Overview of Idaho’s Medicare Medicaid Coordinated Plan
Idaho’s Medicare Medicaid Coordinated Plan (MMCP) is a voluntary managed care program for elderly and disabled adult Idahoans who are “dual eligible” (eligible and enrolled in both Medicaid and Medicare). Through MMCP, program participants receive a variety of benefits, including medical care, hospitalization, prescription drugs, in-home personal care services, nursing home care, and home and community based services (HCBS). HCBS may include adult day health care, homemaker services, personal emergency response systems, respite care, and home modifications. Supplemental benefits, such as gym memberships and nurse advise lines, are also available.
Program participants receive all of their Medicaid and Medicare benefits via a single health plan provided by a Medicare Advantage Organization (MAO). A MAO is essentially a private healthcare company. The MAO has a network of care providers and program participants receive services via these providers. In some areas of the state, MMCP program participants have the option of two managed care health plans from which to choose. In other areas of the state, only one MAO plan is available.
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 the Medicare Medicaid Coordinated Plan.
Program participants can reside in their own private home, that of a loved one, a certified family home (adult foster care home), a residential assisted living facility, or a nursing home facility.
MMCP is not a statewide program. It currently is available in 33 of the 44 counties in Idaho: Ada, Adams, Bannock, Benewah, Bingham, Blaine, Boise, Clark, Bonner, Cassia, Clearwater, Bonneville, Boundary, Canyon, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Shoshone, Twin Falls, Valley, and Washington.
MMCP 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.
Idaho’s Medicare Medicaid Coordinated Plan is authorized under a 1915(a) Medicaid Waiver, which authorizes voluntary 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.
Benefits of Idaho’s Medicare Medicaid Coordinated Plan
Program participants receive all of their Medicaid and Medicare (Parts A, B, and D) benefits through MMCP. Medicaid also covers the cost of one’s Medicare premium. Other potential benefits include the following.
– 24/Hour Nurse Advice Line
– Behavioral Health
– Care Coordination
– Durable Medical Equipment / Supplies
– Gym Memberships
– 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
– Personal Care Services
– Physicians / Specialists
– Prescription Medications
– Skilled Nursing Facility / Nursing Home Care
While program participants can reside in certified family homes and assisted living residences and receive MMCP services, the cost of room and board is not paid for by this program.
Eligibility Requirements for Idaho’s Medicare Medicaid Coordinated Plan
Applicants must be 21+ years old and enrolled in Medicare Parts A, B, and D.
They must live in a county that offers MMCP. These counties include Ada, Adams, Bannock, Benewah, Bingham, Blaine, Boise, Clark, Bonner, Cassia, Clearwater, Bonneville, Boundary, Canyon, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Shoshone, Twin Falls, Valley, and Washington.
They must also be eligible for ID “enhanced Medicaid”. The Medicaid eligibility criteria that follows is relevant for seniors.
Financial Criteria: Income, Assets & Home Ownership
The income limit in 2023 for a single applicant is $967 / month. When an applicant is married, regardless of whether or not their spouse is also an applicant, there is a couple income limit of $1,391 / month.
For Nursing Home Medicaid and home and community based services via the Aged and Disabled Medicaid Waiver, applicants are permitted a higher income. The individual applicant limit is $2,762 / month. When both spouses of a married couple are applicants, there is a couple income limit of $5,504 / month. When only one spouse is an applicant, the individual income limit of $2,762 / 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 ID, there is a minimum income allowance, which is set at $2,465 / month (eff. July 2023 – June 2024). This is intended to bring a non-applicant spouse’s monthly income up to this amount. In 2023, there is also a maximum income allowance, which is $3,715.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, the exact amount one 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 $3,715.50.
In 2023, 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 the 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). In 2023, the CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $148,620. If 50% of the couple’s assets falls under $27,724, 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.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, 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 2023, 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.
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 and Instrumental Activities of Daily Living are considered. These activities include bathing, dressing, mobility, eating, toileting, preparing meals, laundry, and housecleaning. 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.
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, trusts are an option. Irrevocable Funeral Trusts (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs) are also an option. They are trusts that not only protect assets from Medicaid, but also protect them from Medicaid’s Estate Recovery Program. Persons may also “spend down” extra assets on non-countable ones, such as household appliances and furnishings or making home reparations. 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 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’s Medicare Medicaid Coordinated Plan
Before You Apply
Prior to submitting an application for MMCP, 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.
Persons must be eligible for Idaho Medicaid in order to enroll in the Medicare Medicaid Coordinated Plan. 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 2-1-1 or 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.
Persons who are already enrolled in ID Medicaid (Idaho Health Plan Coverage) can enroll in MMCP by contacting a Medicare Advantage Organization (MAO) in their area of residence.
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: Adams, Benewah, Blaine, Clark, Clearwater, Gooding, Jerome, Latah, Lincoln, Shoshone, Valley, and Washington.
Molina Healthcare of Idaho – 866-403-8293
Blue Cross of Idaho – 888-495-2583
Learn more about the Medicare Medicaid Coordinated Plan here. Idaho’s Department of Health and Welfare (IDHW) in conjunction with Blue Cross of Idaho and Molina Healthcare of Idaho administer the Medicare Medicaid Coordinated Plan.
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. Furthermore, as a waiting list may exist, approved applicants may spend many months waiting to receive benefits.