Medicaid and the elderly.Introduction and summary
Expenditures on medical care by Medicaid Medicaid, national health insurance program in the United States for low-income persons; established in 1965 with passage of the Social Security Amendments and now run by the Centers for Medicare and Medicaid Services. and Medicare Medicare, national health insurance program in the United States for persons aged 65 and over and the disabled. It was established in 1965 with passage of the Social Security Amendments and is now run by the Centers for Medicare and Medicaid Services. , America's two main public health insurance programs, are large and growing rapidly. Although Medicare is the main provider of medical care for the elderly and disabled, it does not cover all medical costs. In particular, it covers only a limited amount of long-term care expenses (for example, nursing home expenses). The principal public provider of long-term care is Medicaid, a means-tested program for the impoverished im·pov·er·ished
1. Reduced to poverty; poverty-stricken. See Synonyms at poor.
2. Deprived of natural richness or strength; limited or depleted: . Medicaid now assists 70 percent of nursing home residents (1) and helps the elderly poor pay for other medical services as well. In 2009, Medicaid spent over $75 billion on 5.3 million elderly beneficiaries. (2)
An important feature of Medicaid is that it provides insurance against catastrophic medical expenses by providing a minimum floor of consumption for households. Although Medicaid is available only to "poor" households, middle-income households with high medical expenses usually qualify for assistance also. Given the ongoing growth in medical expenditures, Medicaid coverage in old age is thus becoming as much of a program for the middle class as for the poor (Brown and Finkelstein Finkelstein (פֿינק(ע)לשׁטײַן, פינקלשׁט(י)ין, , 2008).
Another important feature of Medicaid is that it is asset and income tested; in contrast, almost all seniors qualify for Medicare. This implies that Medicaid affects households' saving decisions, not only by reducing the level and risk of their medical expenses, but also by encouraging them to consume their wealth and income more quickly in order to qualify for aid (Hubbard, Skinner Skin·ner , B(urrhus) F(rederick) 1904-1990.
American psychologist. A leading behaviorist, Skinner influenced the fields of psychology and education with his theories of stimulus-response behavior. , and Zeldes, 1995). Although Medicaid covers poor people of all ages, this article focuses on Medicaid's coverage for the elderly.
Many recent proposals for reforming Medicaid could have significant effects on the financial burdens of the elderly, on the medical expense risk that they face, and on their saving decisions. Moreover, Medicaid is a large and growing component of the federal budget. The share of total federal, state, and local government expenditures absorbed by Medicaid rose from less than 2 percent in 1970 to almost 7 percent in 2009, (3) and it is expected to increase even more in the future. Controlling the cost of Medicaid is an important component in correcting the federal government's longterm fiscal imbalance imbalance /im·bal·ance/ (im-bal´ans)
1. lack of balance, such as between two opposing muscles or between electrolytes in the body.
2. dysequilibrium (2). .
In this article, we describe the Medicaid rules for the elderly and discuss their economic implications. We focus on the rules for single (that is, never married, divorced, or widowed) individuals to avoid the additional complications involved in considering couples. The main difference between singles and couples is that the income and asset limits for Medicaid eligibility are higher for couples.
Medicaid is administered jointly by the federal and state governments, but each state has significant flexibility on the details of implementation; hence, there is large variation across states in income and asset eligibility and in coverage. This variation may well provide elderly people in different states with different saving incentives, and it might even encourage them to move from one state to another. We focus on finding the features common to all states, and identifying the most salient state-level differences.
Overview of the Medicaid program
Medicaid and Medicare were created by the Social Security Act Amendments of 1965. Although the program was initially intended to cover the population on welfare (for example, recipients of Aid to Families with Dependent Children Aid to Families with Dependent Children (AFDC) was the name of a federal assistance program in effect from 1935 to 1997, which was administered by the United States Department of Health and Human Services. , AFDC AFDC
Aid to Families with Dependent Children
AFDC n abbr (US) (= Aid to Families with Dependent Children) → ayuda a familias con hijos menores
AFDC n abbr , or Supplemental Security Income Supplemental Security Income
A Social Security program established to help the blind, disabled, and poor. , SSI (1) See server-side include and single-system image.
(2) (Small-Scale Integration) Less than 100 transistors on a chip. See MSI, LSI, VLSI and ULSI.
1. (electronics) SSI - small scale integration.
2. ), over time legislation has expanded coverage to non-welfare recipients overwhelmed o·ver·whelm
tr.v. o·ver·whelmed, o·ver·whelm·ing, o·ver·whelms
1. To surge over and submerge; engulf: waves overwhelming the rocky shoreline.
a. by their medical costs. Box 1 provides a chronology chronology,
n the arrangement of events in a time sequence, usually from the beginning to the end of an event. of important Medicaid-related legislation for the elderly. Two key themes emerge from box 1. First, Medicaid has increased the number of services provided over time. Second, Medicaid has attempted to limit the abuse of the system by using increasingly stringent and comprehensive asset tests to determine eligibility.
For our purposes, it is useful to divide elderly Medicaid recipients into three groups: 1) the categorically needy need·y
adj. need·i·er, need·i·est
1. Being in need; impoverished. See Synonyms at poor.
2. Wanting or needing affection, attention, or reassurance, especially to an excessive degree. , whose low income and assets qualify them for Medicaid. This group includes those who qualify for SSI, as well as "dual eligibles," whose Medicare deductibles and co-pays are covered by Medicaid; 2) the institutionalized in·sti·tu·tion·al·ize
tr.v. in·sti·tu·tion·al·ized, in·sti·tu·tion·al·iz·ing, in·sti·tu·tion·al·iz·es
a. To make into, treat as, or give the character of an institution to.
b. medically needy, who qualify for Medicaid because their financial resources do not cover their nursing home expenses; and 3) the noninstitutionalized adj. 1. not committed to an institution; - op people. Opposite of institutionalized nt>.
Adj. 1. noninstitutionalized - not committed to an institution
noninstitutionalised medically needy, who qualify for Medicaid because their financial resources cannot cover catastrophic noninstitutional adj. 1. not institutional. Opposite of institutional nt>.
Adj. 1. noninstitutional - not institutional
institutional - organized as or forming an institution; "institutional religion" medical expenses. Each group faces a different set of asset and income tests. Figure 1 presents data on Medicaid enrollment and expenditures. In 2008, Medicaid spent roughly $75 billion (4) on 5.3 million beneficiaries aged 65 and older (data from the Center for Medicare and Medicaid Medicare and Medicaid
U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. Services). These data provide information on the number of people and expenditures in the different groups. Of those aged 65 and older, SSI recipients account for 40 percent of all beneficiaries and 27 percent of all Medicaid expenditures. "Dual eligibles" represent 29 percent of all beneficiaries and 9 percent of all Medicaid expenditures and are the second-largest group of Medicaid beneficiaries. "Medically needy" individuals represent 10 percent of all beneficiaries and 23 percent of all expenditures. "Others," a category largely made up of those with catastrophic medical expenses who are not technically "medically needy," represent 29 percent of all beneficiaries and 41 percent of all expenses. Although the Center for Medicare and Medicaid Services technically refers to "others" as categorically needy, a large share of this group are what we will refer to as medically needy, because their circumstances CIRCUMSTANCES, evidence. The particulars which accompany a fact.
2. The facts proved are either possible or impossible, ordinary and probable, or extraordinary and improbable, recent or ancient; they may have happened near us, or afar off; they are public or (catastrophic medical expenses) are more like those of the strictly medically needy than those of the other categorically needy groups.
The categorically needy: SSI beneficiaries
In most states, SSI recipients qualify for Medicaid as categorically needy recipients. Under the Social Security Act Amendments establishing SSI in 1972, states were mandated to provide elderly SSI recipients with Medicaid benefits. The law exempted states that in 1972 were using Medicaid eligibility criteria stricter than the newly enacted SSI criteria (Gruber, 2000). The 11 states that had the more restrictive rules for Medicaid are referred to as 209(b) states (Gardner and Gilleskie, 2009).
SSI pays monthly benefits to people with limited incomes and wealth who are disabled, blind, or aged 65 years and older. There is a (maximum) monthly SSI benefit that is paid for by the federal government. States can supplement this benefit. Figure 2 plots the federally provided monthly SSI benefit from 1975 to 2010. Table 1 shows the state-level supplements for all states that have offered a supplement over the sample period. In contrast to the federal benefit, which in real terms has been constant, the state supplements have varied greatly over time as well as across states.
To qualify for SSI, individuals must pass both an income test and an asset test. In non-209(b) states, the income test is based on the combined federal and state maximum monthly benefit. Individuals with no income receive this maximum monthly benefit if they pass the asset test. Otherwise, each individual's "countable income" is deducted de·duct
v. de·duct·ed, de·duct·ing, de·ducts
1. To take away (a quantity) from another; subtract.
2. To derive by deduction; deduce.
v.intr. from the maximum to produce a net benefit. In most states, individuals receiving any benefit, no matter how small, are categorically eligible for Medicaid. This implies that the implicit marginal tax rate Marginal Tax Rate
The amount of tax paid on an additional dollar of income. As income rises, so does the tax rate.
Many believe this discourages business investment because you are taking away the incentive to work harder. for the threshold dollar of countable income--the incremental dollar that pushes the individual over the income threshold--is extremely high, because that last dollar of income eliminates the individual's Medicaid coverage.
BOX 1 Medicaid time line Social Security Act Amendments of 1965 * Medicaid program enacted. * Medicare program for the elderly also started. Social Security Act Amendments of 1972 * Enacted Supplemental Security Income (SSI) program for elderly and disabled, replacing state-level programs that served the elderly and disabled. * Required states to extend Medicaid to SSI recipients or to elderly and disabled meeting that state's 1972 requirements. Omnibus Reconciliation Act of 1981 * Section 1915(c) home- and community-based waiver program launched. This program allows people with serious health problems to obtain home-based care instead of nursing home care. Tax Equity and Fiscal Responsibility Act of 1982 * Allowed states to make institutionalized individuals pay for Medicaid services if they owned a home and did not plan to return to that home. Omnibus Reconciliation Act of 1986 * Allowed states to pay for Medicare premiums for Medicare beneficiaries with incomes below the poverty level (qualified Medicare beneficiaries, QMBs). Omnibus Reconciliation Act of 1990 * Allowed states to cover Medicare premiums for Medicare beneficiaries with incomes between 100 and 120 percent of the poverty level (specified low income beneficiaries, SLMBs). Omnibus Reconciliation Act of 1993 * Tightened prohibitions against transfer of assets in order to qualify for Medicaid nursing home coverage. Instituted a three-year look-back period. Required recovery of nursing home expenses from beneficiary estates. Deficit Reduction Act of 2005 * Increased cost sharing (for example, increased copayments for certain drugs) and reduced certain benefits. * Extended the look-back period for assessing transfers from three to five years. * Imposed an upper bound on the amount of home equity excluded from asset tests. Sources: For 1965-93, Kaiser Commission on Medicaid and the Uninsured (2002); for 2005, Kaiser Commission on Medicaid and the Uninsured (2006).
The conversion of actual income into countable income depends on whether the income is earned or unearned. Earned income consists of financial or inkind income from wages, self-employment The perspective and/or examples in this article do not represent a world-wide view. Please [ edit] this page to improve its geographical balance. (net), and sheltered workshops (5) Each dollar of earned income in excess of $65 counts as 50 cents of countable income. Unearned income Unearned Income
Any income that comes from investments and other sources unrelated to employment services.
Examples of unearned income include interest from a savings account, bond interest, tips, alimony, and dividends from stock. includes Social Security benefits, worker or veteran compensation, annuities, rent, and interest from assets. Each dollar of unearned income counts as one dollar of countable income. In addition, the first $20 of income, earned or unearned, is disregarded dis·re·gard
tr.v. dis·re·gard·ed, dis·re·gard·ing, dis·re·gards
1. To pay no attention or heed to; ignore.
2. To treat without proper respect or attentiveness.
n. ; the amount varies slightly across states. By way of example, in 2010 the maximum federal benefit for single, aged SSI recipients was $674. To qualify for SSI, an individual must have had less than $674 x 2 + $65 + $20 = $1,433 of earned income or $674 + $20 = $694 in unearned income. Finally, several types of income, most notably food stamps, are excluded from the income test. (6)
The income standards used by the 209(b) states do not have to follow this formula, although some do. The law only requires that the states impose criteria no stricter than those in effect in 1972 (House Ways and Means WAYS AND MEANS. In legislative assemblies there is usually appointed a committee whose duties are to inquire into, and propose to the house, the ways and means to be adopted to raise funds for the use of the government. This body is called the committee of ways and means. Committee, 2004).
[FIGURE 2 OMITTED]
The asset test is more straightforward. Individuals with assets at or below the state-specific threshold qualify. Individuals with assets above the threshold do not qualify. This implies that the implicit marginal tax rate for the threshold dollar of assets is extremely high, as that last dollar of assets eliminates the individual's SSI and Medicaid benefits. Such a penalty provides a strong disincentive dis·in·cen·tive
Something that prevents or discourages action; a deterrent.
something that discourages someone from behaving or acting in a particular way
Noun 1. to saving and encourages people to spend down their assets until they fall below the threshold.
The asset threshold varies across states, with a modal value Noun 1. modal value - the most frequent value of a random variable
statistics - a branch of applied mathematics concerned with the collection and interpretation of quantitative data and the use of probability theory to estimate population parameters of $2,000. It is also the case, however, that many important categories of wealth are exempt, including one's principal residence. Box 2 lists assets that are excluded for elderly individuals.
Table 2 shows the current income and asset thresholds for each state. The 209(b) states appear at the bottom of the table. The only common factor across 209(b) states is that individuals have to apply for Medicaid separately from their SSI benefit application. Although some of the 209(b) states impose tighter income or asset restrictions for Medicaid, SSI eligibility implies Medicaid eligibility in most of these states.
The categorically needy: Dual eligibles
"Dual eligibles" are individuals who are enrolled in Medicaid and have Medicaid pay their Medicare premiums. Medicare covers basic health services health services Managed care The benefits covered under a health contract , including physicians and hospital care, for the elderly. Medicare Part B, which covers outpatient services outpatient services Hospital-based services Managed care Medical and other services provided, to a nonadmitted Pt, by a hospital or other qualified facility–eg, mental health clinic, rural health clinic, mobile X-ray unit, free-standing dialysis unit Examples such as doctor visits, costs $96.40 per month. As a dual eligible, an aged individual can get Medicaid to cover Medicare premiums and services that Medicare does not cover. Depending on their income, dual eligibles can qualify as Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicare Beneficiaries (SLMBs), or Qualified Individuals (QIs)-QMBs are assisted with Medicare Part B premiums and co-payments. In most states, the QMB QMB Qualified Medicare beneficiary, see there income limit is 100 percent of the federal poverty level ($903 for single elderly people), and the asset limit is $6,600. However, nine states (including New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of ) do not impose any asset limits, and a subset A group of commands or functions that do not include all the capabilities of the original specification. Software or hardware components designed for the subset will also work with the original. of these states also provide more generous income limits and disregard amounts. SLMBs are elderly individuals with income between 100 percent and 120 percent of the federal poverty level. SLMBs are assisted with premiums only. QIs are individuals with income between 120 percent and 135 percent of the poverty level who, depending on funding availability, may receive assistance with Medicare Part B premiums (Kaiser Commission on Medicaid and the Uninsured, 2010a and 2010b). Table 3 shows the asset and income limits for QMBs, SLMBs, and QIs.
The medically needy
Individuals with income or assets above the categorically needy limits may nonetheless not have enough resources to cover their medical expenses. Under the medically needy provisions, Medicaid pays part of these expenses. The implementation of medically needy coverage, however, varies greatly across states and types of medical care. The types of care covered under these arrangements include institutional (long-term) care, as well as home- and community-based service (HCBS HCBS Home & Community Based Services ) care.
As pointed out earlier, the term "medically needy" has both a loose and a strict definition. The loose definition we use refers to all programs for receiving Medicaid due to catastrophic medical expenses. However, in formal Medicaid language, the term "Medically Needy" refers to just one of several mechanisms for coping with unaffordable un·af·ford·a·ble
Too expensive: medical care that has become unaffordable for many.
un medical expenses. As a rule, we will use the lowercase term "medically needy" to refer to the loose definition, and the uppercase term "Medically Needy" to refer to the formal program.
BOX 2 Assets excluded from the SSI asset test 1. The home you live in and the land it is on, regardless of value. 2. Property that you use in trade (gas station, beauty parlor, etc.). 3. Personal property used for work (tools, equipment, etc.). 4. Household goods and personal effects. 5. Wedding and engagement rings. 6. Burial funds (up to $1,500). 7. Term life insurance policies (regardless of face value) and whole life insurance policies (with face value up to $1,500). 8. One vehicle (regardless of value). 9. Retroactive SSI or social security benefits for up to nine months after you receive them (includes payments received in installments). 10. Grants, scholarships, fellowships, or gifts set aside to pay educational expenses for up to nine months after you receive them. 11. Some property may be partially excluded, such as the property used to produce goods or services needed for daily life, and nonbusiness property that produces income, such as rented land, real estate, or equipment. Source: Social Security Administration (200%).
Figure 3 presents a diagram diagram /di·a·gram/ (di´ah-gram) a graphic representation, in simplest form, of an object or concept, made up of lines and lacking pictorial elements. of how individuals may qualify for medically needy coverage under the various provisions. In addition to having different mechanics, the provisions impose different asset and income thresholds. For example, Medicaid imposes more generous asset limits for noninstitutional care. We discuss these provisions below.
The institutionalized medically needy
We begin by looking at provisions for institutional (that is, nursing home) care. (7) If an institutionalized elderly individual's monthly income is within 300 percent of the SSI limit, then she qualifies for Medicaid (Gruber, 2000) in 39 states, plus the District of Columbia District of Columbia, federal district (2000 pop. 572,059, a 5.7% decrease in population since the 1990 census), 69 sq mi (179 sq km), on the east bank of the Potomac River, coextensive with the city of Washington, D.C. (the capital of the United States). , through the expanded nursing home provision. Virtually all of the person's income will still be applied toward the cost of care, and the individual will get an allowance. If an institutionalized person's income is greater than 300 percent of the SSI limit, but still insufficient to cover her medical expenses, she may qualify for Medicaid through one of two mechanisms. The first option is to use the formal Medically Needy provision, which can be used for any sort of medical expense, to cover institutional care. The individual will have a "spend-down" period that lasts until her net income--income less medical expenses--falls below the Medically Needy threshold. After qualifying as medically needy, the person still has to direct most of her income to pay for her care. She can keep only a small amount as a personal allowance, while Medicaid uses the rest to keep the individual at the institution (Gruber, 2000).
The second mechanism for receiving institutional care is to use a Qualified Income or Miller trust. Income deposited in these trusts is excluded from the Medicaid tests. The individual deposits enough income in a trust to fall below the 300 percent limit and qualify for expanded nursing home coverage. Once the individual passes away, the state receives any money remaining in the trust, up to the amount that Medicaid has paid on the individual's behalf (8) (Weschler, 2005).
Of the 39 states offering enhanced nursing home coverage, 25 also offer Medically Needy coverage. The remaining 15 states are required by federal law to allow applicants to use Miller trusts. Four of the states that provide medically needy coverage permit Miller trusts as well (Stone, 2002).
Of the 11 states not offering expanded nursing home coverage, nine offer Medically Needy coverage. The difference between these states and the states offering expanded nursing home coverage is that individuals in these states are not automatically eligible for Medicaid nursing home care if their incomes are below 300 percent of the SSI level. However, given that most individuals in nursing homes incur To become subject to and liable for; to have liabilities imposed by act or operation of law.
Expenses are incurred, for example, when the legal obligation to pay them arises. An individual incurs a liability when a money judgment is rendered against him or her by a court. medical expenses far greater than 300 percent of the SSI level, there is little practical difference in Medicaid eligibility across the different states. All individuals with incomes below 300 percent of the SSI level in either type of state will deplete de·plete
1. To use up something, such as a nutrient.
2. To empty something out, as the body of electrolytes. all their resources and will be eligible for Medicaid nursing home care through the Medically Needy program. The remaining two states, Indiana Indiana, state, United States
Indiana, midwestern state in the N central United States. It is bordered by Lake Michigan and the state of Michigan (N), Ohio (E), Kentucky, across the Ohio R. (S), and Illinois (W). and Missouri Missouri, state, United States
Missouri (mĭzr`ē, –ə), one of the midwestern states of the United States. , lack both provisions. However, Indiana and Missouri are both 209(b) states. To reduce the hardships that SSI beneficiaries may face in 209(b) states, federal rules require these states to allow individuals to spend down to the states' income and asset limits for Medicaid. (9) The rules thus mandate that 209(b) states offer the equivalent of a Medically Needy program, even if the states do not formally offer the Medically Needy option (Carpenter, 2000). Four 209(b) states--Indiana, Missouri, Ohio, and Oklahoma--offer a spend-down provision in accordance Accordance is Bible Study Software for Macintosh developed by OakTree Software, Inc.
As well as a standalone program, it is the base software packaged by Zondervan in their Bible Study suites for Macintosh. with this mandate. With this provision in place, institutionalized individuals in every state have at least one way to qualify for Medicaid if they are destitute des·ti·tute
1. Utterly lacking; devoid: Young recruits destitute of any experience.
2. Lacking resources or the means of subsistence; completely impoverished. See Synonyms at poor. and institutionalized. (10)
[FIGURE 3 OMITTED]
Table 4 shows the provisions offered in each state and the associated income and asset limits. In most states, the Medically Needy income limits (income less medical expenses) are stricter than the income limits for the categorically needy.
Medicaid's ability to recover assets from the estate
The asset limits presented in table 4 are similar to the asset limits for the categorically needy presented in table 2. There are two key distinctions between the two sets of asset tests, both relating to relating to relate prep → concernant
relating to relate prep → bezüglich +gen, mit Bezug auf +acc their treatment of housing. First, the Medicaid asset test for the categorically needy excludes the individual's principal residence, whereas the Deficit Reduction Act of 2005 stipulates that the Medicaid asset test for the medically needy places limits on the amount of home equity that is excluded. Although there are limits on the amount of home equity that can be excluded, the second-to-last column of table 4 shows that these limits are quite generous. (11) Second, and more importantly, houses owned by institutionalized individuals who do not plan to return to that house no longer serve as principal residences. (12) Therefore, the home equity of that individual is no longer excluded from the asset test. More precisely, the U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS (2005c, p. 2) states that an individual's house is included in the asset test when he "has no living spouse spouse A legal marriage partner as defined by state law or dependents and moves into a nursing home or other medical institution on a permanent basis without the intent to return, transfers the home for less than fair market value, or dies." An essential part of the definition is "the intent to return" provision, designed to exempt individuals whose stays at the institution are temporary. In most states, the intent to return is based on the beliefs of the institutionalized individual, with no reference to the individual's underlying medical condition. Only the 209(b) states are allowed to use more objective criteria, such as a professional medical diagnosis or the duration of stay, to assess the likelihood that the individual might return to his home. A mechanism that is available to non-209(b) states is to restrict the institutionalized individual's income allowance so much that the individual can no longer cover property taxes and maintenance costs, forcing her to sell her home. However, individuals may be able to resist such "squeezes" by using reverse mortgages to fund taxes and maintenance (U.S. Department of Health and Human Services, 2005c).
Once an individual dies, his home ceases to be protected. The Omnibus omnibus: see bus. Reconciliation Act of 1993 requires states to seek from beneficiary beneficiary
Person or entity (e.g., a charity or estate) that receives a benefit from something (e.g., a trust, life-insurance policy, or contract). A primary beneficiary receives proceeds from a trust or insurance policy before any other. estates reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. for long-term care, both in-house and institutional, and services provided concurrently with long-term care. However, states cannot pursue homes occupied by the beneficiary's spouse or dependents (U.S. Department of Health and Human Services, 2005d). Furthermore, because the state may be one of many claimants to the estate, and given the general complexity of estate law--which in a few states explicitly protects estates from Medicaid claims--Medicaid collects relatively little money from estates. (13) In 2004, estate recoveries equaled 0.8 percent of Medicaid spending on nursing homes, with the most successful state, Oregon Oregon, city, United States
Oregon, city (1990 pop. 18,334), Lucas co., NW Ohio, a suburb adjacent to Toledo, on Lake Erie; inc. 1958. It is a port with railroad-owned and -operated docks. The city has industries producing oil, chemicals, and metal products. , recovering 5.8 percent of its nursing home expenditures (U.S. Department of Health and Human Services, 2005a). Table 5 provides information on asset recovery practices and outcomes.
One device states use to enhance their recovery prospects is to place liens on their beneficiaries' assets. The Tax Equity and Fiscal Responsibility Act (TERFA) of 1982 allows states to place liens on the homes of permanently institutionalized Medicaid beneficiaries. After the beneficiary dies, states may also place "post-death" liens on her estate (U.S. Department of Health and Human Services, 2005b).
TERFA liens can help states protect themselves from abuses of the "intent to return" provision. While the intent to return is generally based on the subjective opinion of the beneficiary himself, TERFA liens may be established on the basis of objective criteria (U.S. Department of Health and Human Services, 2005b). Table 6 (p. 30) summarizes the criteria states use.
TERFA liens also protect states if a beneficiary attempts to transfer the house to a third party (for example, a child) prior to applying for Medicaid. The Deficit Reduction Act of 2005 extended Medicaid's "look-back" period from the three years preceding application to five years. Transfers made during the look-back period are subject to Medicaid review. If the applicant is found to have made a net transfer, that is, sold some of his assets at prices below their fair market value, his eligibility will be delayed (ElderLawNet, Inc., 2011).
The degree to which elderly individuals transfer their assets in order to become eligible for Medicaid has been the subject of several studies. These studies find that the elderly transfer little if any of their money to their heirs for the purpose of making themselves eligible for Medicaid. Thus, extending the look-back period past five years or more aggressive pursuit of transferred assets is unlikely to defray de·fray
tr.v. de·frayed, de·fray·ing, de·frays
To undertake the payment of (costs or expenses); pay.
[French défrayer, from Old French desfrayer : des-, much of Medicaid's expenses. Norton Nor·ton , Charles Eliot 1827-1908.
American educator, writer, and editor who founded the Nation (1865). (1995) argues that elderly individuals are more likely to receive transfers in an attempt to avoid Medicaid. In contrast, Bassett Bassett is a surname, and may refer to:
Irish writer whose works, including The Lonely Girl (1962) and Johnny I Hardly Knew You (1977), explore the lives of women in modern-day Ireland.
Noun 1. (2005) concludes that the evidence "do[es] not support the claim that asset transfers are widespread or costly to Medicaid." In summary, the evidence is mixed whether the elderly give or receive transfers to affect their Medicaid eligibility. However, there is a clear consensus that these transfers are small relative to the size of Medicaid transfers.
The noninstitutionalized medically needy
The structure of Medicaid coverage for noninstitutionalized medically needy individuals is similar to that for those in institutions. Individuals with specific needs, such as home health care, can qualify under provisions tailored to those needs. Individuals not qualifying under these limited provisions can qualify under the general medically needy provision, if their state offers it.
Individuals needing long-term care can often substitute home-based care for care at a nursing home or another institution. To promote the use of home-based care, states can utilize 1915(c) home- and community-based service care (HCBS) waivers, which give them additional flexibility in how they provide these services (Carpenter, 2000). Services that can be offered under an HCBS waiver The voluntary surrender of a known right; conduct supporting an inference that a particular right has been relinquished.
The term waiver is used in many legal contexts. range from traditional medical services, such as dental care and skilled nursing services, to nonmedical services, such as case management and environment modification.
In most states, the income test used for 1915(c) waivers is the same as the one used for expanded nursing home coverage, namely 300 percent of the SSI limit. Other states (for example, California California (kăl'ĭfôr`nyə), most populous state in the United States, located in the Far West; bordered by Oregon (N), Nevada and, across the Colorado River, Arizona (E), Mexico (S), and the Pacific Ocean (W). ) impose more stringent tests. As Table 4 shows, many states (including Arizona Arizona (âr'əzō`nə), state in the southwestern United States. It is bordered by Utah (N), New Mexico (E), Mexico (S), and, across the Colorado R., Nevada and California (W). ) allow the use of Miller trusts. As with the expanded nursing home program, beneficiaries are expected to direct their income toward the cost of their expenses. The income allowances, however, vary greatly across states (Walker and Accius Accius, a Latin poet of the 16th century, to whom is attributed a paraphrase of Aesop's Fables, of which Julius Scaliger speaks with great praise. References , 2010).
The asset limits for 1915(c) applicants are the ones for the categorically needy (Stone, 2002). Housing is excluded from the asset test, but the Omnibus Reconciliation Act of 1993 requires states to pursue estates to recover the cost of long-term care. On the other hand, states do not have to pursue these costs if they decide it would not be cost-effective (U.S. Department of Health and Human Services, 2005d). Given the limited success of state cost recovery efforts in general, such efforts are unlikely to play a large role in the case at hand.
Some states limit access by requiring 1915(c) beneficiaries to exhibit difficulties in performing at least three "activities of daily living" (bathing, dressing, grooming, and so on); functional eligibility for nursing homes requires only two. Most states impose limits on how much they spend per year for home and community-based service care. Furthermore, states are free to choose how many applications to approve. They are also free to limit the number of waivers. (14) Many states have more individuals in need of waivers than open "slots," and thus operate waiting lists (Kaiser Commission on Medicaid and the Uninsured, 2009). Table 7 summarizes the 1915(c) HCBS waiver programs offered by each state.
In addition to utilizing 1915(c) waivers, states can provide HBCS services under two other provisions: the federally mandated home health benefit provided by all states; and the optional personal care benefit, which in 2006 was provided by 31 states. In 2006, the two programs incurred 34 percent of total HCBS expenditures and assisted 61 percent of the HCBS beneficiaries. Most states screened applicants to these programs with the income and asset tests for categorically needy recipients. There is variation in the financial eligibility limits states require to get this benefit. Some states keep it at the 300 percent level, but others restrict it further. Many states also provide a medically needy spend-down option (Kaiser Commission on Medicaid and the Uninsured, 2009).
The noninstitutionalized medically needy: Other pathways
For individuals unable to qualify under any of the preceding pathways, the Medically Needy provision provides an important "last chance" opportunity to qualify for Medicaid (Crowley Crowley (krou`lē), city (1990 pop. 13,983), seat of Acadia parish, SW La.; inc. 1888. It is a shipping, milling, and storage center for a large rice-growing area and has a rice experiment station. Oil and natural gas wells are located nearby. , 2003). The income and asset levels for the noninstitutionalized Medically Needy applicants are the same as the ones for institutionalized individuals presented in table 4. Similarly, noninstitutionalized individuals with high incomes end up paying most if not all of their medical expenses before they receive aid.
Because the income limits for the Medically Needy provision are usually stricter than the limits for the "income needy" (for example, the SSI recipients, dual eligibles, and certain HCBS beneficiaries), noninstitutionalized individuals also face a possible discontinuity dis·con·ti·nu·i·ty
n. pl. dis·con·ti·nu·i·ties
1. Lack of continuity, logical sequence, or cohesion.
2. A break or gap.
3. Geology A surface at which seismic wave velocities change. in coverage. In consequence, the penalty to being Medically Needy rather than income needy may be significant.
By way of example, consider two individuals in Pennsylvania Pennsylvania (pĕnsəlvā`nyə), one of the Middle Atlantic states of the United States. It is bordered by New Jersey, across the Delaware River (E), Delaware (SE), Maryland (S), West Virginia (SW), Ohio (W), and Lake Erie and New York . Both individuals require health care costing $500 per month. The first individual has a monthly income of $900 per month, which in Pennsylvania allows him to qualify as categorically needy (table 2). This person pays nothing for medical care. The second individual has a monthly income of $1,100 and does not qualify as categorically needy. Deducting medical expenses leaves her with a net income of $600, which is above Pennsylvania's Medically Needy net income limit (table 4). In short, receiving an additional $200 of income costs the second person $500 of Medicaid benefits. The quantitative importance of these discontinuities is of course an empirical matter, depending both on the formal provisions and their practical application by Medicaid administrators.
In a number of recent studies, the joint effect of Medicaid and public assistance programs such as SSI is modeled as a consumption floor: If an individual is not able to cover her medical expenses and purchase a minimal amount of consumption, the government will cover the difference (Hubbard, Skinner, and Zeldes, 1995; Palumbo, 1999; De Nardi, French, and Jones, 2010; French and Jones, 2011). Is this a reasonable approximation approximation /ap·prox·i·ma·tion/ (ah-prok?si-ma´shun)
1. the act or process of bringing into proximity or apposition.
2. a numerical value of limited accuracy. of the Medicaid system?
Our review suggests that the effective consumption floor provided by Medicaid varies greatly by income and asset levels, as well as medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. . Individuals in nursing homes are given much smaller allowances, and are more likely to forfeit To lose to another person or to the state some privilege, right, or property due to the commission of an error, an offense, or a crime, a breach of contract, or a neglect of duty; to subject property to confiscation; or to become liable for the payment of a penalty, as the result of a the value of their house, than noninstitutionalized individuals. This distinction has been recognized by Brown and Finkelstein (2008), among others. The extent to which institutionalized individuals must surrender their homes depends on a number of factors, including the interpretation of the intent to return, the willingness of the state to impose liens, and the effectiveness of estate recovery, all of which vary across states.
We also find the potential for discontinuities in coverage. Medicaid recipients can be placed in two groups. The first group is the income needy, who receive benefits because they have low incomes. Income-needy individuals include those receiving expanded nursing home coverage, many recipients of HCBS services, and dual eligibles, as well as the categorically needy. The second group is the expenditure needy, who receive benefits because their medical expenses are large relative to their income. This group includes individuals utilizing Miller trusts, as well as the Medically Needy. In some cases, the net income (income less medical expenses) limits for the medically needy are stricter than the income limits for the income needy. This raises the possibility that the income needy receive more generous coverage. We believe that the scope for such unequal treatment is greatest for noninstitutionalized individuals.
Bassett, William William, crown prince of Germany
William or Frederick William, 1882–1951, crown prince of Germany, son of William II. In World War I he commanded (1914) an army on the Western Front and was nominal commander in the German attack F., 2007, "Medicaid's nursing home coverage and asset transfers," Public Finance Review, Vol. 35, No. 3, May, pp. 414-439.
Brown, Jeffrey R., and Amy Finkelstein, 2008, "The interaction of public and private insurance: Medicaid and the long-term care insurance market," American Economic Review, Vol. 98, No. 3, June, pp. 1083-1102.
Carpenter, Letty, 2000, "Financial eligibility rules eligibility rules,
n.pl the conditions that define who may be entitled to dental benefits, when persons first become entitled to such benefits, and any provisions that determine how long an individual remains entitled to benefits. and options," in Understanding Medicaid Home and Community Services: A Primer; Felicity Skidmore Skidmore can mean:
Crowley, Jeff, 2003, "Medicaid medically needy programs: An important source of Medicaid coverage," Kaiser Commission on Medicaid and the Uninsured, issue paper, No. 4096, January January: see month. .
De Nardi, Mariacristina, Erie Erie, indigenous people of North America
Erie (ĭr`ē), indigenous people of North America of the Iroquoian branch of the Hokan-Siouan linguistic stock (see Native American languages). French, and John Bailey John Bailey may refer to one of the following people:
ElderLawNet, Inc., 2011, "Medicaid rules," ElderLawAnswers, June, available at www.elderlawanswers.com/Elder_Info/Elder Article.asp?id=2751#1.
French, Eric ERIC Educational Research Information Clearinghouse
ERIC Educational Resources Information Center
ERIC ERISA Industry Committee
ERIC Epidemiologic Research and Information Center (Durham, NC) , and John Bailey Jones, 2011, "The effects of health insurance and self-insurance self-insurance,
n the setting aside of funds by an individual or organization to meet anticipated dental care expenses or dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses and claims. on retirement behavior," Econometrica Econometrica is an academic journal of economics, publishing articles not only in econometrics but in many areas of economics. It is published by the Econometric Society via Blackwell Publishing. , Vol. 79, No. 3, May, pp. 693-732.
Gardner, Lara, and Donna B. Gilleskie, 2009, "The effects of state Medicaid policies on the dynamic savings patterns and Medicaid enrollment of the elderly," University of North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. , working paper, February.
Goldfarb Goldfarb is German for golden color and is the surname of:
Gruber, Jonathan Jonathan (jŏn`əthən) [short for Jehonathan, Heb.,=Yahweh has given].
1 In the Bible, Saul's son and David's friend, both killed at the battle of Mt. Gilboa. David showed kindness to his son Mephibosheth. , 2000, "Medicaid," National Bureau of Economic Research, working paper, No. 7829, August.
Hubbard, R. Glenn, Jonathan Skinner Jonathan Skinner worked for The Universities and Colleges Christian Fellowship (UCCF). He is currently a British author, journalist, and Baptist minister. He is also a minister at Widcombe Baptist Church in Bath, England. , and Stephen Stephen, 1097?–1154, king of England (1135–54). The son of Stephen, count of Blois and Chartres, and Adela, daughter of William I of England, he was brought up by his uncle, Henry I of England, who presented him with estates in England and France and P. Zeldes, 1995, "Precautionary saving and social insurance," Journal of Political Economy, Vol. 103, No. 2, pp. 360-399.
Kaiser Commission on Medicaid and the Uninsured, 2010a, "Dual eligibles: Medicaid's role for low-income Medicare beneficiaries," report, Washington, DC, December December: see month. .
--, 2010b, "Medicaid financial eligibility: Primary pathways for the elderly and people with disabilities," report, No. 8048, Washington, DC, February.
--, 2009, "Medicaid home and community-based service programs: Data update," issue paper, No. 772003, Washington, DC, November November: see month. .
--, 2006, "Deficit Reduction Act of 2005: Implications for Medicaid," report, No. 7465, Washington, DC, February.
--, 2002, The Medicaid Resource Book, July.
Karp KARP Korean Association of Retired Persons , Naomi, Charles P. Sabatino, and Erica F. Wood, 2005, "Medicaid estate recovery: A 2004 survey of state programs and practices," AARP Public Policy Institute, paper, No. 2005-06, June.
Niesz, Helga, 2002, "Money follows the person: State Medicaid legislation," OLR See offline reader. Research Report, Office of Legislative Research, No. 2002-R-0837, November 12.
Norton, Edward C., 1995, "Elderly assets, Medicaid policy, and spend-down in nursing homes," Review of Income and Wealth, Vol. 41, No. 3, pp. 309-329.
O'Brien, Ellen, 2005, "Medicaid's coverage of nursing home costs: Asset shelter for the wealthy or essential safety net?," Georgetown University Georgetown University, in the Georgetown section of Washington, D.C.; Jesuit; coeducational; founded 1789 by John Carroll, chartered 1815, inc. 1844. Its law and medical schools are noteworthy, and its archives are especially rich in letters and manuscripts by and , Long-Term Care Financing Project, issue brief, May.
Palumbo, Michael G., 1999, "Uncertain medical expenses and precautionary saving near the end of the life cycle," Review of Economic Studies, Vol. 66, No. 2, April, pp. 395-421.
Sheltered Workshops, Inc., 2011, Washington, MO, available at http://shelteredworkshopsinc.org/about.html.
Social Security Administration, 2009a, Annual Report of the Supplemental Security Income Program, Baltimore Baltimore, city (1990 pop. 736,014), N central Md., surrounded by but politically independent of Baltimore co., on the Patapsco River estuary, an arm of Chesapeake Bay; inc. 1745. , MD: Social Security Adminstration, May.
--, 2009b, State assistance programs for SSI recipients," Social Security Online, January available at www.ssa.gov/policy/docs/progdesc/ssi_st_asst/ 2009/index.html.
Stone, Julie Lynn, 2002, "Medicaid: Eligibility for the aged and disabled," CRS CRS Course
CRS Certified Residential Specialist (real estate certification)
CRS Central Reservation System
CRS Can't Remember Stuff (polite form)
CRS Cost Reduction Strategy
CRS Consumer Relations Specialist Report for Congress, Congressional Research Service The Congressional Research Service (CRS) is a branch of the Library of Congress that provides objective, nonpartisan research, analysis, and information to assist Congress in its legislative, oversight, and representative functions. U.S. , No. RL31413, July 5.
U.S. Bureau of Economic Analysis, 2011, National Income and Product Accounts of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , April, available at www.bea.gov/national/nipaweb/ index.asp.
U.S. Department of Health and Human Services, Office of Assistant Secretary for Policy and Evaluation, 2005a, "Medicaid estate recovery collections," Medicaid Eligibility for Long-Term Care Benefits series, policy brief, Washington, DC, No. 6, September.
--, 2005b, "Medicaid liens," Medicaid Eligibility for Long-Term Care Benefits series, policy brief, Washington, DC, No. 4, April.
--, 2005c, "Medicaid treatment of the home: Determining eligibility and repayment for long-term care," Medicaid Eligibility for Long-Term Care Benefits series, policy brief, Washington, DC, No. 2, April.
--, 2005d, "Medicaid estate recovery," Medicaid Eligibility for Long-Term Care Benefits series, policy brief, Washington, DC, No. 1, April.
U.S. House of Representatives, House Ways and Means Committee, 2004, Green Book 2004: Background Material and Data on Programs within the Jurisdiction of the Committee on Ways and Means, March 2004, Washington, DC: U.S. Government Printing Office, March.
Waidmann, Timothy, and Korbin Liu, 2006, "Asset transfer and nursing home use: Empirical evidence and policy significance," Kaiser Commission on Medicaid and the Uninsured, issue paper, No. 7487, April.
Walker, Lina, and Jean Aeolus, 2010, "Access to long-term services and supports: A 50-state survey of Medicaid financial eligibility," Insight on the Issues, AARP Public Policy Institute, No. I-44, September.
Weschler, Kathy, 2005, "A qualified income trust: Keep your Medicaid eligibility," MDA/ALS Newsmagazine news·mag·a·zine
1. A magazine, usually published weekly, containing reports and analyses of current events.
2. A television program that presents a variety of topics, usually on current events, often by using interviews and , Vol. 10, No. 3, April.
(1) Figure is taken from the Kaiser Family Foundation The Henry J. Kaiser Family Foundation (KFF), or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. (2010).
(2) Figures are taken from the 2010 Medicaid Actuarial ac·tu·ar·y
n. pl. ac·tu·ar·ies
A statistician who computes insurance risks and premiums.
[Latin Report (Office of the Actuary actuary
One who calculates insurance risks and premiums. Actuaries compute the probability of the occurrence of such events as birth, marriage, illness, accidents, and death. , Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and , 2010) for those who are "aged." Data from the Medicaid Statistical Information System show that over 0.6 million disabled people are also aged 65 and older.
(3) Figures are taken from the US. Bureau of Economic Analysis, 2011, tables 3.1 and 3.12.
(4) Data from the Medicaid Statistical Information System (MSIS MSIS Medicaid Statistical Information System (formerly MedStat)
MSIS Marine Safety Information System
MSIS Man-Systems Integration Standards
MSIS Mass Spectrometer and Incoherent Scatter
MSIS Master of Science Information Systems ) cited in figure 1 show $68.3 billion, but these data do not include certain payments such as Medicare premiums paid for dual eligibles. For this reason, the MSIS data likely understate un·der·state
v. un·der·stat·ed, un·der·stat·ing, un·der·states
1. To state with less completeness or truth than seems warranted by the facts.
2. dual eligibles" share of total expenditures. Also, the MSIS categories are slightly different from those in figure 1. However, virtually all "cash recipients" over age 65 are those receiving SSI and virtually all "poverty related" individuals over age 65 are dual eligibles.
(5) Sheltered workshops are organizations that provide employment to people with disabilities (Sheltered Workshops. Inc, 2011).
(6) In addition to food stamps, the exempt categories include income that is set aside toward an approved plan for achieving self support Plan to Achieve Self Support, also known as a "PASS", is a program offered to the US citizens by the Social Security Administration (SSA) for disabled or blind individuals who receive or could qualify for Supplemental Security Income (SSI). (used by the blind and disabled to pay off educational or vocational costs), and certain types of assistance for home energy needs.
(7) The remainder of this section utilizes overviews by Stone (2002), Walker and Accius (2010), and the Kaiser Commission on Medicaid and the Uninsured (2010).
(8) Prior to the passage of the Omnibus Budget Reconciliation Act in 1993, it was acceptable to place extra income in a self-created discretionary fired to acquire Medicaid coverage. Since 1993, apart from limited trusts such as the Miller or Qualified Income trusts, most discretionary trust An arrangement whereby property is set aside with directions that it be used for the benefit of another, the beneficiary, and which provides that the trustee (one appointed or required by law to administer the property) has the right to accumulate, rather than pay out to the funds are treated as countable income or assets and may restrict people from obtaining Medicaid (see Goldfarb, 2005).
(9) The mandate is in the 2000 House Bill 1111, Section 11.445, which specifies that an individual eligible for or receiving nursing home care must be given the opportunity to have those Medicaid dollars follow them to the community and to choose the personal care option in the community that best meets their needs (Niesz, 2002).
(10) This raises the possibility of a discontinuity in coverage. An individual whose income is $1 above the categorically needy limit may need to spend a considerable amount to qualify under the Medically Needy provision. However, in practice the discontinuity in coverage is unimportant un·im·por·tant
Not important; petty.
unim·portance n. in most cases because institutionalized Medicaid recipients must spend almost all of their income on their care. The median cost of nursing home care was $5,550 per month in 2010. Whether an individual's income is slightly more or less than 300 percent of the SSI limit ($674 x 3 = $2,022), Medicaid will still provide a nursing home, but all of their income must be put toward the cost of the nursing home.
(11) If a spouse or dependent resides in the house, the equity limits do not apply (ElderLawNet, Inc., 2011).
(12) The inclusion of housing in the asset tests for institutionalized individuals applies to the categorically needy as well as the medically needy. Most categorically needy individuals, however, do not hold significant housing equity (U.S. Department of Health and Human Services, 2005c).
(13) States do not have to pursue an estate if they determine pursuit would not be cost-effective. The definition of "cost-effective," not surprisingly, varies across states (U.S. Department of Health and Human Services, 2005d).
(14) For example, New Hampshire New Hampshire, one of the New England states of the NE United States. It is bordered by Massachusetts (S), Vermont, with the Connecticut R. forming the boundary (W), the Canadian province of Quebec (NW), and Maine and a short strip of the Atlantic Ocean (E). and Michigan Michigan (mĭsh`ĭgən), upper midwestern state of the United States. It consists of two peninsulas thrusting into the Great Lakes and has borders with Ohio and Indiana (S), Wisconsin (W), and the Canadian province of Ontario (N,E). limit 1915(c) waivers for the aged to those who are also disabled. Only two states, Arizona and Vermont Vermont (vərmŏnt`) [Fr.,=green mountain], New England state of the NE United States. It is bordered by New Hampshire, across the Connecticut R. , do not offer HCBS waivers, and Arizona offers a similar program.
Mariacristina De Nardi is a senior economist and research advisor; Eric French is a senior economist and research advisor; and Angshuman Gooptu is an associate economist in the Economic Research Department of the Federal Reserve Bank of Chicago
The Federal Reserve Bank of Chicago is one of twelve regional Reserve Banks that, along with the Board of Governors in Washington, D.C. . John Bailey Jones is an associate professor of economics at the University at Albany, State University of New York (body) State University of New York - (SUNY) The public university system of New York State, USA, with campuses throughout the state. , and a consultant to the Federal Reserve Bank of Chicago. The authors thank Daisy Chen, John Klemm, and representatives of Medicaid offices in Florida, Alabama, Indiana, Wisconsin Wisconsin, state, United States
Wisconsin (wĭskŏn`sən, –sĭn), upper midwestern state of the United States. It is bounded by Lake Superior and the Upper Peninsula of Michigan, from which it is divided by the Menominee , and Ohio, who helped verify (1) To prove the correctness of data.
(2) In data entry operations, to compare the keystrokes of a second operator with the data entered by the first operator to ensure that the data were typed in accurately. See validate. the facts in this paper, and a referee A judicial officer who presides over civil hearings but usually does not have the authority or power to render judgment.
Referees are usually appointed by a judge in the district in which the judge presides. and Richard Porter for comments.
Economic Perspectives is published by the Economic Research Department of the Federal Reserve Bank of Chicago. The views expressed are the authors' and do not necessarily reflect the views of the Federal Reserve Bank of Chicago or the Federal Reserve System.
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TABLE 1 State SSI supplements (in 2010 dollars) for aged individuals living independently (selected -years, 1975-2009) State 1975 1980 1985 1990 1996 2002 2009 Alaska 575 622 529 552 503 439 588 California 409 482 363 407 217 249 233 Colorado 109 146 118 90 78 45 25 Connecticut 0 270 286 611 0 245 171 District of 0 40 30 25 7 0 233 Columbia Hawaii 69 40 10 8 7 6 370 Idaho 255 196 158 122 51 63 27 Illinois (a) NA NA NA NA NA NA NA Maine 41 26 20 17 14 12 233 Massachusetts 450 363 261 215 175 156 233 Michigan 49 64 55 50 19 17 233 Minnesota 126 90 71 125 113 98 233 Nebraska 271 199 140 63 17 10 233 Nevada 223 124 73 60 50 44 37 New Hampshire 49 122 55 45 38 33 41 New Jersey 97 61 63 52 43 38 233 New York 247 167 124 144 120 105 95 Oklahoma 109 209 122 107 75 64 45 Oregon 69 32 4 3 3 2 2 Pennsylvania 81 85 65 53 38 33 233 Rhode Island 126 111 109 107 89 78 233 South Dakota 0 40 30 25 21 18 15 Utah 0 26 20 10 0 0 233 Vermont 117 109 107 105 65 72 246 Washington 146 114 77 47 35 32 47 Wisconsin 284 265 203 172 117 102 85 Wyoming 0 53 41 33 14 12 25 (a) Illinois supplements are determined on a case-by-case basis. Notes: Converted to 2010 dollars using Consumer Price Index data from Haver Analytics. NA indicates not applicable. Sources: For 1975-2002, U.S. House of Representatives, House Ways and Means Committee (2004); for 2009, Social Security Administration (2009b). TABLE 2 Income and asset limits (in $) for SSI Medicaid recipients, 2009 Maximum SSI and federal Medicaid SSI benefit asset plus state Disregarded State limit (b, d) supplement income Non-209(b) states Alabama 2,000 674 20 Alaska, 2,000 1,262 20 Arizona No limit 903 20 Arkansas 2,000 674 20 California 2,000 907 230 Colorado 2,000 699 20 Delaware 2,000 674 20 District of 4,000 907 20 Columbia Florida 5,000 674 20 Georgia 2,000 674 20 Idaho 2,000 701 20 Iowa 2,000 674 20 Kansas 2,000 674 20 Kentucky 2,000 674 20 Louisiana 2,000 674 20 Maine 2,000 907 75 Maryland 2,500 674 20 Massachusetts 2,000 907 20 Michigan 2,000 907 20 Mississippi 4,000 724 50 Montana 2,000 674 20 Nebraska 4,000 907 20 Nevada 2,000 711 20 New Jersey 4,000 907 20 New Mexico 2,000 674 20 New York 4,350 769 20 North Carolina 2,000 903 20 Oregon 4,000 676 20 Pennsylvania 2,000 907 20 Rhode Island 4,000 907 20 South Carolina 4,000 903 20 South Dakota 2,000 689 20 Tennessee 2,000 674 20 Texas 2,000 674 20 Utah 2,000 907 20 Vermont 2,000 920 20 Washington 2,000 721 20 West Virginia 2,000 674 20 Wisconsin 2,000 759 20 Wyoming 2,000 699 20 209(b) states SSI: 2,000 Connecticut Medicaid 1,600 845 278 Hawaii, 2,000 1,044 20 Illinois 2,000 674 25 SSI: 2,000 Indiana Medicaid: 1,500 674 20 Minnesota 3,000 907 20 SSI: 2,000 Missouri, Medicaid: 1,000 768 20 SSI: 2,000 New Hampshire (c) Medicaid: 1,500 715 13 North Dakota 3,000 674 20 Ohio SSI: 2,000 Medicaid: 1,500 674 20 Oklahoma 2,000 719 20 Virginia 2,000 722 20 Monthly (earned) income limit for SSI/Medicaid State eligibility Non-209(b) states Alabama 1,433 Alaska, 2,609 Arizona 1,891 Arkansas 1,433 California 2,109 Colorado 1,483 Delaware 1,433 District of 1,899 Columbia Florida 1,433 Georgia 1,433 Idaho 1,487 Iowa 1,433 Kansas 1,433 Kentucky 1,433 Louisiana 1,433 Maine 1,954 Maryland 1,433 Massachusetts 1,899 Michigan 1,899 Mississippi 1,563 Montana 1,433 Nebraska 1,899 Nevada 1,507 New Jersey 1,899 New Mexico 1,433 New York 1,623 North Carolina 1,891 Oregon 1,437 Pennsylvania 1,899 Rhode Island 1,899 South Carolina 1,891 South Dakota 1,463 Tennessee 1,433 Texas 1,433 Utah 1,899 Vermont 1,925 Washington 1,527 West Virginia 1,433 Wisconsin 1,603 Wyoming 1,483 209(b) states Connecticut 2,033 Hawaii, 2,173 Illinois 1,438 Indiana 1,433 Minnesota 1,899 Missouri, 1,621 New Hampshire (c) 1,508 North Dakota 1,433 Ohio 1,433 Oklahoma 1,523 Virginia 1,529 (a) Based on Alaska Public Assistance payments. (b) Disabled individuals under the age of 65 face no asset limits. (c) individuals receiving reduced SSI benefits may not qualify for Medicaid. (d) In 209(b) states, SSI and Medicaid asset limits are sometimes different. Source: Kaiser Commission on Medicaid and the Uninsured (2010b). TABLE 3 Income and asset limits (in $) for dual eligibles, 2010 Monthly Monthly Monthly income income income Income limit, limit, limit, disregard State QMBs SLMBs QIs amount Non-209(b) states Alabama 903 1,083 1,219 20 Alaska 1,108 1,333 1,503 20 Arizona 903 1,083 1,219 20 Arkansas 903 1,083 1,219 20 California 903 1,083 1,219 20 Colorado 903 1,083 1,219 20 Delaware 903 1,083 1,219 20 QMB: 1,803; District of 2,706 2,708 NA SLMB: 1,625; Columbia QI: NA Florida 903 1,083 1,219 20 Georgia 903 1,083 1,219 20 Idaho 903 1,083 1,219 20 Iowa 903 1,083 1,219 20 Kansas 903 1,083 1,219 20 Kentucky 903 1,083 1,219 20 Louisiana 903 1,083 1,219 20 Maine 1,354 1,535 1,670 75 Maryland 902 1,083 1,218 20 Massachusetts 903 1,083 1,219 20 Michigan 903 1,083 1,219 20 Mississippi 903 1,083 1,219 50 Montana 903 1,083 1,219 20 Nebraska 903 1,083 1,219 20 Nevada 903 1,083 1,219 20 New Jersey 903 1,083 1,219 20 New Mexico 903 1,083 1,219 20 New York 903 1,083 1,219 20 North Carolina 903 1,083 1,219 20 Oregon 903 1,083 1,219 20 Pennsylvania 903 1,083 1,219 20 Rhode Island 903 1,083 1,219 20 South Carolina 903 1,083 1,219 20 South Dakota 903 1,083 1,219 20 Tennessee 903 1,083 1,219 20 Texas 903 1,083 1,219 20 Utah 903 1,083 1,219 20 Vermont 903 1,083 1,219 20 Washington 903 1,083 1,219 20 West Virginia 903 1,083 1,219 20 Wisconsin 903 1,083 1,219 20 Wyoming 903 1,083 1,219 20 209(b) states QMB: 876; Connecticut 1,779 1,960 2,092 SLMB: 877; Q1: 873 Hawaii 1,039 1,246 1,402 20 Illinois 903 1,083 1,219 25 Indiana 903 1,083 1,219 20 Minnesota 903 1,083 1,219 20 Missouri 903 1,083 1,219 20 New Hampshire 903 1,083 1,219 13 North Dakota 903 1,083 1,219 20 Ohio 903 1,083 1,219 20 Oklahoma 903 1,083 1,219 20 Virginia 903 1,083 1,219 20 Asset State limit Non-209(b) states Alabama No limit Alaska 6,600 Arizona No limit Arkansas 6,600 California 6,600 Colorado 6,600 Delaware No limit District of No limit Columbia Florida 6,600 Georgia 6,600 Idaho 6,600 Iowa 6,600 Kansas 6,600 Kentucky 6,600 Louisiana 6,600 Maine No limit Maryland 6,600 Massachusetts 6,600 Michigan 6,600 Mississippi No limit Montana 6,600 Nebraska 6,600 Nevada 6,600 New Jersey 6,600 New Mexico 6,600 New York No limit North Carolina 6,600 Oregon 6,600 Pennsylvania 6,600 Rhode Island 6,600 South Carolina 6,600 South Dakota 6,600 Tennessee 6,600 Texas 6,600 Utah 6,600 Vermont No limit Washington 6,600 West Virginia 6,600 Wisconsin 6,600 Wyoming 6,600 209(b) states Connecticut No limit Hawaii 6,600 Illinois 6,600 Indiana 6,600 Minnesota 10,000 Missouri 6,600 New Hampshire 6,600 North Dakota 6,600 Ohio 6,600 Oklahoma 6,600 Virginia 6,600 Notes: OMB indicates qualified Medicare beneficiaries; SLMB indicates specified low-income Medicare beneficiaries; and QI indicates qualified individuals. NA indicates not applicable. Source: Kaiser Commission on Medicaid and the Uninsured, 2010b. TABLE 4 Income and asset limits (in $) for institutionalized medically needy Medicaid recipients, 2009 Income limit (income less Asset medical State Coverage limit expenses) Non-209(b) states Alabama No NA NA Alaska No NA NA Arizona Yes 5,000 (b) 360 Arkansas Yes 2,000 108 California Yes 2,000 600 Colorado No NA NA Delaware No NA NA District of Yes 4,000 577 Columbia Florida Yes 5,000 180 Georgia Yes 2,000 317 Idaho No NA NA Iowa Yes 10,000 483 Kansas Yes 2,000 495 Kentucky Yes 2,000 217 Urban: 100; Louisiana Yes 2,000 Rural: 92 Maine Yes 2,000 903 Maryland Yes 2,500 350 Massachusetts Yes 2,000 9,035 (d) Region 1: 341; Region 2: 341; Region 3: 350; Region 4: 375; Region 5: 391; Michigan Yes 2,000 Region 6: 408 Mississippi No NA NA Montana Yes 2,000 625 Nebraska Yes 4,000 392 Nevada No NA NA New Jersey Yes 4,000 367 New Mexico No NA NA New York Yes 2,000 767 North Carolina Yes 2,000 242 Oregon No NA NA Pennsylvania Yes 2,400 425 Rhode Island Yes 4,000 800 South Carolina No NA NA South Dakota No NA NA Tennessee Yes 2,000 241 Texas No NA NA Utah Yes 2,000 370 916 (991 for Vermont Yes 2,000 Chittenden) Washington Yes 2,000 674 West Virginia Yes 2,000 200 Wisconsin Yes 2,000 592 Wyoming No NA NA 209(b) states Region A: 576; Connecticut Yes 1,600 Regions B and C: 476 Hawaii Yes 2,000 469 Illinois Yes 2,000 903 Indiana No, NA NA Minnesota Yes 3,000 677 Missouri No, NA NA New Hampshire Yes 2,500 591 North Dakota Yes 3,000 750 Ohio No (e) NA NA Oklahoma No (e) NA NA Group I: 281; Group II: 324; Virginia (f) Yes 2,000 Group III: 421 Expanded Income nursing allowed if Home home institutionalized equity State coverage in 2003 limit Non-209(b) states Alabama Yes NA 500,000 Alaska Yes (a) NA 500,000 Arizona Yes 76.65 500,000 Arkansas Yes 40 500,000 California No 35 750,000 Colorado Yes NA 500,000 Delaware Yes (c) NA 500,000 District of No 70 750,000 Columbia Florida Yes 35 500,000 Georgia Yes 30 500,000 Idaho Yes NA 750,000 Iowa Yes 30 500,000 Kansas Yes 30 500,000 Kentucky Yes 40 500,000 Louisiana Yes 38 500,000 Maine Yes 40 750,000 Maryland Yes 40 500,000 Massachusetts No 60-65 750,000 Michigan Yes 60 500,000 Mississippi Yes NA 500,000 Montana Yes 40 500,000 Nebraska Yes 50 Disregarded (c) Nevada Yes NA 500,000 New Jersey Yes 40 750,000 New Mexico Yes NA 750,000 New York No 50 750,000 North Carolina No 30 500,000 Oregon Yes NA 500,000 Pennsylvania Yes 30 500,000 Rhode Island Yes 50 500,000 South Carolina Yes NA 500,000 South Dakota Yes NA 500,000 Tennessee Yes 30 500,000 Texas Yes NA 500,000 Utah Yes 45 500,000 Vermont Yes 47.66 500,000 Washington Yes 41.62 500,000 West Virginia Yes NA 500,000 Wisconsin Yes 45 750,000 Wyoming Yes NA 500,000 209(b) states Connecticut Yes 54 750,000 Hawaii No 30 750,000 Illinois No 30 NA Indiana No NA 500,000 Minnesota No 69 500,000 Missouri No NA 500,000 New Hampshire Yes 50 500,000 North Dakota No 40 500,000 Ohio Yes NA 500,000 Oklahoma Yes NA 500,000 Virginia (f) Yes 30 500,000 State- allowed Miller State trust Non-209(b) states Alabama Yes Alaska Yes Arizona Yes Arkansas Yes California No Colorado Yes Delaware Yes District of No Columbia Florida Yes Georgia No Idaho Yes Iowa Yes Kansas No Kentucky No Louisiana No Maine No Maryland No Massachusetts No Michigan No Mississippi Yes Montana No Nebraska No Nevada Yes New Jersey No New Mexico Yes New York No North Carolina No Oregon Yes Pennsylvania No Rhode Island No South Carolina Yes South Dakota Yes Tennessee No Texas Yes Utah No Vermont No Washington No West Virginia No Wisconsin No Wyoming Yes 209(b) states Connecticut No Hawaii No Illinois No Indiana No Minnesota No Missouri No New Hampshire No North Dakota No Ohio Yes Oklahoma Yes Virginia (f) No NA indicates not applicable. (a) Income limit frozen at $1,656. (b) Liquid asset limit-total assets, including housing, cannot exceed $100,000. (c) Income limit set at 250 percent, rather than 300 percent, of SSI limit. (d) Limit is $1,200 for those with professional care assistance. (e) State is required to offer a spend-down provision. (f) The state of Virginia is split into three groups, each with a different Medically Needy income limit. Source: Kaiser Commission on Medicaid and the Uninsured (2010b); Miller trust information from Stone (2002). TABLE 5 Share of Medicaid nursing home expenses collected from estates Medicaid collections/ State nursing home costs (%) Alabama 0.8 Alaska 0.0 Arizona 10.4 (a) Arkansas 0.4 California 1.5 Colorado 1.5 Connecticut 0.8 Delaware 0.3 District of Columbia 1.0 Florida 0.6 Georgia 0.0 Hawaii 0.9 Idaho 4.5 Illinois 1.3 Indiana 1.8 Iowa 2.9 Kansas 1.4 Kentucky 0.9 Louisiana 0.0 Maine 2.5 Maryland 0.6 Massachusetts 2.0 Michigan 0.0 Minnesota 2.8 Mississippi 0.1 Missouri 1.1 Montana 1.4 Nebraska 0.3 Nevada 0.3 New Hampshire 1.6 New Jersey 0.6 New Mexico 0.0 New York 0.5 North Carolina 0.5 North Dakota 1.2 Ohio 0.5 Oklahoma 0.3 Oregon 5.8 Pennsylvania 0.1 Rhode Island 1.0 South Carolina 1.3 South Dakota 1.0 Tennessee 0.9 Texas 0.0 Utah 0.0 Vermont 0.4 Virginia 0.1 Washington 1.8 West Virginia 0.1 Wisconsin 1.8 Wyoming 2.7 (a) Results for Arizona are not comparable to those for other states because of data issues arising from the extensive use of prepaid managed care contracts. Sources: Probate data--Karp, Sabatino, and Wood (2005), policy range and collections data--U.S. Department of Health and Human Services (2005a). TABLE 6 Decision criteria for TERFA liens Number of Length months Intent of stay triggering to return Physician's State presumption presumption home declaration Alabama Yes 3 Yes Yes Arkansas Yes 4 Yes Yes California Yes No No No Connecticut Yes 6 Yes Yes Delaware Yes 24 Yes No Hawaii Yes 6 Yes Yes Idaho Yes Yes No No Illinois Yes 4 Yes No Indiana NR Yes Yes Yes Maryland Yes NR Yes Yes Massachusetts Yes 6 Yes Yes Minnesota Yes 6 Yes No Montana Yes Yes No No New Hampshire Yes No No No New York Yes No No No Oklahoma Yes 6 Yes Yes South Dakota Yes Yes No No West Virginia NR NR Yes No Wyoming NR No NR NR Other third-party State evaluation Other Alabama No No Arkansas No No California No No Connecticut Yes Yes Delaware No No Hawaii No No Idaho No No Illinois No No Indiana Yes Yes Maryland No Yes Massachusetts Yes No Minnesota No No Montana No Yes New Hampshire No Yes New York No No Oklahoma No No South Dakota No Yes West Virginia No Yes Wyoming NR NR Notes: TERFA is the Tax Equity and Fiscal Responsibility Act of 1982. NR indicates no response. Source: Karp, Sabatino, and Wood (2005). TABLE 7 Eligibility criteria for Medicaid 1915(c) HCBS waivers, 2008 Income limit Income limit for the aged/ for the aged Waiting disabled (% of SSI list for (% of SSI States limit) (a) the aged limit) (a) Non-209(b) States Alabama 300, MT Alaska 300, MT 0 Arizona NP (d) Arkansas 300, MT 0 California 100 Colorado 300, MT Delaware 100, MT 0 250, MT District of 300 Columbia Florida 300, MT 0 300, MT Georgia 300, MT Idaho 300, MT Iowa 300, MT 0 Kansas 300 0 Kentucky 300, MT Louisiana 300 Maine 300 Maryland 300 6,000 Massachusetts 100 0 Michigan 300 Mississippi 300, MT Montana 100 Nebraska 100 Nevada 300, MT 343 300, MT New Jersey 300 New Mexico 300 New York 300, MT North Carolina 100 Oregon 300, MT Pennsylvania 300 0 Rhode Island 300 0 300 South Carolina 300, MT South Dakota 300, MT 0 Tennessee 300, MT Texas 300, MT Utah 300 0 Vermont NP Washington 300 West Virginia 300 Wisconsin 300 Wyoming 300, MT 209(b) states Connecticut 300 Hawaii 100 Illinois 100 0 100 Indiana 100, MT Minnesota 300 0 Missouri 100 New Hampshire 100 0 North Dakota 100 Ohio 300, MT Oklahoma 300, MT Virginia 300 0 300 Waiting Tougher list for functional Income the aged/ requirements; (b) allowed, States disabled cost limits (in $) Non-209(b) States Alabama 7,094 Yes; yes UL Alaska No; yes 1,656 Arizona Arkansas No; yes UL California 1,200 No; yes <2,022 Colorado 0 No; no 2,022 Delaware 0 Yes; no 1,685 District of 0 No; yes 2,022 Columbia Florida 12,684 Yes; yes 674 Georgia 763 Yes; no 674 Idaho 0 No; no 674 (e) Iowa No; yes 2,022 Kansas Yes; yes 727 Kentucky 0 No; yes 694 Louisiana 8,433 No; yes 2,022 Maine 0 No; yes 1,128 Maryland No, yes 2,022 Massachusetts No; no 2,022 Michigan 3,404 No; no 2,022 Mississippi 6,000 Yes; yes UL Montana 600 No; yes 625 Nebraska 0 No; yes 903 Nevada 0 No; no UL New Jersey 0 No; yes 2,022 New Mexico 5,000 No; no UL New York 0 Yes; yes 787 North Carolina 6,000 No; yes 903 Oregon 0 No; yes 1,822 Pennsylvania No; yes 2,022 Rhode Island 99 No; no 923 South Carolina 2,016 No; yes 2,022 South Dakota No; yes 694 Tennessee 350 No; yes 1,348 Texas 40,107 Yes; yes 2,022 Utah Yes; no [greater than or equal to] 903, [less than or equal to] 2,022 Vermont Washington 0 No; yes [less than or equal to] 2,022 West Virginia 0 No; yes 674 Wisconsin 13,296 No; no [less than or equal to] 2,022 Wyoming 210 No; yes UL 209(b) states Connecticut 0 No; yes 1,805 Hawaii 100 No; no 1,128 Illinois 0 No; no 674 Indiana 1,279 No; yes 2,022 Minnesota No, yes 935 Missouri 0 No; yes 1,113 New Hampshire No; no Varies North Dakota 0 No; no 750 Ohio 1,224 No; yes 1,314 Oklahoma 0 No; yes 1,011 Virginia 0 No; no [less than or equal to] 2,022 (a) MT indicates that the state allowed Miller trusts in 2009-10. (b) Individual must exhibit difficulty performing three (rather than two) activities of daily living. (c) Cost allowance for 2009-10. These limits may be exceeded through the use of Miller trusts. (d) Offers a similar program. (e) Allowance is $1,128 for renters. Note: HCBS is home- and community-based service care; NP indicates not a participant; UL denotes unlimited with a Miller trust; [less than or equal to] means at most, but the income allowance depends on multiple factors. Source: Kaiser Commission on Medicaid and the Uninsured (2009); Miller trust information from Walker and Accius (2010). FIGURE 1 Medicaid enrollment and expenditures by maintenance assistance status in 2008, age 65+ A. Enrollment SSI recipients 40% Medically Needy 10% Dual eligibles 29% Other 21% B. Expenditures SSI recipients 27% Medically Needy 23% Dual eligibles 9% Other 41% Source: Centers of Medicare and Medicaid Services, Medicaid Statistical Information System (MSIS). Note: Table made from pie chart.