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Financial help for Missouri Medicare enrollees

Medicaid estate recovery applies to all MO HealthNet enrollees age 55+, including people who gain eligibility once the state expands Medicaid in 2021.

Josh Schultz // October 4, 2020

Reviewed by our health policy panel.

As a Medicare beneficiary, the state where you live can have a significant impact on the care that you receive and how you pay for that care during your “golden years.” This page explains how Missouri’s regulations and policies are likely to affect your bottom line.

Does Missouri help with my Medicare premiums?

Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Missouri, these programs pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.

  • Qualified Medicare Beneficiary (QMB): QMB pays for Part A and B cost sharing, Part B premiums, and – if a beneficiary owes them – it also pays their Part A premiums. The income limit is $1,083 a month if single or $1,457 a month if married.
  • Specified Low Income Medicare Beneficiary I (SLMB I): SLMB pays for Part B premiums. The income limit is from QMB levels up to $1,296 a month if single or $1,744 a month if married.
  • Specified Low Income Medicare Beneficiary II (SLMB II): QI pays for Part B premiums. The income limit is from SLMB levels up to $1,456 a month if single or $1,960 a month if married.
  • Qualified Working Disabled Working Individuals (QDWI): The income limit is $2,126 a month if living alone and $2,873 a month if living with one other person. QDWI pays the Part A premiums for certain disabled beneficiaries who have returned to work.

MSP asset limits: The asset limit for QMB, SLMB and QI is $7,860 if single and $11,800 if married.

Missouri doesn’t count the first $20 of each applicant’s unearned income (e.g., Social Security or pensions) when determining their eligibility for an MSP or Medicaid ABD.

Additionally, income limits for MSPs and Medicaid ABD are significantly higher for applicants who are still working, because only a little less than half of income  from employment is counted. This may allow some individuals with disabilities to return to work while maintaining benefit eligibility.

The income and asset limits for QMB, SLMB and QI vary based on an applicant’s marital status. But in most states, eligibility rules for QDWI, Medicaid ABD and Long Term Services and Supports (LTSS) programs vary based on the number of household members.

Who's eligible for Medicaid for the aged, blind and disabled (ABD) in Missouri?

Medicare covers a great number services – including hospitalization, physician services, and prescription drugs – but Original Medicare doesn’t cover important services like vision and dental benefits. Some beneficiaries – those whose incomes make them eligible for Medicaid – can receive coverage for those additional services if they’re enrolled in Medicaid for the aged, blind and disabled (ABD).

In Missouri, Medicaid ABD covers routine dental care, including exams, cleanings, fillings and extractions.

The Medicaid program is called MO HealthNet in Missouri.

Income eligibility: The income limit is $904 a month if single and $1,222 a month if married. (Note that a higher income limit – of $1,064 a month if single and $1,437 if married – applies to applicants who are blind.)

Asset limits: The asset limit is $5,000 if single and $10,000 if married. These asset limits are somewhat higher than in other states, where Medicaid enrollees often can’t have more than $2,000 if single and $3,000 if married.

Help with prescription drug expenses in Missouri

The Extra Help program lowers prescription drug costs under Medicare Part D. Beneficiaries who also have Medicaid, an MSP, or Supplemental Security Income (SSI) automatically receive this program, but other beneficiaries can apply for it themselves. The income limit is $1,615 a month for individuals and $2,175 a month for spouses, and the asset limit is $14,610 for singles and $29,160 for spouses.

How does Missouri regulate long-term services and supports (LTSS)?

Medicare beneficiaries increasingly rely on long-term services and supports (LTSS) – or long-term care – which is mostly not covered by Medicare. In fact, 20 percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015.

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Medicaid fills this gap in Medicare coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.

Applicants who are seeking Medicaid long-term care benefits have to undergo a level of care assessment.

Medicaid nursing home coverage

Income limits: There is no income limit for nursing home coverage.

However, this doesn’t mean enrollees can keep all of this income. Nursing home enrollees must pay nearly all their income each month toward their care, other than a small personal needs allowance (of $50 a month) and money to pay for health insurance premiums (such as Medicare Part B and Medigap).

Assets limits: The asset limit is $5,000 if single and $10,000 if married (and both spouses are applying). If only one spouse has Medicaid, federal rules allow the other spouse can keep up to $128,640.

Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car.

Home and Community Based Services (HCBS) waivers

Every state’s Medicaid program covers community-based long-term care. Programs that pay for this type of care are called Home and Community Based Services (HCBS) waivers. Recipients of these services can live in the community, rather than entering a nursing home.

Income limits:
The income limit is $1,370 a month per applicant.

Asset limits: The asset limit is $5,000 per applicant. If only one spouse has Medicaid, federal rules let the other spouse keep up to $128,640.

Spousal impoverishment protections in Missouri

Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. When this occurs, only the applying spouse’s income is counted. (Normally with Medicaid benefits, the income of both spouses is counted – regardless of who is applying.)

If only one spouse needs Medicaid, spousal impoverishment rules allow the other spouse to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s income. This rule applies only to nursing home care and HCBS – and not other Medicaid benefits.

In Missouri in 2020, these spousal impoverishment rules allow community spouses to keep:

Medicaid home equity limit in Missouri

Federal law requires states to limit eligibility for Medicaid nursing home and HCBS to applicants with a home equity interest below a specific dollar amount. In 2020, states set this home equity level based on a federal minimum of $595,000 and maximum of $893,000.

Missouri requires Medicaid LTSS applicants to have a home equity interest of $595,000 or less.

Penalties for transferring assets in Missouri

Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to make themselves eligible for Medicaid LTSS. To curb these asset transfers, federal law requires states to have a penalty period for applicants seeking Medicaid nursing home care who give away or transfer assets for less than their value. States can choose to also have a penalty period for HCBS. Medicaid will not pay for LTSS during the penalty period.

Missouri has chosen to have an asset transfer penalty for nursing home care and HCBS. This penalty period is based on a 60 month lookback period during which asset transfers and gifts are prohibited. The penalty’s length is calculated by dividing the amount of assets transferred or given away by the cost of nursing home care (and this is $6,425 a month in Missouri in 2020).

Estate recovery in Missouri

State Medicaid agencies have to attempt to recover what they paid for long-term care related expenses enrollees received beginning at age 55. States can choose to also pursue estate recovery from costs that aren’t long-term care related, and for enrollees who did not receive LTSS.

As of 2007, Missouri had chosen to pursue estate recovery for the cost of all Medicaid benefits (and not only recover from recipients of LTSS). So Missouri Medicaid (MO HealthNet) beneficiaries who are age 55 or older are subject to Medicaid estate recovery, even if they don’t use LTSS. Missouri has not yet expanded Medicaid under the ACA, but that will change in mid-2021, under the terms of a ballot initiative that voters passed in 2020. The number of MO HealthNet members who are 55 or older will increase significantly when coverage is expanded, and they will be subject to Medicaid estate recovery unless Missouri changes its rules.

When Medicaid coverage was administered by a Managed Care Organization (MCO) (ie, a private insurer with which the state contracts to administer Medicaid benefits), the state will attempt to recover what it paid the MCO. That means the estate recovery amount could differ from the actual cost of Medicaid services received.

Missouri will not pursue estate recovery for enrollees who are survived by a spouse or a child who is under 21 or disabled. The state may also grant other hardship exemptions from estate recovery under specific circumstances.

Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid will try to recover what it paid for MSP through that date.

Where can Medicare beneficiaries get help in Missouri?

Missouri State Health Insurance Assistance Program

Free volunteer Medicare counseling is available by contacting the Missouri State Health Insurance Assistance Program at 800-390-3330. The SHIP program in Missouri is called “CLAIM.”

The SHIP can help beneficiaries enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. SHIP counselors may also be able to offer referrals to local agencies for services like home care and long-term care. The SHIP’s website has more information on services it offers.

Elder Law Attorneys

Elder law attorneys can help individuals plan for Medicaid long-term care benefits. You can use this National Academy of Elder Law Attorneys (NAELA) search feature to find an elder attorney locally.

Missouri Area Agencies on Aging (AAAs)

Medicare beneficiaries in Missouri can also receive help from Area Agencies on Aging (AAAs). These organizations can provide information about services that help with aging or living with a disability, and assist with planning for long-term care needs. Here is a list of AAAs in Missouri.

Where can I apply for Medicaid in Missouri?

Medicaid is administered by the Department of Social Services in Missouri. You can use this website to apply for Medicaid ABD or an MSP in Missouri.

Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to non-profit work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He has also held consulting roles, including at Sachs Policy Group, where he worked on Medicaid and Medicare related client projects.

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