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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 West 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 West 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. QDWI has an asset limit of $4,000 if living alone and $6,000 if living with others.
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. 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.
In West Virginia, Medicaid ABD only covers dental care in emergencies (i.e., for extractions and pain relief) for adults. Here is a list of free or low-cost dental clinics in the state.
Medicaid ABD also does not cover routine vision care for adults in West Virginia.
This program is called SSI-Related Medicaid in West Virginia.
Income eligibility: The income limit is $783 a month if single and $1,175 a month if married. (This is the same income limit as the Supplemental Security Income program.)
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 West Virginia.
West Virginia approves an enrollee’s spend-down benefits in six month increments – with additional coverage periods requiring new medical expenses to be submitted.
The Medicaid spend-down in West Virginia does not cover LTSS.
Income eligibility: The income limit was $200 a month if single and $275 a month if married in 2018.
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
Medicare beneficiaries who receive Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that lowers the 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 – and may qualify with incomes up to $1,615 a month if single and $2,175 a month if married. Applicants must also meet an asset test.
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 their income up to the limit. Nursing home enrollees must pay nearly their entire income toward their care, other than a small personal needs allowance (of $50 in 2020) and money to pay for 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 are also 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 Services (HCBS) waivers because recipients continue living in the community.
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.
HCBS recipients in West Virginia are allowed to keep their entire income up to the eligibility limit – of $2,349 a month – as a personal needs allowance.
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 are not allowed to 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 West 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 who have significant home equity. In 2020, states set this home equity limit based on a federal minimum of $595,000 and maximum of $893,000.
West 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.
West 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 (which is $9,930 in 2020).
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.
West Virginia has chosen to only recover the cost of Medicaid benefits for enrollees who received nursing home care or HCBS. But if it does pursue estate recovery, West Virginia may attempt to recover what it paid for all Medicaid benefits for those enrollees (and not just LTSS).
When an enrollee’s Medicaid coverage was administered by a managed care organization (MCO), 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.
West Virginia will grant an exemption to estate recovery in cases where recovering from an estate would cause undue hardship to an enrollee’s heirs.
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid could recover benefits paid through that date. This would only occur in West Virginia if an enrollee received Medicaid long-term care.
Free volunteer Medicare counseling is available by contacting the West Virginia State Health Insurance Assistance Program (SHIP) at 1-877-987-4463.
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. The SHIP’s website has more information about the services it offers.
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.
West Virginia’s Medicaid program is administered by the Department of Health and Human Resources (DHHR). Individuals can apply for Medicaid or an MSP using this website or by visiting a local DHHR office.
An in-person interview is always required when applying for long-term care benefits, and some states also require one for Medicaid ABD. However, interviews are not required for applicants who are only seeking an 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 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.
