Long Term Care Medicaid |
Obsolete Policy |
Contact DWS Program Specialist for previous policy
Medicaid cannot pay for long-term care services in a nursing facility or under a home and community based waiver during a penalty period applied for transferring assets or when an individual has over $525,000 of equity in his or her home. If the individual later becomes eligible for Medicaid, do not use the expenses the individual incurred while services were restricted at any time to reduce the individual's cost-of-care or spenddown to receive Medicaid for long-term care services. (For NCW eligible clients, see sec. 386 to decide when transfer of assets policy applies.)
Restriction for Transfers for Less Than Fair Market Value.
Medicaid may restrict services available to the client for nursing home services and long-term care services under a waiver when a client or spouse has:
• Transferred an asset for less than fair market value on or after the look-back date
• Reduced or eliminated access to or ownership of an asset on or after the look-back date
• Transferred income or a right to a stream of income on or after the look-back date
The amount of time Medicaid restricts services depends on the value of the asset. See sections 371-10 to determine when the penalty period starts and how long it will be.
Restriction for Substantial Home Equity: Applications Received On or After January 1, 2006.
Medicaid also restricts nursing home services and long-term care services under home and community-based waivers when the individual's equity value in the individual's home exceeds $525,000. This restriction applies to individuals who apply for nursing home services or services under a home and community based waiver on or after January 1, 2006.
If the individual applied before this date and remains continuously eligible for nursing home or waiver services based on that application date, do not restrict services based on substantial home equity.
If an individual borrows against the equity of the home, do not decrease the equity value until the individual actually receives the cash. The cash received is a countable resource. Verify the arrangements and the amount of funds the individual receives. Any such arrangements must be done under a written, legally enforceable contractual agreement that includes a repayment arrangement.
This restriction applies as long as the equity exceeds this amount. An exception to this requirement applies only in the following two situations:
The individual's spouse lawfully resides in the home, or
The individual's minor child, or blind or disabled child, lawfully resides in the home. Unless presented contradictory evidence, assume the occupation of the home by a spouse, or a child is lawful.
Determine equity value at the time an individual applies for Medicaid on or after January 1, 2006 for either institutional or HCB waiver services. For a client who is eligible for Medicaid and then enters an institution, the application date is the date of entry to the institution. For waivers, use the first of the month for which the client requests waiver services.
For individuals who applied on or after January 1, 2006 and were determined eligible for nursing home or waiver services before this requirement became effective, this provision becomes effect at the first re-determination of eligibility.
Do this at each subsequent review because equity values change over time. If the equity in the individual's exceeds $525,000 when you complete a review, restrict nursing home or waiver services from that point forward.
[NOTE: If the determination of home equity was not done at the earliest time it should have been done (either at application or at the first review as applicable), an overpayment may have occurred. (825) Determine the equity value back to the date when it should have been done. Take appropriate action for future eligibility based on the current equity value.]
A client may claim undue hardship if the agency restricts long-term care services because the client or spouse transferred assets or because the individual has substantial home equity. See 371-9.
Consider the client’s eligibility for non-institutional Medicaid to cover ancillary services. Examples of ancillary services are:
Physical therapy and speech therapy.
Oxygen.
Prosthetic devices to include (a) artificial legs, arms and eyes and (b) special braces for the leg, arm, back and neck.
Physician services for direct patient care.
Laboratory and radiology.
Dental services except annual examinations for ICF/MR patients.
Emergency ambulance for life threatening or emergency situations.
Other professional services for direct patient care, including psychologists, podiatrists, optometrists, and audiologist.