1. September 2006 VDSS 1 Medicaid 101 Helping VICAP Clients Apply for Medicaid

2. September 2006 VDSS 2 The Basics Medicaid Eligibility Part I

3. September 2006VDSS3 What is Medicaid? Medicaid is an assistance program that helps pay for medical care. To be eligible for Medicaid, individuals must: –Be in one of the groups covered by Medicaid –Have limited income and resources Since Medicaid is funded by the State and Federal governments, it is subject to both State and Federal regulations.

4. September 2006VDSS4 How Does Someone Apply for Medicaid?  Obtain an application by: –Calling the local Department of Social Services (LDSS) office –Picking up an application at the LDSS office –Downloading and printing an application from the DSS web site at www.dss.state.va.us. www.dss.state.va.us

5. September 2006VDSS5 How Does Someone Apply for Medicaid?  Complete the application –The applicant may have assistance with completing the application. –The applicant or authorized representative must sign the application.

6. September 2006VDSS6 How Does Someone Apply for Medicaid?  Submit the application to the LDSS in the locality in which the applicant lives: –in person –by mail A face-to-face interview is not required when applying only for Medicaid.

7. September 2006VDSS7 Application Processing The applicant will receive a letter requesting any required verifications. The eligibility worker (EW) must process the applications within a specified time period. –45 days or 90 days if a disability determination is required The applicant will receive a “Notice of Action on Medicaid and FAMIS Programs” form explaining the action taken, the type of coverage, and the appeal process.

8. September 2006VDSS8 How is Eligibility Determined? The applicant must meet all non- financial criteria: Legal Presence Citizenship/Alien Status Virginia residence Social Security Number Assignment of rights Application for other benefits Institutional status Health Insurance Premium Payment (HIPP) requirements

9. September 2006VDSS9 How Does Eligibility for Other Benefits Affect Medicaid Eligibility? The applicant must apply for any benefits he or she has earned the right to receive, such as: –Social Security Disability –VA Pensions and Compensation –Worker’s Compensation The applicant is not required to apply for Supplemental Security Income (SSI) in order to be eligible for Medicaid.

10. September 2006VDSS10 How is Eligibility Determined? The applicant must be in a covered group. All covered groups fall into one of two broad groups, each with its own set of policies: –Aged, Blind and Disabled (ABD) –Families and Children (F&C)

11. September 2006VDSS11 How is Eligibility Determined? Medicaid coverage for older adults and adults with disabilities is under the ABD group –Aged = 65 years or older –Blind = SSI definition (having best corrected central visual acuity of 20/200 or less in the better eye) –Disabled = Social Security Administration (SSA) definition

12. September 2006VDSS12 Applicants with Disabilities The disabled or blind covered groups include individuals who: –receive Social Security Disability benefits –receive SSI based on blindness or disability –have been determined to be blind by Va. Dept. for the Blind and Vision Impaired –receive Railroad Retirement benefits due to a disability.

13. September 2006VDSS13 What if There Has Not Been a Disability Determination from SSA? If an applicant with blindness or a disability is not receiving Social Security or Railroad Retirement total disability benefits and has not been denied disability or has not had disability determined by Disability Determination Services (DDS), the EW makes a referral to DDS.

14. September 2006VDSS14 Referral to DDS The applicant must complete the Disability Report (SSA-3368-BK) The applicant must sign an Authorization to Disclose Information to the Social Security Administration (SSA- 827-02-2003) –Due to HIPAA requirements, the applicant will be asked to sign multiple copies. –Each provider must have an original signature

15. September 2006VDSS15 Referral to DDS Eligibility Worker (EW) completes DDS Referral Form and forwards to DDS along with Disability Referral Cover Sheet and Authorizations. DDS obtains necessary medical records. DDS advises EW of the applicant’s disability status as soon as it is determined. DDS provides EW with a notice to be sent to the applicant advising him/her of the outcome of the disability determination.

16. September 2006VDSS16 Disability Decisions The SSA disability decision made within the past 12 months is final for Medicaid purposes unless: A.the applicant alleges a condition that is new or in addition to the condition already considered or B.the applicant alleges the condition has changed or deteriorated, causing a new period of disability and –The applicant no longer meets the SSI financial requirements but might meet the Medicaid requirements or –The applicant applied to SSA for a reconsideration or a reopening and SSA refused to reopen the case.

17. September 2006VDSS17 Disability Decisions - Denials If the applicant does not meet another covered group, his Medicaid application must be denied. Disability denials may be appealed. If the SSA reverses the decision, the EW will reevaluate the denied Medicaid application. Medicaid entitlement is based on the Medicaid application date, but eligibility as a disabled individual cannot begin prior to the disability onset date.

18. September 2006VDSS18 How is Eligibility Determined? The applicant is first evaluated for full coverage. –Includes hospital care, doctor’s visits, prescriptions for those not entitled to Medicare, and transportation to receive covered services –Also includes payment of Medicare premiums, deductibles, and copayments for Medicare beneficiaries

19. September 2006VDSS19 How is Eligibility Determined? If the applicant is not eligible for full coverage, he or she may receive limited coverage if he/she has Medicare. –Qualified Medicare Beneficiary (QMB): Medicaid pays for Medicare Part A and B premiums, co- payments, and deductibles –Special Low-Income Medicare Beneficiary (SLMB) and Qualified Individuals (QI): Medicaid pays for Medicare Part B premiums only

20. September 2006VDSS20 Medicaid &Medicare Prescription Drug Coverage Medicaid cannot cover prescriptions for individuals who are enrolled in/entitled to Medicare. Dual Eligibles (full Medicaid & Medicare), QMBs, SLMBs, and QIs are deemed eligible for Extra Help subsidy for out-of-pocket costs associated with Medicare Part D Prescription Drug Coverage. –Are auto-enrolled or facilitated with enrollment in prescription drug plan.

21. September 2006VDSS21 What Determines Full or Limited Coverage? Full Coverage: Resource Limit: $2,000 for an individual or $3,000 for a couple Countable Income (after allowable deductions): must be within limit for covered group –For ABD = 80% Federal Poverty Level –In 2006, $654 for individual; $880 for couple

22. September 2006VDSS22 What Determines Full or Limited Coverage? Limited Coverage (QMB, SLMB, QI): Resource Limit: $4,000 for an individual or $6,000 for a couple Countable Income (after allowable deductions): must be within limit for covered group

23. September 2006VDSS23 2006 Income Limits QMB: < 100% FPL –$817 for individual; $1,110 for couple SLMB: > 100%FPL but < 120 FPL –$980; $1,320 QI: > 120% FPL but < 135%FPL –$1,103; $1,485

24. September 2006VDSS24 Medicaid & Supplemental Security Income (SSI) In Virginia, an SSI recipient who wishes to receive Medicaid must also apply for Medicaid--enrollment is not automatic!

25. September 2006VDSS25 Why is Medicaid not automatic for SSI recipients who live in Virginia? The real property eligibility requirements for Medicaid in Virginia are different than the real property eligibility requirements for SSI.

26. September 2006VDSS26 Medically-Needy (MN) Spenddown Applicants who meet all other Medicaid requirements except income are placed on a MN spenddown and may be able to receive a period of full coverage. When the period is up, the spenddown must be met again. The income limit for MN is based on the applicant’s locality and is lower than for other ABD covered groups.

27. September 2006 VDSS 27 Medicaid Long-term Care (LTC) Nursing Facility (NF) and Community-based Care (CBC) Part II

28. September 2006VDSS28 Community-based Care Most older adults in CBC receive services under the Elderly and Disabled with Consumer-direction (EDCD) Waiver: –Personal care, –Respite care, and/or –Adult day health care –Personal Emergency Response System (PERS) Other Waivers have different admission processes.

29. September 2006VDSS29 Prescreening Completed by local DSS Social Worker and Health Department RN or hospital staff. Universal Assessment Instrument (UAI) is used. Not required when person is in nursing facility at time of application or has been in nursing facility for at least consecutive days.

30. September 2006VDSS30 Eligibility for LTC Services Must meet regular eligibility rules + special LTC rules –Non-financial, resources, income –Asset transfer –Substantial home equity Resource eligibility considerations –Single or married? –Is spouse living in the community in a home couple owns?

31. September 2006VDSS31 Resource Assessment (RA) Is a determination of spousal share of couple’s resources. Only for institutionalized applicant with a community spouse who had the first continuous period of institutionalization (>30 days) on or after 9/30/1989. Can request RA prior to application for Medicaid. Only one RA is completed.

32. September 2006VDSS32 Income Eligibility Income limit < 300 % of SSI payment for one person. –In 2006, $1,809 per month.

33. September 2006VDSS33 Patient Pay Patient Pay = gross income – allowances Allowances differ for nursing facility and CBC patients –NF = $30 personal needs allowance –CBC = $995 personal maintenance allowance Other allowances include health insurance premiums, non-covered medical expenses, community spouse and dependent child allowances, guardianship fee, earned income

34. September 2006 VDSS 34 Deficit Reduction Act of 2005 Changes Part III

35. September 2006VDSS35 Deficit Reduction Act (DRA) of 2005 Signed into law by President Bush on 2/8/06. Imposes new requirements to document citizenship and identity beginning 7/1/06. Impacts ABD resource policy –Annuities –Continuing care retirement community (CCRC) entrance fees Changes LTC policy –Substantial home equity –Transfer of assets on or after 2/8/06 –Annuities –Community spouse –income first rule

36. September 2006VDSS36 DRA Citizenship and Identity Effective 7/1/06, States are required to obtain documentary evidence of citizenship and identity from all applicants for and recipients of Medicaid. –For applicants, must be obtained at time of application for Medicaid. –For recipients, must be obtained at time of first renewal on or after 7/1/06. –Once satisfactory evidence is obtained, no further requirement to obtain additional documentation.

37. September 2006VDSS37 DRA Citizenship and Identity SSI recipients and Medicare Beneficiaries are exempt from providing documentation of citizenship and identity because the SSA has already documented this information. This includes former SSI recipients.

38. September 2006VDSS38 DRA Citizenship and Identity At time of application or renewal, individuals must given a reasonable opportunity period to provide any necessary documentation of citizenship and identity. Federal regulations allow for additional time when receipt of required information has been delayed due to circumstances beyond the individual’s or agency’s control.

39. September 2006VDSS39 DRA Citizenship and Identity An extension of 30 calendar days may be granted when the applicant/recipient has requested, but not received the required documents, or requested assistance in obtaining documents. An additional extension of up to 10 working days may be granted at the end of the 30-day extension when there is documentation that the information has been requested, but has not been received. If the required information has not been received by the end of the extensions, appropriate action to deny or cancel coverage must be taken.

40. September 2006VDSS40 DRA Citizenship and Identity Individual who provides a citizenship and identity document (documents that include a picture) will not have to present any other documentation. Individual who provides citizenship only document will also have to provide identity document. One-time activity – once documented and recorded, additional information is not required at renewal or reapplication. List of acceptable documents on VDSS web site: www.dss.virginia.gov www.dss.virginia.gov

41. September 2006VDSS41 DRA Citizenship and Identity Compliance –An applicant or recipient who does not cooperate with the requirement to present documentary evidence of citizenship may be denied eligibility or terminated. –Individuals denied or terminated must be sent the appropriate notice giving appeal rights.

42. September 2006VDSS42 DRA Resources Annuities –Applies to annuities purchased on or after 2/8/06. –Ownership of all annuities must be disclosed on application; added to the new Application for Benefits.

43. September 2006VDSS43 DRA Annuities Annuities –Must be issued by bank, insurance company or other registered or licensed entity approved to do business and authorized to sell annuities in the Commonwealth. –If issued in state other than Commonwealth, must be issued by an entity licensed to do business in the state in which the annuity is established.

44. September 2006VDSS44 DRA Annuities Annuities –EW must send copies of all annuity agreements to DMAS for review. –DMAS may notify insurer of the right of the Commonwealth to be named as the preferred beneficiary.

45. September 2006VDSS45 DRA Resources Continuous Care Retirement Center (CCRC) Entrance Fees –Countable resource when individual can use fee to pay for care if other resources or income is insufficient to pay for care; is eligible for a refund at death or when leaving the CCRC; and does not receive an ownership interest in CCRC –Countable amount is amount that could be refunded; no requirement to seek refund. –Payment of CCRC entrance fees are not subject to transfer of assets evaluation.

46. September 2006VDSS46 DRA LTC Substantial Home Equity –Individuals with equity in excess of $500,000 are not eligible for Medicaid payment for LTC services unless home is occupied by: Spouse Dependent child under age 21 Blind or disabled child of any age –Applies to nursing facility and CBC patients who meet the requirements for LTC on or after 1/1/06. Does not apply to recipients approved for LTC prior to 1/1/06 who maintain continuous eligibility. Applies to all applications and renewals for cases approved on or after 1/1/06. –Home equity does not impact Medicaid coverage for other services

47. September 2006VDSS47 DRA LTC Substantial Home Equity –Applies to home property as defined in Medicaid Eligibility Manual. –Assessed value must be obtained. –Equity value is the assessed value minus any encumbrances, including liens and reverse mortgages that are in effect. Encumbrances against the property must be verified. –Line of credit with no payment in effect does not reduce equity value.

48. September 2006VDSS48 DRA LTC Substantial Home Equity –There will be an undue hardship provision for individuals denied Medicaid payment for LTC services due to substantial home equity.

49. September 2006VDSS49 DRA LTC Transfer of Assets –Rules for asset transfers that occurred on or after 8/11/1993 and before 2/8/06 remain unchanged.

50. September 2006VDSS50 DRA LTC Transfer of Assets –Transfers that have a cumulative value less than or equal to $1,000 per calendar year will not be considered a transfer for less than fair market value and no penalty period will be imposed.

51. September 2006VDSS51 DRA LTC Transfer of Assets –Transfers that have a cumulative value of greater than $1,000, but less than or equal to $4,000 per calendar year may not be considered an uncompensated transfer if documentation is provided that establishes pattern existed for at least 3 years prior to requesting Medicaid for payment of LTC services. Examples include: Gifts (holiday, birthday, wedding, graduation, etc).

52. September 2006VDSS52 DRA LTC Transfer of Assets –New policy for transfers on or after 2/8/06 changes Treatment of promissory notes, loans, mortgages, purchases of life estates and annuities Look-back period Period of ineligibility –Begin date of penalty –Partial months ineligibility –Undue Hardship

53. September 2006VDSS53 DRA LTC Promissory Notes, Loans, or Mortgages obtained on or after 2/8/06 –Evaluate as an uncompensated transfer unless: repayment is actuarially sound, provides for fixed, equal payments with no deferral or balloon payments, and prohibits cancellation of balance upon death of lender. –Uncompensated amount is the outstanding balance as of the date of the individual’s application for Medicaid. –Countable value as a resource is the outstanding principal balance for the month for which a determination is being made.

54. September 2006VDSS54 DRA LTC Life Estates obtained on or after 2/8/06 –Funds used to purchase a life estate in another individual’s home must be evaluated as an uncompensated transfer unless the purchaser resided in the home for at least 12 consecutive months. –If the purchaser resided in the home for less than 12 consecutive months, the entire amount of the purchase is considered a transfer for less than fair market value.

55. September 2006VDSS55 DRA LTC Annuities purchased by institutionalized or community spouse on or after 2/8/06 will be treated as uncompensated transfer unless: –Commonwealth is named as the beneficiary on all annuities when individual requests LTC: Owned by single individual, Commonwealth must be named as primary beneficiary; Owned by married individual with CS, Commonwealth must be named as beneficiary behind the CS/minor or disabled child; Owned by CS, must name Commonwealth as primary beneficiary if no minor or disabled child; Owned by CS with a minor or disabled child, must name Commonwealth as secondary beneficiary.

56. September 2006VDSS56 DRA LTC Annuities - annuities owned by an institutionalized individual and purchased on or after 2/8/06 will be considered an uncompensated transfer unless the annuity –is irrevocable and non-assignable, –is actuarially sound, and –provides for payments in equal amounts during the term of the annuity, with no deferral or variable payments (no balloon).

57. September 2006VDSS57 DRA LTC Annuities –owned by an institutionalized individual and purchased on or after 2/8/06 which –are described in subsection (b) – individual retirement annuities – or (q) – deemed IRAs under qualified employer plans – of section 408 of IRS Code of 1986 OR

58. September 2006VDSS58 DRA LTC are purchased with the proceeds from: –an account or trust described in subsection (a) – individual retirement account – ( c ) accounts established by employers and certain associations of employees or (p) simple retirement accounts of section 408 of such Code –a simplified employee pension [within the meaning or section 408 (k) of such Code], or –a Roth IRA will be considered an uncompensated transfer unless the Commonwealth is named the primary beneficiary.

59. September 2006VDSS59 DRA LTC Annuities –If uncompensated transfer and penalty period is established, Medicaid will not pay for LTC costs. –DRA provisions do not apply to annuities purchased with the assets of a third party (legal settlements).

60. September 2006VDSS60 DRA LTC – Transfers-Look-back Period Prior to 2/8/06 For trusts, 60 months before the first date the individual is both an institutionalized individual and has applied for Medicaid to cover his LTC services. For all other transfers, 36 months. On or after 2/8/06 For all transfers, 60 months before the first date the individual is both an institutionalized individual and has applied for Medicaid to cover his LTC services.

61. September 2006VDSS61 DRA LTC-Transfers – Penalty Period Prior to 2/8/06 For Applicants: –Begins on first day of month of transfer For Recipients: –begins month following month of transfer On or after 2/8/06 For Applicants: –Begins first day of the month the institutionalized individual would be eligible for Medicaid payment of LTC services except for imposition of the penalty For Recipients: –begins month following month of transfer

62. September 2006VDSS62 DRA LTC Transfers Partial Month Penalty Period Prior to 2/8/06 No partial month penalty period. Once penalty period is calculated, drop any fractional portions. On or after 2/8/06 There can be a partial month penalty period. Penalty period is calculated without dropping fractional portion of the month.

63. September 2006VDSS63 Penalty Period Calculation for Transfers that Occurred On or After February 8, 2006 In order to calculate a penalty period for an uncompensated transfer that occurred on or after February 8, 2006, the amount of the uncompensated transfer is divided by the average private nursing facility monthly rate at the time of the individual’s application for Medicaid, and the remainder is divided by the daily rate (monthly rate divided by 31). The penalty period begins with the month the applicant is both institutionalized and eligible for Medicaid. Individuals are responsible for paying the cost of care until their penalty period expires. Medicaid begins paying for long-term care services after the penalty period expires.

64. September 2006VDSS64 Penalty Period - Example An individual makes an uncompensated transfer of $30,534 in April 2006, the same month he applies for Medicaid. The uncompensated transfer amount of $30,534 is divided by the average monthly rate of $4,060 and equals 7.52 months. The full 7-month penalty period runs from April 2006, the month he applies for Medicaid as an institutionalized individual and meets the requirements, through October 2006 with a partial month penalty calculated for November 2006. The partial month penalty for November is calculated by dividing the partial month penalty amount by the daily rate.

65. September 2006VDSS65 Example - Continued The calculations are as follows: Step #1 $30,534.00uncompensated transfer amount ÷ 4,060.00average monthly nursing facility rate at time of application = 7.52penalty period Step #2 $4,060.00average monthly nursing facility rate at time of application × 7seven-month penalty period $28,420.00penalty amount for seven full months

66. September 2006VDSS66 Example - Continued Step #3 $30,534.00uncompensated amount - 28,420.00penalty for seven full months $ 2,114.00partial month penalty amount Step #4 $ 2,114.00partial month penalty amount ÷ 130.97daily rate ($4,060 ÷ 31) = 16.14number of days for partial month penalty For November 2006, the partial month penalty of 16 days would be added to the seven (7) month penalty period. This means Medicaid would authorize payment for LTC services beginning November 17, 2006.

67. September 2006VDSS67 DRA LTC Undue Hardship –Exists when applying transfer of assets penalty would deprive the individual of medical care such that his health or life would be endangered. –Also exists when applying transfer of assets penalty would deprive the individual of food, clothing, shelter, or other necessities of life.

68. September 2006VDSS68 DRA LTC Undue Hardship –All individuals who have transferred assets without receiving adequate compensation must be notified that Undue hardship can be claimed and the process for requesting an undue hardship. Written information must be provided that documents that the resources transferred cannot be recovered. Documentation must clearly substantiate the immediate adverse impact of the denial of Medicaid coverage of LTC services and would result in the individual being removed from the institution or unable to receive life sustaining medical care, food, clothing, shelter, or other necessities of life.

69. September 2006VDSS69 DRA LTC Undue Hardship –Requests for undue hardship must be sent by local DSS to DMAS, for an evaluation. –The individual, his personal representative or, if authorized by the individual, the nursing facility can file an undue hardship request. –DMAS will evaluate and provide local DSS with a decision. –Denial of a claim for undue hardship may be appealed.

70. September 2006VDSS70 DRA LTC Income First Rule –All income of the institutionalized spouse that could be made available to the community spouse (CS) in calculating the CS income allowance must be made available before resources are allocated by DMAS hearing officer. –Virginia was already doing this.

71. September 2006VDSS71 For Additional Information… Contact the Local Department of Social Services office in the city or county where the individual lives: For questions about applying for Medicaid and to request applications and Fact Sheets about Medicaid eligibility To report changes in income or resources and for questions about continuing eligibility Local DSS contact information available online at www.dss.virginia.govwww.dss.virginia.gov

72. September 2006VDSS72 VDSS Medical Assistance Unit Staff Stephanie Sivert, Program Manager (804) 726-7660 VDSS Home Office : –Susan Hart (804) 726-7363 –Diane Drummond (804) 726-7390 –Sandy Gilbert (804) 726-7397 –Sherry Sinkler- Crawley (804) 726-7367 Regional Field Offices: –Abingdon - Sharon Craft (276) 676-5639 –Roanoke - Lois Brengel (540) 857-7947 –Roanoke - Judy Ferrell (540) 857-7972 –Virginia Beach - Johnical Owens (757) 491-3983 –Warrenton - Donald McBride (540) 347-6326

73. September 2006VDSS73 No matter how you say it…for all you do,