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Medicaid
It is important to realize that changes may occur in this area of law. This information is not intended to be legal advice regarding your particular problem, and it is not intended to replace the work of an attorney.

Medicare and Medicaid are two very different programs with names that sound alike. Medicare is a federal health insurance program for people over age 64 and people with disabilities. It has premiums, co-payments and deductibles. Medicaid is a government assistance program created to pay for health care for low-income individuals and families. You or someone you know may need Medicaid assistance to help pay for long-term care in a nursing home or other setting.

Medicaid helps pay for health care for people who have low income and limited assets. The Oregon Health Plan is a Medicaid program. Medicaid covers many items and services, including the full range of long term care. People who have Medicare coverage may also qualify for Medicaid. When they do, Medicaid may pay for the Medicare premiums as well as the deductibles, co-payments and health care not covered by Medicare.

Medicaid Eligibility
People who receive certain government benefits are automatically entitled to Medicaid. These include people who are over age 65 or disabled and who receive Supplemental Security Income (SSI) from Social Security. The income standard for SSI for one person is $637 and $956 for a couple per month in 2008. The asset limit for one person is $2,000, and $3,000 for a couple. Certain assets, including the person’s home (regardless of its value), one vehicle (regardless of its value if it is needed for work or medical purposes), clothing and household items, and a burial fund of up to $1,500 are exempt and are not counted in determining eligibility for SSI or Medicaid.

According to the state office for Seniors and People with Disabilities, the average cost for long term care is over $5360 per month. Few people can afford to continue paying that much for very long. People with higher incomes (up to three times the SSI standard, $1911 for one person in 2008) may qualify for Medicaid assistance if they need long term care in a nursing home, adult foster home, residential care facility, assisted living facility, adult day services program, or their own homes. A person whose income is over the Medicaid limit may still be able to qualify for assistance by creating a special type of trust, called a Medicaid income cap trust. The asset limit for someone who needs Medicaid for long term care is $2,000, the same as for SSI. The same assets are exempt for Medicaid purposes.

If you are facing long term care bills and think that you have too many assets to qualify for Medicaid, do not give your assets away. If you or your spouse gives assets away within the five years before you apply for Medicaid, you will not be eligible for assistance for some period of time, based on the value of what was given away. Certain transfers are permitted. Talk to an elder law attorney or another lawyer who has experience in this area. You may be able to keep some of the assets, or use them in a way that will benefit you and your spouse. If you are married, the Medicaid rules allow the spouse who does not need care to keep a share of the couple’s income. Generally, this is one-half of the total assets belonging to either or both the husband and the wife, up to $104,400 in 2008. The well spouse may also get a monthly allowance from the ill spouse’s income. The standard allowance is the amount needed to bring the well spouse’s gross income up to $1,750 per month (in 2008). If these amounts are not sufficient to cover the well spouse’s expenses, an attorney can explain the options that are available to increase the amount of assets or income or both.

How to Apply
You can apply for Medicaid through the local Area Agency on Aging, or Seniors and People with Disabilities office. Note that the eligibility worker can help you complete the application but is not able to advise you on what steps you (or your spouse) can take to avoid having the well spouse become impoverished.

Services Covered
Medicaid covers a broad range of services,including:

Medicaid does have limitations. First, most people who get Medicaid assistance have to join a health Maintenance Organization (HMO) or other managed care plan. The primary physician is responsible for deciding when his or her patients should get medical items or services. Second, the state has a list of treatment priorities. Treatment for certain medical conditions, those that are least likely to be helped by treatment, is not covered if the conditions are not within the current priorities.

Payment for Services
Medicaid pays the health care provider or managed care plan directly. There are no claim forms to complete. If you have Medicaid, you should tell the doctor or other health care provider before you receive treatment or other items or services. You may need to get a referral from your primary physician or prior authorization from your managed care plan. Health care providers are not allowed to charge you additional amounts for services covered by Medicaid.

People who are not eligible for SSI and who are not receiving long term care may have to pay monthly premiums and modest co-payments as part of the Oregon Health Plan. People who are getting long term care services will have to pay some or most of their income toward the cost of their care. The amount that each person pays depends on the setting in which the care is being provided, whether the person is single or married, and a number of other factors.

Estate Recovery
The state wants to be reimbursed for what it spends on the care for Medicaid recipients. But there are limits on what it can do and when it can do it. For example, the state cannot collect its Medicaid claim while the Medicaid recipient is alive or has a surviving spouse or a minor or disabled child living in the family home. After the spouse passes away, the state can make a claim against the spouse’s estate to collect whatever it could have collected from the estate of the Medicaid recipient. Oregon does not place a lien on the person’s home or on another piece of property. If you have questions about how estate recovery will affect your property, or if you have received a Medicaid claim from the state, contact a lawyer for advice.

Medicaid Denials and Appeals
You will receive a written notice from the Area Agency on Aging or the Seniors and People with Disabilities office if your application for Medicaid assistance is denied or if your benefits are being reduced or terminated. The notice will give the reason for the action, tell you which administrative rules are involved, and explain how to request a hearing. The hearings are held by administrative law judges who work for the state. The hearing may be in person at the local office or by telephone. You may want to have an attorney represent you at the hearing. You may be able to get representation through a legal aid office near you.

Managed Care Issues
Each HMO or managed care organization that serves people who receive Medicaid assistance has an Exceptional Needs Care Coordinator (ENCC). The role of the ENCC is to help people who are having difficulty getting the care they need through the managed care system. If you are having problems, ask your primary physician to help. If your primary physician is the problem, ask to change to another primary physician or contact the ENCC. If the problems continue, you may want to change to a different HMO. You may also be able to get information and advice from a legal aid office.

Legal editor: Sam Friedenberg, June 2008