Medicaid for the Elderly and People with Disabilities Handbook

Appendix XXXIII
Medicaid for the Elderly and People with Disabilities Information

Revision 15-1; Effective March 1, 2015

Introduction

Assistance is available to help pay for medical care and supportive services for people who have limited income and assets. The following information explains some of the requirements used to determine if you are eligible for help and what must be done to get help.

If you are interested in getting Medicaid to pay for medical and supportive services, you will need to file an application. Depending on how much income you have, you will file the application with either the Social Security Administration for Supplemental Security Income (SSI) or with the Texas Health and Human Services Commission (HHSC). If the Social Security Administration determines you are eligible for SSI, you will also be eligible for Medicaid without having to file a separate application with HHSC.

At HHSC, Medicaid for the Elderly and People with Disabilities (MEPD) staff are responsible for the financial eligibility for Medicaid. This Medicaid assistance is available for those who do not have SSI and need care:

There is also help to pay for Medicare premiums (Part A and/or Part B), deductibles and coinsurance costs through the Qualified Medicare Beneficiary (QMB) program, and for Medicare Part B premium costs through the Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals-1 (QI-1) programs.

You or your representative must complete an application for Medicaid and furnish the proof needed to make an eligibility determination. HHSC will determine your eligibility for Medicaid based on an analysis of the information on the application, documents you send in and information that you orally explain.

If you meet all eligibility requirements, HHSC is required to completely review your circumstances at least once a year to make sure you are still eligible for help. By federal law, HHSC must also use your Social Security number to compare its records with other state and federal agencies, such as the Internal Revenue Service, Social Security Administration, Texas Workforce Commission and any others to ensure that your benefits are correctly determined.

You have the responsibility to let HHSC know, within 10 days, of any changes in your circumstances. These changes include changes in your address and living arrangements, your income and assets, and private health insurance premium amounts.

 Non-Financial Eligibility

Income

HHSC must consider your income from all sources. Gross income is usually used for the eligibility determination. Therefore, when comparing your income to the income limit for a program, HHSC includes deductions that are withheld from your income before you get it.

If you get your income less frequently than monthly, it may or may not be countable. An example of income that may not be countable is a small amount of interest that is paid quarterly.

If you live in someone else's home or get help with food, clothing and shelter costs, a dollar value of the help you get may be considered for an eligibility determination (except in waiver programs).

There are certain income exemptions and exclusions that may be allowed for specific types of income. An example of an exemption is health insurance payments for a medical bill.

If you have a spouse who is living in the same household, HHSC may count your spouse's income. If minor children are in the household, certain deductions from your spouse's income may be allowed. HHSC also considers the income of the parent(s) living with a minor child with a disability. The income of spouses and parents is not considered for waiver programs.

Proof of Income

HHSC requires proof of income and deductions from income, such as award letters; check stubs from pension checks; check stubs from mineral rights payments; amortization schedules; bank statements listing interest/dividend payments; rent receipts (tax, insurance and repair expense receipts); and copies of checks.

It sometimes takes a long time to gather all the needed proof. Any of the above items that you send in with an application may help to speed up the eligibility decision. HHSC may need additional proof, depending on your individual circumstances as determined by the information on the application form, collateral contacts and documents used to verify your eligibility.

If you are determined to be eligible, HHSC may also need proof of your income whenever there is a change in the amounts, and once a year when HHSC must completely review your circumstances.

Resources

Resources are things you own or are buying. You must report the resources of both you and your husband or wife, regardless if the resources are community or separate property. The total value of resources that HHSC must count cannot exceed certain resource limits. Resource values are determined as of 12:01 a.m. on the first day of the month(s) that eligibility is determined. Some resources are not counted.

For a waiver program, HHSC does not consider the resources of your parent(s). HHSC does consider the resources of your spouse.

Examples of Excluded Resources — The following are examples of some resources that HHSC does not count when determining eligibility:

Examples of Countable Resources — The following are examples of resources you may own that HHSC counts when determining eligibility:

Spousal Impoverishment

HHSC uses the term "spousal impoverishment" to identify a part of a federal law that allows a spouse who stays in the community to keep more of the couple's resources and income, thereby not becoming impoverished.

HHSC determines a spousal protected resource amount (SPRA) for your spouse who stays in the community when you apply for Medicaid in a nursing facility, ICF/IID, IMD or for a waiver program. The SPRA is determined as of the month you are admitted to a facility or the month you select or choose to apply for waiver services.

To determine the SPRA, HHSC combines the value of your and your spouse's total resources and divides that amount in half. HHSC does not include the value of a homestead, vehicle, personal goods and certain burial funds for both you and your spouse in the resource total. A minimum of $23,844, effective January 2015, is protected for the community spouse. If half the combined resources exceed this minimum, that amount is the amount protected for the community spouse, up to a maximum of $119,220, effective January 2015.

The amount of resources not included in the SPRA is your countable resource amount. Your countable resources cannot exceed the $2,000 resource limit to be eligible for medical assistance.

Example: If the value of your and your spouse’s resources is $50,000, your spouse at home will have $25,000 protected. The other $25,000 is your countable resource amount and must be spent down to $2,000 before you are eligible for Medicaid.

At the first annual redetermination of your circumstances, the SPRA exclusion ends. All resources that remain in your name are considered in determining eligibility. Countable resources cannot exceed the $2,000 resource limit for you to stay eligible for medical assistance.

Proof of Resources

HHSC requires proof of the ownership and value of resources. Examples of proof are bank statements, copies of notes, stocks, bonds, property deeds, loans, mortgages, insurance policies, prepaid burial contracts, annuities, letters from appraisers and trust instruments.

It sometimes takes a long time to gather all the needed proof. Any of the above items that you send in with an application may help to speed up the eligibility decision. HHSC may need additional proof to determine the resource amount for specific months, depending on your individual circumstances as determined by analysis of the application and verification documents.

If you are determined to be eligible, HHSC may also need proof of your resources whenever there is a change in the ownership or values, and once a year when HHSC must completely review your circumstances.

Transfer of Assets

Giving away resources for no compensation or refusing to accept income or reducing income you could get may result in a penalty of non-payment for nursing facility services or ICF/IID facility services or ineligibility for waiver program services or state supported living center services.

For income and resources that you transfer, the look-back time may be up to 60 months before you apply for institutionalization or waiver services, depending on the type of resource.

Care Cost Responsibility

If you are eligible for Medicaid in a nursing facility, ICF/IID, IMD (if age 65 or older) or for waiver program services, you may have to pay toward the cost of your care. This is referred to as your co-payment. From your total income, HHSC deducts a standard personal needs allowance. The amount of this allowance is different for different programs. HHSC may also deduct certain medical expenses you pay, such as general health insurance premiums, Medicare premiums/deductibles and coinsurance, certain dental fees, or prescription drug costs. There may also be a deduction for your spouse's living expenses. HHSC staff will calculate your co-payment and notify you, your case manager and/or your service provider of the amount. The arrangement for your portion of the payment is between you, your case manager and/or the service provider. Medicaid payments for your care will be made directly to the service provider.

To access the Medicaid eligibility rules on the Internet, follow the steps below:

This recorded information is a general overview about Medicaid eligibility financial determinations and may not specifically cover your situation. The information is dated because the eligibility limits and policies may be changed by federal, state and department rules. If you have questions about your situation, please contact an HHSC eligibility specialist that determines eligibility for the elderly and people with disabilities.

Current Income and Resource Limits

Current budget limits are available in Appendix XXXI, Budget Reference Chart, of the Medicaid for the Elderly and People with Disabilities Handbook.

To access Appendix XXXI on the Internet, follow the steps below: