What is Community Medicaid?

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The Community Based Medicaid program assists applicants in paying for the cost of nursing home level care while remaining in their home. The Medicaid home care program can also pay for certain adult day care programs and needed medical supplies. Since Medicaid is a mean-based joint state and federal program, certain eligibility requirements must be met in order to qualify.

Asset & Income Limits

First, the applicant must meet the necessary assets levels.  An individual applying for home care Medicaid may have up to $15,750.00 in non-exempt assets.  Certain assets are exempt, and include an irrevocable pre-paid burial fund, life insurance with a cash surrender value not to exceed $1,500.00, and retirement accounts so long as the minimum distributions are being taken.

A primary residence is also an exempt resource for Community Medicaid eligibility if a spouse, minor child, or disabled child is living in the home – or if single, the equity value in the home is less than $893,000. However, where the applicant owns a home it is advisable to consult an attorney to avoid any potential estate recovery after the Medicaid recipient passes away, which can result if the applicant enters a nursing home or if the spouse, minor or disabled child no longer live there.

Second, the applicant is permitted to keep $875.00 per month in income plus a $20.00 disregard. However, where the applicant has income which exceeds that $895.00 threshold, a Pooled Income Trust can be established to preserve the applicant’s excess income and direct it to a fund where it can be used to pay his or her household bills.

Establishing a Need for Services

Third, although persons over the age of sixty-five are presumptively disabled for the purpose of Medicaid eligibility, the applicants must show that they require assistance with their activities of daily living (ADLs).  Some examples of activities of daily living include dressing, bathing, toileting, ambulating and feeding. Community Medicaid will not provide care services where the only need is supervisory; therefore, it is important to establish an assistive need with the tasks listed above.  For some clients, this is not a difficult threshold to reach.  However, for many of our clients, when we first inquire as to whether the individual in need of care requires assistance with these tasks the answer is no. However, after further discussions it becomes clear that they do in fact require assistance with many of these activities. This discrepancy lies in the fact that in order to establish need, the applicants need only show that they are unable to complete these tasks unassisted.  It is not necessary that there be a showing that they are unable to manage any part of the task, only that they need some level of help.

The amount of home care hours awarded will depend upon the frequency with which the tasks are necessary. For example, an individual who only needs help dressing and bathing may receive minimal coverage during the scheduled times, maybe two hours in the morning and two hours in the evening.  Contrast that with an individual who requires assistance with ambulating and toileting, here because these tasks are considered “unscheduled” the hours awarded will be maximized.  In fact, where the need is established, the Medicaid program can provide care for up to twenty- four hours per day, seven days per week.

2020 Changes in the Law

It is important to note that changes enacted by New York State’s 2020-2021 Budget will directly effect eligibility and approval for Community Medicaid, including a 30 month look back period. Prior to this new law, we could move assets out of the applicant’s name and qualify the applicant the next month for home care services. This has changed the landscape and will require starting medicaid planning early.

The Community Based Medicaid Program is an invaluable program for many seniors who wish to age in place but are unable to do so without some level of care and would otherwise face entering a nursing home.

–          By Nancy Burner, Esq.

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Burner Law Group, P.C.

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