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BASICS OF MEDICAID

Medicaid is a health care program funded by the federal and state governments to help people with low incomes pay their medical bills. The Medicaid program is operated by the Georgia Department of Medical Assistance (DMA) with the Department of Family and Children's Services (DFACS) providing field services. Some third-party providers now offer services as well. Learn how to apply for Medicaid BY CALLING OR VISITING YOUR COUNTY DEPARTMENT OF FAMILY AND CHILDREN SERVICES OR BY VISITNG THIS WEBSITE.

Subject to certain restrictions, Medicaid is a program providing coverage of medical expenses to people whose incomes are insufficient to meet their medical needs. Medicaid is the only government program providing assistance for long-term care. In order to be eligible, a person must be either aged (over 65), blind or disabled or be a caretaker for minor children. If one of these categorical requirements is met the person must then meet the financial requirements which govern income and assets. Income includes most payments coming to a person including wages, interest, rents, pensions, government benefits, etc. Resources include real property, bank accounts, IRAs, stocks, life insurance and other assets.

Eligibility numbers can be found by clicking HERE

While the resource limitations are low, there are numerous exclusions from countable resources. Countable resources differ depending on the category of Medicaid eligibility sought. A home does not count toward the resource limit. Applicants may also put aside certain assets for burial which do not count as resources. Household goods and automobiles are excludable. Real property, promissory notes or mortgages that also produce income are excluded although income received from these sources is counted toward the income limitations. Life insurance policies with face values of $10,000 or less are not counted as a resource. If a life insurance policy has a face value exceeding $10,000, the cash surrender value of the policy is applied toward the resource limit.

Income and resource levels frequently change as do rules for how income and resources are counted so you should always make sure you have up-to-date eligibility information.  

There are several categories of people eligible for Medicaid:

(1) Supplemental Security Income. Those people receiving Supplemental Security Income (SSI). If you are approved for SSI, you are automatically enrolled in the Medicaid program. You do not have to fill out a separate application for the Medicaid program. SSI is a federal program and applications are taken at Social Security offices.

(2) Temporary Assistance for Needy Families (TANF) Benefits. Those people receiving Temporary Assistance for Needy Families (TANF) benefits. TANF replaces Aid to Families with Dependent Children (AFDC) which was eliminated in 1996 as part of federal welfare reform legislation. Persons who were eligible for AFDC benefits under the old law are allowed to continue receiving Medicaid benefits even though they may not be eligible for TANF due to changes in the law. TANF provides cash assistance to caretakers of children who do not have a parent in the home providing support due to absence or disability. TANF resource limits also differ somewhat from other Medicaid categories. If you are approved for TANF benefits, you are automatically enrolled in the Medicaid program and you do not have to fill out a separate application for Medicaid. Applications for TANF benefits are made through the county Department of Family and Children Services (DFACS) office. I don’t know enough about TANF but I believe this to be correct

Certain persons who live in a nursing home may qualify for Medicaid even if they would not be eligible for SSI or AFDC if they left the nursing home. To qualify, a person must be certified by a physician to be in need of nursing home care. An applicant must also meet income and resource limitations set by DFACS. See the following section on nursing home Medicaid for more detailed information.

(3) Social Security Benefits for Certain People. Certain persons who at some time after April 1977, received both a Social Security and SSI check in the same month but now receive only a Social Security check because the SSI check was terminated due to annual cost of living increases in the Social Security check. An application for this and all following categories of Medicaid should be made through the county Department of Family and Children Services (DFACS).

Widows or widowers between ages 50 and 64 who currently receive Social Security benefits as a widow(er) and who in the past received SSI benefits which were terminated because of the receipt of increased widow(er) benefits from Social Security. Such persons must be currently ineligible for Medicare. Not sure about this paragraph

(4) Other categories. People whose income is less than 100% of the Federal Poverty Level are eligible for a type of Medicaid, called Qualified Medicare Beneficiary (QMB), which pays their Medicare premiums, coinsurance and deductibles. Gross income is total income before Medicare Part B premiums are deducted. This benefit not only pays for some medical expenses but also actually gives a person more money to spend because the monthly Medicare Part B premium is no longer deducted from the Social Security check. This type of Medicaid does not, however, pay for the full range of Medicaid services for persons eligible under other categories of eligibility.

The Adult Medically Needy(AMN) or Spenddown category of eligibility allows aged, blind or disabled persons whose incomes are too high for other Medicaid categories of eligibility to become eligible by deducting medical expenses from income.  Applicants must meet all other eligibility requirements, such as resources, except for income. An applicant may use virtually any kind of medical bill to meet the spenddown amount. The bill must be incurred by the applicant and be for medical care given to the applicant. Medical bills include amounts incurred for medical insurance coverage payments and also include coinsurance or deductible amounts which remain unpaid after insurance coverage is used. If a bill is covered by a third party resource, such as Medicare or private health insurance, Medicaid will not pay.

Inpatients in a Medicaid participating hospital for at least 30 continuous days preceding a Medicaid application may be eligible for Hospital Medicaid. Individuals must be low-income and have limited resources. There is not any patient liability or cost share under this Medicaid category of assistance. Learn how to apply for Medicaid by visiting this website.

Medical Services Covered by Medicaid

Medicaid pays for a broad range of medical expenses. Medicaid will pay for doctor's services, some dental services but not dentures, prescription drugs, emergency ambulance service, in and out patient hospital services, laboratory and x-ray services, prosthetic devices such as artificial limbs and braces, nursing home services and home health care services. Home health care services include part-time nursing, physical, occupational, and speech therapy, medical social services, and part-time home health aid services. Medicaid will also pay for family planning services, eye examinations that are related to cataract treatment, and psychological services. Finally, Medicaid pays for the rental on hospital beds, wheelchairs, crutches and walkers when prescribed by a doctor for use in the patient's home.

If you are not eligible for Medicare, or another payment source such as private insurance, Medicaid will pay for hospital stays if they are approved by your doctor and prior approval is obtained from the Department of Medical Assistance.

Medicaid will provide or pay for non-emergency transportation to the nearest medical provider if you have no other transportation resources. You must call the transportation broker serving your area at least three business days in advance and tell them you need transportation to and from a medical provider. Medicaid pays up to 12 doctor visits per year unless more are medically justified and no more than 5 prescriptions per month, unless prior approval from DMA is obtained. I don’t know if this last sentence is still current but it sounds like what I have been told.

Medicaid maypay retroactive medical bills incurred from the 1st day of the 3rd month prior to application if your application is approved and:

(1) you have met eligibility requirements for that time period; and

(2) there are medical expenses from that period which have not been paid in full; and

(3) you receive the services from a Medicaid participating provider.

Also, Medicaid pays the monthly Medicare premium, deductibles and co-payments for those persons who are also eligible for Medicare insurance benefits.

Nursing Home Medicaid

A patient may be eligible for nursing home Medicaid (MAO category) if his or her individual gross income fits criteria listed on this website.

Nursing home residents can qualify for Medicaid to pay a portion of their medical bills, including nursing home expenses, even if their income exceeds these  figures if they have a Qualified Income Trust (Miller's Trust). Nursing home residents not currently eligible should contact the Georgia Senior Legal Hotline at 1-888-257-9519 to see if they qualify for such a trust before they apply for Medicaid. 

In addition to meeting the financial requirements an applicant for nursing home care under Medicaid must also have a medical need for nursing home care. The person must require the "level of care" provided by a nursing home. In order to determine if an applicant requires the appropriate level of care, a doctor must fill out a form called a DMA-6. Medicaid will not pay for nursing home care unless the applicant meets the level of care requirements.

Medicaid pays the difference between the approved billing rate for the nursing home and the patient's income after certain deductions are allowed from the patient's income. Nursing home residents are allowed to deduct a small amount each month as a personal needs allowance as well as non-Medicaid covered incurred medical expenses and income contributions to spouses under certain circumstances. If a resident has non-Medicaid covered incurred medical expenses, such as dentures or non-Medicaid covered medications, for example, the resident can file a claim with DFACS to deduct these expenses. This time period to submit such a claim is very short. Therefore, the resident should contact a Medicaid caseworker immediately after expenses are incurred.

Eligibility for Medicaid benefits for medically indigent persons begins with the first full month of institutionalization. The Georgia's Department of Medical Assistance currently interprets a "full month" of institutionalization as a stay of thirty continuous days in a hospital or a skilled or intermediate care nursing facility.

An application for nursing home Medicaid benefits must be made at the DFACS office in the county where the nursing home is located. At the time of application, the patient and family should make sure when Medicaid eligibility will be determined and when Medicaid benefits can begin. It is very important for the patient's family to assist the patient in obtaining the documents required for the Medicaid application process.

Home and Community Based Services

Home and Community Based Services are Medicaid funded services that provide individuals the alternative of remaining in their own home, a family member’s home or a personal care home rather than entering an institution such as a nursing home. Services can be provided to the elderly (persons 60 years or older), and those who are functionally impaired or disabled but are under 60.  Applicants must be Medicaid eligible or capable of becoming Medicaid eligible, at risk of being institutionalized and meet nursing home level of care.

Individuals applying for nursing home care reimbursed by Medicaid must be assessed by a doctor who completes a form called a DMA-6 examining the health and social needs of the applicant.  Based upon this assessment, the doctor recommends either nursing home or community based services. If community based services are recommended, an individual is entitled to receive mandatory services such as client assessment, case management, homemaker services and personal support services. Optional services include adult day health and rehabilitation, alternative living services, respite care and non-emergency medical transportation. If an individual is already in a nursing home and wishes to return to the community with these supports brought in, they may seek assistance in applying by speaking with the nursing facility social worker, the Office of the Long Term Care Ombudsman at 1-888-454-5826.or by contacting Money Follows the Person at 800-724-9655.  Each client in the program has a case manager who must coordinate the client's needs with services available through local community resources.

There are several possible programs targeting specific disability communities.  More on these individual programs, including a program for those with significant physical disabilities and/or traumatic brain injury as well as those with intellectual and developmental disabilities, and how to apply may be found in the State of Georgia’s Handbook on Home and Community based Services by clicking here https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/DocumentsAndForms/04212009_Web_Home_n_comm.pdf

sorry, I don’t know how to add a link for “just click here”

Applicants for community care services must meet the same income and resource eligibility criteria as institutionalized persons. Some of the home and community based services programs have a cost share for persons receiving these services which is the difference between a person's income and the SSI benefit rate. However, recipients are allowed to divert income to a spouse and any dependent children. The allowable diversion is deductible from income in determining cost share.

Hospice Care

A hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management and support services to terminally ill people and their families. Medicaid can help pay for services to persons who are terminally ill with a medical prognosis of six months or less life expectancy and who voluntarily elect to receive at home hospice care services from an approved hospice care provider. To be eligible, an individual must meet the income and resource standards for institutionalized persons. Services must be provided in the person's home with possible intermittent short-term confinements to a hospital or nursing home. Covered services include but are not limited to nursing care, medical social services, physician services, counseling services and home health aid services.. Effective 03/23/2010, children will no longer be required to forego curative care. These children may concurrently receive palliative and curative treatment.

Hospice coverage for Georgia Medicaid members is available for an unlimited number of days. It is subdivided into election periods as follows: two (2) initial periods of ninety (90) days each, and an unlimited number of subsequent sixty (60) day periods each. Benefit periods can be used consecutively or at different times during the individual’s life span. Each benefit period requires a physician to certify at the beginning of the period that the individual has a terminal illness with a prognosis that the individual’s life expectancy is six (6) months or less if the illness runs its normal course.

I took the paragraph above straight from the Hospice manual – I could not find confirmation of the sentence I deleted anywhere in the manual.

Spousal Impoverishment 

Once a nursing home resident or home and community based services  participant who has a spouse at home has been determined to be eligible for Medicaid, he or she can contribute as much of his or her income to the spouse at home as it takes to bring the at home spouse's income up to certain limits.

This amount is also deducted from the patient liability for the nursing home resident and Medicaid pays this amount in payment to the nursing home. Additional deductions are available for dependent children, siblings or parents who live with the community spouse.

If an at-home spouse has exceptional circumstances resulting in significant financial duress, that person can request a hearing to increase the amount diverted from the institutionalized spouse to go over the limit. 

Transfer of Assets

Medicaid has rules relating to the transfer of assets that effect Medicaid payments for nursing home residents and participants in home and community based services programs. Please review the Office of the State Long-Term Care Ombudsman's information pamphlet on this subject.  This is a complex issue and you may need an attorney specializing in elder law. You may also call the Georgia Senior Legal Hotline at 1-888-257-9519 (toll free). Click HEREto go to the Ombudsman's pamphlet on transfer of assets.  The LTCO link doesn’t work

How to Ensure Coverage

Medicaid recipients can choose their own doctors and hospitals. However, not all medical care providers accept Medicaid patients. Be sure to check with your doctor to see if Medicaid is accepted. Your Medicaid card should be shown to the provider before you are treated. If your doctor does not accept Medicaid, you have two choices - change doctors or pay with your own funds. You should not receive a bill from a doctor's office. If you do, contact the Georgia Department of Community Health. Contact number can be found HERE.

The Right to Appeal

If you are denied enrollment in the Medicaid program, terminated from coverage or denied coverage for a particular medical service, including the home and community based services mentioned above, you have the right to appeal such a decision and request a hearing. You must request a hearing at the nearest Department of Family and Children's Services office or to the Deartment of Community Health for home and community based services. There is a short period of time in which to appeal a Medicaid decision and if a timely hearing request is not made, the decision is final. When benefits are terminated, you have a 10-day period in which to appeal if you want benefits to continue until the date of the hearing decision. It is generally advantageous to request this continuation of benefits because otherwise the Medicaid recipient may have no way to obtain needed medical care while waiting for a decision on his or her appeal.

For more information please contact the Atlanta Legal Aid Society or Georgia Legal Services Program office nearest you.

For Atlanta Legal Aid Call: South Fulton and Clayton (404-669-0233), Cobb (770-528-2565), Dekalb (404-377-0701), Atlanta/Fulton (404-524-5811), and Gwinnett (678-376-4545

For all other counties, call Georgia Legal Services Program:  1-800-498-9469 (toll free)

For Seniors age 60 and older, call the Georgia Senior Legal Hotline: 1-888-257-9519 (toll free)