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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 Utah’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 Utah, 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 if married.
Medicare covers many services – including hospitalization, physician services, and prescription drugs. However, Medicare can also leave its enrollees with large out-of-pocket costs (i.e. co-pays, coinsurance, deductibles). Original Medicare also does not cover routine dental or vision care.
Enrollees who have low incomes and assets can receive coverage for Medicare cost sharing expenses and Medicaid-covered services if they’re enrolled in Medicaid for the aged, blind and disabled (ABD). In Utah, Medicaid ABD covers preventive dental visits, as well as more expensive services like fillings, crowns, root canals, and dentures.
However, Medicaid ABD doesn’t usually cover Long Term Services and Supports (LTSS). Enrollees usually have to apply for those services separately, undergo an assessment, and satisfy different income limits.
Income eligibility: The income limit is $1,063 a month if single and $1,437 a month if married.
In Utah, individuals whose incomes are too high to qualify for Medicaid ABD can enroll the Medicaid spend-down program, which allows medical expenses to be subtracted from an enrollee’s income that is counted toward the Medicaid eligibility limit.
Utah usually approves spend-down benefits in 1 month increments – with additional coverage requiring new medical expenses to be submitted.
Enrollees must satisfy the same asset test as other Medicaid ABD enrollees.
In Utah, the Medicaid spend-down program covers long-term care.
Income eligibility: The income limit is $1,063 a month if single and $1,437 a month if married.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Many Medicare beneficiaries who live long enough will have to rely on long-term services and supports (LTSS) – or long-term care – which Medicare usually doesn’t cover. In fact, one fifth 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.
Income limits: There is no income limit, but enrollees must pay nearly all their income to the nursing home.
Nursing home enrollees are allowed to keep a $45 personal needs allowance and money to pay for health insurance premiums (such as Medicare Part B and Medigap). When only one spouse needs Medicaid, only income received by the spouse requiring nursing home benefits is paid toward care.
Assets 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 $126,800.
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 community-based long-term care services, which are provided at home, in an assisted living facility, or another “community” setting. Medicaid programs that pay for this care are called Home and Community Based Services (HCBS) waivers because recipients continue living in the community, and don’t have to enter a nursing home.
Income limits: The income limits vary based on the program.
The following HCBS programs have an income limit that is $1,063 a month per person:
These HCBS programs have an income limit that is $2,349 a month per applicant:
Both the Physical Disabilities Waiver and New Choices Waivers allow applicants to become eligible by “spending-down” their income to $2,349 a month if it is higher than this eligibility limit. Applicants can qualify for the other HCBS waivers despite having incomes higher than the limit for those programs by enrolling in Utah’s regular Medicaid spend-down (where the income limit is $1,064 a month).
When only one spouse needs Medicaid HCBS, the income limit for single applicants is used – and only the applying spouse’s income is counted.
Assets limits: The asset limit is $2,000 per applicant. If only one spouse needs Medicaid, spousal impoverishment rules allow the other spouse to keep up to $126,800.
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. With other Medicaid benefits, income received by both spouses is counted – regardless of who is applying.
Spousal impoverishment rules allow the spouses of Medicaid LTSS recipients 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 receives Medicaid long-term care coverage, and the other doesn’t have Medicaid.
In Utah in 2020, these “community spouses” are allowed to keep:
Federal law requires states to not allow Medicaid nursing home and HCBS to applicants to have more than a certain amount in home equity. States currently set this home equity level based on a federal minimum of $595,000 and maximum of $893,000.
Utah uses the lowest allowed home equity limit – meaning applicants with more than $595,000 in home equity are not eligible for LTSS programs.
Some individuals attempt to give away or transfer assets to make themselves eligible for Medicaid to cover the high cost of long-term care. Federal law requires states to have a penalty period for Medicaid nursing home applicants who give away or transfer assets for below their value. States can also have a penalty period for HCBS.
Utah has an asset transfer penalty for both nursing home care and HCBS. The state uses a 60-month lookback period to calculate this asset transfer penalty – meaning asset transfers or gifts made during this period may result in ineligibility. This penalty is calculated by dividing the value of asset transfers and gifts by the cost of nursing home care (which is $4,526 a month in 2020).
A state’s Medicaid agency is required to recover what it paid for LTSS and related medical costs while a enrollee was 55 or older. The law allows states to also pursue estate recovery against beneficiaries who did not receive LTSS.
Utah has chosen to only recover from the estates of enrollees who receive LTSS.
When a deceased enrollee’s Medicaid coverage was administered by an insurer, the state will attempt to recover what it paid the insurer. That means the estate recovery amount could be more (or less) than the actual cost of Medicaid services received.
Utah will grant an exemption to estate recovery in cases where recovering from an estate would cause undue hardship.
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid may attempt to recover benefits paid through that date.
Free volunteer Medicare counseling is available by contacting the Senior Health Insurance Program (SHIP) at 1-800-541-7735. This federal government sponsored program is offered through the Utah Insurance Department.
The SHIP can help you enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. Counselors may also be able to provide referrals for home care agencies or long-term care services. This website has more information about SHIP.
Elder law attorneys can help you plan for Medicaid long-term care benefits. Use this search feature from the National Academy of Elder Law Attorneys (NAELA) to find an elder attorney locally.
Eligibility for Medicaid in Utah is determined by the Department of Workforce Services (DWS). You can apply for Medicaid ABD or an MSP using the DWS website – or you can submit a paper application (available here). The phone number for DWS is 866-435-7414.
States can no longer require you to sit for an interview for the MSP, but some choose to require one for Medicaid ABD. You’ll have to be interviewed if you’re applying for long-term care benefits.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare 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 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.