Wisconsin Medicaid Definition
Medicaid is a wide-ranging, jointly funded state and federal health care program for low-income people of all ages, including pregnant women, children, families, disabled individuals, and seniors. That said, the focus of this page is on Medicaid eligibility for Wisconsin senior residents (65 and over), and specifically for long-term care Medicaid, whether that is in one’s home, a nursing home facility, an adult foster care home, or in assisted living. In Wisconsin, the Wisconsin Department of Health Services’ Division of Medicaid Services (DMS) administers the state’s long-term care Medicaid Programs for the elderly.
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which Wisconsin seniors may be eligible. These programs do not have all the same eligibility requirements, nor do they have the same benefits.
1) Institutional / Nursing Home Medicaid – is an entitlement (anyone who is eligible will receive assistance) and is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – Limited number of participants. Provided at home, adult day care, adult family home, or in assisted living.
3) Regular Medicaid / Elderly, Blind, or Disabled – is an entitlement (if eligibility requirements are met, services will be received) and is provided at home or adult day care.
Eligibility for these programs is complicated by the facts that the criteria vary with marital status and that Wisconsin offers multiple pathways towards Medicaid eligibility. The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a Wisconsin 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 long-term care Medicaid in Wisconsin. More.
|2020 Wisconsin 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 Intermediate Care Facility||$4,698 / month||$4,000||Nursing Home or Intermediate Care Facility||$2,349 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Nursing Home or Intermediate Care Facility|
|Regular Medicaid / Elderly Blind and Disabled (EBD)||$605.78 /month + Actual Shelter up to $261.00 / month**||$2,000||None||$915.38 / month + Actual Shelter up to $391.67 / month**||$3,000||None||$915.38 / month + Actual Shelter up to $391.67 / 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, Veterans benefits, rental income, and stock dividends.
When just one spouse of a married couple is applying for nursing home Medicaid or benefits via a HCBS Medicaid waiver, only the income of the applicant is counted towards eligibility. To avoid any confusion, this is not true for married couples with one spouse applying for regular Medicaid. In this situation, the income of both spouses counts toward the eligibility of the applicant spouse. Learn more here.
For married couples with one spouse applying for institutional Medicaid or a Medicaid waiver, there is what is called a Minimum Monthly Maintenance Needs Allowance (MMMNA). This is the minimum amount of monthly income in which a non-applicant (community) spouse is entitled. From July 2019 through June 2020, this figure is $2,818.34. Simply stated, a non-applicant spouse may be transferred as much as $2,818.34 / month from his or her non-applicant spouse to bring the non-applicant’s monthly income up to this amount. However, based on shelter and utility costs, a non-applicant spouse may be transferred as much as $3,216 / month from his or her non-applicant spouse. (The higher figure will change in January of 2021). This spousal income allowance is in place to prevent impoverishment of the community spouse. It is important to mention that the non-applicant spouse of a regular Medicaid applicant is not entitled to a MMMNA.
** Please note that Wisconsin is a bit unusual in that in addition to the income limit for Elderly, Blind, or Disabled Medicaid, there is also an “Actual Shelter” allowance. “Actual Shelter includes the cost of one’s mortgage, property taxes, rent, and utilities.
What Defines “Assets”
Countable assets (resources) include cash, stocks, bonds, life insurance policies, investments, credit union, savings, and checking accounts, and real estate in which one does not reside. However, for Medicaid eligibility purposes, there are many assets that are considered exempt (non-countable). Exemptions include IRA’s and 401K’s in payout status, personal belongings, household items, such as furniture and appliances, an automobile, irrevocable burial trusts, and one’s primary home, given the Medicaid applicant or his or her spouse lives in the home and the equity value is under $750,000.
For married couples, as of 2020, the community spouse (the non-applicant spouse) of a nursing home Medicaid or HCBS waiver applicant can keep half of the couple’s assets, up to $128,640 as shown in the chart above. However, if the couple has assets equal to or under $100,000, the non-applicant spouse is able to retain $50,000 of the assets. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA). In Wisconsin, this is also referred to as a Community Spouse Asset Share (CSAS). Like the spousal income allowance, this non-applicant resource allowance does not extend to married couples with one spouse applying for regular Medicaid.
Qualifying When Over the Limits
For Wisconsin residents, 65 and over who do not meet the eligibility requirements in the table above, there are other ways to meet the qualifications for Medicaid.
1) Medically Needy Pathway – In Wisconsin, the Medically Needy Pathway, also called the Medicaid Deductible Program, allows seniors who would otherwise be over the income limit to qualify for Medicaid if they have high medical bills. This program is intended for those that are categorically elderly, blind or disabled. In simple terms, one may still qualify for Medicaid services by paying what is called a Deductible. (Taking one’s countable monthly income and subtracting the income limit for the program is a simplified definition of how one’s deductible is calculated.) For the Medicaid Deductible Program, as of September 2019, the income limit is $1,040.83 / month for a single senior applicant and is $1,409.17 / month for a household of two. Sometimes referred to as a Spend Down program, one’s “excess income,” (the amount that is determined as one’s deductible), is used to cover medical bills. Once one has paid his or her deductible, Medicaid will kick in for the remainder of the deductible period, which is six months in Wisconsin. This program, regardless of name, provides a means to “spend down” one’s extra income in order to qualify for Medicaid.
Make note, the Medically Needy Pathway does not assist one in spending down extra assets for Medicaid qualification. Said another way, if one meets the income requirements for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in “spending down” extra assets. However, one can reduce their assets by spending excess assets on ones that are not counted towards the asset limit, such as home modifications, like the addition of wheelchair ramps or stair lifts, prepaying funeral and burial expenses, and paying off debt. When spending down assets, it’s important that one does not give away assets or sell them way under market value. This is because in Wisconsin, Medicaid has a “Look-Back” period of 5 years, and if one is in violation, a period of Medicaid ineligibility may result.
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 Wisconsin Medicaid Programs
1) Family Care and Family Care Partnership – Two managed care programs that allow program participants the freedom to direct their own care, including hiring the caregiver of their choosing. The Partnership program covers medical care and prescription drugs, while Family Care only covers non-medical care.
2) IRIS Program – This Medicaid Waiver, Include, Respect, I Self-Direct, is a consumer directed program, and with the assistance of a case manager, a plan of care is put into place. Benefits may include adult day care, adult foster care, home modifications, live-in caregivers, and more.
3) Medicaid Personal Care – Also called Medical Assistance Personal Care (MAPC), assistance with Activities of Daily Living (ADLs) and some Instrumental Activities of Daily Living (IADLs), such as bathing, grooming, mobility, meal preparation, and laundry is provided.
How to Apply for Wisconsin Medicaid
To apply for Family Care/Family Care Partnership or IRIS in Wisconsin, or to learn more about these programs, seniors should contact their local Aging and Disability Resource Center (ADRC). To apply for regular Medicaid, which includes Medicaid Personal Care, seniors can do so online at ACCESS, by phone, in person via their local Income Maintenance and Tribal Agency, or by submitting a completed paper application.
It’s very important that seniors applying for Medicaid in Wisconsin be certain that they meet all eligibility requirements (in detail above) prior to submitting their completed application. Elderly applicants who have income and / or resources in excess of the limit(s) should consider Medicaid planning for the best chance of receiving Medicaid benefits. While the application process can be complicated and lengthy, persons can learn more about the process here.