Oregon Medicaid Definition
In Oregon, Medicaid is also called the Oregon Health Plan (OHP) and is administered by the Oregon Health Authority (OHA).
Medicaid is a wide-ranging, jointly funded state and federal health care program for low-income individuals of all ages. While there are many different eligibility groups, this page is focused strictly on Medicaid eligibility for elderly Oregon residents who are 65 years of age and older. This page will specifically cover long term care Medicaid, whether that is in one’s home, a nursing home, an adult foster care home, or an assisted living facility.
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which Oregon seniors may be eligible. These programs have slightly different financial and medical eligibility requirements, as well as varying benefits. Further complicating eligibility are the facts that the criteria vary with marital status and that Oregon offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – This is an entitlement (anyone who is eligible will receive assistance). It is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – Waivers limit the number of participants. Therefore, wait lists may exist. Services are provided at home, adult day care, adult foster care, or in assisted living.
3) Regular Medicaid / Aged Blind and Disabled – This is an entitlement (as long as one meets the eligibility requirements, services can be received). It is provided at home or adult day care.
The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from an Oregon Medicaid program. Alternatively, one can take the Medicaid Eligibility Test. IMPORTANT: Not meeting all the criteria below does not mean one is not eligible or cannot become eligible for Medicaid in Oregon. More.
|2020 Oregon Medicaid Long Term Care Eligibility for Seniors|
|Type of Medicaid||Single||Married (both spouses applying)||Married (one spouse applying)|
|Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required|
|Institutional / Nursing Home Medicaid||$2,349 / month||$2,000||Nursing Home||$4,698 / month||$4,000||Nursing Home||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$2,349 / month||$2,000||Nursing Home||$4,698 / month||$4,000||Nursing Home||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home|
|Regular Medicaid / Aged Blind and Disabled||$783 / month||$2,000||None||$1,175 / month||$3,000||None||$1,175 / month||3,000||None|
What Defines “Income”
For Medicaid eligibility purposes, any income that a Medicaid applicant receives is counted. To clarify, this income can come from any source. Examples include employment wages, Veteran’s benefits, alimony payments, pension payments, Social Security Disability Income, Social Security Income, IRA withdrawals, and stock dividends. That said, when just one spouse of a married couple is applying for nursing home Medicaid or a HCBS Medicaid waiver, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. Please note that this is not true for a married couple with one spouse applying for regular Medicaid. In this case, both the applicant and non-applicant’s income is considered for eligibility purposes. For more details on how Medicaid counts income, click here.
For non-applicant spouses of a nursing home Medicaid applicant or a Medicaid waiver applicant, there is a Minimum Monthly Maintenance Needs Allowance (MMMNA), which is the minimum amount of monthly income to which the non-applicant spouse is entitled. (This is also called a spousal allowance.) As of July 2019, this figure is $2,113.75 / month and is set to increase again in July 2020. However, a non-applicant spouse may be entitled to as much as $3,216 / month based on his/her shelter costs. (This figure will next increase in January 2021). This rule allows the Medicaid applicant to transfer income to the non-applicant spouse to ensure he or she has sufficient funds with which to live, while also effectively lowering the applicant spouse’s countable income. To be clear, this spousal income allowance does not extend to regular Medicaid.
What Defines “Assets”
Countable (non-exempt) assets include cash and most anything that can easily be converted to cash to be used to pay for the cost of long-term care. Other non-exempt assets include stocks, bonds, investments, credit union, savings, checking accounts, and real estate in which one does not reside. However, for Medicaid eligibility purposes, there are also many assets that are considered exempt (non-countable). Exemptions include personal belongings, such as clothing, household furnishings, an automobile, irrevocable burial trusts, term life insurance, and one’s primary home, given the Medicaid applicant or their spouse lives in the home and the home is valued under $595,000 (in 2020).
For married couples with one spouse applying for nursing home Medicaid or home and community based services via a Medicaid waiver, the community spouse (the non-applicant spouse) can retain up to half of the couple’s joint assets, up to a maximum of $128,640 (in 2020), as shown on the chart above. That said, the non-applicant spouse can keep 100% of the assets up to $25,728, given half of the couple’s assets are not greater than this figure. In Medicaid terminology, this is called the Community Spouse Resource Allowance (CSRA). To avoid confusion, it is important to mention that this spousal resource allowance does not apply to regular Medicaid.
When considering assets, one should be aware that Oregon has a Medicaid Look-Back Period, which is a period of 60 months that dates back from one’s Medicaid application date. During this time frame, Medicaid checks to ensure no assets were sold or given away under fair market value. Please note, this also includes gifts, as well as asset transfers one’s spouse has made. If one is found to be in violation of the look-back period, a penalty period will be established and one will be ineligible for Medicaid for the duration of the penalty period.
Qualifying When Over the Limits
For Oregon elderly residents (65 and over), who do not meet the eligibility requirements in the table above, there are other ways to qualify for Medicaid.
1) Qualified Income Trusts (QIT’s) – QIT’s, also referred to as Miller Trusts, are for Medicaid applicants who are over the income limit, but still cannot afford to pay for their long-term care. (For Oregon Medicaid purposes, a Miller Trust is often called an Income Cap Trust.) This type of trust offers a way for individuals over the Medicaid income limit to still qualify for long-term care Medicaid, as money deposited into a QIT does not count towards Medicaid’s income limit. In simple terms, one’s excess income (over the Medicaid limit) is directly deposited into a trust, in which a trustee is named, giving that individual legal control of the money. The account must be irreversible, meaning once it has been established, it cannot be changed or canceled, and upon death of the Medicaid participant, any remaining funds must be paid to the state of Oregon. In addition, the money in the account can only be used for very specific purposes, such as paying long term care services / medical expenses accrued by the Medicaid enrollee.
Unfortunately, Income Cap Trusts are not helpful if one has assets over the Medicaid eligibility limit. Said another way, if one meets the income requirements for Medicaid eligibility, but not the asset requirement, the above option cannot assist one in reducing their extra assets. However, one can “spend down” assets by spending excess assets on non-countable assets, such as home modifications (wheelchair ramps, roll-in showers, and stair lifts), vehicle modifications (wheelchair lifts, adaptive control devices, and floor modifications to allow one to drive from a wheelchair), prepaying funeral and burial expenses, and paying off debt. Learn more about reducing one’s countable assets in order to meet Medicaid’s asset limit here.
2) Medicaid Planning – the majority of persons considering Medicaid are “over-income” or “over-asset” or both, but still cannot afford their cost of care. For persons in this situation, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible. Read more or connect with a Medicaid planner.
Specific Oregon Medicaid Programs
1) Aged & Physically Disabled Waiver – This Medicaid Waiver, abbreviated as APD, assists seniors and physically disabled persons to transition from an institutionalized setting, like a nursing home facility, back into a community setting, such as one’s home.
2) Independent Choices Program (ICP) – ICP is an option under Oregon’s state Medicaid plan that allows participants to manage their own care services. Via monthly cash assistance, one can hire the care provider of their choosing, which includes spouses and adult children.
3) Client-Employed Provider Program (CEP) – Similar to ICP, seniors are able to hire and manage their own personal care provider to assist with Activities of Daily Living (ADLs) and Independent Activities of Daily Living (IADLs). Examples include assistance with bathing, mobility, eating, housekeeping, and meal preparation.
4) K Plan – More formally called the Community First Choice (CFC) Option, this state plan option provides supportive services for Oregon residents who require a nursing home level of care. Benefits include adult day health, home modifications, meal delivery, and more.
5) Spousal Pay Program – This is a unique program that pays non-applicant spouses to assist their senior applicant spouses with daily living activities. This program helps to prevent and / or delay nursing home placements.
How to Apply for Oregon Medicaid
To apply for the Oregon Health Plan, elderly individuals can apply online at ONE.Oregon.gov, complete a paper application and mail it to OHP Customer Service, P.O. Box 14015, Salem OR, 97309-5032, or fax it to 503-378-5628. For persons who need assistance filling out the Medicaid application, free local assistance is available. Click here to find help or call 800-699-9075 to reach OHP Customer Service for assistance in finding help or to request an application be mailed to your home. Please note that the application process may be slightly different depending on the Medicaid program in which one is applying. OHP Customer Service should be able to answer questions pertaining to the various programs and the application process. Persons might also find their local Area Agency on Aging office helpful.
Prior to submitting a Medicaid application in Oregon, senior applicants need to be certain that all eligibility criteria is met (discussed in detail above). Persons who have excess income and / or assets, should strongly consider Medicaid planning to help prevent denial of benefits. Please note that the application process can be lengthy and confusing, and specific documentation must be included with the application. For general information about the application process for long-term care Medicaid, click here.