Medicare Eligibility Washington DC

Medicare is a government-funded insurance program that provides health insurance coverage to U.S. citizens who are aged 65 and older, those who are under 65 and permanently physically disabled, or those who meet other specialized criteria. For more information on Medicare eligibility in Washington, DC, see local resources below.

Laura P Masurovsky
(202) 408-4043
901 NEW YORK AVE NW
WASHINGTON, DC
Specialties
Health Care, Intellectual Property
Education
Harvard University,Tufts University,Tufts University
State Licensing
DC

Sarah H Zinn
1001 PENNSYLVANIA AVE NW OFFICE BLDG
WASHINGTON, DC
Specialties
Health Care
Education
University of Virginia School of Law,Haverford College
State Licensing
DC

Sheree R Kanner
1001 PENNSYLVANIA AVE NW OFFICE BLDG
WASHINGTON, DC
Specialties
Health Care
Education
University of Michigan Law School,The State University of New York, Stony Brook University
State Licensing
DC

Alexander John Passantino
(202) 828-3595
975 F Street, N.W.
Washington, DC
Specialties
Employment, Health Care, Litigation
Education
University of Georgia
State Licensing
Georgia

Robert M Jenkins III
1090 K Street Northwest
Washington, DC
Specialties
Federal Regulation, Antitrust, Health Care, Government Contracts
Education
University of California at Berkeley, Boalt Hall School of Law,Harvard College
State Licensing
DC

David Louis Vanik
(202) 508-3406
555 11th Street Nw, 6th Floor
Washington, DC
Specialties
Life Science & Biotech, Health Care, Intellectual Property
State Licensing
DC

James P Holloway
(202) 416-5824
1001 PENNSYLVANIA AVE NW OFFICE BLDG
WASHINGTON, DC
Specialties
Health Care
Education
University of California, Hastings College of the Law,Boston University
State Licensing
DC

Lesley Carol Reynolds
(202) 662-0247
801 Pennsylvania Ave Nw
Washington, DC
Specialties
Health Care, International Law, Class Action
State Licensing
Maryland

Joan Sylvain Baughan
(202) 434-4147
1001 G ST NW
WASHINGTON, DC
Specialties
Health Care, Criminal Defense, Business
Education
Catholic University of America,University of Massachusetts, Amherst,University of Massachusetts, Amh
State Licensing
DC

Nolan S Young
(202) 857-6063
51 Louisiana Avenue Nw
Washington, DC
Specialties
Health Care, Fraud, International Law
State Licensing
DC

Medicaid and Long Term Care

Medicaid was established as Title IX of the 1965 Amendment to the Social Security Act while Medicare was established at the same time as Title VIII of the Act. Medicaid is a health insurance program for certain low-income people. These include: certain low-income families with children; aged, (65 and older) blind, or disabled people on Supplemental Security Income; certain low-income pregnant women and children; and people who have very high medical bills.

Medicaid is funded and administered through a state-federal partnership. Although there are broad federal requirements for Medicaid, states have a wide degree of flexibility to design their program. States have authority to establish eligibility standards, determine what benefits and services to cover, and set payment rates. All states, however, must cover these basic services: inpatient and outpatient hospital services, laboratory and X-ray services, skilled nursing and home health services, doctor’s services, family planning, and periodic health checkups, diagnosis and treatment for children.

Long-term care recipients of Medicaid come almost exclusively from the aged, blind and disabled group of eligible beneficiaries but very few of those are actually receiving SSI (Supplemental Security Income). SSI is a welfare payment for certain disabled or handicapped individuals who are unable to work, have no assets and have no extended family financial support. Certain provisions of the enabling Act, as well as congressional amendments since 1965 have allowed the aged, blind and disabled who don't qualify for SSI to receive Medicaid under an alternate set of eligibility rules.

Medicaid enrollment almost doubled over the period of 1990 to 1998 from about 25 million U.S. recipients to about 40 million in 1998. Today, 47 million people--a little over 1 in 7 of all Americans--are receiving Medicaid. In 1998 about 10.6 million aged, blind and disabled were receiving Medicaid assistance, in the form of medical and long-term care services. Although this group only represented 1 in 4 of all Medicaid recipients in 1998, the group accounted for a large portion of the budget. For the group receiving old age (65+) long term care, Medicaid spends more per recipient than for any other group.

During the 1990's there was a large one-time influx of younger Medicaid enrollees due to changes in governing Federal law. This skewed the picture such that growth of long-term care services was hidden.  But in the future, a growing larger proportion of aged and disabled are expected to receive benefits. 

The number of long-term care enrollees went up by 80% between 1990 and 1998. As impressive as that may appear, actual spending on long-term care increased 3 times faster than enrollment.  From 1990 to 1998, Medicaid spending for long-term care skyrocketed an astronomical 225%.

Federal Medicaid grants to States now account for the fifth largest federal budget item, after Social Security, defense, federal debt and Medicare, but Federal Medicaid is growing at such a fast rate it will soon overtake Medicare and move into fourth place.  State Medicaid budgets in most states account for the second or third largest budget item expenditures after education and transportation.

A doubling in expenditures every 7 years, which we experienced this last decade, would eventually bankrupt government budgets. The growth of Medicaid spending, including long-term care, cannot go unchecked without some sort of offsetting reduction in services.

Federal and State Partnership
Congress determines the rules under which Medicaid operates but the States have broad discretion in determining who gets covered and how they qualify financially. States also determine reimbursement rules under Federal guidelines and disperse funds to providers. In order to receive Federal grant money, certain groups must be covered. These are mentioned above. The Feds may also withhold funds if mandatory provisions in the form of occasional Congressional amendments are not followed.

Federal reimbursement for Medicaid is in the form of block grants to States. The Federal Medical Assistance Percentage (FMAP) is determined annually for each State by a formula that compares the State's average per capita income with the national average. By law, the FMAP can be no higher than 83% nor lower than 50%. As an example, in 2000, Connecticut, Massachusetts, New Jersey, New York and Maryland had the highest per capita income in that order. Federal matching funds for Connecticut will be 50% and the other 50% will come from its state budget. On the other hand, Mississippi, West Virginia, Arkansas, New Mexico, Montana and Utah had the lowest per capita income in that order. In this case, the Federal grant for Mississippi will 83% of its Medicaid costs and the other 17% will come from its state budget. All other states fall somewhere between 50% and 83% for FMAP.

Overall the Federal Government provides about 70% of total Medicaid costs and the States provide the other 30%. From 1990 to 1998, Federal outlays for Medicaid rose about 12% a year. Estimates for the longer period from 1990 to 2001 put the average annual increase at about 11%. Total combined State and Federal Medicaid costs from 1990 to 1998 went up about 10.2% per year. The higher Federal spending increase compared to a lower combined increase means the Federal Government has been shouldering an ever-increasing share of costs whereas the States' portion has been decreasing. Total Medicaid spending is estimated to be a little over $200 billion for 2002. Medicaid costs will soon surpass those of Medicare, since Medicaid is going up at a much faster rate.

Congress is concerned about rising Medicaid costs and over the years, attempts have been made to curtail spending. In 1988, legislation was directed at tightening financial eligibility. This mostly affected the elderly population receiving long-term care since this is the fastest growing segment of expenses. In 1993, legislation directed States to implement a mandatory estate recovery program for recipients over age 55, who are receiving nursing home and community waiver care. And in 1998 Congress mandated that States set up recovery service agencies.  Again the targeted group was primarily the elderly long-term care beneficiaries. Apparently Congress is concerned that some recipients are qualifying for Medicaid by shifting assets that could be used for care, to their children, thus forcing tax payers to pick up the cost.

States, on the other hand, are not so anxious to tighten up payment rules for long-term care recipients. States feel that most elderly long-term care recipients are truly impoverished by long-term care costs and attempts to "squeeze" these people only create a greater burden for overextended family members. West Virginia most recently lost a lawsuit over this issue.

The West Virginia State Medicaid refused to enforce estate recovery rules and subsequently the Feds withheld matching funds. The state sued over withheld funds and lost the suit. West Virginia is probably representative of many states. The feeling is that elderly recipients are truly deserving and shouldn't be punished. Besides, state governors and legislators are well aware of the political power of elderly Americans and the politicians probably tone down programs like estate recovery in order to avoid offending this group. Even states like California that seem to be more aggressive at weeding out undeserving Medicaid coverage, appear to exhibit more bark than bite.

The only state that has an effective recovery program is Oregon.  As of 2004, a few states had no functiong recovery program and it's estimated that all states recover about 0.3 % of state Medicaid budgets nationwide.  So far recovery is a dismal failure.

Financial Eligibility Rules for Aged (65+) and Disabled in Institutions or Receiving Community Care Waivers

Income and Resource Rules for Institutions (Nursing Homes)
Financial eligibility for Medicaid nursing home and community waiver requires the recipient to be receiving SSI payments. If the recipient is not receiving SSI but is qualifying under alternate income rules, he or she must have less than $2,000 in resources. ($3,000 if a couple needs care) A few states use lower limits.

Resources are defined as any asset that can be utilized to produce income. There are numerous rules as well as gifting lookback provisions that define what a resource is and what a so-called "disregard" resource is. Some important resources that often aren't required to be counted are a personal residence and a car. If the recipient is married, the spouse keeps the residence and a vehicle worth any value. Also if the recipient is single but plans on returning home, the residence is not included. Disabled dependents living at home also "disregard" the residence. Also money invested in an income annuity is a disregard. Only the income counts. Assets that don't produce cash are subject to estate recovery at the death of the recipient.

Lookback provisions require any gift or so-called transfer-for-less than- value within 36 months of a community waiver or nursing home stay to be counted as a resource and any irrevocable trust assets created in the prior 60 months to be counted. Revocable trusts or any other arrangements in which the beneficiary has a "life interest" are counted as resource. Counting these transferred resources, even though they haven't been spent down on medical care or become subject to recovery, requires adding the equivalent dollar amount to a nursing home or waiver stay before Medicaid starts to pay for care.

Here's how it works. Suppose Mary gives her daughter her $120,000 dollar residence, 2 years before entering a nursing home. It takes Mary 5 months in a nursing home before she has spent her remaining liquid resources down to less than $2,000 at which point she would normally become eligible for Medicaid. But she still must incur a penalty period or sanction because the $120,000 transfer occurred within 3 years. The sanction period is determined by dividing the sanctioned resources by the average Medicaid reimbursement rate in the state which in this example is $3,000 per month. The result, in this case, is a period of 40 months in which someone other than Medicaid pays for care. In this case it may be Mary's daughter. Her daughter can also transfer the title to the house back to Mary and avoid a sanction. The sanction period starts on the date of transfer and runs concurrently with a spend down so that Mary or her daughter have to pay for 11 months of care before Medicaid takes over. (40 months minus the 29 months since the gift)  Mary is single but if she had a husband, the community spouse resource protection which we will discuss next still applies even during a sanction period.

Also note that the sanction is longer by four months, then the three year look back. This is a paradox. If Mary had given the gift exactly three years before entering a nursing home, she would have only had to wait 36 months before Medicaid paid for care as opposed to 40 months before Medicaid would pay with a sanction. With a large gift, penalty periods could last up to five to ten years or more. A shorter look back provides a planning opportunity for gifting prior to receiving Medicaid. Look in the Medicaid planning section for more details.

Most recipients in nursing homes or on community waivers are not receiving SSI payments. Special rules allow aged (over 65) and disabled people in nursing homes or receiving waivers and who are not receiving SSI to meet alternate income tests. Most states have a "Medically Needy Program" that allows individuals to deduct the cost of care from their income. This spend down allows them to meet the alternate income test levels typically set at 100% of SSI.

States that do not follow Federal guidelines for Medicaid eligibility and that apply stricter rules, are called 209(b) states. Eleven states are 209(b) but most of them have a medically needy program. Federal law requires 209(b) states without medically needy to allow spend down to trigger Medicaid eligibility. Spend down means that all nursing home and medical costs not covered by Medicare, are deducted from a person's income until the person meets the income test. In some 209(b) states this is set at the state dictated level and in others there is no level. The difference between what a person can afford and what care costs determines eligibility.

States that are not 209(b) and who don't have a medically needy program are called income test states. Twelve of these states set income eligibility for Medicaid nursing home coverage at 300% of SSI--$1,692 per month in 2004. Delaware, the 13th of these states, sets income at 250% SSI. A person who makes more than the income level is not eligible for Medicaid in these states. Income is gross income, not medically adjusted income. Federal law requires these states to allow a person to establish a Miller Trust in order to circumvent the income test.

A Miller Trust is a legal document that transfers all of a person's income to another individual--the trust. The trust must be set up to pay the long-term care costs for its beneficiary--the person transferring income. Thus the person transferring income, has no income and comes in below the state income eligibility trigger. A Miller Trust must be set up so that the State can recover money at the death of the Medicaid beneficiary.

After meeting the income, resource and level of care (need for care assessment) tests and qualifying for Medicaid, a recipient is required to share Medicaid costs by contributing all of his or her total income to the total cost of care and Medicaid picks up the balance, if any. An allowance is added back in to provide monthly personal care. (a Federal minimum of $45 per month but as much as $75 in some states) Also, an allowance for medical costs and insurance premiums not covered by Medicare is added back in.

Income and Resource Rules for Medicaid Community Waivers
Medicaid Home Based and Community Services (HBCS) waivers are an attempt to provide services not originally dictated by Federal law. Federal Medicaid rules originally required only nursing home coverage for eligible long-term care recipients and thereby did not allow for other long-term care options. Rules do allow, however, for the Centers for Medicare and Medicaid Services (CMS) to grant waivers from Medicaid nursing care. The waiver is a state plan approved by CMS to provide community services such as home care or assisted living to a certain number of qualifying people.

Eligibility requirements for waivers are determined by the States, sometimes varying among different waiver types. Waivers might be designed to cover recipients who are: aged (over 65) or disabled, mentally retarded or developmentally disabled, children, AIDs infected, mentally disturbed and so on. The number of participants is controlled, probably due to funding and administrative constraints. Federal rules require that waiver participants meet State Medicaid level of care eligibility rules for nursing homes and that the cost for waivers be neutral, meaning they can't exceed equivalent nursing home costs.

Local Events

American College of Surgeons 102nd Annual Clinical Congress
Dates: 10/16/2016 – 10/20/2016
Location:
Walter E. Washington Convention Center Washington
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