An Overview of the Medicaid Program

Medicaid is a federal and state program that provides health care coverage for qualifying individuals and families, including seniors and people with disabilities. Medicaid covers a range of services, such as doctor visits, hospital stays, prescription drugs, home health care, and long-term care. However, Medicaid eligibility and benefits vary by state, and the rules can be complex and confusing. That’s why you may need the help of an experienced New York elder law firm to guide you through the Medicaid process and protect your rights and assets.

Community Medicaid

“Community Medicaid” refers to Medicaid benefits that cover home health care and other community-based services for seniors and people with disabilities who need assistance with daily living activities. Community Medicaid can help you stay in your own home or at an assisted living facility, rather than moving to a nursing home.  

Community Medicaid benefits are traditionally administered through either personal care services, home health aide services provided by a licensed agency, or through CDPAP, the Consumer-Directed Personal Assistance Program, which allows a Medicaid recipient to direct the way in which their community-based services are provided. Through CDPAP, a Medicaid recipient can arrange for a caregiver of their own choosing, such as a friend or family member, to provide the care that they need to remain in the community, and for the caregiver to be compensated for their services through the Medicaid program.     

There are also waiver programs, such as the Nursing Home Transition and Diversion (NHTD) Waiver program and the Traumatic Brain Injury (TBI) Waiver program, administered through the Community Medicaid program, which provide significant benefits to individuals in the community who would ordinarily be living in a residential health care facility.

While the same financial eligibility criteria applies for both Community Medicaid and Nursing Home Medicaid applicants, currently, in New York, there is no “look back” period for Community Medicaid, meaning that the financial eligibility determination is based on a “snapshot view” of what your financial resources are as of date of your Medicaid application. This means that, under most circumstances, a person who does not qualify for Community Medicaid today can engage in Medicaid planning, with the assistance of an elder law attorney, and become financially eligible for Medicaid the following month.  

Nursing Home Medicaid

Nursing Home Medicaid (or Institutional Medicaid) refers to Medicaid benefits that cover or contribute toward the cost of nursing home care for seniors and people with disabilities who need skilled nursing care and supervision.  

When a person is deemed eligible for nursing home Medicaid benefits, their financial contribution toward their nursing home care is typically limited to the amount of their monthly income, as calculated by the local social services district overseeing the benefits program. A recipient of nursing home Medicaid benefits is permitted to keep $50 each month from their monthly income, which they may spend on anything they would like, and the remainder is budgeted as the recipient’s Net Available Monthly Income, or “NAMI”. The individual’s NAMI must be paid, in full, to the nursing home each month, while the Medicaid program contributes the remainder of the cost of care to the nursing home. If a person has assets over the Medicaid resource allowance threshold, he or she may need to “spend down” their excess resources before Medicaid benefits can begin to cover the cost of their care.

Understanding the Medicaid Five-Year Look Back Period

A major difference between the Community Medicaid and Nursing Home Medicaid programs is the five-year “look-back” period that applies to Nursing Home Medicaid applicants. For individuals seeking nursing home Medicaid, in addition to demonstrating that they meet the current financial eligibility requirements at the time of the application submission, they must also provide financial records for the five-year period immediately preceding their admission to the nursing home. As part of the Medicaid application review process, the local social services district will look at your income and asset history for the past five years to see if you have transferred or given away any of your resources to avoid paying for your care. A finding that a Medicaid applicant (or the applicant’s spouse) has performed these uncompensated transfers of assets during the five-year look-back period can result in a penalty period during which the Medicaid program will not contribute toward the cost of care in the nursing home. If a penalty period is assessed, this means that you will be personally responsible for contributing more toward the cost of your care in the nursing home from your own financial resources.

While the Medicaid program presumes that any uncompensated transfer of your assets performed during the five-year look back period was made for the purpose of qualifying for Medicaid benefits, our attorneys have assisted clients in rebutting this presumption by providing evidence that the transfer of assets was performed exclusively for a purpose other than qualifying for Medicaid benefits. There are also some transfers of assets that are “exempt” under Medicaid rules and regulations that will not result in the imposition of a penalty.        

Our Elder Law Attorneys Can Help You Navigate the Medicaid Application Process

It is important to review your financial information with an experienced elder law attorney, who can examine your transaction history and determine whether there are any problematic transfers of assets during the five-year look-back period, and help you to address them proactively in the context of the Medicaid application process.  

Even if you think that you don’t qualify for Medicaid, or that you will incur a lengthy penalty period because of a history of asset transfers, our extensive knowledge of the Medicaid program and Medicaid planning techniques allows us to help our clients achieve Medicaid eligibility much sooner than they thought possible. 

Contact our knowledgeable Medicaid attorneys today to schedule a meeting to discuss how we can help you establish a clear path to achieving Medicaid eligibility, so you can receive the home care or nursing home coverage that you need, and ensure your plan for your long-term care needs is secure for the future.