The Medicare and Medicaid Eligibility Requirements

The long-term healthcare industry is changing and so are Medicare and Medicaid eligibility requirements. Here is an overall summary of Medicare and Medicaid eligibility for Texas Long-Term Care coverage. There are exceptions throughout this process, so please consult with one of our highly trained employees to discuss your specific circumstances.

Medicare: What is it?

Medicare Part A is a federal health insurance program that guarantees access to health insurance for Americans aged 65 and older who have worked and paid into the system. Younger people with certain disabilities are also eligible to receive Medicare regardless of income.

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Medicare Part A: How do I qualify for Skilled Nursing Facility (SNF) Care in a Long-Term Care facility?

• Must have a 3 consecutive night inpatient hospital stay.

• Must require skilled nursing or therapy services on a daily basis.

• Meet with a facility Business Office Manager to verify SNF benefits available.

Medicare Part A: What to expect after qualifying for SNF benefits.

• If you or your loved one qualifies for SNF benefits, Medicare pays for up to 100 days of SNF care.

  • The first 20 days of care are covered by Medicare at 100%, as long as any Medicare days haaven't already been used within the last 60 days.

  • After the first 20 days a copay will be required.

• After 20 days there is a copay of $157.50/day (set by medicare). *Medicare increases this copay every January. Please confirm the accurate rate with the Business Office Manager at the facility.

• Medicare doesn't pay for private rooms. There is an additional fee associated. If you are interested in a private room please consult a facility Business Office Manager.

Note: It is extremely important to consult with the facility Business Office Manager to assess your specific circumstances and needs.

Medicaid: What is it?

Medicaid is a joint federal and state program that helps low-income Americans pay for long-term care. Medicaid eligibility for Long-Term Care is determined by State of Texas, not by the facility.

Medicaid: How do I qualify?

• Must be a resident of Texas and U.S. citizen or alien with approved status (e.g., legalized or permanent resident alien).

• Must be a patient in a Medicaid-contracted long term care facility for 30 consecutive days.

• Additionally financial and medical necessity requirements must be met.

Medicaid: Medical Necessity Requirements.

• You or your loved one, must require the care of a skilled nurse on a daily basis in order to meet medical necessity requirements. Some examples include:

  • Complex wound care

  • IV therapy

  • Diagnosis of Legal Blindness

  • Cognitive deficits such as Alzheimer's Disease or Dementia

  • Seizure Disorder

  • Other care that requires a skilled nurse daily

• Custodial care, such as assistance bathing, toileting, eating, mobility alone does not meet medical necessity requirements.

Income as of 2014

• Maximum gross income

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• What counts as income?

  • Social Security Benefits

  • Certain Veterans Benefits

  • Private Pensions

  • Interest & Dividends

  • Royalty & Rental Payments

  • Federal Employee Annuities

  • Railroad Benefits

  • State & Local Retirement Benefits

  • Gifts & Contributions

  • Earnings & Wages

Resources as of 2014

• Maximum countable resources

  • Individual - $2,000

  • Couple - $3000

• What is a resource?

  • Bank Accounts & CDs

  • Real Estate Property

  • Life Insurance Policy Cash Value

  • Burial Funds

  • IRA

  • Stocks & Bonds

  • Oil/Gas/Mineral Rights

  • Jewelry & Antiques

  • Cars & Other Vehicles

  • Boats & Recreational Vehicles

• What can be excluded?

  • Homestead where the individual intends to return.

  • Life insurance if the face value is $1,500 or less

  • Separately identifiable burial funds of $1,500 (less any excluded life insurance or irrevocable arrangement for burial)

  • Car, regardless of value

  • Burial spaces

• Protected resources amount for a spouse in the community

  • $23,844 Minimum - $119,220 Maximum (Excludes value of homestead, household goods, personal goods, one car, and irrevocable preneed burial funds). Assets are only protected for 1 year. Within that year the assets can be transferred to only the spouse with no penalties.

Meet with a facility Business Office Manager to complete Medicaid Application and discuss your specific situation. The following items are will need to be provided when completing a Medicaid Application:

• Bank records from the current and past three months

• Life insurance policies (Include Cash Values and policies of spouse)

• Proof of income (Awards letter showing gross and net amounts received)

• Property information (land titles, vehicle titles, etc.)

• Wage garnishments

Note: Medicaid eligibility requirements for a long-term skilled facility is not the same as community Medicaid requirements.

Medicaid: What to expect after qualifying?

• You or your loved one’s income will be applied towards care received at the long term care facility with the exception of a Personal Needs Allowance that is determined by the Texas Medicaid Program.

• Individual

  • Total gross income less $60 for personal needs.

• Individual with a spouse in the community:

  • Total gross couple income less $60 for personal needs, less $2,980.50 for community spouse, less certain amount for dependents living with community spouse.

• Couple

  • Total gross income, less $120 for personal needs.