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D.C. Medicaid and Long Term Care: Questions and Answers for the Family

    1. What is Medicaid?
    2. What is Medicare?
    3. What determines if DC Medicaid will pay for someone's care?
    4. If someone prefers to live at home, can they get services there?
    5. Will DC Medicaid cover everything?
    6. What will happen to my spouse if I go into a nursing home?
    7. How do I apply for DC Medicaid?
    8. What will I need to do when I apply?
    9. How do I make sure that I continue to get DC Medicaid?
    10. If someone needs personal assistance but not nursing home care, can they get services at home?
    11. Who can help in determining whether a nursing home care is appropriate?
    12. Who can help choose a nursing home?
    13. How is income treated?
    14. How are resources treated?
    15. What resources are not counted?
    16. What can I do if my resources are too high?
    17. How are my resources treated if my spouse is living in the community?
    18. What income can my spouse living at home keep if I go into a nursing home?
    19. How might my estate be affected if I receive Medicaid?
    20. Who should I call for more information about DC Medicaid?

NOTE: DIRECT Action is providing this information from the DC department of Health. DIRECT Action expresses no view about the quality or accuracy of the information provided by this agency of the DC government.

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1. What is Medicaid?

Medicaid, also called Medical Assistance, is an entitlement program that pays the medical bills of certain lower-income individuals and those with high medical expenses. It is administered by the District and pays medical bills, including nursing home care or, sometimes, care in your home, with Federal and local funds.

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2. What is Medicare?

Medicare is a federal insurance program that pays medical bills for persons age 65 or older, no matter how much money they have. Medicare also helps disabled persons who are under age 65 who have been receiving Social Security Disability Insurance (SSDI) payments for two years and certain persons with kidney failure. Medicare pays for nursing home services only under very limited circumstances, such as short-term rehabilitative stays. Medicare will only pay for a maximum of 100 days of nursing home care during the lifetime of an enrollee.

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3. What determines if DC Medicaid will pay for someone's care?

In order for DC Medicaid to pay for long-term care, the person must be eligible for Medicaid and need substantial help with their daily activities. To determine if someone is eligible, they will check to see that the person is:

Finally, they will check the person's *income and resources (assets). Individuals may qualify for at least some help from DC Medicaid even if their incomes are relatively high.

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4. If someone prefers to live at home, can they get services there?

Yes, DC Medicaid pays for many services that help people to remain living in their homes rather than go to a nursing facility. These home-based services include home nursing, personal assistance (e.g.. help with bathing, cooking, etc.) and elder day care. For more information about home-based services, please call (202) 442-9055.

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5. Will DC Medicaid cover everything?

No, not always. If someone eligible for DC Medicaid needs home care services, then DC Medicaid will pay for most costs, though there will be some limits. If a DC Medicaid client is in a nursing home, he or she will most likely pay part of the cost (based on income) directly to the nursing facility; DC Medicaid will pay the rest. DC Medicaid will provide payment for hospitalizations and other needed services.

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6. What will happen to my spouse if I go into a nursing home?

Medicaid uses special rules to protect a spouse's income and assets. Also, DC Medicaid will generally not count a house or car as an asset, so a spouse can continue to live at home as before. Please see the additional details regarding financial eligibility, which follow.

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7. How do I apply for DC Medicaid?

We encourage all applicants to start the DC Medicaid application process as soon as it becomes apparent that help will be needed with daily activities. To receive a DC Medicaid application, please call the Income Maintenance Administration (IMA) Customer Service Line at (202) 724-5506. For questions about and eligibility for home-based services, please call (202) 442-9055. If you have already been admitted to a hospital or nursing home, you may ask the hospital admissions office or social work staff for help in applying for DC Medicaid.

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8. What will I need to do when I apply?

When you apply, you will need to complete and sign an application form. The application form will request complete and detailed information on your financial situation. We will ask for some documents such as proof of the information on your application. We will need these items before a decision on your eligibility can be made. An interview may be required as part of the application process. A friend or relative can help you, and you can also call lMA Customer Service at (202) 724-5506 for assistance.

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9. How do I make sure that I continue to get DC Medicaid?

Once a year, DC Medicaid staff will review your eligibility to make sure your situation has not changed. They will send to you a short form to be completed and returned by mail. If applicable, customers or their family members can choose to have their private case manager or the nursing facility complete this annual "recertification process." Please speak with your case manager or the nursing facility's social work staff to make these arrangements. If you complete the recertification form yourself, you can call IMA Customer Service at (202) 724-5506 for assistance.

We encourage all applicants to start the DC Medicaid application process as soon as it becomes apparent that help will be needed with daily activities. If you need long- term care services, be sure to file an application for DC Medicaid as soon as possible, even if you are still looking for a provider. They can make corrections to your application even after you submit it.

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10. If someone needs personal assistance but not nursing home care, can they get services at home?

As noted above, DC Medicaid pays for many long-term care services in the community. Elderly and physically disabled individuals may also be eligible for the Home and Community Based Services Waiver, which covers case management, homemaker and other services. For more information, please call (202) 442-9055.

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11. Who can help in determining whether a nursing home care is appropriate?

Placement in a nursing facility is a medical decision based on a "level of care" assessment. Customers or their families may speak with one or more nursing homes to see if the level of care required by the disabled or elderly person meets the criteria for nursing home care. For your convenience, we include a list of nursing facilities that are DC Medicaid providers, though please note that some facilities have waiting lists and may not be able to accept new patients. If customers do not need the level of care provided by the nursing home. DC Medicaid will not pay for the nursing home services.

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12. Who can help choose a nursing home?

The Centers for Medicare and Medicaid Services has published their "Guide to Choosing a Nursing Home," which is available from 1-800-MEDICARE (1-800-633-4227). When you call, ask for publication CMS-O2174. For specific information about individual nursing facilities, you may contact:

If you have access to the Internet, you may also explore:

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13. How is income treated?

Any income that you receive (paid to your name) is counted. Income in your spouses name is not counted. *Income includes all of the income you receive. For home-based service, you will generally meet the income eligibility for home-based services if your monthly income is below 300% of the SSI payment standard (totalling $1,737 for 2005).

The process is slightly different for nursing home care. From your income, certain deductions are made:

If you are in a nursing home, a limited monthly allowance to maintain your home for a maximum of six months (if certain conditions are met): If your monthly income, after these deductions, is less than the monthly cost of nursing home services, then you will generally meet the income eligibility criteria for DC Medicaid services in a nursing home. The income remaining after these deductions must be paid to the nursing home. DC Medicaid pays the balance of the nursing home bill up to the maximum that the nursing home is entitled to charge under DC Medicaid.

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14. How are resources treated?

Your countable resources cannot be worth more than $2,600. If you exceed this limit by even $1 at any time during a month, then you will be ineligible for DC Medicaid for the entire month. Note: If you are married, your resources are treated differently than if you are single (see below). Special rules may apply to minor children who are disabled and in need of long-term care.

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15. What resources are not counted?

The following resources are not counted in determining whether you fall within the $2,600 resource limit:

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16. What can I do if my resources are too high?

Resources over the $2,600 limit may be used in several ways as long as they are not given away or exchanged for something of lesser value. For example, you may use your excess resources to pay for the cost of care in the nursing home, to pay other bills that you may have, or to prepay your funeral expenses.

For individuals in nursing homes: if the amount of your excess resources is less than a full month's cost for nursing care, you may wish to make an advance payment of that amount towards your next month's bill. This will reduce your resources to the eligibility level before the first day of the next month. If resources are reduced to the $2,600 limit by the last day of the current month and all other conditions of eligibility are met, you may qualify for Medicaid as of the first day of the next month.

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17. How are my resources treated if my spouse is living in the community?

When you apply for DC Medicaid, an assessment will be made of the total value of all of your and your spouse's combined countable resources as of the month that one of you entered the nursing home. Your spouse at home can keep air resources that are not counted towards the resource limit. Your spouse is also allowed to keep the larger of the two following amounts:

The remainder is attributed to you and is compared to the DC Medicaid resource level for one person. You meet Medicaid's resource requirements when the share attributed to you does not exceed the resource eligibility level for one person ($2,600).

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18. What income can my spouse living at home keep if I go into a nursing home?

When one spouse goes into a nursing home, DC Medicaid allows the spouse who remains at home to keep certain income. If you enter a nursing home, your spouse living at home may keep the greater of:

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19. How might my estate be affected if I receive Medicaid?

Under federal law, the District must seek to recover the costs of services provided to a person of any age in a nursing facility, intermediate care facility for the mentally retarded, or other medical institution. For customers age 55 or older, the District must seek to recover from the customer's estate the cost of nursing facility services, home and community-based services, and related hospital and prescription drug services. These recoveries may come either from the individual's estate (after death) or from the sale of property subject to a lien (which could be during the individual's lifetime). However, the District will not initiate any recoveries for these expenditures if the customer is survived by a community spouse, a minor child, or an adult disabled child who lives at home. There may be other circumstances under which the District would not initiate recoveries; please call (202) 442-9227 or (202) 442-5981 for additional information.

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20. Who should I call for more information about DC Medicaid?

If you need any assistance with eligibility or have questions about the patient contribution amount for nursing facilities, please call DC Medicaid at (202) 698-4258. For questions regarding home-based services, please call (202) 442-9055.

* Income includes but is not limited to: wages, Social Security benefits, pension, and Veteran's benefits. Resources include but are not limited to: bank accounts, stocks, bonds, trusts, annuities, and real property.

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