Medicare and Medicaid are two very different programs with names that
sound alike. Medicare is a federal health insurance program
for people over age 64 and people with disabilities. It has premiums,
co-payments and deductibles. Medicaid is a government assistance
program created to pay for health care for low-income individuals and
families. You or someone you know may need Medicaid assistance to help
pay for long-term care in a nursing home or other setting.
Medicaid helps pay for health care for people who have low income and
limited assets. The Oregon Health Plan is a Medicaid program. Medicaid
covers many items and services, including the full range of long term
care. People who have Medicare coverage may also qualify for Medicaid.
When they do, Medicaid may pay for the Medicare premiums as well as
the deductibles, co-payments and health care not covered by Medicare.
People who receive certain government benefits are automatically entitled
to Medicaid. These include people who are over age 65 or disabled and
who receive Supplemental Security Income (SSI) from Social Security.
The income standard for SSI for one person is $637 and $956 for a couple
per month in 2008. The asset limit for one person is $2,000, and $3,000
for a couple. Certain assets, including the person’s home (regardless
of its value), one vehicle (regardless of its value if it is needed
for work or medical purposes), clothing and household items, and a
burial fund of up to $1,500 are exempt and are not counted in determining
eligibility for SSI or Medicaid.
According to the state office for Seniors and People with Disabilities,
the average cost for long term care is over $5360 per month. Few people
can afford to continue paying that much for very long. People with
higher incomes (up to three times the SSI standard, $1911 for one person
in 2008) may qualify for Medicaid assistance if they need long term
care in a nursing home, adult foster home, residential care facility,
assisted living facility, adult day services program, or their own
homes. A person whose income is over the Medicaid limit may still be
able to qualify for assistance by creating a special type of trust,
called a Medicaid income cap trust. The asset limit for someone who
needs Medicaid for long term care is $2,000, the same as for SSI. The
same assets are exempt for Medicaid purposes.
If you are facing long term care bills and think that you have too
many assets to qualify for Medicaid, do not give your assets away.
If you or your spouse gives assets away within the five years before
you apply for Medicaid, you will not be eligible for assistance for
some period of time, based on the value of what was given away. Certain
transfers are permitted. Talk to an elder law attorney or another lawyer
who has experience in this area. You may be able to keep some of the
assets, or use them in a way that will benefit you and your spouse.
If you are married, the Medicaid rules allow the spouse who does not
need care to keep a share of the couple’s income. Generally,
this is one-half of the total assets belonging to either or both the
husband and the wife, up to $104,400 in 2008. The well spouse may also
get a monthly allowance from the ill spouse’s income. The standard
allowance is the amount needed to bring the well spouse’s gross
income up to $1,750 per month (in 2008). If these amounts are not sufficient
to cover the well spouse’s expenses, an attorney can explain
the options that are available to increase the amount of assets or
income or both.
How to Apply
You can apply for Medicaid through the local Area Agency on Aging,
or Seniors and People with Disabilities office. Note that the eligibility
worker can help you complete the application but is not able to advise
you on what steps you (or your spouse) can take to avoid having the
well spouse become impoverished.
Medicaid covers a broad range of services,including:
medical equipment and supplies;
mental health services;
ambulance services and medical transportation; and
the full range of long term care services.
Medicaid does have limitations. First, most people who get Medicaid
assistance have to join a health Maintenance Organization (HMO) or
other managed care plan. The primary physician is responsible for deciding
when his or her patients should get medical items or services. Second,
the state has a list of treatment priorities. Treatment for certain
medical conditions, those that are least likely to be helped by treatment,
is not covered if the conditions are not within the current priorities.
Payment for Services
Medicaid pays the health care provider or managed care plan directly.
There are no claim forms to complete. If you have Medicaid, you should
tell the doctor or other health care provider before you receive treatment
or other items or services. You may need to get a referral from your
primary physician or prior authorization from your managed care plan.
Health care providers are not allowed to charge you additional amounts
for services covered by Medicaid.
People who are not eligible for SSI and who are not receiving long
term care may have to pay monthly premiums and modest co-payments as
part of the Oregon Health Plan. People who are getting long term care
services will have to pay some or most of their income toward the cost
of their care. The amount that each person pays depends on the setting
in which the care is being provided, whether the person is single or
married, and a number of other factors.
The state wants to be reimbursed for what it spends on the care for
Medicaid recipients. But there are limits on what it can do and when
it can do it. For example, the state cannot collect its Medicaid claim
while the Medicaid recipient is alive or has a surviving spouse or
a minor or disabled child living in the family home. After the spouse
passes away, the state can make a claim against the spouse’s
estate to collect whatever it could have collected from the estate
of the Medicaid recipient. Oregon does not place a lien on the person’s
home or on another piece of property. If you have questions about how
estate recovery will affect your property, or if you have received
a Medicaid claim from the state, contact a lawyer for advice.
Medicaid Denials and Appeals
You will receive a written notice from the Area Agency on Aging or
the Seniors and People with Disabilities office if your application
for Medicaid assistance is denied or if your benefits are being reduced
or terminated. The notice will give the reason for the action, tell
you which administrative rules are involved, and explain how to request
a hearing. The hearings are held by administrative law judges who work
for the state. The hearing may be in person at the local office or
by telephone. You may want to have an attorney represent you at the
hearing. You may be able to get representation through a legal aid
office near you.
Managed Care Issues
Each HMO or managed care organization that serves people who receive
Medicaid assistance has an Exceptional Needs Care Coordinator (ENCC).
The role of the ENCC is to help people who are having difficulty getting
the care they need through the managed care system. If you are having
problems, ask your primary physician to help. If your primary physician
is the problem, ask to change to another primary physician or contact
the ENCC. If the problems continue, you may want to change to a different
HMO. You may also be able to get information and advice from a legal
Legal editor: Sam Friedenberg, June 2008