CCMC Definitions Related to Medicaid
Medicaid Waiver- Waiver Programs, authorized under Section 1915(C) of the Social Security Act, provide states with greater flexibility to serve individuals with substantial long-term care needs at home or in the community rather than in an institution. The federal government “waives” certain Medicaid rules. This allows a state to select a portion of the population on Medicaid to receive specialized services not available to Medicaid recipients.
Treatment of Trusts- When an individual, their spouse, or anyone acting on the individual’s behalf establishes a trust using at least some of the individual’s funds, that trust can be considered available to the individual for purposes of determining eligibility for Medicaid.
Transfers of Assets for Less Than Fair Market Value- This practice is prohibited for purposes of establishing Medicaid eligibility. Applies when assets are transferred, sold, or gifted for less than they are worth by individuals in long-term care facilities or receiving home and community-based waiver services, by their spouses, or by someone else acting on their behalf.
Estate Recovery- State Medicaid programs must recover from a Medicaid enrollee’s estate the cost of certain benefits paid on behalf of the enrollee, including nursing facilities services, home and community-based services, and related hospital and prescription drug services. State Medicaid programs may recover for other Medicaid benefits, except for Medicare cost-sharing benefits paid on behalf of Medicare Savings Program beneficiaries.
- Run by the Center for Medicare and Medicaid Services (CMS)
- Is jointly funded by the States and the Federal government
- States may charge premiums
- States may establish out of pocket costs for the enrollee including copayments, coinsurance and deductibles
- Historically fee for service, but increasingly more managed care options
- Medicaid is always the last payer
- Varies from state to state
- May start retroactively, up to 3 months prior to the month of application
- Federal government sets minimum standards for “categorically needy”
– Limited income families with children who meet the requirements for Aid to Families with Dependent Children
– Pregnant women who meet income guidelines (Services limited to those related to pregnancy)
– Infants born to Medicaid eligible women, for the first year of life
– SSI recipients
- Medically Needy