Coordinating Medicare, Medicaid and Disability Benefits for Elder - - PowerPoint PPT Presentation

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Presenting a live 90-minute webinar with interactive Q&A

Coordinating Medicare, Medicaid and Disability Benefits for Elder and Special Needs Clients

Today’s faculty features:

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific WEDNESDAY, NOVEMBER 29, 2017

Christine A. Alsop, Elder Law Practice Group Leader, TuckerAllen, St. Louis David Pollan, Partner, The Pollan Law Firm, Atlanta Lori J. Parker, Esq., Parker Law Office, Rochester, N.Y .

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INTERPLAY OF MEDICAID AND SSI MEDICARE SAVINGS PROGRAMS

DAVID PAUL POLLAN, ESQ. david@pollanlawfirm.com

FINDING THE LAWS AND NAVIGATING THE MEDICAID SYSTEM

Medicaid was designed to meet the healthcare needs of low-income Americans and was enacted into law in 1965 through Title XIX of the Social Security Act, 42 U.S.C §1396 et seq. Medicaid is a partnership between the federal government and individual states with financial contributions from each to provide medical care, supportive services, and prescription drugs for those individuals who meet income and/or resource testing limits. Although states are not mandated to participate, all 50 states have a Medicaid program.

6

THE BASICS OF SUPPLEMENTAL SECURITY INCOME (SSI)

SSI provides a monthly cash benefit to a disabled individual or to a representative payee appointed by the Social Security Administration to manage the benefit on behalf of the disabled beneficiary. Like Medicaid, eligibility for SSI is contingent on the individual being “aged”, “blind”, or “disabled” and meeting income and assets eligibility criteria.

7

KEY MEDICAID RELATED LAWS

The federal government requires each participating state to cover certain Medicaid services (called “mandatory”) and then permits the state to add additional services if the state chooses (“non- mandatory” services). The states also have some flexibility in determining who will be eligible for Medicaid in he state. Because of this flexibility, each state’s Medicaid program is different.

8

SSI & MEDICAID ELIGIBILITY

1634(a) States

Refers to the majority of states under the Social Security Act that have a contract with the Social Security Administration to determine eligibility for Medicaid at the same time a determination of eligibility is made for SSI

• benefits. These States also use the SSI eligibility criteria for

Medicaid eligibility for their aged, blind and disabled SSI recipients.

9

SSI CRITERIA STATES

Refers to those states that use the same Medicaid eligibility criteria that is used by social security for SSI eligibility, but require individuals to apply separately for Medicaid.

10

209(b) STATES

Refers to those states that use more restrictive eligibility criteria for Medicaid eligibility that is used by Social Security for SSI eligibility.

11

WHAT DOES “MEANS-TESTING MEAN?

“Means” or “needs” tested refers to financial eligibility requirements for the respective benefit government

• program. In the State of Georgia, there are more than

23 classes of medical assistance or Medicaid. SSI and Medicaid have both income and asset testing requirements for eligibility. Depending on the class of Medicaid, there may only be income, but not asset testing.

12

MEDICAID QUALIFICATIONS – THE BASIC RULES

There are two main steps to qualifying for Aged, Blind or Disabled Medicaid. The individual must be: Aged, or be totally disabled, or be blind.

• Aged is defined as 65 years or older.
• Disabled is defined as “the inability to engage in any

substantial gainful activity by reason of a medically determinable physical or mental impairment.

• Blind is defined as “a central visual acuity of 20/200
• r less in the better eye with the use of correcting

lens, or limitation in the fields of vision such as the widest diameter of the visual field.

13

CLASSES OF MEDICAL ASSISTANCE

A person must fall within at least one class of

• assistance. In Georgia, there are over 20 different

coverage categories of Medicaid, known as classes

• f assistance, each with it’s own eligibility criteria.

The class of assistance that an individual is eligible for is determined by a person’s living arrangement, types and amounts of income, marital income, marital status and prior Medicaid coverage, among other factors.

14

MEDICAID WAIVER PROGRAMS

• Community Care Services Program (CCSP)
• Services Options Using Resources in a

Community (SOURCE)

• Independent Care Waiver Program (ICWP)
• New Options Waiver Program (NOW) and

Comprehensive Supports Waive Program (COMP)

15

FINANCIAL CONSIDERATIONS AND GOVERNMENT BENEFITS

The Basics of Nursing Home Medicaid and Medicaid Waivers (excluding SOURCE).

For 2017, the income “cap” for institutional classes of Medicaid and most of the Medicaid Waivers is $2,205/month in gross income (i.e., before deductions for the Medicare Part B and D premiums). Only the income of the Medicaid eligible is considered for eligibility purposes; the income of a community spouse is disregarded.

16

THE FOSTER CARE INDEPENDENCE ACT OF 1999 AND SSI ELIGIBILITY ISSUES

The “Foster Care Independence Active of 1999” radically altered how assets may be preserved for purposes of SSI

• eligibility. The law included new SSI “anti-fraud” provisions

to pay for the increased foster care spending. The major SSI changes included reinstatement of the SSI transfer of assets penalty which was abolished in 1988, and changes to the SSI rules regarding the treatment of trusts as a resource for eligibility purposes. SSI and Medicaid rules governing third-party trusts, such as testamentary trusts or inter vivos trusts established with a third party’s assets for the benefit of a disabled individual remain unchanged.

17

SSI TRANSFER OF ASSETS PENALTY

Section 206 of the Act reinstates the transfer of assets penalty which was eliminated by Congress in 1988. The SSI rules provide for a maximum 36 month penalty period for asset transfers for the purpose of qualifying for

• SSI. The penalty is calculated based upon the value of

the asset transferred divided by the SSI benefit rate.

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Family The Interplay of Medicaid and SSDI

Christine A. Alsop, TuckerAllen calsop@tuckerallen.com November 29, 2017

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Family

The main federal government benefits programs for the disabled

• Supplemental Security Income (SSI)
• Medicaid
• Medicaid Waiver Programs
• Social Security Disability (SSD)
• Medicare
• Federally Assisted Housing through HUD (Department of

Housing and Urban Development)

• Food Stamps

21

A Primer on Public Benefits

Needs Based Benefits Benefits based on Entitlement Cash Assistance Supplemental Security Income SSD (Social Security Disability) CDB (Childhood Disability Benefits) Medical Assistance Medicaid Medicare

22

Family

Social Security Disability Insurance (SSDI)

Social Security Disability insurance is a national program for injured workers that have paid the requisite number of work credits into the Social Security System.

23

Family

Social Security Disability Insurance (SSDI)

To meet the definition of disability benefits, recipient must not be able to engage in any substantial gainful activity (SGA) because

• f a medically-determinable physical or mental impairment(s)

that is expected to last longer than a year or end in death.

24

Family

Social Security Disability Insurance (SSDI)

• The monthly Substantial Gainful Activity (SGA) amount for

statutorily blind individuals for 2017 is $1,970.

• For non-blind individuals, the monthly SGA amount for 2017 is

$1,180.

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Family

Social Security Disability Insurance (SSDI)

• SSDI has no income or resource limits. An SSDI recipient

could win the lottery and remain eligible.

• Earned income may cause ineligibility for benefits.

26

Family

Compassionate Allowances

• Social Security has an obligation to provide benefits quickly to

applicants whose medical conditions are so serious that their conditions obviously meet disability standards.

• Compassionate Allowances is not a separate program from

the Social Security Disability Insurance or Supplemental Security Income programs.

• Some Examples:
• Adult Onset Huntington’s Disease
• Inoperable Cancers
• Early Onset Alzheimer’s Disease
• Child and Adult Brain Tumor

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Family

Childhood Disability Benefits

A disabled child may be eligible for Social Security Disability Insurance if a parent is eligible, and the child’s disability began before age 22.

28

Family

Childhood Disability Benefits

Social Security is not affected by the child’s assets but the child’s income may result in an ineligibility determination.

29

Family

Childhood Disability Benefits

• Upon the disability or retirement of the parent, an eligible

disabled child will receive an amount equal to ½ of the parent’s benefit.

• Upon the death of the parent, an eligible disabled child will

receive an amount equal to ¾ of the parent’s SSA benefit.

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Family

Social Security Eligibility

Individuals can visit Social Security’s website to determine eligibility of a participant at www.socialsecurity.gov/myaccount

31

Family

SSDI/Medicare v. Medicaid

• SSDI/Medicare is not tested by income or resources.
• Medicaid is a shared state-federal program, paid part by both

entities and administered by state agencies with federal

• versight.
• SSDI/Medicare is entirely a federal program and benefits are

paid entirely from federal resources.

• Medicare and Medicaid programs are overseen by the Centers

for Medicare and Medicaid Services (CMS) formerly known as the Health Care Financing Administration (HCFA), a component of the United States Department of Health and Human Services (HHS).

• SSDI is overseen by the Social Security Administration.

32

Family

Medicare Pays For:

Diagnosis, treatment, and rehabilitation

• Services must be medically reasonable and necessary to treat

an illness or injury, 42 C.F.R. 1395y(a)(1)(A).

• Care provided must be “skilled” (the costs for custodial care are

excluded, except for hospice services, 42 C.F.R. 1395y(a)(9)).

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Family

Medicare’s Four (4) Parts

• Part A – hospital insurance, home health care, hospice care;

funded through payroll taxes

• Part B – Outpatient therapist services, durable medical

equipment and supplies, prosthetic devices, ambulance services, home health, and certain preventive benefits; funded through premiums and general revenue

• Part C – managed care version of A & B; funded by federal

government to plan and premiums

• Part D – prescription drug benefit; funded through premiums

34

Family

Medicare Eligibility

• Over age 65 and has paid for 40 quarters
• Person eligible for Railroad Retirement benefits
• Disabled, as determined under the Social Security Act for at least 24 months

(regardless of age)

• Persons (children included) with end-stage renal disease (ESRD) who require

dialysis treatment or kidney transplant, or with ALS

• Over age 65 and ineligible for Social Security benefits because of not having

requisite amount of quarters, but who elect to pay a monthly premium for Part A and also buy Part B

• Dependents (spouses, widows, widowers) at age 65
• Individuals who are receiving Social Security benefits cannot waive their entitlement

to Medicare Part A – in order to waive Part A, they must withdraw their Social Security application and return any retirement or disability benefits they receive Because Part B is voluntary, an individual may always decline Part B 35

Family

Enrollment

• Upon application for SS if age 65
• Automatically at age 65 if already receiving SSR
• Automatically after 24 months if receiving SSD
• Must apply within 6 months of becoming 65 to avoid penalties
• Annual open enrollment occurs between October 15th and

December 7th

• Allowed to switch to Part C or Part D plan with 5-star rating

anytime during year

36

Family

Medicaid

• Medicaid is a welfare program which pays medical bills for the

aged, blind and disabled – it is a medical payment program, not a medical insurance program.

• Medicaid was established in 1965 as an amendment to the

Social Security Act – it can be found in Title XIX of the Social Security Act and is found at 42 U.S.C. Section 1396 and 42 C.F.R. Parts 430, 431 and 435.

• The federal government provides matching payments to the

state – it is a federal program administered in cooperation with the states (although some provisions are delegated to state determination, state programs must meet requirements imposed by the federal government).

37

Family

Medicaid Eligibility

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program, 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.

38

Family

Medicaid Eligibility

• Medicaid eligibility for individuals age 65 and older or who

have blindness or a disability is generally determined using the income methodologies of the supplemental security income (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’s methodologies).

• To be eligible for Medicaid, individuals must also meet certain

non-financial eligibility criteria – Medicaid beneficiaries must generally be residents of the state in which they are receiving Medicaid and they must either be citizens of the United States

• r certain qualified non-citizens, such as lawful permanent

residents (see 42 C.F.R. §435.406).

39

Family

Spousal Impoverishment

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

• r other community-based setting, from becoming impoverished

in order for the spouse in need of LTSS to attain Medicaid coverage for such services (see 42 U.S.C. §1396r-5).

40

Family

Spousal Impoverishment Rules

• The Medicare Catastrophic Act of 1988 (MCCA) applies to couples

when one is institutionalized and is seeking Medicaid services and the

• ther remains in the home.
• Congress indicated that the purpose of the MCCA was to protect the

spouse that remains in the community, or the “community spouse,” from becoming destitute – the protections enacted are commonly referred to as the “spousal impoverishment rules” (see H.R. Rep. No. 100-105(II), 100th Cong., 1st Sess. 1987 at 65 (1988)).

• Income and assets are considered separately – the community

spouse is allowed to have a minimum amount of income each month, and this allowance is known as the “Monthly Maintenance Needs Allowance (“MMNA”)” (42 U.S.C. §1396r-5(d)(2)).

41

Family

Spousal Impoverishment Rules (Cont’d)

• The community spouse is also entitled to a “Community

Spouse Resource Allowance (CSRA)” which is the portion of the couples resources set aside for the benefit of the community spouse (see 42 U.S.C. §1396r-5(f)).

• If there is a shortfall on the MMNA, the institutionalized

spouse’s income is used to cover the shortfall – this allowance is known as the “Community Spouse Monthly Income Allowance (CSMIA)”; if the institutionalized spouse’s income is insufficient, additional resources may be allocated to the community spouse to reduce the shortfall (42 U.S.C. §1396r- 5(e)(2)(C)).

42

Family

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 (see 42 U.S.C. §1396p(c)).

• 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.

43

Family

Estate Recovery

State Medicaid programs must recover from a Medicaid enrollee’s estate the cost of certain benefits paid on behalf of the enrollee, including nursing facility services, home and community-based services, and related hospital and prescription drug services. State Medicaid programs may recover for other Medicaid benefits, except for Medicare cost-sharing benefits paid on behalf of Medicare Savings Program beneficiaries (see 42 U.S.C. §1396p(b)).

44

Family

Exempt Transfers

Transfer of Family Home is exempt if:

• The participant’s child who is under age 21, or blind or

permanently and totally disabled (42 U.S.C. §1396p(b)(2)(A))

• The participant’s sibling, if that sibling has an equity interest in

the home and was residing for at least one year immediately prior to the participant’s date of institutionalization (42 U.S.C. §1396p(b)(2)(B)(i))

• The participant’s child who resided in the home for at least two

years immediately prior to the participant’s date of institutionalization if it is established that care provided by the child allowed the participant to remain in the home and not be placed in a nursing home (42 U.S.C. §1396p(b)(2)(B)(ii))

45

Family

Exempt Transfers (cont’d)

Other assets may be transferred without penalty:

• The participant’s spouse (42 U.S.C. §1396p(b)(2))
• The participant’s child who is blind or totally and permanently

disabled (42 U.S.C. §1396p(b)(2))

• Or to a trust, including a Special Needs “(d)(4)(a) trust

established for the benefit of an individual under age 65 and who is disabled as defined in 42 U.S.C. §1382c(a)(3)(A) (see 42 U.S.C. §1396p(d)(4))

• Note that the requirement is that an individual be disabled, not

necessarily a child

46

Family

QUESTIONS?

For valuable resources and more information please visit our website: www.TuckerAllen.com

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48

VA BENEFITS FOR ELDERS

Lori J. Parker lori@parker-law-office.com

VETERANS’ PENSION

• Tax-free monetary benefit
• Criteria:

1. Low-income 2. Wartime Veterans 3. Age and/or disability qualification

50

PENSION ELIGIBILITY IS A PREREQUISITE FOR:

• Aid and Attendance
• Housebound

51

PENSION CRITERIA #1 LOW INCOME

• 1. Annual family income must be less than annual limit set by Congress, MINUS:

Benefits from means-tested programs, including SSI Medical expenses in excess of five percent

• 2. Benefit amount = Annual limit amount

MINUS Annual family income (after adjustments)

• 3. Typically paid in 12 equal monthly payments

52

2018 INCOME LIMIT AMOUNTS (EFFECTIVE 12-1-17)

Veterans with NO dependents

• Veteran

$13,166

• Housebound veteran

$16,089

• Veteran eligible for A&A

$21,962

53

2018 AMOUNTS, CONTINUED

Veterans WITH ONE dependent

• Veteran

$17,241 $1,436/mo

• Housebound veteran

$20,166

• Veteran eligible for A&A

$26,036

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2018 AMOUNTS, CONTINUED

Two married veterans $17,241 More than one dependent Add $2,250 for each

55

PENSION CRITERIA #2 ACTIVE DUTY/WARTIME SERVICE

• At least 90 days of active duty service,
• With at least one day during a wartime period

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SPECIFIC “WARTIME” DATES

• Mexican Border Period (May 9, 1916 – April 5, 1917 for

Veterans who served in Mexico, on its borders, or adjacent waters)

• World War I (April 6, 1917 – November 11, 1918)
• World War II (December 7, 1941 – December 31, 1946)
• Korean conflict (June 27, 1950 – January 31, 1955)
• Vietnam era (February 28, 1961 – May 7, 1975 for

Veterans who served in the Republic of Vietnam during that period; otherwise August 5, 1964 – May 7, 1975)

• Gulf War (August 2, 1990 – through a future date to be set by law or Presidential

Proclamation)

NOTE: Those entering active duty after September 7, 1980, in general, must have served at least 24 months or the full period for which they were called or ordered to active duty, with at least one day during a wartime period.

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PENSION CRITERIA #3 AGE AND/OR DISABILITY

• Age 65 or older, OR
• T
• tally and permanently disabled, OR
• A patient in a nursing home receiving skilled nursing care, OR
• Receiving Social Security Disability Insurance, OR
• Receiving Supplemental Security Income

58

PENSION CALCULATION EXAMPLE #1

2018 annual income limit for veteran and spouse = $17,241 $1,436/mo Vet’s annual income = Social Security $18,000 IRA distribution 6,000 Employee pension 25,000 Spouse’s annual income = Social Security 12,000 $51,000 $4,250/mo Unreimbursed medical ( 0) NOT ELIGIBLE - Family income is over the annual limit

• Can reapply if countable income falls below the limit
• 59

PENSION EXAMPLE #2

Same as #1 Except unreimbursed medical is now $48,000

60

PENSION CALCULATION #2 STEP 1

Our first step is to calculate five percent of the maximum pension amount: $17,241 max. pension x .05 = $862

61

PENSION CALCULATION #2 STEP 2

We deduct the “five percent amount” of $862 from $48,000, the total amount of unreimbursed medical expense: $48,000 (862) $47,138

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PENSION CALCULATION #2 STEP 3

This adjusted unreimbursed medical amount--$47,138—is the amount by which we can reduce the $51,000 in family income: $51,000 (47,138) $3,862 Our adjusted family income has been reduced to $3,862.

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PENSION CALCULATION #2 STEP 4

To find the amount of our benefit, we now subtract adjusted family income of the $3,862 from $17,241, the maximum pension amount: $17,241 (3,862) $13,379 Our annual pension benefit is $13,379; monthly benefit is $1,114.92.

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AID AND ATTENDANCE

Aid and Attendance (A&A) increases the amount of monthly pension if the vet:

• Has less than $80,000 in assets, excluding home and vehicles; and
• Meets disability criteria

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AID AND ATTENDANCE DISABILITY CRITERIA

• 1. Needs help in ADLs-”plus” i.e., adjusting prosthetic devices; needs constant

supervision; OR

• 2. Is bedridden; OR
• 3. Is a nursing home patient; OR
• 4. Is blind:
• Eyesight is limited to a corrected 5/200 visual acuity or less in both eyes; or
• Concentric contraction of the visual field to 5 degrees or less.

66

HOUSEBOUND BENEFIT

Housebound benefit increases the monthly pension if:

• 1. Substantially confined to your immediate premises
• 2. Because of permanent disability.

67

HOUSEBOUND

Housebound is an increased monthly pension amount paid if you are substantially confined to your immediate premises because of a permanent disability.

68

VA HEALTH CARE FOR ELDERLY VETS

• Long-Term Care/Extended Care
• Veterans of all ages who need the daily support and assistance of another

individual.

• Elderly

Veterans can receive geriatric and long term care programs at home, at VA medical centers, or in the community.

69

MEDICARE SAVINGS PROGRAMS

QUALITIFIED MEDICARE BENEFICIARY (QMB) SPECIFIED LOW INCOME MEDICARE BENEFICIARY (SLMB)

Qualified Medicare Beneficiaries (QMB) is a Q Track class of assistance (COA) that provides a Medicare supplement to individuals who meet financial criteria based on the Federal Poverty Level (FPL).

70

MEDICARE SAVINGS PROGRAMS

QUALITIFIED MEDICARE BENEFICIARY (QMB) SPECIFIED LOW INCOME MEDICARE BENEFICIARY (SLMB)

Specified Low-Income Medicare Beneficiaries SLMB) is a Q Track class of assistance (COA) that pays the monthly premium for Medicare Supplemental Medical Insurance (Part B) for individuals who meet financial criteria based

• n a percentage of the Federal poverty Level (FPL).

71

QUALIFYING INDIVIDUALS - 1

Qualifying Individuals – 1 (QI-1) is a Q Track class of assistance (COA) that pays the monthly premium for Medicare supplemental Medical Insurance (Part B) for individuals who meet financial criteria based on a percentage of the Federal Poverty Level (FPL). Eligibility criteria are identical to SLMB except that the coverage is time limited depending on available State funds and the income limit is higher than the SLMB limit.

72

LOW INCOME SUBSIDY (Extra Help for Medicare Part D)

Certain Medicare recipients may be eligible to receive a Low Income Subsidy (LIS) to help pay for the expenses incurred under Medicare Part D.

73

QUALIFIED DISABLED WORKING INDIVIDUALS

Qualified Disabled Working Individuals (QDWI) is a class

• f assistance (COA) that provides payment of the

monthly Part A Medicare premium for disabled working individuals.

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