PA Medicaid Eligibility

Besides restrictive financial rules for determining PA Medicaid eligibility, there are also medical qualifications to meet before a person will be eligible for Medicaid coverage for a nursing home stay. The applicant must prove he or she is:

  • At least age 65
  • Blind or
  • Disabled

The actual definition of disabled will include the following: a person is unable “to do any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

So as you can see, you can qualify for Medicaid and not be “disabled” or blind, provided you are at least age 65 and need daily nursing services of the type provided in a nursing home. Most states will confirm one's need by sending out a local case manager and conduct a formal interview and assessment.

The entire assessment is based on the Activities of Daily Living (ADLs) and in order to be deemed “sick” enough to qualify for Medicaid, the applicant must “fail” a certain number of these tests. 

How Much Income Is Allowed?

Income eligibility is different based on whether the Medicaid applicant is single or married. Let’s look at a single person case first.

An unmarried individual in an institution may not have available income of more than three times the then applicable SSI income limit. The 2011 figure is $2,022, which is published by the federal government and updated each January 1 to reflect cost-of-living changes.

The treatment of income of a married couple is markedly different than that of a single individual. The primary reason centers rules that allows the income of the sick spouse to be shifted to the spouse still residing in the community, known as the “Community Spouse”.

As a result of this opportunity, there is much planning that can be done to maximize the income of the Community Spouse and minimize the income of the nursing home spouse.

If the spouses own assets jointly, then any income from the assets will be deemed to be earned by each spouse 50/50, unless the controlling document (if any) specifically allocates the income otherwise.

Although the Community Spouse never has to contribute any of his or her income to the other spouse’s care, it is possible for the nursing home spouse’s income to be paid to the Community Spouse. That’s because the Community Spouse is entitled to a minimum monthly income.


How Much Assets Are Allowed?

Before we determine the maximum amount of assets you can have and still qualify for Medicaid, let’s first look at the 3 categories of assets and see how Medicaid views those assets:

3 Categories of Assets

1. Excluded Assets: certain assets while available to you will be viewed excluded to Medicaid. The most common assets in this category are: $2000 in cash, the home, 1 car, pre-paid burial/funeral and a small amount of cash value life insurance.

2. Unavailable Assets: these are assets that are not legally accessible to you like: real estate that cannot be sold or an interest in someone else’s estate.

3. Countable Assets: like the name suggest, these are assets that Medicaid will ask you to spend down on the long term care like: cash, CD’s stocks, bonds, mutual funds etc.

In a single person case, the maximum amount of assets they can have is between $1500-$2000, depending on which state you live in.

In a marital case the rules are much more favorable. Depending on your state, the well spouse at home is entitled to 50% of all assets but only up to a maximum of $109,560.

For example: if all assets are totaled and the amount is $100,000, then the well spouse will be entitled to either $50,000 or $100,000, depending on your state. The reason for this is because some states are known as 50% state whiles others are not. You should seek the help of a professional who knows your states rules on this.

So as you can see if you are single or married you need to know the rules. However, what’s more important after knowing the rules is to learn how to use strategies for qualifying even if you have too much income or too many assets.

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