Medicaid and Payment of Long-Term Services

Long-term care (LTC) services include both home and community-based services (HCBS) and LTC facility services (also called nursing facilities). A person who needs LTC services may apply for Medicaid and payment of LTC services but must meet all eligibility requirements.

You can apply for benefits online using COMPASS — the online website to gain access to cash assistance, the Supplemental Nutrition Assistance Program (SNAP), help with child care, health care coverage, home heating assistance (LIHEAP), school meals, SelectPlan for Women and long-term living services, or complete the Medicaid financial eligibility application for long-term care, supports, and services . You may also mail or give your application to your local county assistance office. The county assistance office will then determine your eligibility.

Please note: The following Medicaid LTC eligibility criteria do not apply to the Adult Community Autism Program (ACAP). See Medical Assistance General Eligibility Requirements for additional information.

Non-Financial Eligibility

A person must:

• Have a medical need for long-term care services — A doctor must complete a form telling the department of the medical need. This form is then reviewed by a department-approved agent. The agent will tell the county assistance office if services are needed.
  
• Be a U.S. citizen or a qualified non-citizen
• Be a resident of Pennsylvania
• Have a social security number

Financial Eligibility

The financial eligibility factors are:

NOTE: Any transfer of assets (income and resources) for less than fair market value in a 5-year period prior to applying for Medicaid LTC services could affect eligibility. See additional information under "Transfer of Assets" below.

Income

Most income is counted, including:

• Social security
  
• Pensions
• Interest and dividends from savings and investments
• Rental income
• Withdrawals from an IRA

Income Limits (for one person)

• For non-money payment (NMP) categories, the limit is 300 percent of the federal benefit rate (FBR), which changes annually. For 2013, the individual income limit is $2,130.
  
• For medically needy only (MNO) categories, the limit is $2,550 (semi-annual net income)
  • If your income exceeds 300 percent of the FBR limit, the anticipated cost of long-term care facility services for a 6-month period is an allowable medical expense deduction to reduce monthly income.
    

  Resources

  Examples of resources that are counted:

  • Bank accounts
    
  • Stocks, bonds, and mutual funds
  • IRA and Keogh accounts
  • Non-resident property
  • Cash value of life insurance — if the face value of all policies is greater than $1,500 per person (the first $1,000 of cash value is excluded)

  Examples of resources not counted:

  • The home
    • If the value of the home is less than or equal to $525,000 and you intend to return to the home or are residing in it
    • If a spouse or dependent resides in the home

    Resource Limits (for one person)

    • If your income is below or equal to 300 percent of the FBR (currently $2,130), the resource limit is $2,000 with an additional $6,000 resource disregard.
      
    • If your income is above 300 percent of the FBR (currently $2,130), the resource limit is $2,400.
    • Many individuals pay for LTC with personal funds and eventually reduce their resources to the Medicaid LTC limits.

    NOTE: The resources of a parent who is applying for or receiving HCBS and is living with their child who is under the age of 21 are excluded.

    Transfer of Assets (Income and Resources)

    Any asset that was transferred, sold, or given away within the past 60 months (look-back period) must be reviewed by the county assistance office when a person applies for Medicaid long-term care. The look-back period is determined by the date a person is admitted to an LTC facility or assessed eligible for HCBS and has applied for Medicaid long-term care.

    The county assistance office will review the exchange of assets to determine if the fair market value has been received. If the fair market value has not been received, a period of ineligibility, known as a penalty period, takes place. During the penalty period, DHS will not pay for LTC services. The uncompensated value (UV) of the asset is used to figure the penalty period. UV is the difference between the fair market value and the amount received. The penalty period is figured by dividing the UV by the average daily private pay rate for LTC services. The penalty period begins on the date a person is eligible for Medicaid long term care.

    Special Rules for Married Couples (Spousal Impoverishment)

    Special Medicaid rules apply to couples to ensure that the spouse who stays in the community (known as the "community spouse") is not made poor when one spouse (known as the "institutionalized spouse") is admitted to an LTC facility or assessed eligible for HCBS. All resources owned by the institutionalized spouse and the community spouse are reviewed to determine the part of the resources (called the "spousal share" or the "protected share") that the community spouse may keep. The spousal share is one-half of the couple's total countable resources, but no less than $23,184 (for 2013) and no more than $115,920 (for 2013). These minimum and maximum figures are revised annually. You can file a Resource Assessment Form (PA 1572) to determine the spousal share. A couple should file this form when one of them enters an LTC facility or is assessed eligible for HCBA.

    The community spouse is not required to pay for the institutionalized spouse's long-term care services. The community spouse is allowed to keep all of his/her own earnings, regardless of the amount, and that income is not included in determining the institutionalized spouse's eligibility for Medicaid long-term care. If the institutionalized spouse is in a long term care facility, the community spouse may be eligible for a community spouse monthly maintenance needs allowance (CSMMNA). The county assistance office will use the community spouse's income and shelter costs to determine the amount of the CSMMNA. If the institutionalized spouse has enough income to pay the CSMMNA, the institutionalized spouse's income must be used first. However, if a shortfall still exists after the institutionalized spouse gives all of his/her available income, an additional amount of resources exceeding the protected share of the couple's resources can be made available to the community spouse to generate additional monthly income up to the CSMMNA. In addition, if the community spouse needs more income in excess of the CSMMNA because of exceptional circumstances that result in significant financial duress, you may request an increase in the CSMMNA. An application must be submitted for Medical Assistance long term care and a hearing requested.

    What Medical Assistance Long-Term Care Pays For
    

    • If an individual receiving HCBS meets all eligibility requirements, Medicaid LTC pays for the LTC services received at home and in the community. For additional information see the page entitled Long-Term Care Services.
      
    • If an individual receiving LTC facility services meets all eligibility requirements, Medicaid LTC pays the difference between the LTC facility's charge for providing care and the individual's monthly payment toward the cost of care.