MEDICAID BENEFITS (NJ)
What is it?
Federal program to assist paying for long term care: (a) community Medicaid - living at home, (b) assisted living facilities (ALF), (c) nursing home (LTC-SNF) (d) certain Adult Day Centers, for 65 and older applicants (aged, blind and disabled).
Two types of eligibility: (1) Clinical and (2) Financial
Clinical Eligibility - Do you need help with activities of daily living?
If you are at home the family needs to contact the Office on Aging in their county to have a nurse from the State do a Pre- Admission Screening (PAS evaluation). A nurse from the agency will come out to assess the applicant to determine whether they are eligible for Medicaid clinically.
If the applicant lives in an Assisted Living (ALF), the ALF is responsible for sending out a referral to the state (AL-6 form) to the Office of Community Choice Options for a State PAS nurse to come out and evaluate the applicant.
In a Nursing Home Skilled Nursing or Long-Term Care center (SNF/LTC) the facility also has the responsibility of sending the referral form (LTC-2 form) to OCCO for the nurse to come.
Nurses must show up (usually) within 30 days of the request but there are times the State is backed up.
The end result is the PAS which indicates if the applicant has a "nursing home level of care need" (applicable even if they aren't in SNF) – this eligibility is good for 1 year.
Financial Eligibility – How much money can I keep?
For a single person - assets cannot exceed $2000 individually on the 1st of each month (last day of each month balance cannot exceed $2000)
Couples filing together cannot have an asset of more than $3000 monthly combined.
Income limit currently is $2,901 a month in NJ.
Income over $2,901 filter into a Qualified Income Trust bank account (QIT) - that money can be used for very specific expenses such as medical expenses that Medicaid doesn't cover, and insurances (premiums).
If applicant is married – the applicant is called the institutionalized spouse (IS) and the resource limit is $2000, the healthy spouse is called the community spouse (CS) and can’t have more than $157,920 but doesn’t have to go lower than $31,584 (poverty limit). This is called the CSRA – Community Spouse Resource Allowance. Please note that you can only keep up to $157,920 if your total assets are over $316,000.
What is the Medicaid look-back?
Medicaid caseworkers review all asset statements going back 5 years (60 months of statements for each account) from your month of application. For example, if they file the application with the County Board of Social Services on 1/1/25 then you will need to supply statements for all assets owned and opened from 1/1/20 to the closing or current month.
Caseworkers reviewing the 5 years of statements are for looking for gifts to friends and family members, transfers not made for value and other assets not disclosed to them when applying for benefits (when looking back at financial statements).
What is the Penalty Divisor?
The current penalty divisor is $440.10 daily or $13,423.05 monthly – THIS changes every Spring. It is based on the average cost of a month at a nursing home.
The penalty divisor will be imposed on the total of ALL gifts or transfers made ‘not for value’ in the look-back period.
A gift can be in many forms such as cars, houses, cash, life insurance, paying for family member's bills and/or vacations.
If the applicant gifted $100,000 to someone other than their spouse or disabled child, then Medicaid will impose a penalty of 227 days or 7.4 months = $100,000 / $440.10 or $100,000/$13,423.05. This means for 7.4 months (227 days) the benefit from Medicaid will be postponed or delayed until the penalty period is expired. Once the penalty period expires Medicaid will begin paying for care.
What is the Cost share (co-pay)?
Once you are approved for Medicaid benefits you are responsible for a cost share (co-pay) each month. If you are single and are living in your home with income less than $2901, you can keep all of your income. If your gross income is over $2901, you must send the excess income over $2901 to Trenton via a Qualified Income Trust bank account each month.
If you are living in an assisted living facility or a nursing home, you must turn over all your income with the exception of the cost of your health insurance and a small personal needs allowance (PNA). This year the PNA in an assisted living facility is $143.65 per month. In a nursing home the PNA is $50 per month.
Medicaid prepares this cost share worksheet once you are approved for the benefit.
What is the yearly redetermination (renewal)?
Each year Medicaid will send out a redetermination/renewal.
Your income and your health insurance premiums go up each year, unless it is a fixed amount, and the County Medicaid office needs to update the cost share worksheet.
Each December you will receive a Statement of Social Security Benefits detailing your social security income for the upcoming year.
Each January you will need to request a monthly premium statement for your health and RX insurance.
If you have a QIT, you will need to supply a year of statements with copies of checks over $1000 for the renewal.