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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. Please note that all the numbers listed in the examples are for 2006. Numbers for eligibility change every year.

Eligibility

Medicaid is a program providing coverage of medical expenses to people whose incomes are insufficient to meet their medical needs. 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.

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 assets for burial which do not count as resources. These include $5,000 in a designated burial account, in addition to pre-paid burial contracts and prepurchased burial items such as casket, vault, opening and closing of casket and vault, burial plot and headstone. 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 $5,000 or less are not counted as a resource. If a life insurance policy has a face value exceeding $5,000, 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.

Please note that all the numbers listed in the examples are for 2006. Numbers for eligibility change every year.
A person is eligible for SSI if the person is aged, blind or disabled and the person's monthly countable income is less than $603 and the person has assets under the resource limits. A married couple, both of whom receive SSI benefits, can receive a maximum of $904 in monthly SSI benefits. An individual may have no more than $2,000 in non-exempt resources. A person eligible for combined SSI and SSA benefits can receive combined benefits of $623 per month. A married couple can have no more than $3,000 in non-exempt resources. A married couple can receive combined benefits of $924 per month. The resource limitations for SSI differ from the resource limits for other Medicaid categories. Designated burial accounts are limited to $1,500 and one automobile with a fair market value less than $4,500 is excluded.

(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.

Certain persons who live in a nursing home may qualify for Medicaid even if they who 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.

(4) Income Less than 100 % of Poverty Level. Please note that all the numbers listed in the examples are for 2006. Numbers for eligibility change every year. 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. An individual with less than $817 gross income and $4,000 in non-exempt resources is eligible. Gross income is total income before Medicare Part B premiums are deducted. A husband and wife with less than $1,100 per month in gross income and no more than $6,000 in non-exempt resources are eligible. This benefit not only pays for some medical expenses but 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.

Individuals whose gross monthly income does not exceed $980 and couples whose gross monthly income does not exceed $1,320 are eligible to have Medicaid pay their Medicare Part B premiums under the Specified Low Income Medicare Beneficiaries (SLMB) program. The resource limits for SLMB are the same as those under QMB. Eligible persons will not have to pay the Medicare Part B premium.

Individuals whose gross monthly income does not exceed $1,103 and couples whose gross monthly income does not exceed $1,485 are eligible to have Medicaid pay their Medicare Part B premiums under the QI-1 program if they are not otherwise eligible for Medicaid. The resource limits for QI-1 are the same as those under QMB and SLMB. Eligible persons will not have to pay the Medicare Part B premium.

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. If countable income after deductions for incurred medical expenses falls below the Medically Needy income limit (MNIL) of $317 per month for a single individual or $375 per month for a married couple, AMN eligibility is achieved. Applicants must meet all other eligibility requirements, such as resources, except for income. There is no spenddown for resources

Eligibility for AMN is calculated each month for all applicants including nursing home residents. $317 is subtracted from an applicant's countable monthly income to determine how much the applicant will have to spend on medical expenses before he is eligible for Medicaid. The difference between a person's countable income and the Medically Needy income limit (MNIL) is called the spenddown amount. Once incurred medical bills equal the spenddown amount, a person is eligible for Medicaid to pay Medicaid covered medical bills incurred after the spenddown amount is reached. The applicant is responsible for paying bills incurred prior to meeting the spenddown amount. Before a medical bill will be paid under the spenddown program, the bill must be either unpaid or paid within the same period for which the spenddown application was filed. The bill does not have to be incurred in the same month the application is filed - it must only be owed during the application period.

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 have income which does not exceed $1,803 per month. Also, there is a $2,000 non-exempt resource limit for single persons and $101,540 for a married person. There is not any patient liability or cost share under this Medicaid category of assistance.

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.

NOTE: Medicaid may pay 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

Please note that all the numbers listed in the examples are for 2006. Numbers for eligibility change every year. A patient may be eligible for nursing home Medicaid (MAO category) if his or her individual gross income is not more than $1,803 per month. An individual's non-exempt resources cannot exceed $2,000 but a husband and wife may have combined non-exempt resources which cannot exceed $101,540. ($2,000 for the nursing home spouse and $99,540 for the at-home spouse). Nursing home residents can qualify for Medicaid to pay a portion of their medical bills, including nursing home expenses, even if their income exceeds this figure if they have a Qualified Income Trust (Miller's Trust). Nursing home residents with incomes over $1803 per month should contact the Georgia Senior Legal Hotline 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. The level of care requirements are less stringent for Medicaid than for Medicare. 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 $30 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.

Community Care

Community Care is a Medicaid covered service which provides the alternative of remaining in one's home rather than entering an institution such as a nursing home. Services can be provided to functionally impaired persons 60 years and older who are Medicaid eligible or would be eligible within 180 days of nursing home admission, and are at risk of being institutionalized and have been certified eligible for nursing home services. Individuals applying for nursing home care reimbursed by Medicaid must be assessed by a Department of Human Resources Public Health Assessment Team to examine the health and social needs of functionally impaired and financially eligible persons and recommend 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 home health services. Optional services include adult day care and rehabilitation, alternative living services, respite care and medical transportation. Each client in the program has a case manager who must coordinate the client's needs with services available through local community resources.

Applicants for community care services must meet the same income and resource eligibility criteria for institutionalized persons. There is a cost share for persons receiving community care services which is the difference between a person's income and the SSI benefit rate (currently $603 per month). However, recipients are allowed to divert income to a spouse and any dependent children and 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. An individual must sign a statement electing hospice care services for 90 days and must receive services for at least 30 continuous days before payment is made. However, if a person dies before 30 days, services are covered.

Spousal Impoverishment

Please note that all the numbers listed in the examples are for 2006. Numbers for eligibility change every year. Once a nursing home resident or community care 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 $2,488.50 per month. For example, if a nursing home resident receives $1,500per month in Social Security benefits and has a spouse at home who receives $1,000 per month in income, the nursing home resident can give $1,488.50 of income to the spouse at home. 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.

EXAMPLE: A Medicaid participating nursing home has an approved Medicaid billing rate of $2,000 per month. The resident has income of $1000 and the resident's spouse has $1,600income per month. The resident does not have any incurred medical expenses for the month. To determine patient liability, first deduct the $30 monthly personal needs allowance from the resident's income. Then the resident can contribute $888.50 of income to the spouse at home to increase the at home spouse's income to $2,488.50. The resident's income after allowable deductions is $111.50 which must be contributed to the $2,000 nursing home bill. Medicaid will pay the remaining balance of $1,888.50.

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 $2,488.50 limit.

Transfer of Assets

Medicaid also has rules relating to the transfer of assets which can affect Medicaid payments for nursing home residents and participants in the community care program.

In August 1993, Congress passed a new federal law concerning the transfer of assets. The purpose of the law is to disqualify certain individuals from receiving Medicaid to pay for nursing home expenses and community care expenses if an asset is transferred for less than fair market value for the purpose of attaining Medicaid eligibility. The law applies to Medicaid benefits paid beginning October 1, 1993 and to asset transfers or trusts established after August 10, 1993. If you have a situation which might be subject to a transfer penalty, contact an attorney specializing in elder law.

There are several transfers which are exempted from this law's penalty provisions. These exempted transfers include those in which there was an intent to obtain fair market value for the asset, if the transfer was not for the purpose of obtaining Medicaid, or if application of a penalty resulting in denial of nursing home or community care payments would cause undue hardship.

Other exempted transfers include those made for the sole benefit of a spouse and transfers of a homeplace to a spouse, a blind or permanently and totally disabled child, a sibling who has an equity interest in the property and who lived there for one year prior to the Medicaid applicant's admission to a nursing facility, or to an adult child who lived in the homeplace for two years prior to admission and provided care to the applicant. If there has been a transfer for less than fair market value, no penalty will apply if all the assets transferred for less than fair market value have been returned to the individual.

Georgia recently implemented the 1993 federal statute requiring states to seek recovery of the amount of Medicaid benefits paid beginning October 1, 1993 on behalf of nursing home residents and community care recipients from that individual's estate at the time of death. If the individual had a surviving spouse, the state is not permitted to seek recovery of the Medicaid benefits it paid until the death of the surviving spouse. As yet, Georgia has not implemented an estate recovery program. Georgia law provides other exceptions to this recovery. Contact an attorney specializing in elder law if you think you qualify.

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.

Recipients of Medicaid in Georgia are not required to pay any portion of those medical bills which are required to be paid by Medicaid. If you receive a medical bill from a doctor, hospital or anyone else, and you think that the bill should have been paid by Medicaid, you should telephone the Department of Medical Assistance toll free at 1-800-282-4536.

There are services and treatments for which Medicaid will not make payments. In order to insure payment for a service before you receive the service, contact the Department of Medical Assistance. Ask them whether the service or treatment you wish to undergo is covered under the Medicaid system.

The Right to Appeal

If you are denied enrollment in the Medicaid program, terminated from coverage or denied coverage for a particular medical service, 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. 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 Clayton, Cobb, Dekalb, Fulton, and Gwinnett Counties, call Atlanta Legal Aid Society: 404-524-5811

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)