Medicaid is a federal program that provides
payment for medical care for persons unable
to afford to pay. Medicaid covers
physicians’ services, hospital care,
medications, supplies and other necessary
services once a person has been made
eligible for the program. It also pays for
the expenses of long-term care in a nursing
home or an adult care home.
It is important to distinguish between
Medicare and Medicaid. Medicare is an
insurance program providing payment for
medical needs for persons 65 and over and
for certain disabled persons. All persons 65
and over, regardless of financial resources
or income, are eligible for Medicare.
Medicare, however, provides only limited
coverage in the case of an illness,
excluding payment for prescription
medications and not covering any of the cost
of long-term custodial care in nursing homes
or adult care homes. These non-covered items
must be paid privately by Medicare insureds,
unless coverage is provided under some type
of supplemental policy the person has
purchased independently. Medicaid, on the
other hand, pays for all medical needs for
those of any age who have been determined to
be eligible. In fact, a person with limited
income and resources who has Medicare
coverage may also qualify for Medicaid
benefits.
Medicaid is most often of importance to
middle-income Americans because the cost of
long-term care for such illnesses as
Alzheimer’s Disease or paralysis caused by a
stroke is not covered by Medicare. Most
people who need such care for extended
periods will eventually deplete their assets
and be unable to pay the costs of their
care. At such time Medicaid is available to
pay the difference between their income and
the actual costs of care, including not only
room and board, but also including
physicians’ care, medications, hospital care
and all other reasonable necessary medical
expenses. Medicaid covers the costs of such
care in nursing homes, adult care homes,
hospices, and, in appropriate cases, in the
patient’s own home. If faced with the
possibility of such long-term care expenses,
there are certain rules that you should be
aware of:
- In determining eligibility for
Medicaid payment for long-term care
expenses, the eligibility team will review
the individual’s actual need for care, the
person’s available resources (including
life insurance and retirement plans) and
income received from any source.
- In determining the eligibility for one
spouse, the resources and income for both
spouses is considered, regardless of
community property laws or the nature of
the ownership of the asset.
- Any assets transferred within 60
months prior to application will be
considered available if they were
transferred for less than their value
whether individual or in trust.
- Assets of married couples, however,
receive special treatment so that the
spouse who remains living at home will not
be unduly impoverished. Such a
non-institutionalized spouse is permitted
to keep one-half of all of the available
assets (up to a federally-established
maximum) and is allowed to keep a
substantial portion of the income of the
couple in order to provide for support
expenses at home.
- In addition, there are certain
resources that are considered
non-countable for eligibility purposes;
these include the family residence,
household contents, a vehicle, a prepaid
burial fund and other necessary items.
- It is important to be aware of the
specific eligibility provisions and
exemptions so that assets will not be
wasted before applying for Medicaid.
Finally, it is important to know that
there are appeals processes built into the
Medicaid system. If you are unhappy with
eligibility determinations, care decisions
or placements made under Medicaid, there is
a process for an administrative review, an
administrative hearing and even court
proceedings to enforce your rights.
Medicaid is considered to be one of the most
complex laws of the United States. It is
important to see an attorney as soon as
possible to enable the greatest benefit from
under the law. The attorneys at Kaminsky,
Thomas, Wharton, Lovette & Vigna will be able to
assist you in this endeavor.
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