Laurie Hanson
Attorney at Law
Long, Reher & Hanson, P.A.
Minneapolis, Minnesota
952-929-0622
©October 29, 2007
TABLE OF CONTENTS
I.INTRODUCTION...... 1
II.FEDERAL PROGRAMS...... 1
- Medicare...... 1
- Veterans Benefits...... 1
III.FEDERAL/STATE PROGRAMS...... 2
- Medical Assistance (Medicaid)...... 2
- Medical Assistance For Employed Persons With Disabilities...... 3
- Medicare Savings Programs
- Qualified Medicare Beneficiary (QMB)...... 3
- Service Limited Medicare Beneficiary (SLMB)...... 4
- Qualified Individual...... 4
- Qualified Working Disabled Adults...... 4
- Medical Assistance Waiver programs...... 4
1. Elderly Waiver (EW)...... 4
- Community Alternative Care (CAC)...... 5
- Community Alternatives for Disabled Individuals (CADI)...... 5
- Mental Retardation or Related Conditions (MR/RC)...... 6
- Traumatic Brain Injury (TBI)...... 6
IV.STATE PROGRAMS
A. General Assistance Medical Care (GAMC)...... 8
B. MinnesotaCare...... 8
C. Minnesota Comprehensive Health Association (MCHA)...... 9
D. Group Residential Housing (GRH)...... 10
E. Alternative Care (AC)...... 10
F. MinnesotaVeterans Home...... 11
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Appendix A. Case Scenarios 12
LONG, REHER & HANSON, P.A.1 MINNESOTA ELDER LAW ATTORNEYS SM
I.iNTRODUCTION
This outline is a survey of the public programs available to individuals to cover the cost of medical care. Determining which program is the right for your client canbe tricky – eligibility can depend upon, among other things, the client’s age, financial situation, medical needs, residency, work history, and/or whether or not the client has been determined “disabled”by the Social Security Administration or the State Medical Review Team. Some programs are available only to veterans and their spouses, others to those who are disabled and in need of an institutional level of care.The purpose of this outline is to give the practitioner an overview of each program along with statutory and program manual citations where relevant. The material presented in this outline is current as of July 1, 2007.
II. FEDERAL PROGRAMS
A. Medicare 42 U.S.C.A.§ 1395et. seq. 42 CFR Part 400.
1. Basic Eligibility and Coverage: Medicare is an insurance program that provides health care coverage to individuals eligible to receive Social Security and Railroad Retirement benefits who have reached age 65. People who are younger than 65 are eligible for Medicare if:
- They have received Social Security Disability benefits for 24 months; or
- Are eligible to receive Social Security disability benefits and have ALS or chronic kidney disease (no 24-month waiting period).
It includes Medicare Part A which provides hospital, skilled nursing home, home health care, and hospice benefits; Part B which pays for physicians' services, durable medical goods, home health care, ambulance services, etc.; Part C –Medicare Advantage- which broadens options for providers and services; and Part D which covers prescription drug benefits. For a more complete listing see 2007 Health Care Choices for Minnesota Seniors published (each year) by the Minnesota Senior Federation. It is also on their website at
2.Medicare Supplemental Policies. In Minnesota, private insurance companies sell five types of policies to supplement Medicare coverage: a Basic and Extended Basic policy; and Medicare Select, Medicare Cost, and Medicare Advantage HMO plans. Generally, people purchase policies to cover the deductibles and co-payments, including the co-payments for days 21-100 in the nursing home. Some plans cover services not covered by Medicare, such as prescription drugs. As a general rule, if Medicare does not cover the service, the supplemental policy does not cover the deductible, co-payment, or service. For a more complete discussion of Medigap and Medicare Advantage plans see 2007 Health Care Choices for Minnesota Seniors
B. Veterans Benefits38U.S.C.A. §§ 1701et seq.; and 38 CFR §§ 17.43 et seq.
1.Veterans Health Care Benefits. To receive health care from the VA, veterans must be “enrolled.” For veterans with service-connected disabilities, enrollment is automatic. Others must enroll, and enrollment is controlled by the VA to fit the resources available from Congressional appropriations.[1]The VA’s standardmedical benefit’s package is available to all enrolled veterans. This plan emphasizes preventive and primary care, and offers a full range of outpatient and inpatient services within VA health care system. It includes prescription drugs. The reader is referred to the Veterans Health Benefits and Services web site at: for further information on enrollment, eligibility, and coverage.
2.Aid-and-Attendance or housebound benefits for veterans 38 U.S.C.A. § 1521(d)(e); 38 U.S.C.A. § 1541(a)(e). Aid-and-Attendanceis a monthly income benefit available to veterans or to widows or widowers of veterans who require care in a long-term care setting. Aid and Attendance benefits may also be available to veterans who reside outside of a nursing home, but who require daily assistance to live independently. This benefit is means-related and is available only to veterans or widows of veterans who have limited assets. Generally, assets must not exceed $50,000 and income must not exceed $1,500/month to be eligible. Each County has a County Veterans Service Officer who may be contacted for information about all Veterans benefits.
3.Veterans Hospitals: The Veterans Hospital in St. Cloud provides extended care rehabilitation services and skilled nursing care to veterans, although the service is limited. There are only 28 beds and the facility is not for permanent placement; rather it is for rehabilitation and care until a community placement can be found. If a community placement is available, the veteran will not be able to reside at the VeteransHospital. Payment is based upon disability status and need. If the veteran has a permanent disability that’s 70%-100% service connected and needs nursing facility care, there is no cost to the veteran. If the disability is 50% service connected, then the veteran will have some financial obligation. If there’s no service connection, they look at the income and assets of the veteran to determine the daily rate. As of September, 2004, the most a veteran would have to pay was $97 per day.
III. FEDERAL/STATE PROGRAMS
A.Medical Assistance (Medicaid).[2]
Medicaid is a state and federal program that provides health care coverage for financially eligible Minnesota residents who are either: under 21, 65 or over, a parent or caretaker of a dependent child, a pregnant woman, or certified blind or disabled.[3] Each state has its own Medicaid Program. In Minnesota, the Medicaid Program is called Medical Assistance. Medical Assistance pays for most medically necessary services, including prescription drugs, home health care and long-term care services.[4] Both federal and state laws govern medical assistance. See 42 U.S.C. § 1396a, et. seq., and Minn. Stat. §256B. The Minnesota Department of Human Services (MDHS) is responsible for administration of the Medical Assistance program. The MDHS issues an extensive health care programs manual (HCPM) to county financial workers that contains instructions for Medical Assistance and several other health care programs administered at the county level. It also publishes instructional bulletins. The manual and these publications can be found on the web at
At the federal level, Medicaid is administered by the Centers for Medicare and Medicaid Services (CMS – a division of Health and Human Services. The regulations interpreting the federal regulations can be found at 42 CFR § 430, et.seq. Below is a brief summary of asset and income limits for elderly and disabled individuals.
1.Asset limits: To be eligible for MA, the MA recipient is limited to $3,000 in available assets[5]. A married couple, both of whom are applying for MA, is limited to $6,000 in available assets. Minn. Stat. § 256B.056, subd. 3. For a married couple where only one spouse is applying for MA and that spouse resides in a nursing home or is receiving services under the Elderly Waiver program, spousal impoverishment rules apply and the spouse in the community will be allowed to retain one half of the couple’s assets subject to a minimum and maximum amount. Minn. Stat. § 256B.059. The maximum and minimum limits of $101,640 and $28,589 are increased as of January 1 of each year based on the Consumer Price Index, and the increased amounts are used for those individuals who apply for MA on or after January 1 of that year.
2.Income standards for the elderly, blind, or disabled residing in the community and not receiving long-term care services. One-person household: The income limit is 100% of federal poverty guideline standards (FPG)[6], currently $851 per month. People with income over 100% of FPG may be eligible by spending down to 75% of FPG, currently $639. In other words, they can pay a "deductible" (for medical costs) equal to the amount by which their countable income exceeds $639.Two-person household: The income limit for a household of two is currently $1,101 per month. People with income over 100% of FPG may be eligible by spending down to 75% of FPG, currently $857. These figures change on July 1, each year.
3.Income standards for individuals residing in a long-term care setting: A resident of a long-term care facility must pay all of his/her income to the nursing home less allowable deductions including a $82 personal needs allowance ($90 for certain veterans and spouses of veterans) and an allowance for payment of medical insurance premiums. Further, a community spouse is entitled to a spousal allocation to bring his or her income to $1,712/month, or up to $2,541 if shelter costs are greater than $514 per month. MA pays the rest of the long-term care costs.
B. Medical Assistance for Employed Persons with Disabilities (MAEPD). Minn. Stat. §256B.057, subd. 9.
1.Coverage: Eligible individuals receive all Medical Assistance covered services, including long-term care services.
2. Basic Eligibility: Individuals between the ages of 17 and 65 who are certified disabled by the Social Security Administration or by the Minnesota State Medical Review Team and who earn more that $65.00 each month may pay a premium which is a percentage of earned and unearned income and remain on Medical Assistance.
2.Asset limit: Available assets may not exceed $20,000; income and assets of a spouse are not included and all retirement accounts and medical expense accounts set up through an employer are excluded.
3.Income limit: Premium fee is based upon income received on a sliding basis up to 7.5% of all income at or above 300% of the FPG.)
- Medicare Savings Programs. Minn. Stat. § 256B.057 Subd. 3-4.
Federal law requires that State Medicaid programs pay Medicare costs for certain elderly and disabled persons with low incomes and very limited assets. There are three programs with three different income levels, all based on the Federal Poverty Guidelines. See HCPM 22.05. For all programs, individuals may have $10,000 in assets and a couple may have $18,000.
1. Qualified Medicare Beneficiary (QMB). An individual whose income is below $871 (100% FPG plus $20.00 disregard), and a couple with income below $1,141 qualifies for the QMB program. The QMB program pays Medicare Part A and Part B premiums, co-pays and deductibles. (Note that $871 is only $20.00 higher than eligibility for MA in Minnesota.)
2. Service Limited Medicare Beneficiary (SLMB). An individual whose income is below $1,041 and a couple with income below $1,389 (120% FPG plus $20.00 disregard) is eligible for the SLMB program. The SLMB program pays the Medicare Part B monthly premium.
3. Qualified Individual (QI-1). An individual whose income is below $1,169 and a couple with income below $1,561(135% FPG plus $20.00 disregard) is eligible for the QI-1 program. The QI-1 program pays the Medicare Part B monthly premium. This coverage is identical to the SLMB program; the only difference is that enrollment may be limited.
4. Qualified Working Disabled Adults. A person who is entitled to Medicare Part A benefits under section 1818A of the Social Security Act; whose income does not exceed 200% of FPG for the applicable family size; whose nonexempt assets do not exceed twice the maximum amount allowable under the supplemental security income program, according to family size; and who is not otherwise eligible for medical assistance, is eligible for medical assistance reimbursement of the Medicare Part A premium.
- Home and Community Based Waiver Programs.
Home and community based waiver programs were established under section 1915(c) of the Social Security Act of 1981 to correct the institutional bias in Medicaid programs. The waivers allow states to offer a broad range of home and community-based services to people who may otherwise be institutionalized. In all of these programs, the eligible person may have only $3,000 in assets and must apply his or her income to the cost of care. Each Waiver is for a specific population.
1.Elderly Waiver (EW) Minn. Stat. § 256B.0915.
1.1Covered services. Includes regular Medical Assistance benefits, adult day care, respite care, homemaker services, adult foster care, extended home health care, case management, equipment and supplies, companion services, extended personal care, extended home health nursing, homedelivered meals, and caregiver training and education.
1.2Eligible persons. The EW program may provide funding for services in the community for an individual who:
a.Is 65 years of age or older;
b.Has had a long-term care consultation screening;
c.Requires a nursing facility level of care;
d.Can remain in the community rather than a nursing facility;
e.Can receive services in the community at a cost to MA that does not exceed 100% of the cost to MA of institutional care; and
f.Is eligible for MA (using spousal impoverishment rules for married couple)
1.3Special Income Standard Elderly Waiver (SIS EW). The SIS EW program is for those persons who have income that does not exceed $1,869. The requirements and services covered are the same as in the Elderly Waiver program, but the person is allowed to retain more of his or her monthly income for non-medical expenses than under the regular EW program (currently $839), and the person's income spenddown is applied only to Elderly Waiver services and not to other medical expenses.
2.Community Alternative Care (CAC) Minn. Stat. § 256B.49.
2.1Covered services. Includes regular Medical Assistance benefits, case management, respite care, homemaker, minor adaptations to the home, family counseling and training, foster care, extended MA services of home health, private duty nursing, public health nursing, other professional services, medical supplies and equipment, prescribed drugs, and medical transportation.
2.2Eligible persons: The CAC program may provide funding for alternative services in the community for an individual who:
a.Is under age 65 at the time of long-term care consultation screening for eligibility in the program;
b.Is a resident of a hospital or at risk of inpatient hospital care;
c.Is eligible for MA (considering only the assets and income of the individual);
d.Chooses community care or whose parent or guardian chooses community care of the individual;
e.Can remain in the community at a cost to MA that is less than the cost to maintain the individual in a hospital; and
f.Has an individual care plan that assures health and safety.
3.Community Alternatives for Disabled Individuals (CADI) Minn. Stat. § 256B.49.
3.1Covered services: Includes regular Medical Assistance benefits, adult day care, respite care, homemaker services, adaptations to the person’s home or vehicle and other adaptive equipment; extended home health care, case management, equipment and supplies, companion services, extended personal care, extended home health nursing, homedelivered meals, and caregiver training and education.
3.2Eligible persons: The CADI program may provide funding for alternative services in the community for an individual who:
a.Is determined to be at risk of nursing facility placement.
b.Has been screened by the long-term care consultation team and has a determination that he or she needs a nursing facility level of care.
c.Is under age 65 at the time of the initial screening. People who are on CADI, and who continue to require CADI services, may remain on CADI after their 65th birthday if all other eligibility criteria are met. A person who is receiving CADI services and is nearing age 65 must be informed by the county representative of community support options so that the person can choose which alternative will best meet his or her needs. Options may include going on the Elderly Waiver program, remaining on CADI, or other alternatives that may meet the person’s needs and preferences.
d.Has a disability certification from the State Medical Review Team (SMRT) or the Social Security Administration.
e.Is eligible for MA based only on the person’s own income and assets.
f.Needs community services not available through regular MA or other funding.
g.Can remain in the community at a cost to MA less than 100% of institutional care if age 16 or older, or less than 115% of institutional care if under age 16. A conversion rate may be applied to individuals who are or were (at the time they requested a county waiver screening) residents of a nursing facility: for these individuals, the cost to MA for these services must not exceed the amount MA is reimbursing the nursing facility for the individual’s care or the statewide average, whichever is higher. An individual must reside in a nursing facility for 30 consecutive days in order to be considered a resident. Through the Options Initiative, it is possible for CADI recipients to exceed funding limits based on needs.
h.Chooses community care.
4.Home and Community-Based Waiver for Individuals with Mental Retardation or Related Conditions (MR/RC) Minn. Stat. § 256B.092.
4.1Covered services: Includes regular Medical Assistance benefits, day training and habilitation services including supported employment, supported living services for children and for adults, respite care, homemaker services, adaptive aids, case management, and in-home family supports.
4.2Eligible persons: An individual may be eligible for the MR/RC Waiver Program if the individual meets the following criteria:
a.Is of any age;
b.Has been diagnosed with mental retardation or a related condition and is at risk of placement in an intermediate care facility for people with mental retardation, or lives in a nursing facility in which the person was inappropriately placed;
c.Is eligible for MA (considering only the assets and income of the individual);
d.Has been screened by MR/RC screening team;
e.Chooses community care or whose guardian chooses community care for the individual; and