Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Financial Criteria


  • Two groups are financially eligible for waiver services:

    • Group A includes individuals eligible for SSI, or who have incomes no higher than the SSI/SSP level.

    • Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which was $1,656.

  • Asset limits for both groups are $2,000 for an individual and $3,000 for a couple if both are receiving services. When only one spouse applies and the spouse resides in the community, spousal impoverishment protections apply.

  • The state does not allow spend-down to HCBS waiver eligibility levels but does allow excess income to be placed in Miller trusts. An individual places all their income in the trust, which is a conduit for all spending on behalf of the individual. The trust provides the individual with a personal needs allowance, and pays room and board and any other allowable expenses based on rules for determining cost sharing responsibility. Any remaining money must be spent on the cost of care. If the amount is insufficient, Medicaid pays the balance.

  • Even if there are sufficient funds in the trust to pay the full cost of long term care services, the person is still eligible for Medicaid state plan services. However, if the funds in the trust at any point in time equal or exceed the cost of one month's stay in a nursing home ($4,300 in 2003), the person will no longer be eligible for Medicaid.

  • For persons in Group B, there is a cost sharing requirement. The share of cost is calculated by subtracting the following amounts from the monthly income of the person receiving care:

    • Personal needs allowance of $553.70, which is the protected monthly income for individuals receiving waiver services (SSI $552 + the state supplement of $1.70);

    • At-home spouse income allowance and dependent family allowance;

    • Incurred medical and remedial care expenses not paid by Medicaid or a third party. Remedial care includes medical costs recognized under state law, but not covered under Medicaid, such as dentures.

  • The remaining income, if any, must be paid toward the cost of care.
  • Residents of assisted living facilities are permitted to retain $104 as their Personal Needs Allowance, leaving $449.70 for room and board costs, the maximum that a facility can charge a Medicaid-eligible resident.

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