Applying for Medicaid Benefits

Someone in your life, maybe a parent or a sibling, needs long-term care or has been receiving long-term care and paying for it out of their personal funds.  Now they are in need of help from Medicaid. Medicaid is a very complex program, with strict eligibility criteria and lengthy rules and regulations that change constantly.  There are two different kinds of Medicaid with many different programs under each type.When you come in to meet with us we would be happy to discuss which program would benefit your loved one the most.  Our goal will always be to try to keep your loved one at home but in some cases this cannot always be accomplished.Listed below are the two different types of Medicaid, the programs under each type and a general idea of what must be done in order to apply.

COMMUNITY MEDICAID BENEFITS

A community based Medicaid application is for low income recipients and any elderly/disabled person who wishes to remain in the community, in the setting of their own home.  This benefit requires three (3) months of financial documentation, current proof of income, along with “common documents” and the past year’s income tax filing with the 1099’s.  There are two different applications and you must file with the correct one or the application may be denied.  In New York City and the surrounding boroughs there is a Community Alternative Systems Agency or CASA for each borough. The proper application with the documentation must be sent to the CASA for the area where the applicant lives and you must advise them at this time as to which program you wish to apply for.  In other areas of New York State you may need to call the Department of Social Services for an interview appointment, you may need to go in person and wait for your name to be called or you may need to go in person, make an appointment and return a few days later for that appointment.  Each county has it’s own way of processing these types of applications and they may have their own paperwork that must be attached to the application along with the documentation.

In 2010, once benefits have been applied for and a Medicaid “Pick-up” date has been established, the applicant can keep from their income a total per month of $787 or, for a couple, $1,117.  There are other ways to keep more of the income involving pooled trusts and supplemental needs trust but the state and the counties are making these more difficult to get approved.  The remainder of the applicant’s monthly income is then paid towards their medical costs before Medicaid will begin paying.  Please remember that when you are computing income the  formulary is the gross monthly income (including but not limited to Social Security pensions, dividends, interest and annuity payments), only allowable deductions under Social Services regulations such as health insurance premiums (taxes are not allowable along with many other items) and the net monthly income is what is left minus the personal allowance a individual $787 or a couple $1,117 may keep per month. 

Resources, which are assets belonging to the applicant and/or community spouse must be reported and an individual is allowed to keep $13,800 in 2010 or, for a couple, $20,100.

The following programs are available under the Community Medicaid application:

1. Personal Care Aide Program
2. Certified Home Health Aide Program
3. The Consumer Directed Program (NYC - The Concepts Program)

Each program offers different benefits and each individual must be assessed by a home health agency contracted by Medicaid to determine the hours and care they will receive.  In the New York City area, an M11Q must be completed by the physician and filed with the Medicaid application.  Should you feel that your loved one should be receiving more hours of care or more benefits you would need to file for a Fair Hearing.  During the assessment, should you want to advocate for the applicant, you have the right to be in attendance.

CHRONIC CARE

Maybe your loved one can no longer stay at home because they have become a danger to themselves or others.  Maybe they need too much care or their caregiver can no longer manage their care.  Since they may not qualify for 24/7 care in a Community Based Medicaid Program you may want to apply for Chronic Care benefits.  This type of application covers nursing home care and Long-Term Home Health Care (a/k/a Lombardi Program or Nursing Home Without Walls).  Some assisted living facilities are authorized to accept Medicaid but there are very few and  for these benefits you must also file under this type of application.

The Chronic Care application requires a look-back of 60 months beginning February 1, 2011, under the Deficit Reduction Act of 2005. You must provide all financial statements of any open or closed accounts in this time period.  Again, each county is different in the type of documentation you will need to present.  Some require copies of all checks with a value of $1,000 or more and an explanation of all deposits for this same amount and in the New York City area it is $3,000.  Again, all “Common Documents” must be presented, three years of tax returns, proof of income, and the correct application.

The Department of Social Services will look for any gifts or transfers made in the look-back period (gifts are to children, friends, grandchildren, church donations, charitable donations, etc.).  Each gift will incur a penalty period determined by the New York State Medicaid Regional Rates chart published each year.  Should you apply before the penalty period has expired you may be asked to provide additional documentation.

Once you have compiled the documentation and the completed application,  you may have to call the Department of Social Services for an interview date (you must apply in the county that the applicant lived in prior to being admitted to an assisted living facility or nursing home facility) or you may have to go to the department and sit until you are called.  You must be prepared to answer any of the Case Examiner’s questions and you may be issued a Missing Documentation List giving you ten days to provide what is being asked for.  Failure to provide the documentation will result in denial of the application and could result in a fraud investigation.

On all applications the county will begin an investigation, they will request an IRS report for the past three years, they will request a DMV report to see what vehicles are owned or were owned since February 1, 2006, they will request a financial institution report under the applicant’s and his/her spouse’s Social Security number and if something has not been reported the department could charge you with fraud if they feel you were deliberately trying to hide this documentation from them.Most individuals, when trying to file for Medicaid on their own usually complete the application incorrectly, do not provide the right documentation or give unnecessary information which causes the county to seek more information.  These types of errors almost always require a Fair Hearing to have that straightened out.

An individual applying for chronic care benefits and who is in a nursing home is allowed, in 2010, to keep $50 of their net income after allowable deductions.  The remaining income is paid to the nursing home each month before Medicaid will begin paying.  The community spouse, if there is one, is allowed to keep $2,739 in income and, if they fall short, the applicant may contribute some of their income before they pay the nursing home. An individual applying for the LTHHC program, if they fall under the waiver program, will be allowed to keep $350.

Resources are another concern as an individual in a nursing home is allowed to keep $13,800 in resources and the community spouse may keep between $74,820 and $109,560.  There are additional ways to keep any excess resources by the community spouse.

As you can see from all of this, the Medicaid program can be quite confusing, time consuming and overwhelming.  The New York State Legislature and all the counties are constantly seeking ways to curb Medicaid spending, which can involve changing the rules as you go along.  If you are not aware of the rules and regulations you will not know what your rights are.

Ettinger Law Firm would be happy to help you through these various programs and applications.  We would review the list of documentation you would need to provide to us with you, compile accounting summaries for the open and closed accounts, advise you of ways to compile the documentation needed or where you may call for some of the “common documents”, we will attend the interview and handle all telephone calls and correspondence from the Department of Social Services and follow the application through until a Notice of Decision is supplied.  If a Fair Hearing is required, we will advise you of this and will be able to represent you.  Thank you for considering Ettinger Law Firm.