A government-funded medical insurance and health care services program for people who do not have other medical insurance and cannot afford to pay for needed services. There are strict asset-based requirements for qualification. The federal government and state governments formalized the structure of Medicaid in 1965, establishing a system under Title XIX of the Social Security Act for jointly funding state-managed programs. About 36 million Americans, many of them elderly, receive Medicaid support each year. Medicaid is the largest payer for residential long-term care services in the United States, covering about 80 percent of those in long-term care facilities.
Although the federal government establishes the general framework for Medicaid services, each state structures and administers its Medicaid program, setting its own eligibility requirements, benefits levels, and payment structures. Appendix II, Directory of State Medicaid Offices, lists the Medicaid contact information for each state. States have the option of enhancing basic Medicaid services through state-funded benefits and less restrictive eligibility qualifications but must provide the minimal benefits established by federal guidelines to qualify for matching funds to support state services.
Medicaid is a particular concern for people with Parkinson’s who are at a point in the disease’s progression at which they need more extensive care than a home caregiver can provide and are facing admission to a long-term care facility. Few families have the financial resources to accommodate this need beyond several months to perhaps several years; care in a long-term care facility ranges from $40,000 to more than $100,000 a year, depending on the facility’s services and the person’s level of need.
General Medicaid Eligibility Requirements
At their most basic level of qualification, Medicaid programs generally tie program eligibility to federal poverty guidelines: That is, to qualify for Medicaid assistance a person can have an income no higher than a certain percentage of the established federal poverty level. Federal economists adjust this level annually, so this aspect of qualification changes from year to year. As well, Medicaid considers a person’s assets any property, tangible or intangible, that the person owns. In certain specified situations, a person may exceed income and asset limits but qualify as “medically needy.” There are no requirements related to age; Medicaid serves people of all ages who meet other program qualifications. These qualifications vary widely among states and typically change from year to year. States have broad latitude to use income and resources guidelines that are less restrictive than federal guidelines to establish eligibility for their programs.
General Medicaid Benefits and Services
Medicaid covers a broad base of medical services through basic and enhanced programs. Each state’s program is required to cover basic benefits, which include the following:
• Hospital services including inpatient hospitaliza-tion, surgery outpatient care (including emergency department), lab, X-ray, and other diagnostic procedures
• Doctor, nurse practitioner, and medical clinic services
• Care and services in a residential nursing facility (long-term care facility)
• Home health care as an alternative to care in a residential nursing facility
• Family services including family planning and supplies and screenings, early and periodic screening, diagnosis, and treatment (EPSDT) services for family members younger than age 21
• Services for medical and surgical dental needs (but not routine dental prophylaxis)
States determine the benefits, beyond basic benefits, their programs will provide. The federal government provides matching funds to support additional benefits. Common extended benefits often include:
• Routine dental care and prophylaxis
• Optometry services and eyeglasses
• Prescription medications
• Prosthetic devices
• By waiver (specific written permission), services such as home-based care management, personal care, respite care, home health aide, and other needed services
Medicaid programs contract with community providers to provide care and services, and the person receiving Medicaid benefits can choose among them for care. These providers, which include hospitals, doctors, and pharmacies, agree to accept Medicaid payments for services as payment in full. A growing delivery model in state Medicaid programs is managed care, in which people receiving Medicaid agree to receive care through a closed network of providers. This structure helps states to keep greater control over the costs of medical services. In return, the managed care program provides extended benefits such as payment for prescription medications.
Asset Protection and Spend-Down
It is prudent for most people to begin thinking about asset protection early after a diagnosis of Parkinson’s disease. Asset protection is a method of legally transferring resources and ownership to others, so they do not become counted against Medicaid eligibility. Asset protection can help assure that at least some of the resources the person with Parkinson’s has worked a lifetime to accumulate remain available to support the spouse and family. This is best done with the advice of an attorney who specializes in estate planning or elder law. Spend down is a process of spending assets to reach the qualification mark for Medicaid. Although it serves the purpose of qualifying the person with Parkinson’s for Medicaid benefits, usually to pay for the services of a long-term care facility, spend down does not leave many resources for surviving family members.
Medicaid has strict requirements governing spend down procedures. In general, resources used for spend down must be allocated medical expenses; a person cannot gift property or money to relatives to eliminate assets. Income and resource levels are minimal and to a great extent require the person with Parkinson’s to deplete savings, possessions of value, and even cash-value life insurance policies. Extensive reforms to Medicaid regulations in 1988 made it possible for a person’s spouse to maintain certain assets (such as a home) without jeopardizing his or her spouse’s eligibility. However, Medicaid spend down remains a difficult and complex process. Long-term care facilities generally have staff who work with families to help them meet Medicaid qualifications.
The earlier a family begins planning to protect assets, the less traumatic the spend down process is. It is important to begin spend down early enough before the anticipated time of need, as well; Medicaid looks at all asset disbursements in the previous 30-month period to determine whether they are qualifying spend down actions. If they are determined to be nonqualifying, the person must spend an additional amount to compensate. There are ways to establish Medicaid trusts, such as to cover funeral expenses, that can divert assets within Medicaid guidelines. Again, a long-term care facility’s representative or a lawyer specializing in elder law can help determine whether this is a prudent action.
Medicare-Medicaid Dual Eligibility
Some people who qualify for Medicare but have limited income and resources are also eligible for at least some Medicaid benefits to help pay for medical expenses. Each program covers certain services the other does not, so that the respective program pays for covered services. One of the most significant differences in this regard for the person with Parkinson’s is that Medicaid provides coverage for prescription medications whereas Medicare does not. In situations in which there are overlaps of coverage for services, Medicare pays first and Medicaid pays the balance. Even seniors enrolled in Medicare who do not meet the qualifications for full Medicaid support are sometimes eligible for limited medical benefits through Medicaid as well as partial or complete assistance in paying Medicare Part B premiums.