Important Disclaimer: The information provided in this document is intended for general informational purposes and should not be construed as legal advice or professional counsel.
It is strongly recommended that individuals seeking Medicaid for Long-Term Care consult competent legal professionals. The information presented here is not exhaustive and is also subject to change. It's crucial to recognize that each state's Medicaid program is independently administered, leading to potential variations in eligibility criteria. This article primarily pertains to the rules of New York State's Medicaid program.
  • Coverage Details

    What Nursing Home Medicaid Encompasses:
    Nursing Home Medicaid constitutes the most comprehensive tier of Medicaid coverage, encompassing all available Medicaid services. Those eligible for Nursing Home Medicaid receive coverage for services provided under Community Medicaid, Community Medicaid with Long-Term Care, and additionally, coverage for nursing home care.

    This comprehensive coverage spans essential healthcare services like medical appointments, hospital stays, diagnostic tests, and prescription medications. Moreover, it extends to community-based long-term care services, such as home care, adult day care, and assisted living (for further details, refer to the outline under Community Medicaid).

  • Financial Eligibility

    Financial Assessment for Eligibility:
    When evaluating an applicant’s eligibility, Medicaid scrutinizes two financial categories: income and resources. Income refers to incoming funds like Social Security, pensions, or distributed IRAs. Resources encompass assets like savings, stocks, bonds, real estate, and IRAs not yet distributed.

    Nursing Home Resident Income:
    For nursing home residents, a monthly income allowance of $50 is applicable. All other income is required to be directed towards nursing home expenses. Unlike Community Medicaid and Community Medicaid with Long-Term Care, nursing home residents cannot utilize a pooled income trust to qualify for Medicaid by shielding surplus income.

    Resource Limit for Nursing Home Residents:
    In New York State, nursing home residents face a resource limit of $30,182. Any surplus resources must be depleted before an applicant qualifies for coverage. When dealing with excess resources, consulting an elder law attorney is advisable, as they might assist in safeguarding a significant portion of assets.

  • Five Year Look-Back Period

    To counteract the practice of transferring assets as a strategy for Medicaid qualification without spend-down, Nursing Home Medicaid enforces a five-year look-back period for uncompensated transfers (gifts). When such transfers are detected by Medicaid, penalties are imposed on the applicant.

    Penalty Calculation:
    Medicaid employs monthly “regional rates” to calculate penalties, with these rates varying by county and subject to annual changes. By dividing the total transferred amount by the monthly regional rate, the penalty period in months is determined. During the penalty period, Medicaid does not cover care costs. Instead, the applicant needs to privately cover nursing home expenses during this duration.

    For instance, in 2015, the monthly regional rate in NYC was $11,843. If an NYC applicant gifted $125,000 within the five-year look-back period, Medicaid would calculate a penalty of 10.6 months by dividing $125,000 by $11,843.

  • Homestead Exemption

    A nursing home resident’s primary residence is exempt if the equity falls below $1,033,000, provided the resident intends to return home. This intent is subjective to the nursing home resident. However, even if exempt, the state might seek recovery for services covered after the resident’s demise. A lien could also be imposed during the resident’s life if they are permanently absent, with certain exemptions for the resident’s spouse residing there.

  • Community Spouse Allowance

    When one spouse enters a nursing home while the other remains in the community, the latter is entitled to income and resource allowances. The income allowance for the community spouse can reach up to $3,715.50, comprising the combined income of the couple. The resource allowance stands at $74,820 or one-half of the couple’s total resources, up to $148,620.

  • Exempt Income and Resources

    Several income and resources are typically exempt, including:

    Payments towards health insurance premiums are excluded from Medicaid’s income calculations.

    Holocaust restitution payments are exempt from income calculations and are not considered resources. Even if received for decades, documented restitution payments can be retained in their entirety while still qualifying for Medicaid. These payments are also excluded from calculations affecting the community spouse’s allowances.

    Pre-paid funeral arrangements may be classified as exempt resources in some instances.

    Please Note: This article offers a general overview and does not address advanced strategies such as using promissory notes for asset protection or spousal refusal.