Medicaid Eligibility & Coverage for Individuals 65 and Over or Disabled

Note: This is a general description of a complex program. It contains only basic information. Many rules and circumstances affect eligibility. The information is current as of February, 2009, but can change at any time. If you have a question or want more information, contact the Senior Citizens Law Project (SCLP) of Vermont Legal Aid at (800) 889-2047.

What is Medicaid?
How Can I Qualify for Medicaid?
How Does Medicaid Differ from Medicare?
Can I Have Both Medicaid and Medicare at the Same Time?
What is the Medicaid Income Limit?
Can I Qualify for Medicaid if I Have Too Much Income?
How Can I Qualify for Medicaid if I Have Too Much Income?
What is the Medicaid Resource Limit?
Is Everything I Own Counted Toward the Medicaid Resource Limit?
Are There Limits on the Value of Some Non-Counted Resources?
Do I Have to Use My Excess Resources for my Care?
If I Give Away Property or Assets, Will I Be Eligible for Medicaid?
What Services Does Medicaid Cover?
Do I have to get a Service Pre-Approved by Medicaid?
What do I have to pay for if I am on Medicaid?
Does Medicaid Help with Medicare Costs?
What can I do if I disagree with a Medicaid decision?
How can I get more help?

What is Medicaid?
Medicaid is a state program of medical assistance based on financial need.

How Can I Qualify for Medicaid?
The income and resources of you and your spouse must be within Medicaid limits. Income includes pensions, Social Security, VA benefits and earnings. Resources include property, vehicles, bank funds and investments.

How Does Medicaid differ from Medicare?
Medicare is a federal program which insures those who qualify to receive Social Security benefits. It is not based on need. Medicare has monthly premiums, co-payments and deductibles. Premiums are usually taken out of your Social Security check but can be paid by Medicaid if your income is below $1,223, or $1,646 for a couple. (For more information, see Does Medicaid Help with Medicare Costs? below).

Can I have both Medicaid and Medicare at the same time?
Yes, you can be covered by both programs or dual eligible. Medicaid covers more services than Medicare and pays for some services that are not covered by Medicare, such as long term care. Medicaid can also pays some of your Medicare costs, such as premiums, co-payments and deductibles. (For more information, see What Services are Covered if I am eligible for Medicaid? below).

What is the Medicaid income limit?
$991 in Chittenden County and $916 in every other county. This amount is protected for the non-medical needs of you and your spouse. It is called the Protected Income Level, or PIL.

Can I Qualify for Medicaid if I have Too Much Income?
Yes. Even if your income is more than the PIL, Medicaid can pay for some of your medical expenses so that you do not have to live on less income than the PIL.

How Can I Qualify for Medicaid if I have Too Much Income?
You can qualify for Medicaid by spending down your excess income on medical and remedial expenses for you or your spouse. Such expenses include health insurance premiums, deductibles, co-payments and uncovered medical items or services, over-the-counter items and past bills.

What is the Medicaid resource limit?
$2000 in countable resources for an individual; $3,000 for a couple living together. Resources that count include cash, savings, bonds, CD's, stocks, mutual funds, bank accounts, non-home real property such as a separate parcel of land or a camp.

Is Everything I Own Counted toward the Medicaid Resource Limit?
No. Many resources such as your home, household items, personal property, automobiles and burial funds are NOT counted. More resources are excluded if you qualify for long-term care. For example, the spouse of a long-term care beneficiary can keep $101,640.00 in countable resources. Also, you can keep up to $30,000 to pay for additional services or to make modifications to your home to allow you to stay there. This is called a "contract for care" and you will have to sign a contract with the Department to keep that money. (For more information, see Long-Term Medical Care in Nursing Homes, Residential Care Homes, or in Your Home). Note: Whether resources are counted or not is complicated. Many resources are excluded. Also, countable resources can be spent down or converted to excluded resources. If you have excess resources, you should talk to a lawyer familiar with Medicaid law for help planning what to do. If you are over 60, you can call the Senior Citizens Law Project for help with Medicaid planning at (800) 889-2047.

Are There Limits on the Value of Any Excluded Resources?
Yes. A few resources not counted by Medicaid have limits. You and your spouse can keep up to $10,000 each in separate burial funds. If you qualify for long-term care, the equity value in your home must be less than $500,000.

Do I Have to Use My Excess Resources for my Care?
No, not unless you want past care covered by Medicaid during the 3 months before the month you apply. Otherwise, you can spend your excess resources on bills, debts, resources that are not counted such as a home, a car or burial expenses, or on goods or services. It is also possible to give away excess resources in some circumstances. (For more information, see If I Give Away Property or Assets, Will I Be Eligible for Medicaid? below).

If I Give Away Property or Assets, Will I Be Eligible for Medicaid?
Yes. You can still be eligible for coverage if you give away property or assets. However, you may be disqualified for some long-term care services. The period of disqualification is based on how much you gave away. see Long-Term Medical Care in Nursing Homes, Residential Care Homes, or in Your Home). NOTE: Medicaid long-term care transfer penalties are covered separately. Although gifting property or assets will not make you completely ineligible for Medicaid, you could need long-term care services in the future and should be aware of the possibility of transfer penalties.

What Services Does Medicaid Cover?
Medicaid pays for medically necessary services by hospitals, physicians and other providers, rural health clinic and federally qualified health center services, long-term care, home health, physical and other therapies, X-ray and laboratory, medical supplies and equipment, ambulance and transportation. It also pays some dental and prescription costs. Recent exclusions due to state budget cuts are dentures, chiropractic and eyeglasses.

Do I have to get a Service Pre-Approved by Medicaid?
Some services require prior authorization, or prior approval, before Medicaid will cover. This is to make sure that the service is medically needed, that less expensive alternatives have been considered and that the service conforms to the accepted practices. A written request for prior approval must be filed. Your provider usually makes the written request and sends the necessary documentation.

Do I have to Pay Anything if I am on Medicaid?
Yes. Medicaid has some cost-sharing requirements. These are:

• $1.00 - $3.00 prescription co-pay if you do not have Medicare Part D prescription coverage;
• $1.00 - $5.60 co-pays if have you have Medicare prescription coverage;
• $3.00 dental co-pay for each visit;
• $3.00 co-pay for each outpatient hospital visit; and
• $75.00 per inpatient hospital admission.

Does Medicaid Help with Medicare Costs?
Yes, this is called Medicare Cost Sharing. Your Medicare Part B premium can be paid by Medicaid if your income is below $1,223, or $1,646 for a couple. Medicaid can also pay your Medicare deductibles and co-insurance if your income is below $906 for 1; $1,220 for a couple.

What can I do if I disagree with a Medicaid decision?
You can appeal any Medicaid decision which denies, reduces or terminates coverage. You can even appeal if there is a delay in making a decision. You should be given a written notice of the decision with information on how to appeal. If you already receive Medicaid, coverage should continue while your case is under review if you appeal before the date your notice says coverage will stop.

How can I get more help?
The Senior Citizens Law Project (SCLP) of Vermont Legal Aid will help seniors with questions about Medicaid. You can call Vermont Legal Aid at (800) 889-2047. There are additional rules that may apply to your situation. You can find more information on the Vermont Medicaid program at: http://www.greenmountaincare.org/about/green_mountain_care_programs.html