AN OVERVIEW
The SC Medicaid Program sponsors the payment of long-term care for those individuals who reside in licensed and certified nursing facilities. The Medicaid program also pays for special services for those individuals who participate in the home and community-based waiver. The same eligibility requirements apply for both programs. The difference is that the individuals who need nursing home care, but who choose to stay at home rather than going to an institution, can receive special services through a waiver to help them remain in the home.
Generally, an individual must be age 65 or older, blind or totally and permanently disabled. Disability is determined by using the Supplemental Security Income (SSI) guidelines. An individual who receives assistance through the Low Income Families program may also be eligible to participate in the home and community-based waiver.
I. Non-Financial Requirements
- A. Citizenship and Alienage
– The individual must be a citizen of the United States or aliens lawfully admitted for permanent residence or otherwise residing in the United States under the authority of Section 203(a)(7) or 212(a)(7) of the Immigration and Nationality Act (INA). Citizenship and Identity must be documented for anyone applying for or receiving Medicaid benefits. Applicants who receive SSI or are eligible for Medicare Part A or B do not have to provide additional information to verify citizenship and identity.
- B. Residency
– The individual must be a resident of the state.
- C. Social Security Number
– The individual is required to furnish his/her Social Security Number or apply for a number.
- D. Assignment of Rights
– The individual must assign rights to medical benefits or support to the state and cooperate with the state in obtaining such benefits or support.
II. Financial Criteria
The individual must meet the income and resource criteria described below:
- A. Income
– An individual's gross monthly income must be below the Medicaid Cap. The Medicaid Cap is equal to 300 percent of the current SSI Federal Benefit Rate (FBR). Effective 01/01/09, the gross income limit is $2,022 per month. This special income limit of $2,022 can be used only if an individual is institutionalized. An individual is considered to be institutionalized if s/he has resided in a medical institution or received home and community-based waiver services or a combination of these services for a period of 30 consecutive days.
*If the individual is eligible for Medicaid except that his gross monthly income is greater than the Medicaid Cap, he/she may establish an income trust to become eligible for Medicaid. The individual should contact the Department of Health and Human Services to obtain more information about the income trust provisions.
- B. Resources
– Resources are generally defined as those assets including both real and personal property that an individual owns and can use to meet basic needs of food, clothing and shelter. The value of resources owned by the individual cannot exceed $2,000 (after exclusions).
The following resources are excluded:
- a. the value of the home (for applications received on or after January 1, 2006, the Deficit Reduction Act of 2005 limits the amount of the exemption for homestead property to $500,000 in equity value, unless there is a spouse, minor child, or disabled child lawfully residing in the home);
- the value of one automobile;
- the value of life estate interest in real property;
- the value of household goods and personal effects;
- the value of undivided interest in heirs property; and
- up to $1,500; and set aside for the individual's burial. (An additional $1,500 for a spouse, if living)
- the cash value of life insurance policies owned by the individual when the total face value of all policies is $10,000 or less.
III. Other Criteria
Apply for Other Benefits - The individual must apply for any other benefits for which he/she may be entitled.
Level of Care - The individual must need nursing facility level of care as certified by staff of the Community Long Term Care Program.
IV. Payments for Services
Once the individual is determined eligible for Medicaid, a Partners for Health (Medicaid) card is issued. The individual is eligible to receive all services covered by Medicaid. For the individual in the nursing facility, the Medicaid program also makes a monthly payment to the facility for his/her care. Unless the individual has a spouse in the community, he/she must contribute most of his/her monthly income toward the cost of the care provided by the nursing facility. The Medicaid program then pays the difference between the individual's income and the Medicaid allowable charge. For the individual receiving home and community-based (waiver) services, the individual is allowed to keep his/her monthly income to cover the cost of his/her living expenses unless the income exceeds the Medicaid Cap and he/she has established an income trust to become eligible for Medicaid. The Medicaid program pays for the home and community-based (waiver) services the individual receives.
Applications may be obtained from the Department of Health and Human Services or from out-stationed locations such as the county health departments, community health centers, most hospitals and the county Department of Social Services offices. Applications for Medicaid may be filed in person or by mail.
TRANSFER OF ASSETS
In accordance with Section 1917 of the Social Security Act, payment for institutional services or home and community-based (waiver) services is denied for individuals who dispose of assets for less than the fair market value within 36/60 months of requesting Medicaid sponsorship of such services. The Deficit Reduction Act of 2005 (DRA 2005) created several changes for Medicaid pertaining to the transfer of assets.
A. The penalty applies to institutionalized individuals and to individuals who receive home and community-based (waiver) services. It also applies if the spouse of the institutionalized individual transferred assets.
An institutionalized individual is an individual who resides in a medical institution or nursing facility and his/her eligibility for Medicaid sponsorship of payment depends partly upon his/her meeting the level of care criteria established by the state.
B. The look-back period is 36 months. The look-back period is 60 months if the asset was transferred through a trust. The look-back period begins from the date the individual is both in the nursing facility (or receiving home and community-based services) and he/she applies for Medicaid sponsorship in the cost of nursing facility care.
The look-back period has been changed by DRA 2005 to 60-months from the date of application. This change will be phased in over the next several years. A look-back of 36 months will continue until February 2009. Beginning February 2009, the look-back period will extend month-by-month until February 2011, when the full 60-month look-back will be in effect.
There is no maximum penalty period. The number of months in the penalty period is calculated by dividing the uncompensated value of the transferred asset(s) by the average private pay nursing home rate. The penalty period usually begins the first day of the month in which assets were transferred. For more specific information, contact the Department of Health and Human Services.
The date a penalty period may begin has been impacted by DRA 2005. For transfers on or after February 8, 2006, the penalty period is the later of the first day of the month the transfer occurred, or the date an individual would have become eligible for long-term care services except for the penalty period.
C. No penalty is imposed for the transfer:
1. Of a home to a:
- Spouse,
- Child under age 21 or a blind or disabled child,
- Sibling with equity interest in the home and who lived in the home at least one year before the individual's admission to the institution, or
- Child who lived in the parent(s) home for at least two years before the parent was admitted to the institution and who provided care for the parent, which delayed institutionalization.
2. If the assets were transferred to a community spouse or blind or disabled child.
3. If the individual can show that he/she intended to dispose of assets at fair market value or for other consideration. This would be an individual who inadvertently did not receive adequate compensation or an individual who transferred assets to another individual in return for care, which delayed institutionalization.
4. If the individual can show that assets were transferred for some reason other than to qualify for Medicaid. For example, an individual may have been elderly or had a disabling condition at the time of transfer, but did not need nursing home care. Subsequent to the transfer, the individual's condition deteriorated so that nursing home care became necessary. This individual would not be penalized for a transfer that occurred prior to the time his/her health deteriorated.
5. If the imposition of the penalty would work an undue hardship. An undue hardship is defined as discharge by the medical facility or denial of home and community-based (waiver) services that would result in the individual being placed in a life-threatening situation.
Spousal Impoverishment Provision
The Medicaid Catastrophic Coverage Act of 1988 added Section 1924 of the Social Security Act which included provisions affecting the treatment of income and resources when an individual who is in an institution (or receives home and community-based services) has a spouse remaining in the community. The following is a brief discussion of these provisions:
I. Treatment of Income:
Beginning October 1, 1989, institutionalized individuals who have a spouse in the community are allowed to give a greater amount of their income to the community spouse. In South Carolina, the maximum monthly income amount for the community spouse is $2,610. First, the institutionalized spouse must be determined eligible for Medicaid considering only his/her income. In other words, the institutionalized spouse must have gross monthly income below the Medicaid Cap in order to be eligible. Second, the amount the institutionalized spouse must contribute toward the cost of his/her care (i.e., recurring income) must be established. Generally, the following deductions must be made from the institutionalized spouse's gross income to determine the monthly recurring income. The deductions must be made in the following order:
Personal needs allowance of $30.
The lesser of 10% of gross monthly income or $25 per month when there is a court order requiring guardianship fees.
Community spouse income allowance not to exceed $2,610. The community spouse is allowed to keep enough of the institutionalized spouse's income to bring his/her monthly income up to $2,610, if the institutionalized spouse has that much income.
An allowance for other dependent family members.
The cost of medical expenses not covered by Medicaid or other third-party payers (after November 1989).
II. Treatment of Resources:
Beginning October 1, 1989, the community spouse of an institutionalized individual is allowed to retain a portion of the couple's countable resources. The following steps are taken:
Establish the total combined value of the couple's countable resources. Resources like the home and surrounding land, household goods and personal effects, one automobile, funds designated for burial, etc., are not counted in this determination. Resources like non-home property, bank accounts, certificates of deposits, stocks, bonds, etc., are counted.
Subtract the community spouse's share from the couple's total countable resources. In South Carolina, the community spouse is allowed to retain up to $66,480 in countable resources.
The remainder is the institutionalized spouse's share of resources. If this amount is below $2,000, and he/she is otherwise eligible, the institutionalized spouse is eligible for Medicaid. If this amount is equal to or above $2,000, the institutionalized spouse is not eligible for Medicaid until his/her resources are below $2,000.
01/01/09
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