How Medicaid Calculates the Penalty Period for Look-Back Violations

Last updated: June 06, 2022


Medicaid Look Back and the Penalty Divisor

  If you are already familiar with the Look Back Rule, skip ahead.

To properly explain the Medicaid penalty period, it is important to begin with a brief discussion of Medicaid’s look back rule. Essentially, when a Medicaid long term care applicant submits an application for benefits, a “look back” period of 60-months begins in which the Medicaid agency checks to ensure no assets were given away or sold for under fair market value. California and New York have shorter look-back periods.

For Medicaid eligibility purposes, there is an asset (resource) limit, which in the majority of states, is $2,000 for an applicant. (See state-by-state asset limits). If an applicant has assets over Medicaid’s limit, they must “spend down” the “excess” assets to meet the limit, and hence, become asset eligible. When “spending down” assets, it is vital that one does not violate Medicaid’s look back rule by giving away countable assets or selling them under fair market value. Doing so is known as a “disqualifying transfer”. If an applicant, or their spouse, has made a disqualifying transfer, Medicaid will assume the assets were transferred with the intention of meeting the asset limit. The penalty for violating Medicaid’s look back rule is a period of time in which one is denied Medicaid long term care benefits.

Spousal transfers, or put differently, transferring assets from an applicant spouse to a non-applicant spouse, does not violate Medicaid’s look back rule. There are also other exceptions, such as the caregiver child exemption and sibling exception.


What is the Medicaid Penalty Period?

The Medicaid penalty period, also called a divestment penalty period, is the timeframe of Medicaid ineligibility that results from violating Medicaid’s look back rule. To be clear, this penalty is due to a Medicaid applicant gifting assets / selling them under fair market value during the look back period, and if not for this violation, they would otherwise be eligible for long term care Medicaid. The penalty period generally begins on the date an applicant applies for Medicaid and is denied for the sole reason of violating the look back rule; it does not start the date a disqualifying transfer was made. In some states, the penalty period might begin on the 1st day of the month in which one submits a Medicaid application and is denied. Once the penalty period is over, one can reapply for long term care Medicaid.

To avoid any confusion, it is important to mention the “marriage penalty”. While this penalty is relevant to persons receiving assistance via a government assistance program, such as Medicaid and SSI, it is not relevant to Medicaid’s look back rule and penalty period. Instead, the marriage penalty is referring to a beneficiary losing their benefits because the combined income and / or assets of the newly married couple cause the beneficiary to be ineligible.


What is the Penalty Divisor?

A penalty divisor, also called a divestment penalty divisor or a transfer penalty, is the average cost of private pay nursing home care in the state in which one resides. While perhaps obvious, the penalty divisor is not consistent from state to state, and sometimes even varies based on the geographic region within a state or is nursing home specific. Some states use a daily penalty divisor, some states use a monthly divisor, and some states have both a daily and monthly divisor. Penalty divisors generally change annually.

Medicaid Penalty Divisors by State (in 2022)
Medicaid Penalty Divisors by State (as of Jun. 2022)
Alabama $6,400 per month
Alaska Varies by facility
Arizona $8,029.46 per month in Maricopa, Pima, & Pinal Counties / $7,331.78 per month in all other counties
Arkansas $7,151 per month
California $10,933 per month
Colorado $8,609 per month
Connecticut $13,863 per month
Delaware $346.97 per day / $10,554,83 per month
District of Columbia $14,175.99 per month
Florida $9,703 per month
Georgia $8,821 per month
Hawaii $8,850 per month
Idaho $312 per day / $9,481 per month
Illinois Varies based on the monthly private pay rate of the specific nursing home. Specific to the Supportive Living Program, the penalty divisor is $181 per day / $5,430 per month.
Indiana $6,873 per month
Iowa $253.64 per day / $7,710.66 per month
Kansas $221.96 per day
Kentucky $252.43 per day
Louisiana $164.38 per day / $5,000 per month
Maine $8,476 per month
Maryland $350 per day / $10,190 per month
Massachusetts $410 per day
Michigan $9,880 per month
Minnesota $8,781 per month
Mississippi $226 per day / $6,893 per month
Missouri $6,894 per month
Montana $261.53 per day / $7,954.87 per month
Nebraska Monthly private pay rate
Nevada $9,059.10 per month
New Hampshire $342.80 per day / $10,427.98 per month
New Jersey $374.39 per day
New Mexico $7,811 per month
New York Varies based on geographic location. Central $11,328 per month, Long Island $14,012 per month, NYC $13,415 per month, North East $12,560 per month, North Metro $13,399 per month, Rochester $13,376 per month, and Western $11,884 per month
North Carolina $237 per day / $7,110 per month
North Dakota $352.42 per day / $10,719 per month
Ohio $6,905 per month
Oklahoma $188.21 per day
Oregon $9,551 per month
Pennsylvania $482.50 per day / $14,676.04 per month
Rhode Island $328 per day / $9,961 per month
South Carolina $274.52 per day / $8,349.98 per month
South Dakota $268.21 per day / $8,158.12 per month
Tennessee $228.41 per day / $6,852.30 per month
Texas $237.93 per day / $7,212 per month
Utah $6,908 per month
Vermont $338.28 per day / $10,148.35 per month
Virginia Varies by geographic location. $9,032 per month in Alexandria, Fairfax, Falls Church, Loudoun, Manassas, Manassas Park, and Prince William. $6,422 per month in all other counties.
Washington $355 per day / $10,785 per month
West Virginia $355 per day / $10,650 per month
Wisconsin $307.40 per day / $9,350.08 per month
Wyoming $8,087 per month

How to Calculate the Penalty Period

The length of penalization is personalized based on the amount a Medicaid applicant (or their spouse) gifted / sold under fair market value and the average cost of privately paid nursing home care in the state in which one resides. Essentially, the penalty is equivalent to the length of time one would have been able to pay for long term care had money not been gifted or assets sold under fair market value.

To calculate the length of a Medicaid applicant’s penalty period, the value of all countable assets given away or sold under fair market value during Medicaid’s look back period (60-months in the majority of states) are added together. This amount is then divided by the penalty divisor to come up with the number of days / months / years for which one is penalized. The penalty divisor that is used is the current penalty divisor at the time of application; the penalty divisor at the time of the violation is irrelevant.

  Example: Calculating Medicaid Penalty Period
Jim, who lives in Florida, applied for long term care Medicaid on January 2, 2022. Within the “look back” period of 60-months, Jim sold his home to his son for $20,000, much lower than the fair market value of $120,000, and gifted his granddaughter $15,000 for college. This means that Jim has disqualifying transfers in the amount of $115,000 ($100,000 for the house + $15,000 gifted). In 2022, the penalty divisor in Florida is $9,703 / month, which means that for every $9,703 gifted or sold under fair market value, Jim will be penalized with a month of Medicaid ineligibility. Therefore, Jim will be penalized with 11.85 months of ineligibility ($115,000 ÷ $9,703 = 11.85 months).

Unfortunately, there is no limit to the length of penalty (ineligibility) an applicant can receive. If the penalty period would be significant (greater than the remaining look back period), it would be in one’s best interest to wait to apply for long term Medicaid until the look back period is over. To be clear, anything gifted or sold under fair market value prior to the look back period is not relevant. Stated differently, it won’t impact one’s Medicaid eligibility.

Medicaid planning professionals can assist one in discovering and adding up the value of any disqualifying transfers, calculating how long a penalty period will likely be, and determining the best course of action. Find a Medicaid expert here.


Who Pays for Care During the Penalty Period?

When a Medicaid applicant is penalized with a penalty period for making disqualifying transfers, they have to come up with the money to pay for long term care during the Medicaid ineligibility period. This, unfortunately, puts the applicant in an extremely difficult situation. Remember, for one to be eligible for Medicaid long term care, they must have limited income and assets. If the applicant did not have limited financial means, they would not have otherwise qualified for Medicaid, and hence, be penalized with a penalty period for violating Medicaid’s look back rule. Commonly, if possible, it is the applicant’s family that covers the cost of long term care during the penalty period.

For applicants who receive SSI (Supplemental Security Income), reside in a nursing home, and have violated Medicaid’s look back rule, their monthly SSI payments are reduced to $30 plus any state supplement (if applicable). This reduction in payment leaves one with even fewer funds to help assist with the cost of their long term care.


What Options are There to Fight a Penalty Period?

If an applicant has violated the look back period, they might be able “cure” the penalty, or in other words, get funds back and eliminate or reduce the penalty period. If all of the money is returned, the state may eliminate the penalty period in its entirety, and if funds are partially returned, the length of the penalty period might be recalculated and reduced. Not all states allow a partial return of funds. If a state does allow a full or partial return of assets, the Medicaid applicant will then likely be over Medicaid’s asset limit and will not qualify for long term care benefits until the assets are “spent down” in a way that does not violate the look back rule.

Some states may allow an undue hardship waiver in the event that the money cannot be returned to the Medicaid applicant, although in reality, this happens very infrequently. This is because most states require that all possible legal courses of action be taken when attempting to recover the funds.

If an applicant does not feel they have violated the look back rule and has been denied eligibility for this reason, it is possible to file an appeal. Learn more here.

Another course of action that can be taken, although it is not fighting the penalty period, is to relocate to a different state with a shorter look back period or a lower penalty divisor. Of course, with this option, there are many considerations to be taken into account. Learn more about applying for Medicaid out of state here.

  CAUTION: Prior to taking any course of action, it is strongly recommended that one contact a Medicaid expert for assistance. These professionals are very knowledgeable about Medicaid’s look back rule and penalization, including state specific rules, and can help one plan and carry through the best course of action for one’s specific situation. Find a professional Medicaid planner.

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