Idaho Medicaid Plus: Mandatory Managed Care Program for Medicaid/Medicare Eligible Seniors

Last updated: May 29, 2024

 

Overview of Idaho Medicaid Plus

The Idaho Medicaid Plus Program (IMPlus), also called ID Medicaid Plus, is a managed care program for elderly and disabled adult Idahoans who are “dual eligible”. Persons who are eligible and enrolled in both Medicaid and Medicare are “dual eligible”. Through IMPlus, program participants receive only their Medicaid benefits; they continue to receive their Medicare benefits via Medicare. Medicaid benefits may include medical care, hospitalization, personal care services, nursing home care, and home and community based services (HCBS), such as adult day health care, homemaker services, personal emergency response systems, respite care, and home modifications.

Program participants receive all of their Medicaid benefits via a single health plan provided by a Managed Care Organization (MCO). This is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. In some areas of the state, IMPlus program participants have the option of two managed care health plans from which to choose. In other areas of the state, only one MCO plan is available.

Program participants can reside in their home, a loved one’s home, a certified family home (adult foster care home), or a residential assisted living facility.

Many long-term care Medicaid programs allow program participants a self-directed / participant-directed option, specifically the ability to hire and manage their own caregiver. Unfortunately, this is not an option through IMPlus.

Idaho Medicaid Plus is not a statewide program. It currently is available in 33 of the 44 Idaho counties. In 21 of these counties, this program is mandatory. This means eligible persons in these counties must enroll. These counties include Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Elmore, Fremont, Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, and Twin Falls.

There is one exception to the mandatory enrollment requirement. Persons can instead enroll in Idaho’s other Medicaid managed care program, which is the Medicare Medicaid Coordinated Plan. This program streamlines both the benefits of Medicaid and Medicare into a single health plan.

In the remaining 12 counties, enrollment in IMPlus is voluntary; persons can receive their Medicaid benefits via the regular Medicaid program. These counties include Adams, Benewah, Blaine, Clark, Clearwater, Gooding, Jerome, Latah, Lincoln, Shoshone, Valley, and Washington.

IMPlus is an entitlement program. This means as long as an applicant meets eligibility criteria, benefits will be received. However, with the exception of personal care services, the majority of long-term home and community based services (HCBS) are available via Idaho’s Aged and Disabled Waiver. This Waiver is not an entitlement program. This means the state limits the number of person who can participate in the program, and if all participants slots are filled, a waitlist for HCBS forms.

The Idaho Medicaid Plus Program is authorized under a 1915(b) Medicaid Waiver, which authorizes mandatory managed care enrollment. It is also authorized under a 1915(c) home and community based services Medicaid Waiver. Idaho’s Medicaid program is called Idaho Health Plan Coverage.

 What is Medicaid Managed Care?
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of Idaho Medicaid Plus

Potential IMPlus benefits include the following.

– Behavioral Health
– Care Coordination
– Community-Based Rehabilitation Services
– Durable Medical Equipment / Supplies
– Home and Community Based Services via the Aged and Disabled Waiver (i.e., homemaker services, adult day health care, personal emergency response systems, home modifications, skilled nursing, attendant care)
– Hospice Care
– Hospital Services
– Nursing Home Care
– Personal Care Services
– Physicians / Specialists
– Prescription Drugs

While program participants can reside in certified family homes and assisted living residences and receive IMPlus services, the cost of room and board is not paid for by this program.

 

Eligibility Requirements for Idaho Medicaid Plus

 The American Council on Aging provides a quick and easy Medicaid Eligibility Test for Idaho seniors

IMPlus is for persons 21+ years old, enrolled in Medicare Parts A, B, and D, and live in a county that offers the program. These counties include Ada, Adams, Bannock, Benewah, Bingham, Blaine, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Clark, Clearwater, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Shoshone, Twin Falls, Valley, and Washington. Persons must also be eligible for enhanced Medicaid. The eligibility criteria that follows is relevant for seniors.

 

Financial Criteria: Income, Assets & Home Ownership

Income
The income limit in 2024 for a single applicant is $996 / month. When an applicant is married, regardless of whether or not their spouse is also an applicant, there is a couple income limit of $1,435 / month.

For Nursing Home Medicaid and home and community based services via the Aged and Disabled Medicaid Waiver, applicants are permitted a higher income limit. The individual applicant limit is $2,849 / month. When both spouses of a married couple are applicants, there is a couple income limit of $5,678 / month. When only one spouse is an applicant, the individual income limit of $2,849 / month applies and the income of the non-applicant spouse is disregarded. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).

In Idaho, there is a minimum income allowance of $2,555 / month (eff. July 2024 – June 2025). This allows the applicant spouse to transfer up to $2,555 / month to their non-applicant spouse in order to bring the non-applicant’s total monthly income up to $2,555. In 2024, the state also sets a maximum income allowance of $3,853.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount they can receive is dependent on their shelter and utility costs. However, a Spousal Income Allowance can never push a non-applicant’s total monthly income over $3,853.50.

Assets
In 2024, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is $3,000, regardless of if one or both spouses are applicants.

There is, however, an exception, if only one spouse is applying and requires Nursing Home Medicaid or home and community based services via ID’s Aged and Disabled Waiver. Medicaid still considers the assets of a married couple to be jointly owned, but the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment.

In 2024, the CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If 50% of the couple’s assets falls under $30,828, the non-applicant spouse can keep all of the couple’s assets, up to this amount. The applicant spouse is limited to $2,000 in assets.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid Spend Down Calculator.

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, Medicaid in ID considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $750,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a child under 21 living in the home.
– The applicant has a disabled or blind child of any age living in the home.

While the home is likely exempt while one is receiving Medicaid benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

If an applicant does not require personal care services, home and community based services via the Aged and Disabled Waiver, or nursing home care, there is no functional need criteria. For personal care services, the need for such care must be “medically necessary”. For home and community based waiver services or nursing home care, an applicant must require a Nursing Facility Level of Care (NFLOC). Functional need is assessed utilizing the Uniform Assessment Instrument (UAI). Limitations in the ability to independently complete Activities of Daily Living (i.e., bathing, dressing, mobility, eating, toileting) and Instrumental Activities of Daily Living (i.e., preparing meals, laundry, and housecleaning) are considered. Problematic behaviors, such as wandering, and cognitive impairments commonly seen in persons with Alzheimer’s disease or related dementias are also considered. While persons with dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not mean one will automatically meet the level of care need.

 Learn about long-term care Medicaid in Idaho.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for ID Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limits, Miller Trusts, also Qualified Income Trusts, may be able to help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. The Modern Half a Loaf strategy, although complicated, allows persons to gift approximately half of their excess assets to a loved one and then purchase a Medicaid-Compliant Annuity with the other half. An annuity turns a lump sum of cash into a monthly income stream. While Modern Half a Loaf violates Medicaid’s Look Back Rule, income from the annuity covers the cost of long-term care during the Penalty Period. There are additional Medicaid planning strategies available when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in the state of Idaho to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look-Back Rule, and therefore, should only be implemented with careful planning. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.

 

How to Apply for Idaho Medicaid Plus

Before You Apply

Prior to submitting an application for IMPlus, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

 

Application Process

Persons must be eligible for Idaho Medicaid in order to enroll in the Idaho Medicaid Plus Program. Persons can apply online at idalink, over the phone at 877-456-1233, or in-person at one’s local Department of Health and Welfare office. Furthermore, persons can call the Idaho CareLine at 800-926-2588 to request an application. An Application for Health Coverage Assistance can also be downloaded here and submitted per instructions on the application.

Eligible persons will receive a notification from the Idaho Department of Health and Welfare asking them to select their Idaho Medicaid Plus health plan.

Persons who live in the following counties may select other Blue Cross of Idaho or Molina Healthcare of Idaho: Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Elmore, Fremont, Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, or Twin Falls.

Persons who live in the following counties must enroll in Blue Cross of Idaho if they wish to participate in IMPlus: Adams, Benewah, Blaine, Clark, Clearwater, Gooding, Jerome, Latah, Lincoln, Shoshone, Valley, and Washington.

Additional information about Idaho Medicaid Plus can be found here. Alternatively, persons can reach an IDHW Beneficiary Specialist at 833-814-8568.

Idaho’s Department of Health and Welfare (IDHW) in conjunction with Blue Cross of Idaho and Molina Healthcare of Idaho administer the Idaho Medicaid Plus Program.

 

Approval Process & Timing

The Idaho Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.

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