Common Medicaid Terms....Simplified!

When it comes to Medicaid, well it’s a maze of confusion. The complicated verbiage almost needs its own dictionary. We’ve compiled a list of commonly used terms and their definitions for easy reference when talking to residents and families. LTC Medicaid guidelines require an applicant to meet Financial Eligibility guidelines as well as Medically Needy […]

Eli Kaplovitz

April 25, 2023

When it comes to Medicaid, well it’s a maze of confusion. The complicated verbiage almost needs its own dictionary. We’ve compiled a list of commonly used terms and their definitions for easy reference when talking to residents and families.

LTC Medicaid guidelines require an applicant to meet Financial Eligibility guidelines as well as Medically Needy guidelines. The Level of Care (LOC) is the clinical documentation that proves an applicant’s Medical Need.

A LTC Medicaid application must be supported with documentation that verifies the income and assets reported. The Verification Checklist (VCL) is the response document received from a caseworker that lists out the documents required to support the application and verify applicant eligibility. It lists out the documentation needed to process the application, and provides the deadlines for submission. Once the Department of Human Services (DHS) reviews your application they will send out a Request Letter otherwise known as Deadline Letter requesting any documentation that was missing.

When applying for LTC Medicaid assistance, the DHS office or State Entity responsible for reviewing applications and determining eligibility has the right to request financial verification documents dating as far back as 5 years prior to coverage requested date. The 5 years prior to coverage requested is known as the Look Back Period. The Case Worker will review all assets and financial transactions during this period to ensure accurate reporting was done on the application as well as review for Unallowable Transfers. Unallowable Transfers are transfers of assets/funds that were not a direct benefit to the LTC Medicaid applicant.

If a Case Worker uncovers any unallowable transfer of assets during the look back period a penalty may by imposed. The penalty period is the sum or value of the assets transferred. The state will take the total value and divide it by the private pay rate of the facility to determine the amount of days the resident will be ineligible for LTC Medicaid room & board coverage. The resident must pay for the Room & Board privately during this time. Once the penalty period has been exhausted, Medicaid room & board coverage will begin.

In some states there is an Income Limit to qualify for LTC Medicaid. When Income Limit is an eligibility requirement, if an applicant’s gross monthly income exceeds the eligibility Income Limit set by the State, a Qualified Income Trust (QIT)/ Miller Trust must be established and funded for the applicant to be eligible. A QIT must be established prior to month end for the month Medicaid coverage is needed. The QIT must be funded every month in order for the resident to remain Medicaid eligible. At minimum, the QIT must be funded by the amount of income that exceeds the gross income limit. 

LTC Medicaid will send out a Redet/Redetermination/ Renewal packet every year to confirm an applicant’s ongoing eligibility. The application will ask basic questions regarding f a resident’s income/asset eligibility for the Medicaid program. 

Acing the Medicaid maze one word at a time. 

Always here to help. Reach out to discover why over 649 facilities are using Aidace software to get more Medicaid approvals in less time. Get all the details at aidace.com.

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