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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 Virginia’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 Virginia, 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 limit for QMB, SLMB or QI is $7,860 if single and $11,800 if married. The asset limit for QDWI is $4,000 if living alone and $6,000 if living with others.
Medicare covers a great number of 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 regular Medicaid benefits for the aged, blind and disabled.
Regular Medicaid for the aged, blind and disabled benefits don’t ordinarily cover Long Term Services and Supports (LTSS), but community-based LTSS services are available to beneficiaries whose medical and financial situation makes them eligible for a Home and Community Based Services (HCBS) waiver.
Income eligibility: The income limit is $851 a month if single and $1,150 a month if married.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Individuals with incomes too high to qualify for Medicaid benefits for the aged, blind and disabled can enroll in the Medicaid spend-down in Virginia.
Virginia approves an enrollee’s spend-down benefits in one or six month increments – with additional coverage periods requiring new medical expenses to be submitted. (Enrollees have a ‘budget period’ of one month for nursing home coverage – and six months for other aged, blind and disabled Medicaid benefits, as explained here.)
Enrollees must satisfy the asset test that applies to other aged, blind and disabled Medicaid enrollees.
The Medicaid spend-down in Virginia covers LTSS.
Income eligibility: The income limit varies across three regional areas – or ‘groups’:
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
This Virginia Legal Aid document has more information about the Medicaid spend-down.
Medicare beneficiaries who receive Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that lowers an enrollee’s prescription drug costs under Medicare Part D. Individuals can also apply for Extra Help through the Social Security Administration if they don’t receive assistance automatically.
The income limit for this program 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. Twenty percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015, and the portion of beneficiaries who will need these services will continue increasing as the population ages. 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: 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 only the applicant’s income is counted.
However, this income limit doesn’t mean an applicant can keep all of this income up to the limit. Nursing home enrollees must pay nearly their entire income toward their care, other than a small personal needs allowance and the cost of health insurance premiums (such as Medicare Part B and Medigap).
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.
Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car. Applicants also are not allowed to have more than $595,000 in home equity.
Every state’s Medicaid program covers community-based LTSS services. These services are called Home and Community-Based Waiver (HCBS) services because recipients continue living in the community, rather than entering a nursing home.
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 Medicaid, the income limit for single applicants is used – and only the applicant’s income is counted.
This income limit doesn’t mean applicants can keep all of their income up to this limit once they begin receiving services. Virginia HCBS recipients are allowed a personal needs allowance (which was $1,238 as of 2018), but nearly all their other income must be paid toward their care.
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.
HCBS enrollees also cannot have more than $595,000 in home equity.
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 community spouses of Medicaid LTSS recipients to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income.
In Virginia in 2020, these spousal impoverishment rules allow community spouses 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.
Virginia uses the federal minimum home equity limit – meaning applicants with more than $595,000 in home equity are ineligible 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 institute a penalty period for Medicaid nursing home applicants who give away or transfer assets for less than their value. States can also have a penalty period for community-based LTSS.
Virginia 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 that 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 monthly cost of nursing home care. (These amounts are $9,032 in Northern Virginia and $6,422 everywhere else in the state).
A state’s Medicaid agency is required to recover what it paid for LTSS and related medical costs while an enrollee was 55 or older. The law allows states to also pursue estate recovery against beneficiaries who did not receive LTSS.
Virginia has chosen to recover what it paid for all Medicaid benefits beginning when an enrollee was 55. This means Medicaid expansion enrollees in Virginia are subject to estate recovery after they pass away, with the state allowed to recoup what it spent on their care starting when they turned 55.
When an enrollee’s Medicaid coverage was administered by a managed care organization (MCO; a private health insurance company that contracts with the state to provide Medicaid coverage), the state will attempt to recover what it paid the MCO. That means the estate recovery amount could be more (or less) than the actual cost of Medicaid services received.
Virginia 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 will recover the costs of these benefits received until that date.
Free volunteer Medicare counseling is available by contacting the Virginia Insurance Counseling and Assistance Program (VICAP) at 1-800-552-3402. This federal government sponsored program is offered through Area Agencies on Aging (AAAs) in Virginia.
The SHIP can help beneficiaries 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 a list of AAAs in Virginia.
Elder law attorneys can help individuals plan for Medicaid long-term care benefits. The National Academy of Elder Law Attorneys (NAELA) has a search feature beneficiaries can use to find an elder attorney locally.
Virginia’s Medicaid program is administered by the Department of Virginia Health Access (DVHA). Individuals can apply online for Medicaid or the MSP or can call 855-242-8282 for assistance.
An in-person interview is always required when applying for long-term care benefits, and many states require one for Medicaid ABD. However, interviews are no longer required for the MSP.
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 Virginia 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.
