The Department of Human Services (DHS) will pay all or part of the cost of Long-Term Care (LTC) services for eligible individuals. Medical Assistance (MA) eligibility is based on the individual’s income, resources, and functional need.
An individual applying for or receiving payment of services in a LTC facility must be determined eligible for MA LTC under Step 1 below. If found eligible for payment of services in a LTC facility the individual is responsible to make a monthly payment toward the cost of care. An individual applying for or receiving payment of Home and Community Based Services (HCBS) must also be determined eligible for MA LTC under Step 1. Unlike LTC facility services, if found eligible for HCBS, the individual is not required to make a monthly payment toward the cost of care.
The County Assistance Office (CAO) is responsible for computing the individual’s payment toward the cost of care and notifying the individual and the facility of the amount. The LTC service provider must correctly bill DHS for services provided.
For an individual to qualify for a payment by DHS for LTC services, he or she must be eligible for MA LTC, and his or her payment toward the cost of LTC facility services must be less than the MA LTC payment rate for the services.
The CAO must follow a two-step process:
Step 1: Decide whether the individual is eligible for MA LTC.
Step 2: If the individual is eligible, determine how much the individual must pay for LTC facility services.
NOTE: A Step 1 eligibility determination is not needed for a LTC facility resident who receives federal or state Supplemental Security Income (SSI). An individual who is receiving the SSI personal needs allowance does not make a payment toward the cost of his LTC facility services.
For married couples who are both living in a LTC facility or eligible for HCBS, the CAO must decide on each individual’s eligibility separately.
If an individual is eligible for MA LTC (Step 1) but is not eligible for payment of LTC services (Step 2), he or she must be charged at the MA LTC rate for LTC services.
Exception: The LTC facility can charge the private pay rate for an individual who is not eligible for the payment toward cost of care due to the imposition of a penalty period resulting from the failure to meet fair consideration transfer provisions or due to excess home equity.
An individual may be determined eligible to receive help with payment of LTC services received during a retroactive period. An individual may also receive help to pay for other medical bills received prior to admission to a LTC facility or assessment for HCBS
(See Section 468.5.)
Updated March 12, 2012, Replacing December 2, 2005