To be eligible for Medicaid, applicant must meet the following 3 tests:
- legal presence test
- physical eligibility test, and
- financial tests.
The tests are discussed below:
1. Legal Presence Test and Other Requirements
To be eligible, an individual must be either a citizen of the United States or a certain qualified alien (“full benefit alien”) and be a resident of the state where the individual applies for Medicaid. A full benefit alien can be the following:
· An alien who received SSI
· An American born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act apply or a member of an Indian tribe
· A “qualified alien[1]” who entered the U.S. before August 22, 1996
· A qualified alien refugee, asylee, deportee, Amerasian, Cuban or Haitian entrant, or victim of a severe form of trafficking but only for the first 7 years of residence in the U.S.
· A qualified lawful permanent resident who has at least 40 qualifying quarters of work, but only after 5 years of residence in the U.S.
· A qualified alien who meets the veteran or active duty military requirements
· A “grandfathered” alien who meets the requirements in M0220.314
Applicants who are age 19 or older are required to provide a proof of citizenship or legal presence in the U.S. There are two exceptions to this requirement: (1) non-citizens applying for Medicaid payment for emergency services; and (2) individuals who on June 30, 1997, were Medicaid eligible and were residing in long-term care facilities or participating in home and community-based waivers, and who continue to maintain that status.
The individual must be a Virginia resident in order to be eligible for Virginia Medicaid, but is not required to have a fixed address. Temporary absence does not interrupt continuity of the residence if the intent to return exists. There is no requirement for a specified period of time. Upon the admission to a Virginia institution, the individual becomes a resident of the Commonwealth of Virginia.
Aliens who are non-immigrants (visitors, temporary workers) with valid (unexpired) visas do not meet the Virginia residency requirements. Surprisingly, if an individual has a non-immigrant expired visa and declares that he/she intends to reside in Virginia, then the non-immigrant alien may meet the Virginia residence eligibility.
The other requirements to become eligible are as follows:
· Providing a SSN
· Assignment of rights and pursuit of support from absent parent(s)
· Application of other benefits. Because Medicaid is a “last pay” medical assistance program, the individual must take all necessary steps to apply for and obtain any annuities, pensions, retirements, and disability benefits to which he/she is entitled, unless he/she can show good cause for not doing so.
2. Institutionalization Requirement
To be eligible, the institutionalization test means that the individual has received for 30 consecutive days care in a medical institution (such as a nursing facility), or Medicaid Community-Based Care (CBC) or a combination of the two. A signed hospice election that has been in effect for 30 consecutive days is included in the definition. The 30 days begins with the day of admission to the medical institution. The date of discharge into the community or death is not included in the 30 days.
3. Physical Eligibility Test
For publicly-funded long-term care series such as nursing facility (NF), assisted living facility (ALF), or home- and community-based waiver services, the individual will need to be pre-screened and deemed eligible for services. Individuals under the following categories may be eligible for Medicaid:
· Individuals receiving optional state supplements to SSI, but not federal SSI payments
· Individuals who would be eligible for cash assistance, except for institutional status
· Individuals receiving home and community-based services
· Individuals whose incomes do not exceed the federal poverty level
Covered groups:
o Aged (65 and older), Blind, or Disabled (ABD) groups
o Family & Children (F&C) groups
The pre-screening is required to enter long-term care or community-based care except for a person who already has been in long-term care for at least 30 days before the application date. The screening is generally performed by DMAS-authorized local teams or by staff at the acute care facility.
An individual who cannot perform 4 activities of Daily Activities or Instrumental Daily Activities will qualify physically for Medicaid. The activities of daily living are the following: bathing, dressing, transferring from bed to chair, walking, self feeding, using the toilet, and grooming. The instrumental daily activities are the following: using the telephone, getting out by car or public transportation, grocery shopping, preparing meals, doing housework or handyman work, doing laundry, taking medications, and managing money. Individuals who are suffering from a form of dementia will also qualify when the behavior pattern or orientation is lacking.
4. Financial Test – Income
The income cap for an applicant is $2,022 (in 2009). However, because the Commonwealth of Virginia is a spend-down state, there is an alternative called “spend-down test” where Medicaid will pay the shortfall between the income of the applicant and the cost of the nursing home. So, as long as the cost of care at the nursing home is higher than the income of the applicant, he/she can qualify for Medicaid.
When the applicant is married, Medicaid refers to the institutionalized person as the “institutionalized spouse” and applies special rules for the financial protection of the other spouse. The non-institutionalized spouse is referred to as the community spouse.
Only the income of the institutionalized spouse is counted. As a matter of fact, sometimes a portion of income on the institutionalized spouse is paid to the community spouse under the “post-eligibility rule.”
If a community spouse has monthly income of more than $1,900, a claim may be made for “expected” support. The community spouse income allowance is set by the “Minimum Monthly Maintenance Needs Allowance.”["MMMNA"] The community spouse is entitled[2] to a Monthly Maintenance Needs Standard of $1,821.25. The maximum of monthly maintenance needs allowance is $2,739 as of January 1, 2010. The community spouse may be entitled to an excess shelter standard of $549.38 (July 1, 2009), and a utility standard deduction of $302 or $381 depending on the number of household members. Alternatively, when the income of the community spouse exceeds $1,900 per month, Medicaid expects a contribution from the spouse.