Term Care Insurance – AARP
https://www.aarp.org › health-insurance › info-06-2012
ASSIGNMENT:
Explain who is eligible to receive Medicaid benefits. Do think these eligibility requirements are fair? If you had the power to make changes to the eligibility for Medicaid, what would you suggest, understanding that the program benefits must be somewhat limited to keep it solvent.
Provide one reference that supports your answer in APA style format.
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