Eligibility in Plain English

To be eligible for Medicaid, applicant must meet the following 3 tests:

  1. legal presence test
  2. physical eligibility test, and
  3. 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

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.

5.      Financial Test - Resource

A resource is any property which a person owns and has the authority to convert to cash.  All resources are countable unless they are qualified as exempted or because the owner of the resource does not have the authority or power to convert into cash or because the person is legally restricted from using the resource for his/her support and maintenance is not included. 

    i. Personal Resource Allowance

The personal resource allowance is limited to $2,000.

    ii. Exempt Resources

Home of the institutionalized.  The principal residence is exempted for six months after institutionalization, or longer when certain persons reside there.  There is a Home Equity Limitation of $500,000 unless the home is occupied by a spouse, dependent child under age 21, or a blind or disabled child of any age. 

  • Value of the Real Estate Property.  
The Current Market Value (“CMV”) is determined by the most recent tax assessment notice.  The true Fair Market Value that could be established by an appraisal is not taken into consideration. 
  • Intent to Return
There is a theory that if the institutionalized individual has the intent to return to the home, the real estate property would never become a countable resource.  This rule applies no matter how unlikely it is that the institutionalized individual would ever recover to the point to be able go back home.  A signed statement clearly stating that the individual intends to return home can be useful as proof of intent to return. 
  • Life Estate
Life estates created before August 28, 2008 and on or after February 24, 2009 are considered as exempt resources, while life estates created between August 28, 2008 and February 24, 2009 are accountable resources.

Funds from sale of a home if reinvested timely in a replacement home.

Jointly-owned real property which cannot be sold without undue hardship (due to loss of housing) to the other owner(s). 

Unsellable real estate.  As long as the owner can show reasonable efforts to sell and that the sale is unsuccessful, the real estate property is exempted.

Restricted allotted Indian land, if the Indian/owner cannot dispose of the land without the permission of other individuals, his/her tribe, or an agency of the Federal Government. 

One automobile.  An automobile means any vehicle used for transportation.  It includes cars, trucks, boats, snowmobiles, animal-drawn vehicles, and animals that are used for transportation.  There is no limitation of value.   

United State EE or I Savings Bonds.[3]  If issued after February 1, 2003, they are subject to a 12-month mandatory holding period and Series H and HH bonds are subject to a 6-month mandatory holding period, during which they are not resources.  U.S. savings bonds are resources the first month following the mandatory retention period.  The maximum savings bond purchase per individual per calendar year is limited to $5,000 in paper and $5,000 in electronic bonds each for Series EE, and I bonds, or a total of $20,000.  There is no maximum for Series H. bonds.  There is a penalty for redemption within 5 years of purchase.  Redemption will generally be required as of the first date that the bond(s) can be counted as a resource.  The penalty is forfeiture of interest for 3 months immediately preceding redemption. 

Burial arrangements. 

o Cemetery plots are exempt regardless of the number owned. The burial space exclusion is in addition to and has no effect on the burial funds exclusion.

o Burial funds set aside for expenses: $3,500 for a single person and $1,500 for a married person.

o Burial life insurance policies have no limitation in value.

o Certain prepaid burial contracts are without limitation in value if they are irrevocable.

Household goods and personal effects

Property essential for self-support

Resources of a blind or disabled person which are necessary to fulfill an approved plan for achieving self-support

Retained retroactive SSI or RSDI benefits

Certain settlements

Tax refunds related to earned income tax credits

Life insurance policies, but only up to $1,500 in face value

iii. Community Spouse Resource Allowance (CSRA)

The Community Spouse Resource Allowance (CSRA) or the Community Spouse Protected Resource Amount (“CSPRA”) is the value of countable resources which can be excluded from the couple’s combined countable resources, to be protected for the community spouse while the institutionalized spouse receives Medicaid. 

The combined countable resources of both spouses are determined as of the first day of the calendar month in which one of the spouses becomes “institutionalized.”  This date is the “snapshot” date.  Please know that the snapshot date could have occurred several years before the couple considers applying for Medicaid and regarding a completely different health matter.  It does not matter how the assets are titled in sole or joint names; all of the assets of both spouses are included. 

One half of the combined countable resources determined to exist on the snapshot date is protected as a spousal allowance (CSRA or CSPRA) but is subject to a minimum and maximum amount.  As of January 1, 2010 the minimum amount is $21,912, and the maximum amount is $109,560.  So the maximum that a couple is entitled to keep is $111,560:  $109,560 for the community spouse and $2,000 for the institutionalized spouse. [amount change yearly; always check most recent]

The community spouse can apply for a Fair Hearing or obtain a court order of support.  If the community spouse is under the Minimum Monthly Maintenance Needs Allowance (“MMMNA”), the community spouse can request a Fair Hearing to seek an increase on the CSRA by an amount of assets sufficient to generate the additional income needed to bring the community spouse up to the MMMNA level.  But first, the income of the community spouse must be increased by shifting income from the institutionalized spouse.  Finally, upon proof that the community spouse cannot make ends meet with the default minimum amounts of income or assets allowed under the Medicaid rules, a court order may increase the allocation of both income and resources. 

Please note that if both spouses were to apply for Medicaid, there is no CSRA and the countable assets of both spouses cannot exceed $3,000.  It is recommended to apply for one spouse first, then for the second spouse. 


[1] See definition in M0220.310 (Virginia Medicaid Eligibility Manual)

[2] See M1480.410

[3] Medicaid Manual §M1140.240 A.

[4] Medicaid Manual § M140.400.

[5] Medicaid Manual §M1450.400

[6] Medicaid Manual § M1450.630 E.

[7] See 42 CFR 433.36; Va. Code Section 32.1-326.1 and 32.1-327.