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As a Medicare beneficiary, your state of residence can have a significant impact on the healthcare that you receive and how you pay for that care.
This page explains some of Oregon’s policies and options that can help you pay for Medicare and long-term care, including some options if you are dually eligible for Medicare and Medicaid.
Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Oregon, 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: Oregon eliminated its asset limits for MSPs beginning on January 1, 2016.
The income and asset limits for QMB-BAS, QMB-SMB and QMB-SMF vary based on an applicant’s marital status, but eligibility rules for QMB-DW, regular Medicaid for the aged, blind and disabled and Long Term Services and Supports programs vary based on the number of household members.
Medicare covers many services, but Original Medicare can leave enrollees with significant cost sharing obligations, and doesn’t cover important services like vision and dental benefits. Beneficiaries who meet the income and asset limit for Medicaid eligibility can receive coverage for those additional services if they’re enrolled in Medicaid benefits for the aged, blind and disabled (ABD).
In Oregon, Medicaid ABD covers an extensive number of dental services. Medicaid ABD also covers routine eye exams and and eyeglasses for pregnant women, but not for other adults.
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.
Medicare beneficiaries who are enrolled in Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that lowers prescription drug costs under Medicare Part D. Beneficiaries who don’t receive this program automatically can apply for it through the Social Security Administration (SSA). 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 generally not covered by Medicare.
Income limits: The income limit is $2,349 a month if single or $4,698 a month if married (and both spouses are applying).
However, nursing home residents have to pay nearly their entire monthly income toward their care – other than a $64.11 personal needs allowance and money to pay health insurance premiums (such as Medicare Part B or Medigap).
When only one spouse needs Medicaid, the income limit for single applicants is used – and only the applicant’s income is counted.
Assets limits: The asset limit is $2,000 per applicant. If only one spouse needs Medicaid, the other spouse can keep up to $128,640.
Every state’s Medicaid program covers some community-based long-term care services, which are provided in an enrollee’s home, adult day care center, or another community setting. Medicaid programs that pay for this type of care are called Home and Community Based Services (HCBS) waivers because recipients can continue living in the community.
Income eligibility: 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 Medicaid, the income limit for single applicants is used and the non-applying spouse’s income is not counted.
Asset limits: The asset limit is $2,000 per applicant. If only one spouse needs Medicaid, federal rules allow the other spouse to keep up to $128,640. Enrollees can’t have more than $595,000 in home equity.
Oregon does not have a Medicaid spend-down, which means that individuals with incomes above the Medicaid eligibility limit do not have a way of qualifying for regular aged, blind and disabled Medicaid benefits. However, applicants whose income is over the limit for LTSS programs can become eligible for nursing home benefits or HCBS by depositing income into a Qualified Income Trust (known as a “Miller Trust”). Income placed in the Miller Trust isn’t considered when determining eligibility.
Nursing home enrollees are required to pay most of their income toward their care even if it is first deposited into the Miller Trust. However, some states allow HCBS recipients to keep a significant personal needs allowance. As of 2018 in Oregon, this allowance for HCBS enrollees was either $750 or $1,750.
Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. Normally with Medicaid benefits, the income of both spouses is counted – regardless of who is applying. However, for Medicaid long-term care benefits, only the applying spouse’s income is counted.
Spousal impoverishment rules allow the spouse of a Medicaid LTSS recipient to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income, along with resource and housing allowances. These rules apply when one spouse is receiving Medicaid coverage for LTSS, and the other spouse doesn’t need Medicaid.
In Oregon in 2020, the non-applying for “community spouse” is allowed to keep:
Federal law limits eligibility for Medicaid nursing home and HCBS benefits to applicants with a home equity interest below a specific dollar amount, with states specifying the limit. In Oregon, HCBS and nursing home care recipients can have no more than $595,000 in home equity.
Federal law requires states to apply a period of ineligibility for applicants for nursing home coverage who give away or transfer assets for less than their value. States can choose to also have an asset transfer penalty for HCBS.
Oregon has chosen to have an asset transfer penalty for both nursing home care and HCBS. Asset transfers and gifts made during the 5-year lookback period prior to applying for Medicaid LTSS can disqualify a person from receiving those services. The length of the penalty period is determined by dividing the value of assets given away or transferred for less than their value by Oregon’s average nursing home rate (which is $8,784 a month in 2020).
A state’s Medicaid agency is mandated to recover what it paid for long-term care related expenses beginning at the age of 55. States can choose to also pursue estate recovery for medical expenses that are unrelated to LTSS.
Oregon will only pursue estate recovery for LTSS (and any related medical and prescription drug expenses) for benefits received after September 30, 2013, but the state will attempt to recover the cost of all Medicaid-covered services received before that date. Oregon made this change in late 2013 because the ACA’s expansion of Medicaid was taking effect as of January 2014, resulting in far more people age 55-64 being enrolled in Medicaid but not receiving LTSS. To avoid having estate recovery apply to all of their coverage, the state modified the rules to ensure that for services provided after October 1, 2013, a person would have to be receiving LTSS in order for Medicaid estate recovery to apply.
The state will delay its estate recovery if an enrollee is survived by a spouse or domestic partner, but estate recovery would occur after the spouse or partner’s death. Oregon will not pursue estate recovery if an enrollee is survived by a child who is under 21 or disabled.
Congress exempted Medicare premiums and cost sharing paid after December 31, 2009 from Medicaid estate recovery, but Medicaid could attempt to recover the cost of MSP benefits paid through that date. In Oregon, this could only occur if an enrollee received LTSS.
Free volunteer Medicare counseling is available through Oregon’s State Health Insurance Benefit Advisors (SHBA) 1-800-722-4134. The program is a State Health Insurance Assistance Program (SHIP) offered by the State of Oregon.
SHIBA can help beneficiaries enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. They may also be able to offer referrals to local agencies for services like home care and long-term care. This website has more information about SHIBA in Oregon.
Medicare beneficiaries in Oregon can visit an Area Agency on Aging (AAA) for assistance applying for services to help with aging or living with a disability, and help planning for long-term care. This website has more information about AAAs in Oregon.
Elder law attorneys can help individuals plan for Medicaid long-term care benefits. Use this search feature from the National Academy of Elder Law Attorneys (NAELA) to find a locally based elder attorney.
In Oregon, Medicaid is overseen by the Oregon Health Authority (OHA). You can apply for Medicaid ABD or an MSP using this website. An Area Agency on Aging (AAA) or Department of Human Services (DHS) Office for Aging and People with Disabilities can also help you apply.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare technical assistance contract at the Medicare Rights Center in New York 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 clients on Medicare and Medicaid issues.