Virginia Medicaid Definition
Medicaid is a wide-ranging, jointly funded state and federal health care program for low-income persons of all ages. That being said, this page is categorically focused on Medicaid eligibility for older Virginia residents, aged 65 and over, and specifically for long term care, whether that be at home, in a nursing home, or in an assisted living facility. In Virginia, the Department of Medical Assistance Services (DMAS) administers the Medicaid program, and one’s local Department of Social Services (DSS) determines one’s eligibility.
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which Virginia seniors may be eligible. These programs have slightly different eligibility requirements, such as income, assets, and functional ability, as well as differing benefits. Further complicating eligibility are the facts that the criteria vary with marital status and that Virginia offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – is an entitlement (anyone who is eligible will receive assistance) & is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services – Limited number of participants. Provided at home, adult day care or in assisted living.
3) Regular Medicaid / Aged Blind and Disabled – is an entitlement (benefits are guaranteed if one meets the eligibility requirements) and 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 a Virginia Medicaid program. Alternatively, one may take the Medicaid Eligibility Test. IMPORTANT, not meeting all the criteria below does not mean one is ineligible or cannot become eligible for Medicaid in Virginia. More.
|2020 Virginia 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 or Hospital||$4,698 / month||$4,000||Nursing Home or Hospital||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home or Hospital|
|Regular Medicaid / Aged Blind and Disabled||$851 / month||$2,000||None||$1150 / month||$3,000||None||$1,150 / 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, alimony payments, pension payments, Social Security Disability Income, Social Security Income, IRA withdrawals, and stock dividends.
When only one spouse of a married couple is applying for institutional Medicaid or a Medicaid waiver, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. However, the same does not hold true for a married couple with one spouse applying for Aged Blind or Disabled Medicaid. In this case, the income of both spouses counts towards the income limit, even if only one spouse is an applicant. (Click here for more information on Medicaid and income considerations).
There is a Minimum Monthly Maintenance Needs Allowance (MMMNA) for non-applicant spouses of Medicaid nursing home care applicants and applicants seeking home and community based services via a Medicaid waiver. The MMMNA is the minimum amount of monthly income to which the non-applicant spouse is entitled. As of July 2020, this figure on the low end is $2,155 / month, which will increase in July 2021. On the high end, a non-applicant spouse may be entitled to as much as $3,216 / month (this figure will 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. For clarification purposes, it is important to mention that this spousal income allowance does not extend to non-applicant spouses of regular Medicaid applicants.
*While there is an income limit for nursing home Medicaid, as shown in the chart above, seniors who receive Medicaid-funded nursing home care must contribute nearly all of their monthly income to the nursing home. Beneficiaries are only able to keep a personal needs allowance of approximately $40 / month, and if applicable, pay a monthly income allowance to a non-applicant spouse.
What Defines “Assets”
Countable assets include cash, stocks, bonds, investments, credit union, savings, and checking accounts, and real estate in which one does not reside. However, for Medicaid eligibility, there are many assets that are considered exempt (non-countable). Exemptions include personal belongings, household furnishings, an automobile, irrevocable burial trusts, and one’s primary home, given the Medicaid applicant lives in it or has “intent” to return to it, and his or her equity interest in it is not more than $595,000 (in 2020). (Equity interest refers to the amount of the home’s value owned by the applicant). The home is also exempt, despite where the applicant lives and the applicant’s equity interest in the home if the applicant is married and his or her spouse lives in the home.
In 2020, for married couples with one spouse applying for nursing home Medicaid or a HCBS Medicaid waiver, the community spouse (the non-applicant spouse) can retain 50% of the couple’s joint assets, up to a maximum of $128,640, as the chart indicates above. There is also a minimum resource allowance of $25,728. Therefore, the non-applicant is entitled to whichever is greater; 100% of the assets, up to $25,728, or half of the assets, up to $128,640. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA). As with the spousal income allowance, this resource allowance does not extend to non-applicant spouses of persons applying for regular Medicaid.
It’s important to be aware that Virginia has a 5-year Medicaid Look-Back Period. This is a period of 5 years in which Medicaid checks to ensure no assets were sold for less than their value or given away as a means to meet Medicaid’s asset limit. If one is found to be in violation of the look-back period, a period of long-term care Medicaid ineligibility will ensue.
Qualifying When Over the Limits
For Virginia elderly residents, 65 and over, who do not meet the eligibility requirements in the table above, there are still other means to qualify for Medicaid.
1) Medically Needy Pathway – Virginia’s Medically Needy Pathway is referred to as a Medically Needy Program. This program allows individuals who have income over the limit for other pathways of eligibility to still gain Medicaid eligibility if they have high medical bills relative to their monthly income. Also commonly referred to as a “Spend-down” program, one must “spend-down” their excess income on medical bills (health insurance premiums, physician visits, hospital bills, prescription drugs) in order to meet the income limit for the Medically Needy Program. Once one’s income has been spent down to the income limit, Medicaid services will be available for the remainder of the eligibility period.
For the Medically Needy Program, the income limits vary based on the geographic region of the state in which one resides. These medically needy income limits last changed in July 2020 and are broken into three groups. For Group I, the income limit for a single applicant is $332.18 / month and $422.89 for a married couple. Group II allows $383.29 / month for a single person and $471.97 for a married couple. The final group, Group III, allows $498.28 / month for a single applicant and $600.72 / month for a married couple. The asset limit is the same regardless of the area of the state and is $2,000 for an individual and $3,000 for a married couple.
Unfortunately, the Medically Needy Pathway does not assist one in spending down extra assets for Medicaid qualification. Said another way, if one meets the income requirement for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in reducing extra assets. However, one can “spend down” assets by spending excess assets on ones that are not counted towards eligibility, such as home modifications (wheelchair ramps, chair lift, grab bars, etc.), prepaying funeral and burial expenses, and paying off one’s mortgage or credit card debt.
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 Virginia Medicaid Programs
The Virginia Medicaid program pays for nursing home care, but it also offers a “Medicaid Waiver”, which pays for care outside of nursing homes. Care paid for by Medicaid, outside of a nursing home is called “home and community based services” or HCBS. Virginia recently re-designed its HCBS waivers, consolidating the old Elderly or Disabled Waiver and the Technology Assisted Waiver into the new Commonwealth Coordinated Care Plus Waiver.
This waiver, called CCC+ for short, includes benefits such as adult day care, home care, and financial support to make home modifications that help residents remain living in their homes. Unfortunately, unlike nursing home Medicaid, which is an entitlement, CCC+ is not an entitlement program. This means, CCC+ has limited enrollment and waiting lists can exist. Furthermore, it is unclear at this point whether CCC+ would consider “assisted living” as someone’s home and whether services could be provided in such a location. The same uncertainty applies to “Independent Living”. That said, the state does offer the Auxiliary Grant that can be used to pay for assisted living care.
How to Apply for Virginia Medicaid
To apply for Medicaid in Virginia, seniors can apply online at CommonHelp or via the phone by calling Cover Virginia’s Call Center at 855-242-8282. There is also the option to complete and submit a paper application (Cover Virginia Application for Health Coverage and Help Paying Costs), which can be downloaded and printed from this webpage. Seniors should be aware that supplement forms may also need to be submitted with the application. For instance, for adults over 65 years of age or persons who need long term care, Appendix D: ABD, LTC Application is also required, which can be found on this webpage. Persons can also call their local Department of Social Services (DSS) office and request that paper applications and additional forms be mailed to their home. Completed applications should be returned to one’s local Department of Social Services office. For questions about applying for Medicaid, seniors should contact their local DSS office.
Prior to submitting an application for Medicaid benefits in Virginia, elderly applicants should be certain that all eligibility requirements (discussed above) for the program in which they are applying are met. Having income and / or assets over the limit(s), or uncertainty if eligibility criteria are met, can result in a denial of benefits without Medicaid planning. For additional information about Medicaid planning click here and for more information about applying for long-term care Medicaid, click here.