What is the difference between Medicare and Medicaid?

Medicare is a government program that provides health care benefits to senior citizens, disabled individuals and individuals with certain chronic illnesses. Medicaid is a need-based government program available to individuals with low income and asset levels.

How do I become eligible for Medicaid?

Medicaid has many rules regarding eligibility including income and asset allowances as well as past financial history. The Medicaid rules are different depending on if you’re applying for community benefits, community based home care or nursing home care. We recommend that you schedule an appointment with one of our experienced attorneys to review your individual needs and circumstances to determine if you are eligible for Medicaid benefits and if not, how to become eligible.

What options do I have if my income or assets are greater than the Medicaid limits?

You may still be eligible for Medicaid benefits even if you have excess income. The excess income will be due to Medicaid, the nursing facility or home care agency each month. If your assets are greater than the Medicaid limits you may have several options. Medicaid has several groups of “exempt” individuals to whom excess assets may be transferred without incurring a penalty period or rendering an individual ineligible for benefits. In addition, even if there is no “exempt” individual to whom you may transfer your assets, we may be able to protect a portion of your assets through certain planning methods. Please contact our office to make an appointment to discuss your asset protection options.

Is there any way to protect my income? If I’m looking for community based home care, how do I pay my bills and monthly expenses within the Medicaid income allowances?

If you have excess income and are in need of community-based care, you may create a Pooled Income Trust to protect your additional income. A Pooled Income Trust is a trust set up with a charity in which you deposit your excess income each month. You then submit your bills, up to the deposited amount, and the Trust will pay those bills each month. This allows you to use your income to pay for your expenses as opposed to paying your excess income to Medicaid or the home care agency.

How does Medicaid work with my Medicare and private insurance?

Medicaid is the payor of last resort. This means that with regards to your medical and/or nursing home expenses, your primary insurance (Medicare) pays out first. Then, your supplemental health insurance (if any) pays out – just as it does without Medicaid – and Medicaid pays the remaining balance.

How do the Medicaid rules affect my spouse who is not in need of Medicaid benefits?

The income and assets of the spouse of a Medicaid applicant may be protected. In addition, Medicaid has income allowances for the non-applicant community spouse which in many situations allows the applicant spouse to contribute a portion of their income to the community spouse.

How long does it take for Medicaid to process my application?

The length of the Medicaid review process varies depending on the type of services you are requesting. The review process for community based care applications is approximately 3 to 6 months, whereas the review process for nursing home applications is approximately 6 to 9 months. Please note that these review times are approximate and can vary greatly depending on the complexity of the individual case.

How do I pay my home care or nursing home bills during the application process?

Once your Medicaid application is submitted, your case is considered “Medicaid Pending.” With a Medicaid pending status, nursing homes and many home care agencies will put the monthly billing on hold until Medicaid issues a decision and either Medicaid pays the outstanding balance, or, if the case is denied or a penalty period is issued, you will be billed for any outstanding balance.

What happens after my case is approved?

After Medicaid approves your application you will begin receiving benefits. Medicaid will create a budget based on your income, assets and needs. Medicaid will pay the medical bills that accrued during the pending period and Medicaid will continue to provide benefits pursuant to their regulations.

What happens if my case gets denied?

If your Medicaid application is denied you may still have recourse depending on the reason for the denial. You may submit a reconsideration request in which you set forth the reasons that the decision is erroneous. If you do not succeed at the reconsideration level, you may attend a Fair Hearing to present your case before an impartial Administrative Law Judge. Our law firm is available to assist you at all levels of the Medicaid process.

Note: These answers are informational only, based on New York law and are not to be considered legal advice.