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How is eligibility determined?

Eligibility is based primarily on three criteria:

1) The need for care.

2) The income of the patient only.

3) The combined countable resources of the couple.

Assuming care is required, and the patient's income is under $1,656 per month (or the patient intends to establish an Income Cap Trust), a "Resource Assessment" would be completed thru your local SDS office. The purpose of this assessment is to identify and total all countable (non-exempt) assets and resources. Certain assets are exempt (non-countable), such as the home (assuming that the patient or the spouse is residing there, or is expected to return), one vehicle, household and personal property, medical equipment, burial goods, etc. Virtually everything else of value (bank accounts, CDs, mutual funds, retirement accounts, other real estate, cash value in life insurance, motor homes, additional vehicles, stocks, bonds, etc.) will be counted. It does not make any difference how the assets are titled (single, joint, living trust, etc.); Medicaid simply comes up with a total of all the countable assets.

If that total is less than $18,132 then there will be no "spend down" (reduction of countable resources) - the community (healthy) spouse puts them into his/her name and the patient qualifies. If, however, that total is higher than $18,132 then there likely will be a spend down requirement. If the total is less than $181,320 then the spend down will be approximately 50%. If the total is greater than $181,320 then the community spouse will get to keep $90,660 with the spend down equaling the balance. (For example, a couple with countable assets of $200,000 would have a spend down of approximately $109,340). If there is a spend down requirement the patient would not qualify until the couple could show that they had reduced their countable resources by the required amount.

What is important here is an understanding of the term "spend down." Although this term is commonly used, (even among Medicaid workers), it is a term that is not actually used in the procedural manual. The actual requirement is that the couple "reduce countable resources." The common misconception is that the money has to be spent on care - it does not. The rules do not limit what the couple can spend their resources on. The only requirements are that, (1) they not give it away, and (2) that they receive "fair market value" for that which they spend or transfer.

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