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
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
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
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
How do I pay my home care or nursing home bills during the application
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.
Why should I hire you instead of the nursing home attorney to file a Medicaid application?
For most seniors, obtaining Medicaid to pay for nursing home care is a must. Very few people can afford to pay privately for extended long term care (which is not covered by Medicare).
The nursing home may provide you with a list of attorneys to assist the family with the filing of a Medicaid application. It is suggested that you obtain three attorney references in writing.
A key question for the family to ask is: Whether any of the attorneys on the list have or is currently represent the nursing home?
If so, one should be concerned about a potential conflict of interest if there is a problem with obtaining Medicaid approval. Based on the admission agreement, the nursing home may take legal action against the family for an unpaid nursing home bill.
The better course of action is to hire an independent, experienced elder law attorney for the filing of the Medicaid application.
At my law firm, Russo Law Group, PC, we only represent seniors and their families. We do not represent nursing homes. We have made an ethical decision to act in the best interests of our clients, with no allegiance to any nursing home. We work with our clients and the nursing home to ensure the best quality care for a loved one and to ensure that the nursing home is paid for its services.