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Medicaid Planning FAQs

What is the five-year lookback period for Medicaid?

Medicaid applicants must meet strict income and asset limits to qualify for services. Those applying for Medicaid to pay for long-term care in a nursing home are subject to a five-year lookback period. This is a thorough review of asset transfers in the sixty months prior to ensure the applicant has not given assets away or sold them for less than fair market value to reduce their worth and meet Medicaid’s income limits.

When does the five-year lookback period begin and what is included?

The five-year lookback period begins on the date of the Medicaid application or the date which you request Medicaid to begin paying for benefits. In New York, you can apply for Medicaid benefits and seek reimbursement of benefits up to three months prior to the submission of the application, and thus the lookback would begin on the date you request retroactive Medicaid benefits to begin. Common violations include transferring a house to a child or other family member for less than its fair market value, giving large gifts to loved ones, donating assets to charity or selling valuables for less than their worth. Payments made to a personal care assistant, even when they are a family member or friend, without a formal care agreement is another violation of the Medicaid lookback period unknowingly committed by applicants.

Why does this provision exist?

The lookback period exists to prevent Medicaid long-term care applicants from offloading assets that could be used to pay for services before they apply. A violation of the five-year lookback will result in a period of Medicaid ineligibility, during which the applicant and/or their family will be responsible for long-term care costs. There are income considerations made for non-applicant spouses and other lookback period exceptions, so it is best to consult an estate planning attorney for specific advice.

Does Medicaid pay for long-term care?

Long-term care costs are daunting, leaving many people to wonder how they will pay for this exorbitant expense. There are several options for doing this, including personal funds, government assistance programs, private insurance and financing. Sometimes these options can be used in conjunction with one another.

Paying out of pocket is perhaps the most straightforward, albeit difficult, choice. Many people manage this by using savings, retirement, pension, investment accounts or profits from selling their home and other assets.

Medicaid will pay for some of the long-term care costs for those who meet income and asset qualification requirements. Veterans and their spouses may qualify for long-term care benefits from the Department of Veterans Affairs (VA). Other state and federal aid programs also exist to meet the needs of those in long-term care.

Private insurance and financing options are available too. Long-term care insurance can be purchased, which covers nursing homes and/or assisted living facilities, palliative care and hospice care depending on the coverage level. Other private financing options include life insurance, accelerated death benefits, reverse mortgages, annuities and trusts. An experienced estate planning attorney can advise which payment method might work best for you or your loved one.

What happens if my income exceeds the limit for Medicaid?

Medicaid is an income-based health insurance program run by the New York government but overseen by the federal government. The purpose of Medicaid is to provide health benefits to older Americans, as well as those who suffer from serious disabilities. However, unlike Medicare, Medicaid is only available to those individuals and families who can meet the program’s strict income and asset limits.

If you make too much money to qualify for Medicaid, you may be eligible for a “spend down,” which will enable you to qualify for benefits once you pay a certain amount towards your medical expenses. However, not all Medicaid recipients can take advantage of the spend-down provision, so before you assume that to be the case, it is worth speaking with an elder law attorney.

What is Medicaid spend down?

If your income is more than the Medicaid limit, you will be denied benefits. However, through a process called a spend-down, you may still be able to receive Medicaid benefits once you apply your excess income to qualifying medical expenses. The spend-down process works like a care insurance deductible, in that once you apply your excess income to qualifying expenses, Medicaid will cover all remaining qualifying medical expenses.

In New York, to qualify for the spend-down program, an applicant must be:

• Over the age of 65
• Disabled
• Blind or
• Under the age of 21
• A member of a household in which one or both parents are absent, dead, disabled or out of work

Generally, those eligible for the spend-down program will qualify for Medicaid benefits one month at a time. Once you incur qualifying expenses that bring your income below the Medicaid income limit, you will qualify for benefits for that month. However, if you were recently hospitalized, you may be able to qualify for benefits for a six-month period following your discharge.

What expenses are reimbursable?

Some expenses are reimbursable by Medicaid and count as “qualifying expenses” under the spend-down program, including:

• Medical bills
• A spouse’s medical bills
• Children’s medical bills (for qualifying children)
• Medical costs associated with a child who lives with you or whom you help support
• Past unpaid medical bill
• Any medical bills not covered by Medicare or a private insurance company
• The cost of eyeglasses, medical equipment, surgical supplies, hearing aids and prosthetic devices

There are also other expenses that are not reimbursable by Medicaid, but are considered qualifying spend-down expenses, including:

• Medical services that are not covered by Medicaid
• Medical care services that are provided by non-Medicaid providers and
• Some types of over-the-counter medication and medical supplies

Does Medicaid cover telehealth visits?

Yes, recipients of New York Medicaid benefits are eligible to receive treatment through various telehealth options. Generally, the telehealth services covered by Medicaid are quite limited. However, due to the COVID-19 pandemic, a broad range of telehealth services are reimbursable through Medicaid.

The COVID-19 pandemic drastically changed the way of life for all New Yorkers. Among the many aspects of life that were dramatically altered was how people receive medical care. While telehealth used to be a niche practice that few patients took advantage of, that is no longer the case.

In response to the safety concerns about going out in public—especially to doctors’ offices and other healthcare facilities—Medicaid temporarily altered its procedures to cover telehealth by all Medicaid-qualified doctors and service providers whenever possible. Under the new protocol, most types of care that fall under the telehealth umbrella are covered, including:

• Telephone appointments
• Video appointments
• Prescription consultations
• Telehealth equipment and devices
• Remote patient monitoring

These services can be used anywhere within New York, for those on Medicaid fee-for-service and Medicaid managed care plans. Additionally, Medicaid telehealth benefits are not limited to doctors, and are available for the following types of healthcare providers:

• Physicians
• Nurse practitioners
• Dentists
• Midwives
• Psychologists
• Dieticians
• Social workers

While many telehealth services are currently available through the New York Medicaid program, in part, this is due to the fact that there is an ongoing state of emergency due to the COVID-19 pandemic. While logic suggests that telehealth coverage is extraordinarily beneficial to Medicaid recipients and should continue to be available even after the Governor lifts the state of emergency, for now, it is still an open question whether that will be the case.

Medicaid is known for being extremely complex. Qualifying for Medicaid is, in itself, a major undertaking. An elder law attorney can help those who need assistance understanding how to qualify for Medicaid benefits, or have questions about how to structure their assets to limit the amount they will need to spend down in order to qualify for benefits. Elder law attorneys can also help you better understand—and make the most out of—your benefits.

Will Medicaid or Medicare pay for modifications to my Home to accommodate my disability?

Yes, in some cases, Medicaid will cover the costs of home modifications necessary for recipients to stay at home instead of moving into a nursing home or other long-term care facility. However, determining whether you qualify for Medicaid-paid home modifications is not always straightforward.
As people age, their healthcare needs increase. For example, individuals typically make more frequent trips to the doctor, require the use of assistive devices and need to take more prescription medications. Age-related limitations can also make it more difficult to live at home, as stairs can be difficult to navigate, and common home designs do not accommodate those who have mobility limitations.

If given a choice, most seniors would elect to “age at home” with the assistance of friends, family and other home caregivers. However, for many, the current layout of their home may make this challenging. Making age-related home modifications can allow seniors to stay at home longer, increasing their quality of life. Common home modifications include:

• Bathroom handrails
• Standing showers
• Wheelchair ramps
• Back-up generators to ensure the continued function of medical equipment
• Widening of doorways

Medicaid may help pay for these modifications in some situations. Medicaid is a federal healthcare program; however, each state administers its own specific Medicaid plan. In New York, Medicaid will pay for home modifications if a person meets each of the following criteria:

• They are currently a Medicaid recipient
• They suffer from a disability or have substantial difficulties performing day-to-day tasks due to their age and
• They earn an income of less than 80 percent of the area’s median income

Of course, the applicant must also establish that they could benefit from the home modifications. Certain home modifications are not covered under Medicaid. Some of these, such as the installation of a swimming pool, may seem obvious. However, others may come as a surprise. For example, the following modifications are not covered:

• Any project requiring new construction
• The addition of a room to an existing structure
• Paved driveways
• Elevators
• Air conditioners
• Renovations of rooms designed to house physical therapy equipment

Qualifying for home modifications under Medicaid is not easy, and those who think they could benefit from a modification should consider reaching out to an elder law attorney for assistance. To learn more about how our dedicated team of attorneys can assist your family with its unique needs, call 914-684-2100 to schedule a no-obligation consultation today.

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