Frequently Asked Questions

Medicare is a federal health insurance program for people 65 and older, and some younger people with disabilities. Medicare often covers the cost for doctors and hospitalizations, as well as other medical expenses. Medicare also covers skilled rehabilitation care at a nursing home. It does not, however, cover the long-term cost of care at a nursing home after a rehabilitation (skilled care) period has ended. That is where Medicaid comes in. Medicaid, which has strict income and asset limits for eligibility, is one way to cover the cost of long-term care in a nursing home.

Skilled care in a nursing home involves rehabilitation and is generally when a person is receiving physical or occupational therapy. This is a period of time when a person is continuing to recover after an illness, injury, or surgery. Medicare will cover at least a portion of the cost of skilled care.

Unskilled care comes into play once the period of skilled care is over, and a person cannot or chooses not to return home or to the community. Rehabilitation and therapy services are no longer provided, and the person is assumed to be a long-term care patient at that time. Medicare does not cover the cost of unskilled care, and individuals often look to Medicaid to assist with covering the cost of unskilled care.

A Medicaid spend down refers to the process of reducing one's assets to qualify for Medicaid coverage. This typically involves spending or reallocating assets to meet Medicaid's asset and income eligibility criteria. It's a strategy often employed by individuals needing long-term care but whose assets exceed Medicaid's limits. Proper planning and guidance from a qualified elder law attorney can help navigate this process effectively. The process generally involves the attorney analyzing a client’s assets and income and putting together an asset protection plan to maximize the savings of income and assets while obtaining Medicaid eligibility at the earliest possible date.

If you are a married couple with one spouse institutionalized, your Attorney can assist in protecting and preserving a majority, if not all, of your available assets. If you are a single individual or if both married spouses are institutionalized, your Attorney can assist in protecting and preserving approximately one-half of your available assets. Your attorney can assist you with the best way to do this to meet your personal income and asset situation and your medical needs.

If you have an adult disabled child, or an adult child who has lived with you for at least two years prior to needing to enter a nursing home, we may also be able to save assets for those individuals.

For purposes of long-term care and Medicaid, the Community Spouse is the spouse who is still living in the community.  The spouse who is in the nursing home is called the institutionalized spouse.

The CSRA is the amount of money a community spouse is entitled to keep when their spouse is applying for Medicaid.

In 2024, in Rhode Island, the CSRA allows the community spouse (the non-applicant spouse) to retain 50% of the couple's assets, up to a maximum of $154,140. If the community spouse’s portion of the assets falls under $30,828, 100% of the assets up to $30,828 can be retained by the non-applicant. Any assets beyond these amounts are what is often included in Medicaid Asset Protection Planning in order to preserve additional assets.

In order to be eligible for Medicaid in a nursing home, in 2024 an applicant’s income cannot equal or exceed $10,190.

The Patient Share is the amount a Medicaid applicant and recipient must pay to the nursing home towards their cost of care. If the person is determined to be eligible for Medicaid, then Medicaid will cover the difference in their cost of care after the application of the patient share towards the monthly cost of care.

Even when you are found to be eligible for Medicaid, you will need to pay a portion of your income to the nursing home each month.  This is known as the Patient Share. The Patient Share is calculated by taking your gross monthly income, minus your health insurance premiums (Medicare as well as private supplemental insurance), minus a personal needs allowance ($75.00 in 2024).  If you are married and have a community spouse, they may be eligible to keep a portion of your income as well, depending upon their own income and certain housing expenses.  The remainder after these allowable deductions is called the Patient Share and this is what is paid to the nursing home each month. Medicaid then pays the rest of the monthly nursing home cost of care.

While one’s home is generally an exempt asset when it comes to qualifying for Medicaid, it is not exempt from Medicaid’s Estate Recovery Program. Following a long-term care Medicaid beneficiary’s death, Rhode Island’s Medicaid agency attempts to collect reimbursement of care costs paid by Medicaid through the deceased person’s estate. This is often the home. Without proper planning strategies in place, the home could be required to be used to reimburse Medicaid for providing care rather than going to family as an inheritance.  However, with proper planning, the home may be able to be preserved.

A caregiver agreement, also known as a personal care contract or family caregiver contract, is a legal document that outlines the terms and conditions for compensating a family member or another individual for providing care to an elderly or disabled person. These agreements formalize the caregiver's responsibilities, the compensation they'll receive, and other pertinent details, ensuring transparency and clarity in caregiving arrangements. Utilizing a caregiver agreement can help protect both the caregiver and the care recipient's interests, while also potentially preserving assets for future care needs.

There are several ways to transfer assets while preserving Medicaid eligibility. One is by doing the transfer outside of the five-year look back period. Another is through the child caregiver or adult disabled child exemption. The child caregiver exemption allows transfer of the primary residence of a Medicaid applicant to an adult child who can prove they have been in the home and shows that he or she served as a primary caregiver for the Medicaid applicant for a period of at least two years immediately prior to the need for long term care.

In Rhode Island, if you qualify for Medicaid and you are living in an Assisted Living facility that has Medicaid beds available, the Assisted Living may assist you in obtaining a Medicaid Waiver to assist in covering your cost of care. However, Assisted Living facilities in Rhode Island are not required to accept Medicaid, and most require a certain period of residency on a private pay basis before accepting a Medicaid Waiver.

It is not recommended that you cancel your other health insurance policies.  Medicaid will pay for the patient’s cost of care at the nursing home. However, LTSS Medicaid will not cover the cost of outside doctors and hospitalizations.

Health insurance premiums are an allowable expense that can be deducted from income before the monthly patient share due to the nursing home is determined. If you cancel your additional health insurance, that premium amount will be due to the nursing home each month.

It is a good idea to review your supplemental insurance policies on a regular basis with an insurance and Medicare specialist.