What is the difference between Medicaid and Medicare?

Medicaid is a federal program that provides medical services to qualified individuals who have low income and resources. In New York State, the Medicaid program is overseen by the County Departments of Social Services.

Medicare is a health insurance program for individuals who are 65 years of age or older and disabled. Medicare Part A covers inpatient hospital care, inpatient care in a skilled nursing facility, some home health care services, and hospice care. Medicare Part B covers medical care and medical practitioners, durable medical equipment, outpatient care services, and home health services not covered by Part A. Medicare Part D covers prescriptions.

There are no income or resource limits for Medicare, however if you have low income and resources, you may be eligible for special programs which may pay for your Medicare premiums, coinsurance, deductibles, and copayments. These programs are known as the Qualified Medicare Beneficiary (QMB) or “Buy In” Program and the Specified Low Income Medicare Beneficiary (SLIMB) Program.

 Who is eligible for Medicaid?

You must be a member of an eligible group and be financially eligible to receive Medicaid. Eligible groups include:

  1. People who receive Supplemental Security Income (SSI)
  2. People who receive Social Security Disability Insurance (SSDI) (may require a spenddown).
  3. People who are blind.
  4. People who are determined disabled by their county’s Department of Social Services.
  5. People who are elderly (65 years old and up).
  6. People between ages 21-64 who are not disabled and without children under 21 in the household.

There are other eligibility rules and household income limits for people under 21, a caretaker relative for a child under age 21, or pregnant women, not covered here.

Even though you may fall into one or more of these groups, you must still meet certain financial requirements.

 Does it matter how much money I have?

Yes. Unlike Medicare, there are income limits for all the eligible groups listed above for Medicaid. There are also resource limits for some of the eligible groups listed above. These limits change each year.

Beginning in 2011, the income limits for people who are disabled, blind, or 65 and older is $767 for a household (HH) of 1 and $1,117 for a HH of 2. The Medicaid resource level is $13,800 for a HH of 1 and $20,800 for a HH of 2. However, people who receive SSI must meet a lower resource limit to remain eligible for SSI benefits: $2,000 for single people and $3,000 for couples. Certain income and resources may be exempt and therefore are not counted toward these limits.

Beginning in 2011, the income limits for people who are between ages 21-64 who are not disabled and without children under 21 in the household is $708 for a HH of 1 and $883 for a HH of 2. There is no resource limit for this group of people.

What is counted as income for Medicaid?

Income is any earned or unearned available recurring payment made to you. Examples of income include your Social Security checks, SSI, any pensions, any dividends, or rent you receive from tenants of an apartment or house you own.

 What are counted as resources for Medicaid?

Any resources that can be used to pay your medical bills. You must have access to these resources in order for them to be counted. Some examples include savings and checking accounts, certificates of deposit (CDs), stocks, bonds, and real property.

 What happens if I own joint property?

Medicaid views joint property as owned entirely by the applicant. For example, if you have a joint bank account with your wife, Medicaid will look at that and assume you have access to all the money in the account. They will then count that as a resource and assume that you can therefore use that money to pay for medical expenses.

 Are all of my resources counted for Medicaid eligibility?

No. There are some resources that are not counted for Medicaid eligibility. These include:

  1. Your house and any surrounding land, as long as you, your spouse, or other dependant relative reside there.
  2. Necessary personal property, such as clothing, furniture, other personal effects, and a car (as long as you or your spouse use it)
  3. Certain types of life insurance.
  4. Burial funds up to $1500 per applicant ($3000 for a couple).
  5. Excess resources used to pay medical bills not covered by Medicaid.
  6. Irrevocable prepaid funeral trusts (unlimited amount).
  7. Any German war reparation payments.

Is all of my income counted for Medicaid eligibility?

No. Certain income is not counted for Medicaid eligibility. These include:

  1. For the elderly, blind, or disabled, the first $65 of employment income. Also, the first $20 per month of unearned household income.
  2. Interest from separate burial funds.
  3. German restitution payments.
  4. Surplus income (Spenddown program).

I am just a little over the income and resource eligibility limit. Is there any way I can still receive Medicaid?

Yes. You may be able to be eligible for Medicaid by lowering your actual income and resources. It is possible to do this through the spenddown program or the pay-in surplus program.

 What is a spenddown program?

This program allows some eligible people with disabilities who are over the income and resources limit to still receive Medicaid if they can show that the excess income is used for medical bills. People between ages 21-64 who are not disabled and without children under 21 in the household are NOT eligible for a spenddown. The medical expenses can be for various services, including ones not covered by Medicaid. For example, cotton balls, antiseptic, ointments, and bandages could be medical expenses for the purpose of the spenddown, even though they are not covered by Medicaid. By deducting the amount of medical bills from your monthly income, you may be able to bring your income down to within the eligibility levels. To have these expenses deducted, you are required to keep copies of your medical receipts and show them to Medicaid each month. If you wish to learn more about the spenddown program, the Legal Aid Society has another Legal Life Line entitled Understanding the Medicaid Spenddown.

 What is the Pay-In Surplus Program?

This program is another avenue of becoming eligible for Medicaid if you are over the income and resource limit. As opposed to the spenddown program, where you keep your medical receipts to show Medicaid, here you can simply pay the surplus directly to Medicaid ahead of time. You can also send a combination of receipts and a check equaling the spenddown amount. Always keep a copy of your receipts.

What does Medicaid cover?

Medicaid covers a variety of medical expenses. There are three main areas that Medicaid covers: Community Medical Services, Home Care Services, and Institutional Care Services. Some of these require prior agency approval, and some are covered by Medicaid only in special circumstances.

What are community medical services?

Community Medical Services are services you receive in places other than a hospital room or hospital based clinic. These include ambulatory surgery services, dentists, nurses, optometrists, and the like. They also include rehabilitation, such as physical or speech therapy, prescription drugs, and eyeglasses. There are also other services, which you can find out by contacting Medicaid and your physician.

 What are home care services?

Home Care Services are just what they sound like: services that are provided to you in your own home. Some of these include nursing, home health aides, and physical, speech, and occupational therapy.

 What are institutional services?

Institutional Services are available if you need care in a hospital, a nursing home, or a skilled nursing facility.

My wife needs Medicaid services but I don’t. Should we both apply?

No. Your wife is able to apply for Medicaid services on her own. It is not necessary that you apply as well. However, Medicaid will look to you to see if your income and resources may be able to pay her medical bills.

 I think I have too much money for my wife to be eligible. Is there any way for Medicaid not to count my resources and income?

Yes. You can sign a Spousal Refusal, which simply states that you are not contributing any money to support your wife. Be careful, however, because in New York, a spouse has a duty to support the other spouse. Therefore, if you execute a spousal refusal, Medicaid may take you to court to demand support.

 I have too much money to be eligible for Medicaid. Can’t I just give everything to my kids?

You may be subject to significant penalties if you transfer assets and are seeking Medicaid coverage for the cost of institutional care, such as a nursing home. The rules for these transfers are very complicated. You should consult with an attorney if you are considering transferring your assets to qualify for Medicaid coverage in an institution. For other types of Medicaid coverage, such as home health or community care, you can transfer assets without being penalized.

How do I apply for Medicaid?

You can apply for Medicaid by contacting your local Department of Social Services.

I am visiting relatives in Ohio. If I need medical care, will Medicaid still cover me?

Yes. If you are a Medicaid recipient and reside in New York, your Medicaid will follow you wherever you go. Medicaid may make special provisions if you inform them ahead of time that you are leaving the state. The same applies if you hold a Medicaid card from another state and require emergency medical care while in New York. However, you must prove that you did not go to a different state for the sole purpose of receiving that medical treatment.

 I have been denied Medicaid and I think I should receive it. Is there anything I can do?

Yes. There are certain steps that you must take to appeal Medicaid’s determination that you are ineligible. You should request a Fair Hearing with Medicaid representatives. You are also able to request any and all files Medicaid will use at this hearing. At this hearing, you have the right to representation by anyone (such as a friend or social worker), the right to subpoena and to cross-examine witnesses. You also have the right to an impartial judgment and a written decision.

It is important to remember that there are time limits associated with each step in the appeals process. A Request for a Fair Hearing must be made within 60 days of when you received the decision. If, through no fault of your own, you have not heard a decision from Medicaid regarding your eligibility within 30 days of your application, you should take that as a rejection and request a Fair Hearing. If you do not agree with the decision made at the Fair Hearing, you may appeal it to state court within 120 days. If you do not appeal within that time, you still may be able to appeal, but you would have to show good cause why you waited too long.

 My Medicaid case is being closed and I disagree with the decision. Do I have the same rights as if I were denied Medicaid?

Yes, but you must request your fair hearing within 10 days of the date on the decision, and request that the Fair Hearings office direct your county department of social services to continue your Medicaid until the judge issues a decision.

 My husband needs nursing home care. Does he receive any spending money of his own?

Yes. If your husband is in a nursing home on Medicaid, he receives $50 a month in a patient income account. This money is his to use as he pleases (buy a magazine, music, etc.). This money will be put into his account each month he is in the nursing home. As the community spouse (the spouse living out in the community; your husband is called the institutional spouse), you may also be entitled to some of your husband’s income. This amount would be taken out and given to you before any amount goes to Medicaid. This is used if you need your husband’s income to live on. The remaining portion of his income goes directly to the nursing home.

 I have heard about a program called “nursing home without walls”. What is it? How can I be eligible?

“Nursing Home Without Walls”, also referred to as the Lombardi Program, is a form of long term home health care. It combines services Medicaid would normally pay for with “waivered” services that are usually not covered by Medicaid. For example, New York allows the following services to be reimbursed by Medicaid even though Medicaid itself does not normally provide these services. Some of these include social transportation, social day care, nutrition counseling/education services, and moving assistance. You may even receive Meals on Wheels and have wheelchair ramps installed under this program. This program is good for when one spouse needs Medicaid care and it is necessary to keep some finances in the home.

 Can Medicaid put a claim on any of my property?

Yes. Medicaid can place liens on some of your property. A lien is a claim against the property as security for the payment of a debt. In other words, the property that has the lien cannot be sold unless the proceeds go towards the debt. Medicaid will place a lien on the home of a permanently institutionalized individual only when the state has decided that the person will not return home. However, if there are certain people living in the home, Medicaid cannot place a lien on it. These people include the recipient’s spouse, any children under 21 years old, any blind or disabled children of any age, or a sibling of the recipient who has an “equity interest in the home and has been living there.

 I am in a nursing home but I believe that I will go home someday. Can Medicaid go after my house because I am not living there?

No. If you make a statement that you have a subjective intent to return home, even though you are in a nursing home, Medicaid will not count your house as a resource. You do not need any medical evidence to prove that you will return home someday. However, they are allowed to place a lien on your house if it is vacant. (See above discussion on liens)

 Can Medicaid take any of my money after I die?

Yes. Medicaid can recover from your estate but only in specific circumstances. For Medicaid purposes, the “estate” contains only those resources you own in your name alone at your death. They do not include any resources held jointly, like a joint bank account. These include any Medicaid funds that were correctly paid only after your spouse dies (leaving no children under 21 years of age or any blind or disabled children) and you were 55 years of age or older when you received the assistance. To receive any money from your estate, the Department of Social Services must file a claim against it in Surrogate’s Court. This must be done within six years of your death.

Further, if you were in a nursing home and have any money left in your Patient Income Account, the institution can give what was left to the Department of Social Services to pay for any outstanding debts you may owe. However, they can transfer no more than five thousand dollars ($5000).

Also, if there is any award from a personal injury case, Medicaid can place a lien on the some of the damages. They are limited to the amount allocated for medical expenses for injuries related to the accident.

 I came to the United States in 1997. I was healthy and working then, but now I have become sick and cannot work. Can I get Medicaid benefits?

You may be living and working here legally, but not qualify for benefits such as Medicaid. If you arrived after August 22, 1996, you are ineligible for benefits during the first five years of your residency. After that, you will be eligible only after you become a citizen of the United States, unless you fit into one of the following categories:

  1. Refugee
  2. Asylee (person seeking political asylum), especially from Cuba, Haiti, or are an Amerasian immigrant
  3. Deportation Being Withheld

For these three categories, you may be eligible to receive medical benefits for the first seven years of your residency only. After that, you may become a citizen and become eligible that way.

  1. Legal Permanent Resident who has at least 40 quarters of work history in the Unites States and has not received any type of public assistance since December 31, 1996
  2. Granted Conditional Entry
  3. United States Veteran
  4. Active Military Duty (dependants can be eligible as well)
  5. Battered Spouses

You must also be a resident of the state where you live. For instance, if you live in New York, you must be a resident of New York. To be a resident, you merely have to have a physical presence in the state and a present intention to live there. This can be by having a job or an apartment in the state.