Long Term Care Resources

Medicaid

Medicaid is a jointly-funded state and federal government program that pays for medical care for the medically needy. Medically needy includes those who qualify for Aid to Families with Dependent Children (AFDC), those who are aged, blind or disabled and those whose income does not exceed 133 percent of the AFDC payment level for a family of the same size.

In Illinois for example, Medicaid is administered by the Department of Public Aid . State government contributes one-half of the program's cost, the federal government the other half.

The primary services funded through Medicaid are physician fees, hospital and long term care. Additional coverages include drugs, equipment and transportation.

Who Can Receive Medical Assistance?

Medicaid is available to anyone who can demonstrate need as established through income and asset standards. In Fiscal Year 1996, 1.4 million persons a month or 1 in 8 Illinois residents will be covered by Medicaid.

Many Medicaid recipients have income and assets but still qualify for the program, paying a portion of their medical expenses while Medicaid pays the remainder. This is called "spend down" and extends the program to many low-income families and individuals.

This monthly spend-down amount works like an insurance deductible. The Medicaid program will pay for medical care when persons can show that they owe or have paid medical bills exceeding their monthly spend-down.

Of all Medicaid-eligible persons in Illinois, 650,000 are children under 19 and 60,000 are long term care residents. In Illinois, more than 600,000 people receive Medicaid but no other form of public assistance. This group accounts for nearly one-half of Illinois' public aid clients.

Where Does One Apply for Medicaid?

The Department of Public Aid has a local office in each county with multiple locations in Cook, Kane, Madison and St. Clair counties. Applications may also be completed at the time of service at hospitals and clinics. Pregnant women and children under age 19 may be enrolled at some hospitals and clinics under the Maternal & Child Health application program, and a visit to the local office may not be necessary.

Help With Medicare Premiums

Qualified Medicare Beneficiary (QMB)
Specified Low-Income Beneficiary (SLIB)
Older Americans may be eligible for help with Medicare premiums through the QMB and SLIB programs.

The QMB Program

The QMB program is available to Medicare beneficiaries who have limited income and few assets. QMB pays the Medicare Part B premium. $42.50 per month, the coinsurance of 20 percent for Medicare covered services and the Medicare deductible.

To qualify, Medicare beneficiaries must have a monthly income at or below the poverty level: $645 or below for one person or $863 for a couple. This income includes Social Security benefits, pensions and all other interest payments and income. Additionally, resources, including bank accounts and stocks and bonds, can not exceed $4,000 for one or $6,000 for a family of two.

Some assets and possessions are exempt, including a home, car, burial plot and life insurance. Application is made through local public aid offices, not through Medicare or Social Security offices.

The SLIB Program

The SLIB program is available for those whose countable income is higher than the amount allowed under QMB eligibility requirements. SLIB covers the Medicare Part B premiums for beneficiaries whose income is at or below 120 percent of the federal poverty level: $774 per month for one person; $1,036 per month for two.

All other eligibility requirements are the same as for the QMB.

Mediplan Plus

When approved by the federal government for implementation, MediPlan Plus will establish an integrated health care system for Medicaid by providing 1.1 million clients with a choice of HMOs, primary care physicians, managed care community networks, federally qualified health centers, rural health clinics and insurance companies.

As it is now designed, MediPlan Plus:

Requires managed care entities to inform clients about the services available under each managed care plan and allows for clients to make a choice of which plan to join.
Allows Public Aid to assign clients who do not make a choice. Allows clients to change membership in a plan at least every 12 months.
Requires Public Aid to operate a hotline for clients to resolve problems. Excludes long term care residents and Medicaid spend-down clients from the managed care system.
Requires managed care entities to provide quality assurance, utilization review and grievance procedures consistent with the current provisions of the HMO act.
Includes an "any willing provider" clause which allows physicians, pharmacies, podiatrists and federally qualified health clinics to participate in a managed care system, subject to reasonable terms and conditions.
Requires managed care entities to pay for out-of-plan emergency care and authorized urgent services at fee-for-service rates.
Requires primary care physicians serving clients in managed care to meet access and quality standards established by Public Aid.
Excludes services of children's hospitals, rehabilitation services and behavioral services from the managed care system. Behavioral services, such as mental health services, subacute alcohol and substance abuse treatment services, will be provided through a separate managed care program.

Nursing Home Services
Applying To Public Aid - Nursing Home Expenses

The Department of Public Aid ( or, similarly named state office ) pays for long term nursing home services through a Medical Assistance Program ( MAP ). Public Aid does not pay for nursing home care for everyone, however.

If you want Public Aid to pay for your nursing home care, you must do the following:

Apply For Medical Assistance
Go to your local Public Aid office. A caseworker will ask questions and enter your answers into a computer. When you're done, the computer printout with your answers and signature is your application.
If you are physically unable to go to your local Public Aid office, a caseworker can call you on the telephone to interview you and help you apply. If you are a patient in a hospital, someone on the hospital staff will help you apply.
If your application is approved, your eligibility for Medical Assistance usually begins with the month you apply. However, you may be eligible for Medical Assistance for up to three months before the month you apply. If you have medical expenses during any of the three months before the month you apply, be sure to tell your caseworker so Public Aid can decide whether it will pay for those bills.
If possible, you should not pay your medical bills until you learn whether you are eligible for Medical Assistance so that Public Aid can pay them. It may be necessary for you to pay part of your income to the nursing home for your care - this personal payment requirement is referred to as your "patient credit" in nursing home bookkeeping jargon.
Obtain A Doctor's Certification
You'll need a special form from your doctor stating that you need the services provided by a nursing home. If you already live in a nursing home and are now applying for Medical Assistance, you must get a form from your doctor stating that you should continue to get your care in a nursing home. Without either of these forms, Public Aid will not pay for your care.
Obtain A Screening
A screening is an examination given by the Department on Aging, Department of Mental Health and Developmental Disabilities or the Department of Rehabilitation Services.
The screening helps Public Aid decide if a nursing home is the best place for you to receive your care. If you are about to move into a nursing home and are now applying for Medical Assistance, you must also have a health screening. If you do not have a screening, Public Aid will not pay for the first 60 days you are in a nursing home. If you are now in a hospital, ask your nurse to have someone from the hospital's social service arrange for your screening. If you are now living in a nursing home, ask your nurse to arrange your screening.

You Have A Right To Keep Your Own Money

Public Aid will tell you how much of your own money you will have to pay to the nursing home each month (patient credit). You will be able to keep $30 each month for your personal needs. If you are married, you may be able to keep some money each month to help support your husband or wife.

If you are helping support other members of your family, Public Aid allows you to give income to the dependent family members. Dependent family members include dependent children under age 21, disabled adult children and dependent parents or brothers or sisters of you or your spouse who live with your spouse.

Protecting Property For Your Spouse

When you go into a nursing home, your spouse may keep your home, your car and your household furnishings. Public Aid will then determine the value of your other property, such as bank accounts or certificates of deposit. You may transfer other property to your spouse or to someone else for the sole benefit of your spouse.

Depending on how much property your spouse already has (not counting things like the house and the car), you may give your spouse property valued up to $87,000 for 2001. Each state may set their own limits. This amount will likely increase each year. Your local Public Aid Office will tell you the actual amount you may give to your spouse.

Protecting Income For Your Spouse

When Public Aid decides the amount of income you have to apply to the cost of your nursing care, deductions are permitted, if you give money to your spouse and any other dependent family members. Dependent family members include dependent children under age 21, dependent adult children, dependent parents or dependent brothers or sisters of either you or your spouse who live with your spouse.

In Illinois for example, depending on an individual's circumstances, in 2001 you may give up to $2,175 of your income per month to your spouse. Again, these amounts are determined by the state programs and can vary from state to state. These amounts will likely increase each year. Your local Public Aid Office will be able to provide information regarding the the actual amount you may give.

Transfer Of Property To Qualify For Medical Assistance

Property transfers may affect your eligibility. If you or your spouse have transferred property for less than it's worth, other than as described above, you may be subject to a penalty period for nursing home services and for in-home care services through the Department on Aging. If otherwise eligible, you remain entitled to other covered medical services.

Transfers that may affect your eligibility are those made within 36 months ( 60 months for specific trusts ) of the date of your application, OR those made within 36 months ( 60 months for specific trusts ) of the date you apply for/receive in-home care services through Department On Aging. The is referred to as a "Look Back" period. Deliberate self-impoverishment to receive public funds for healthcare can be a criminal offense.