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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 Washington’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 Washington, 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 and QI is $7,860 if single and $11,800 if married. QDWI’s asset limit is $4,000 for applicants living alone and $6,000 for applicants living with another person.
Certain assets are not counted –including a first home, household belongings, one car, and some prepaid burial plans.
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 Medicaid for the aged, blind and disabled.
In Washington, Medicaid ABD covers exams, cleanings, x-rays, fillings, fluoride, extractions, and several other services for adults. However, Medicaid ABD does not cover dentures or oral surgery.
Medicaid ABD does not pay for eyeglasses or contacts for adults.
Income eligibility: The income limit is $783 if single and $1,175 if married.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Applicants who have incomes above the eligibility limit for Medicaid for the aged, blind and disabled can enroll in the Medicaid spend-down program, which allows individuals to qualify for Medicaid by subtracting incurred medical expenses from their countable income.
The amount that an applicant’s income exceeds the limit for Medicaid spend-down is known as “excess income.” Enrollees must activate their coverage by submitting incurred medical bills equal to this amount. Some states also allow enrollees to pay their excess income directly to Medicaid if they are unable to submit medical expenses.
In Washington, coverage under the Medicaid spend-down lasts for either 3 or 6 months, depending on the amount of medical expenses the person submits. Enrollees can also receive up to 3 months of retroactive coverage.
The Medicaid spend-down does not cover long-term care in Washington.
Income limit: The income limit is $783 a month if single and $1,175 a month if married.
Medicare beneficiaries who are enrolled in Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help. This federal program lowers prescription drug costs under Medicare Part D. Individuals who don’t receive Extra Help automatically can apply for it through the Social Security Administration (SSA). The income limit is $1,615 a month for single applicants and $2,175 a month for married 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.
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married. If only one spouse needs nursing home care, the single applicant income limit is used – and usually only the applying spouse’s income is counted.
Although the income limit is $2,349 a month (for single applicants), nursing home enrollees are not allowed to keep all of their income up to this limit. Once they enter a nursing home, enrollees can only keep $70 each month as a personal needs allowance – along with money to pay for health insurance premiums.
Assets limits: The asset limit is $2,000 if single and $3,000 if married (and both spouses are receiving nursing home care). If only one spouse needs nursing home care, the other spouse can keep up to $128,640.
Certain assets are never counted, including many household effects, family heirlooms, some prepaid burial arrangements, and one car.
Every state’s Medicaid program covers community-based LTSS services. These are called Home and Community-Based Services (HCBS) because recipients don’t have to enter a nursing home to receive them. In Washington, HCBS recipients must need help with at least two activities of daily living (ADLs).
Income eligibility: The income limit is $2,349 a month if single and $4,698 a month if married (and both spouses are applying). If only one spouse needs HCBS, the income limit for single applicants is used – and usually only the applying spouse’s income is counted.
However, HCBS enrollees are not allowed to keep all of their income up to this limit in Washington. As of 2018, these enrollees are allowed to keep $1,012 a month as a personal needs allowance, and remaining income must be paid toward their care.
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.
In Washington in 2020, these spousal impoverishment rules allow these ‘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.
In Washington, recipients of Medicaid nursing home care or HCBS can’t have more than $595,000 in home equity.
Because long-term care is expensive, some individuals have an incentive to give away or transfer assets to make themselves eligible for Medicaid nursing home care or HCBS. 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 HCBS.
Washington has an asset transfer penalty for nursing home care and HCBS. This penalty can last up to 5 years – and is based on asset transfers and gifts made during a 5-year lookback period prior to filing a Medicaid application.
This penalty’s length is calculated by dividing the value of what was transferred or given away by the average cost of nursing home care (which is $341 a day in Washington in 2020).
In Washington, asset transfers and gifts do not disqualify enrollees from receiving certain Medicaid services, including Program for All-Inclusive Care for the Elderly (PACE), Medicaid Personal Care or the Community First Choice (CFC) program. The asset transfer penalty also does not apply to individuals receiving hospice care.
Medicaid is required to recover its payments for long-term care and related medical expenses starting at the age of 55. States can choose to also recover from enrollees in that age range who didn’t receive long-term care.
Washington State has chosen to pursue estate recovery only for enrollees who received long-term care. This means the state will not attempt to recover from the estates of Medicaid expansion enrollees (as long as they didn’t receive LTSS).
Certain assets owned by Alaska Natives and American Indians are exempt from estate recovery.
Estate recovery will be delayed for enrollees who are survived by their spouse or a child who is under 21, blind or disabled. The state would pursue estate recovery once the spouse passes away – or the child turns 21 or is no longer considered disabled.
Congress exempted Medicare premiums and cost sharing paid after December 31, 2009 from Medicaid estate recovery, but Medicaid may attempt to recover its payments for MSP benefits through that date.
Free volunteer Medicare counseling is available through Washington’s State Health Insurance Benefit Advisors (SHBA) 1-800-562-6900. The program is a State Health Insurance Assistance Program (SHIP) sponsored by the federal government.
SHIPs like 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 Washington.
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.
Medicaid is administered by the State Health Care Authority (HCA) in Washington. You can apply online for Medicaid for Medicaid ABD or the MSP. Applicants can also call 855-242-8282 with questions about their Medicaid application.
An in-person interview is always required when applying for long-term care benefits, and many states also require one for Medicaid ABD. However, states can’t require an interview if you’re only applying for an MSP.
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 on Medicare and Medicaid related client projects.