Oregon Health Plan (Medicaid) Spousal Pay Program: Paying Spouses as Caregivers

Last updated: October 20, 2021

 

Overview of Oregon’s Spousal Pay Program

Through Oregon’s Spousal Pay Program, physically disabled adults and frail seniors receive in-home care assistance to prevent premature nursing home admissions. This program is unique in that it specifically pays the spouse of a program participant (care recipient) to provide care. Program participants receive assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This includes bathing, personal hygiene, dressing, transitioning (i.e., from the bed to a chair), preparing meals, and light housecleaning. Especially relevant for persons with Alzheimer’s disease or a related dementia, cognition is another area in which a program participant can receive assistance. Cognition refers to one’s ability to process information and use it accordingly.

Via this participant-directed program, the program participant, the “consumer-employer”, is considered the employer of their caregiving spouse, who is called a “homecare worker”. Spousal Pay homecare workers must have a current provider number with the Oregon Home Care Commission. The process is fairly simple and requires that the spousal caregiver be capable of performing the required tasks, complete a provider enrollment packet, undergo a background check, and attend a homecare worker orientation. The financial aspects of being an employer, such as tax withholding and issuing caregiver payments, are handled by the state.

Program participants who cannot self-direct their own care (meet employer responsibilities) have the option to elect a representative, such as a relative or friend, to do so on their behalf. A representative cannot also be the spouse who is paid to provide care.

 There is another OR Medicaid program, the Independent Choices Program (ICP), through which Oregon seniors can also self-direct their own long-term care, including the ability to hire a spouse. This program differs from the Spousal Pay Program in that the state plays a smaller administrative role. Rather than caregivers be paid by the state, ICP program participants are given a monthly cash benefit with which to pay their selected caregivers.

Program participants can reside in their own home or the home of a friend or family member. They cannot live in an adult foster care home or an assisted living residence.

The Spousal Pay Program is an entitlement program. This means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a waiting list for benefits.

The Spousal Pay Program is a regular state Medicaid program. It is part of the Consumer-Employed Provider Program (CEP). Medicaid in Oregon is called the Oregon Health Plan. The Oregon Supplemental Income Program (OSIPM) is the program through the elderly and disabled receive medical care.

 What is Participant-Directed Care?
Participant-directed care may also be called self-directed care or consumer-directed care. In Medicaid-speak, it is commonly called “Cash & Counseling”. With participant-directed care, program participants are allotted a budget and given freedom to select long-term services and supports to assist them in living independently. Most popular is the option to hire the caregiver of their choosing to provide assistance, such as personal care and homemaker services. Friends and relatives, including adult children, are commonly able to be hired. Furthermore, it is becoming increasingly common that one’s spouse can be hired as the caregiver.

 

Benefits of the Spousal Pay Program

Program participants work with a case manager to develop a service plan based on one’s functional needs. The service plan will include the benefits an individual can receive and the amount of hourly assistance (up to 40 hours / week) that can be provided. Follows are potential benefits via the Spousal Pay Program.

– Personal Care Assistance – i.e., assistance with mobility, transferring (i.e., from a chair to standing), bathing, personal hygiene, dressing, toileting, eating, and cognition.
– Homemaker Services – i.e., housecleaning, preparing meals, shopping for essentials, and transportation
– Health-Related Tasks – i.e., blood sugar testing, wound care, insulin injections
– Medication Management / Oxygen Management

Please note, in some cases, a program participant may have to contribute towards their cost of care.

 

Eligibility Requirements for Oregon’s Spousal Pay Program

The Spousal Pay program is for legally married, physically disabled Oregon adults and frail seniors who would require nursing home care without in-home care assistance provided via this program. Required assistance must be greater than what is generally provided by one’s spouse. Additional eligibility criteria are as follows below.

 The American Council on Aging provides a quick and easy Medicaid eligibility test for Oregon seniors requiring ongoing assistance. Start here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, the applicant spouse can have a monthly income up to $2,382. The income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance.

In Oregon, there is a minimum income allowance, which is set at $2,177.50 / month (effective July 2021 – June 2022). This is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished. To be clear, a non-applicant spouse’s own monthly income combined with the income allowance from the non-applicant spouse cannot exceed $3,259.50.

Assets
In 2021, the asset limit is $2,000 for the applicant spouse. Unlike with income, the assets of a married couple are considered to be jointly owned. Therefore, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

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 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 their home. Fortunately, for eligibility purposes, OR Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a disabled or blind child (any age) living in the home.
– The applicant has a minor child (under 21) living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the Spousal Pay Program, the tool used to determine if this level of care need is met is the Client Assessment and Planning System (CAPS). Via CAPS, it must be determined that the applicant spouse requires “full assistance” with a minimum of 4 of 6 activities of daily living (ADLs). Full assistance means the individual requires hands on assistance throughout all parts of the activity every time the activity is completed. The ADLs that are considered include bathing / personal hygiene, toileting, dressing / grooming, eating, cognition, and mobility. While cognition, which is particularly relevant for persons with Alzheimer’s disease or a related dementia is considered, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC. Furthermore, an applicant must have a debilitating medical condition that limits their ability to complete their ADLs. Some examples include late stage cancer, severe neuropathy, persistent / reoccurring wounds (stage three or four), a spinal cord injury that causes permanent impairment, and frequent / unpredictable seizures. A service priority level is generated during the assessment process. There are 18 levels, with 1 being the highest level of assistance required and 18 the least. For the Spousal Pay Program, an applicant must receive a service priority level between 1 and 13.

 For more information about long-term care Medicaid in Oregon, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for OR 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 called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, they can “spend down” excess assets on ones that are exempt (not counted) from Medicaid’s limit. This includes making safety and accessibility home modifications, buying home furnishings and appliances, and trading in one’s vehicle. Another option to “spend down” assets is to purchase an irrevocable funeral trust (IFT). IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. There are many other options 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 Oregon to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. 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 Oregon’s Spousal Pay Program

Before You Apply

Prior to submitting an application for the Spousal Pay Program, 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 held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for the Spousal Pay Program, applicants should contact their local Area Agency on Aging (AAA) office or Aging and People with Disabilities (APD) office. Contact information by county can be found here. Alternatively, persons can call the Oregon Department of Human Services at 1-800-282-8096.

Additional information about the Spousal Pay Program can be found here. Persons can also contact the Aging and Disability Resource Connection (ADRC) at 1-855-673-2372. The Oregon Department of Human Services (ODHS) Office of Aging and People with Disabilities (APD) administers the Spousal Pay Program.

 

Approval Process & Timing

The 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. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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