Aged, Blind or Disabled (ABD) Medicaid

INTRODUCTION

Medicaid is a federal and state program that pays the medical expenses of people based on their financial need. The Georgia Department of Medical Assistance (the "DMA") runs the Medicaid program in Georgia, and the county offices of the Division of Family and Children Services ("DFACS") of the Georgia Department of Human Resources provide field services.

This Section discusses the 5 different types of Medicaid that senior citizens are most likely to use: general Medicaid, qualified Medicare beneficiary ("QMB"), specified low-income Medicare beneficiary ("SLMB"), ABD Medically Needy Medicaid, and nursing home Medicaid. In addition, the Section on At Home Care in this Website discusses community care Medicaid.

The eligibility requirements and the covered expenses are different for each type of Medicaid, as described below.

ELIGIBILITY

General Medicaid
You will be eligible for general Medicaid if you are eligible for Supplemental Security Income ("SSI"). You will also be eligible for general Medicaid if, after April, 1977, you received both SSI and Social Security benefits in the same month, but now you receive only Social Security benefits because those benefits increased to the point that your SSI ended. Eligibility under this provision is very complicated; so you should contact a lawyer or an ABD Medicaid Eligibility Specialist at the Department of Family and Children's Services (DFCS)if you believe that you might be eligible.

Qualified Medicare Beneficiary (QMB)
You will be eligible for a limited type of Medicaid, called "qualified Medicare beneficiary" ("QMB"), if you receive Medicare and your income and "countable" resources, or you and your spouse's combined income and "countable" resources, are less than certain amounts. QMB pays your Medicare premiums, copayments and deductibles. Please see the Section below called "Resources Counted for Medicaid" for information on countable resources.

For 2002, if you are single, you will be eligible for QMB if your gross monthly income is less than $716 and your countable resources are less than $4,000. Gross income is total income before Medicare Part B premiums are deducted. If you are married, you will be eligible for QMB if you and your spouse's combined monthly gross income is less than $968 and you and your spouse's combined countable resources are less than $6,000. The QMB income limits will increase if the federal poverty guidelines change.

Specified Low-Income Medicare Beneficiary (SLMB)
You will be eligible for a limited type of benefit, called "specified low-income Medicare beneficiary" ("SLMB"), if you receive Medicare and your income and countable resources, or you and your spouse's combined income and countable resources, are less than certain amounts. SLMB will pay your Medicare Part B premiums. Please see the Section called "Resources Counted for Medicaid" below for information on countable resources.

For 2002, if you are single, you will be eligible for SLMB if your gross monthly income is no more than $859 and your countable resources are less than $4,000. If you are married, you will be eligible for SLMB if you and your spouse's combined monthly income is no more than $1,161 and you and your spouse's combined countable resources are less than $6,000. The SLMB income limits will increase if the federal poverty guidelines change.

ABD Medically Needy Medicaid
You will be eligible for "adult medically needy," or "spend-down" Medicaid, if:

A. Your monthly income is less than $317; OR

B. 1.You meet the following eligibility requirements for Supplemental Security Income ("SSI"):

(a) You are age 65 or older; or your corrected vision is 20/200 or less; or you meet the disability test for Social Security benefits.

(b) If you are single your countable resources must not be more than $2,000. If you are married, you and your spouse's combined countable resources must not be more than $4,000. For an explanation of countable resources, see "Resources Counted Under Medicaid" in the next Section of this Website; AND

2. Your monthly medical expenses (including any nursing home expenses) are equal to or greater than your spenddown amount.

(a) If you are single, your spenddown amount is your monthly income minus $337;

(b) If you are married, your spenddown amount is the combined monthly income of you and your spouse minus $395.

The income and resource limits above apply for 2002.

For further detail on Adult Medically Needy eligibility, see §2151 of the Medicaid Manual at www.odis.dhr.state.ga.us.

Nursing Home Medicaid

You will be eligible for nursing home Medicaid if all of the following requirements are met:

1. You live in a nursing home that participates in the Medicaid program.

2. Your doctor certifies that you are in need of nursing home care.

3. You are at least 65 years of age, or you are blind or disabled.

4. You have a valid social security number and you are either a United States citizen, or a legal alien who entered the United States prior to August 22, 1996, or a qualified legal alien who entered thereafter.

5. Your income and "countable" resources, or the combined income and "countable" resources of you and your spouse, meet the applicable test described below:

a. If you are single, (i) your monthly income is not more than $1,635, and (ii) your countable resources are not more than $2,000.

b. If you are married but only you are a nursing home resident, (i) your monthly income is not more than $1,635, (ii) your countable resources are not more than $2,000, and (iii) your spouse's countable resources are not more than $89,280. If you will be applying for Medicaid, you will have one year to transfer any of your resources, like a joint bank account, to your spouse.

c. If you are married and both husband and wife reside in a nursing home, the income and resource amounts for an individual apply to each spouse.

The income limits above apply for 2002. They will change if the cost of living changes.

RESOURCES COUNTED FOR MEDICAID
"Resources" are cash and other items that can be easily changed to cash, like a bank account, personal property, real estate, and the cash value of a life insurance policy. For purposes of Medicaid, all resources are counted, except as described below:

1. The house you live in is not counted.

2. The value of any car is not counted.

3. A burial plot, casket, vault, payment for opening and closing of casket and vault, headstone, and up to $5,000 in a separate account designated for funeral expenses are not counted.

4. The value of household goods and personal items is not counted.

5. The cash value of any life insurance policy with a face amount of $5,000 is not counted.

6. The value of any "life estate" in real property is not counted.

7. Income-producing real property, promissory notes, or mortgages are not counted.

EXAMPLE: You are single and your resources are $600 in the bank, your house, your car, and household goods worth $3,700. Your resources counted for Medicaid are only the $600 in the bank. If you meet the other eligibility requirements, you will be eligible for Medicaid.

The Medicaid program has rules about transfers of resources, which could affect your eligibility for Medicaid. If you will be applying for Medicaid, you will have one year to transfer any of your resources, like a joint bank account, to your spouse. However, if you make any other transfer of resources for less than "fair market value" within 36 months before you apply, you may not be eligible to receive nursing home Medicaid. If you establish a trust within 60 months before you apply, the trust may be examined to determine if your nursing home Medicaid eligibility will be affected. You should contact a lawyer or an ABD Medicaid Eligibility Specialist at DFCS if you believe that a transfer of resources may affect your eligibility for nursing home Medicaid.

COVERED EXPENSES

General Medicaid
General Medicaid will pay the "Medicaid-approved" charge for most medical and surgical services and supplies that are approved by your doctor. Covered expenses include (1) hospital stays if prior approval is obtained from the DMA; (2) home health care; (3) family planning services; (4) psychological services; and (5) Medicare premiums, deductibles, and co-payment amounts. Because the Medicaid-approved charge is generally less than the actual charge, the hospital, doctor, or other health care provider may not participate in the Medicaid program. Thus, although you may choose your own hospitals, doctors, and other health care providers, you should be sure that they participate in the Medicaid program before you receive any services or supplies.

General Medicaid will arrange for non-emergency transportation to and from the nearest medical provider if you have no other means of transportation. You must call the nearest DFACS office in advance and request transportation to and from a medical provider. The DFACS office will assign a social worker to you, and he or she will tell you how the program works. If the DFACS office does not help you with transportation, you may want to contact a lawyer or legal services program.

General Medicaid will not pay for some medical services and treatments, like dentures, eyeglasses, hearing aids, certain drugs, and chiropractic services. Also, general Medicaid will not pay for more than 12 doctors visits per year, unless more are approved by the DMA, or for more than 5 prescriptions per month, unless prior approval from the DMA is obtained. Finally, general Medicaid will not pay any expenses that have been or will be paid by Medicare, private insurance, or any other source.

To check to see if a service or supply is covered by general Medicaid, contact the DMA before you receive it. Also, if you receive a medical bill from a doctor, hospital or other care provider, and you think that the bill should have been paid by general Medicaid, contact the DMA, a lawyer, or a legal services program.

Qualified Medicare Beneficiary (QMB)
QMB will pay only your Medicare premiums, deductibles and co-payment amounts.

Specified Low-Income Medicare Beneficiary (SLMB)
SLMB will pay only your Medicare premiums.

ABD Medically Needy Medicaid
Adult Medically Needy Medicaid (or spend-down Medicaid) will pay your medical expenses (including any nursing home expenses) that are more than your "spend-down amount" during your "budget period" after you become eligible. Although Adult Medically Needy Medicaid will pay your eligible expenses, it will not reimburse you for these expenses if you have already paid them. Medicaid will only reimburse approved providers.

If you are single, your "spend-down amount" is your monthly income minus $337. If you are married, your spend-down amount is the combined monthly income of you and your spouse minus $395. The $337 and $395 amounts apply for 2002.

In Adult Medically Needy Medicaid, the review period (for determining eligibility) is generally for 6 months, beginning with the month of application. Each month of the 6 month review period is a separate budget period, and eligibility is determined for each month individually. The review period begins on the first day of the month in which the application is filed and runs through the last day of the sixth consecutive month.

EXAMPLE: You are single and have monthly income of $537 from Social Security, and you meet the eligibility requirements for SSI, except the adjusted income test. You have applied for Adult Medically Needy Medicaid. Provided you have no prior unpaid medical expenses, your spenddown amount is $200 ($537 minus $337).

On July 1, your Medicare premium of $100 is due, and on July 2, you have $50 worth of prescription medicines. You now have met $150 of your $200 spenddown amount. On July 5, you are taken to the Emergency Room and incur $500 worth of expenses. On this day, you have met your monthly spenddown amount when $50 of the emergency room expense is added to the prior expenses. Thus, Medicaid will pay $450 of the emergency room bill and will cover any other medical expenses incurred in the remainder of July. In August however you must once again meet your spenddown amount before Medicaid will begin paying your medical expenses.

Adult Medically Needy Medicaid will pay the Medicaid-approved charge for medical expenses that are covered by general Medicaid. You can choose your own hospitals, doctors, and other health care providers, but you should be sure that they participate in the Medicaid program before you receive any services or supplies.

For further details on Adult Medically Needy Medicaid, refer to §2151 of the Medicaid Manual at www.odis.dhr.state.ga.us .

Nursing Home Medicaid
Nursing home Medicaid will pay the difference between the "Medicaid-approved" monthly billing rate for a Medicaid-participating nursing home and the "resident's liability." Nursing home Medicaid also will pay the medical expenses that general Medicaid pays.

The "resident's liability" is the resident's monthly income less the deductions described below:

1. $30 as a personal needs allowance.

2. The amount of the resident's medical expenses not covered by general Medicaid.

3. Health insurance premiums paid by the resident.

NOTE: If a resident has medical expenses not covered by general Medicaid, the resident must file a claim with the DFACS office for the county in which the home is located. If the resident does not file a claim, the expenses will not count in determining the resident's liability. The time period to file a claim is very short; so the resident should contact a Medicaid caseworker immediately after the date of those expenses.

4. If the resident has a spouse who does not live in a nursing home and whose monthly income is less than $2,232, then in that event an amount not greater than the difference between $2,232 and the spouse's monthly income can be given by the resident to the spouse, and deducted from the resident's monthly income. This is called diversion of income.

NOTE: The maximum amount permitted the community spouse may be increased in cases of exceptional circumstances resulting in significant financial duress. A request for fair hearing should be filed through DFACS to receive an increase in the minimum monthly maintenance needs allowance.

When a resident applies for nursing home Medicaid, he or she may fill out a Statement of Intention form that says how much he or she will give to the at-home spouse each month.

If both a husband and wife reside in a nursing home, the individual income and resource limits apply to the couple.

The income limit for diversion of income applies for 2002. It will change if the cost of living changes.

EXAMPLE: Mr. Collins is a resident in a nursing home with a Medicaid-approved monthly billing rate of $2,000. He has monthly income of $1,000 from Social Security, and his at-home spouse has monthly income of $1,400. Mr. Collins has signed a Statement of Intention form saying that he will give $832 a month to his spouse to bring her income up to $2,232. In August, he does not have any medical expenses not covered by Medicaid.

To determine Mr. Collins resident's liability for August, deduct from his $1,000 income his $30 personal needs allowance and the $832 he gives to his spouse. The difference is $138, which he must pay to the nursing home for August. Nursing home Medicaid will pay the remaining balance of $1,862 due the nursing home.

PERSONAL NEEDS ALLOWANCE
If (1) you enter a hospital, nursing home or other health care facility, (2) Medicaid starts paying over 50% of your expenses, and (3) your monthly income is $30 or less, you will receive a monthly check from the Social Security Administration as a "personal needs allowance." The check will equal $30 minus your monthly income. Your Medicaid caseworker can help you get your personal needs allowance.

HOW TO APPLY FOR MEDICAID
If you are eligible for SSI, you do not have to apply for general Medicaid. You will be enrolled the same day that you are enrolled for SSI. If you are not eligible for SSI, you must apply for general Medicaid. Whether or not you are eligible for SSI, you must apply for all other types of Medicaid.

To apply for general Medicaid, QMB, SLMB or spend-down Medicaid, you (or your representative) should go to the DFACS office for the county in which you live. To apply for nursing home Medicaid, you (or your representative) should go to the DFACS office for the county in which the nursing home is located. If you cannot get to the DFACS office and no one can go for you, you may request that an application be mailed to you and that a Medicaid caseworker come to your home. However, if possible, you (or your representative) should go to the DFACS office.

WHEN ENROLLMENT IS EFFECTIVE

General Medicaid
If you have to apply for general Medicaid, your enrollment will be effective when you apply. Whether you are automatically enrolled for general Medicaid or you apply for it, you may request that general Medicaid pay your unpaid medical bills for the time period starting on the first day of the third month before the date you were enrolled. If you were eligible for general Medicaid during that time period, general Medicaid will pay the unpaid bills.

QMB of SLMB
Unlike other classes of Medicaid which permit eligibility up to three months prior to the date of application, enrollment for QMB will only become effective the month following the month of your case's determination. SLMB, however, does permit eligibility up to three months prior to the date of application.

ABD Medically Needy Medicaid
Eligibility for Adult Medically Needy or "spend-down" Medicaid is calculated each month for all applicants including nursing home residents. The amount of $337 is subtracted from an applicant's countable monthly income to determine how much the applicant will have to spend on medical expenses before he is eligible for Medicaid. The difference between a person's countable income and the Medically Needy income limit (MNIL) is called the spend-down amount. Once incurred medical bills equal the spend-down amount, a person is eligible for Medicaid to pay Medicaid covered medical bills incurred after the spend-down amount is reached. The applicant is responsible for paying bills incurred prior to meeting the spend-down amount. Before a medical bill will be paid under the spend-down program, the bill must be either unpaid or paid within the same period for which the spend-down application was filed. The bill does not have to be incurred in the same month the application is filed; it must only be owed during the application period.

Nursing Home Medicaid
Enrollment for nursing home Medicaid will be effective after you have been in the nursing home for 30 continuous days. However, nursing home Medicaid will pay for those days.

PROOF OF ENROLLMENT
For each month that you are enrolled for general Medicaid QMB, or SLMB, your local DFACS office will send you a notice you can use to prove you are enrolled. If you are enrolled for spend-down Medicaid, your local DFACS office will send you a form showing the beginning date of your enrollment.

APPEALS
If the DMA denies your enrollment in the Medicaid program, denies your coverage for a particular service, or makes another decision with which you disagree, you have the right to appeal the decision and request a hearing. You must request a hearing at your local DFACS office. There is only a short period of time in which to appeal a Medicaid decision. You may need to contact a lawyer or a legal services program for advice about whether to appeal a Medicaid decision and for representation during the appeal.

RESOURCES AND LINKS
Medicaid

1. For general information and questions call
- Department of Medical Assistance at 1-800-282-4536 or (404) 656-4479

- Georgia Senior Legal Hotline at 1-888-257-9519 or e-mail your questions to seniorlegalhotline@yahoo.com.

2. To review the Georgia ABD Medicaid Manual of Regulations, click on www2.odis.dhr.state.ga.us. Then go to Index, click on Family & Children, then Medicaid, and then Man3480.

3. For information about Medicaid and for assistance with coverage issues, call HICARE (Health Insurance Counseling Assistance and Referral for the Elderly) at 1-800-669-8387 or (404) 463-3350. Or contact www.hicare.state.ga.us

4. For information about at-home care provided by Medicaid under the Community Care Services Program,
- contact www.communityhealth.state.ga.us Click on "Medicaid," then on "Home & Community Based services." OR log on to www2.state.ga.us. Click on "Health and Human Services," then "Aging Services," then "Community Care Services Program."

5. For assistance in determining a person's eligibility for Medicaid, call the Georgia Division of Aging at (404) 657-5258, or the Georgia Senior Legal Hotline at 1-888-257-9519 or e-mail at www.seniorlegalhotline@yahoo.com .

6. For general questions about Medicaid, call the Aging Connection with the Atlanta Regional Commission at (404) 463-3333. Or log on to www.agingatlanta.com

7. For information about eligibility for the major groups within Medicaid, (SSI, Nursing Home Medicaid, QMB, etc.) log on to www.communityhealth.state.ga.us. Then hit "Medicaid", then "Eligibility Criteria."