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As a Medicare beneficiary, where you live – meaning your state of residence – 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 Ohio’s regulations and policies are likely to affect your bottom line.
Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Ohio, these programs pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.
MSP asset limits: The asset limits for QMB, SLMB and QI are $7,860 if single and $11,800.
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.
[mro_survey align ="right"]Medicare can also leave its enrollees with large co-pays, coinsurances and deductibles. Some beneficiaries – those whose incomes make them eligible for Medicaid – can receive coverage for Medicare cost sharing and services only Medicaid covers if they’re enrolled in Medicaid for the aged, blind and disabled (ABD).
In Ohio, Medicaid ABD covers extensive dental benefits, including cleanings, x-rays, extractions, fillings, and dentures. Medicaid ABD also covers one eye exam and a pair of eyeglasses every 12 months for adults 60 and older.
Income eligibility: The income limit is $783 a month if single and $1,175 a month if married.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Help with prescription drug costs in Ohio
Medicare beneficiaries who have limited incomes and assets can apply for Extra Help – a federal program that lowers prescription drug expenses under Medicare Part D. The income limit is $1,615 a month for singles and $2,175 a month for couples, and the asset limit is $14,610 for individuals and $29,160 for spouses.
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. 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.
In past decades, most Americans received long-term care services in nursing homes. Medicaid covers these services for an unlimited number of enrollees in each state who meet income and resource limits.
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married (and both spouses are applying).
When only one spouse needs nursing home care, the income limit for single applicants is used – and usually only the applying spouse’s income is counted. Non-applying spouses are allowed to keep a portion of their Medicaid spouse’s income.
This income limit doesn’t mean nursing home enrollees can keep all of their income up to the limit. Nursing home enrollees have to pay nearly all their income toward their care, other than a small personal needs allowance and money to pay for health insurance premiums (such as Medicare Part B and Medigap).
Assets limits: The asset limit is $2,000 if single and $3,000 if married (and both spouses are applying). If only one spouse has Medicaid, federal rules allow the other spouse to keep up to $128,640.
Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car. Applicants are also not allowed to have more than $595,000 in home equity.
Every state’s Medicaid program covers certain community-based long-term care services, which may be provided in an enrollee’s home, adult day care center, or another community setting. Medicaid programs that pay for this care are called Home and Community Based Services (HCBS) waivers.
Although states do not have to cover HCBS benefits, every state has chosen to do so. However, because these services are expensive, many states use waiting lists for them.
In Ohio, HCBS recipients must need help with at least two activities of daily living (ADLs).
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married (and both spouses are applying).
When only one spouse needs nursing home care, the income limit for single applicants is used – and usually only the applying spouse’s income is counted. Non-applying spouses are allowed to keep a portion of their Medicaid spouse’s income.
Despite this income limit, most states require HCBS recipients to pay a portion of their income toward their care. Ohio allows HCBS recipients to keep $1,463 each month as a personal needs allowance (as of 2018), which can be used to pay for health and living expenses.
Assets limits: The asset limit is $2,000 if single and $3,000 if married (and both spouses are applying). If only one spouse has Medicaid, the other spouse can keep up to $128,64o.
Medicaid long-term care enrollees can’t have more than $595,000 in home equity.
Applicants for nursing home or HCBS benefits in Ohio are only eligible for them if their income is below the income limit. Ohio does not allow applicants with higher incomes to pay the income they have toward their care, and have Medicaid pay the rest. Because of this hard limit on long-term care eligibility, Ohio is known as an “income cap state.”
However, applicants with higher incomes can become eligible for Medicaid LTSS benefits by depositing income into a Qualified Income Trust, which is also called a “Miller Trust.”
Even though it is placed in the Miller Trust beforehand, nursing home enrollees must pay nearly all of this income toward their care. However, Ohio allows HCBS recipients to keep $1,463 each month as a personal needs allowance (as of 2018), which can be used to pay for health and living expenses.
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.)
Spousal impoverishment rules allow spouses of Medicaid LTSS recipients (i.e. the non-applying spouses) to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s income, along with resource and housing allowances. This rule applies when one spouse is receiving Medicaid coverage for LTSS, and the other spouse doesn’t have Medicaid.
In Ohio in 2020, these “community spouses” are allowed to keep:
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.
Ohio uses the federal minimum home equity limit – meaning applicants with more than $595,000 in home equity are not eligible for LTSS programs.
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 Medicaid nursing home applicants who give away or transfer assets for less than their value. States have the option of using a penalty period for HCBS.
Ohio has chosen to have an asset transfer penalty for both nursing home care and HCBS. This penalty is based on 60-month lookback period where asset transfers and gifts are not allowed. The asset transfer penalty is calculated by dividing the value of transfers and gifts by the monthly cost of nursing home care (which is $6,905 in Ohio in 2020).
Medicaid has to try to recover from an enrollee’s estate what it paid for long-term care related costs beginning at age 55. States can choose to also pursue estate recovery for all other Medicaid benefits, and for enrollees who did not receive LTSS.
Ohio uses estate recovery to recoup, to the extent possible, all Medicaid expenditures for people who were 55 or older (including Medicaid expansion enrollees), as well as amounts that Medicaid spent on care for people under 55 who were institutionalized.
If the deceased’s Medicaid coverage was provided via regular managed care (ie, a private insurance company that contracts with the state to provide Medicaid coverage), the amount that the state paid the insurance company for the coverage would be recouped from the estate, which means the estate recovery amount could be more (or less) than the actual cost of Medicaid services received. Most Ohio Medicaid beneficiaries are enrolled in managed care plans offered by one of five insurance companies.
Ohio has significantly expanded the types of assets that it recovers from an estate. Federal law only requires states to recover long-term care related costs from the portion of an estate subject to an enrollee’s will. But Ohio will also recover assets that pass outside of the probate process.
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid will attempt to recover the cost of MSP benefits paid through that date.
You can access free counseling about Medicare benefits through the Ohio Senior Health Insurance Information Program (OSHIIP) at 800-686-1578.
The OSHIIP can help you enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. OSHIIP counselors may also be able to provide referrals for local home care or long-term care services. This website has more information about the services OSHIIP offers.
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.
Medicaid is administered by the State Department of Medicaid in Ohio. You can apply for Medicaid or an MSP using this website or by visiting a county Job and Family Services office.
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 Ohio City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy 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 with hospital, insurer and technology clients.
