Medicaid Case Histories (2024) PDF

1\. **Mr. Lee** is a 56 year old single carpenter. He was injured about a year ago, hurting his back. Since that time, he has had a hard time working as a carpenter. He has been offered several small carpentry jobs since then, but each time his back has started hurting and he has been unable to fini...

1\. **Mr. Lee** is a 56 year old single carpenter. He was injured about a year ago, hurting his back. Since that time, he has had a hard time working as a carpenter. He has been offered several small carpentry jobs since then, but each time his back has started hurting and he has been unable to finish the work in the time specified. Mr. Lee has tried earning money in other jobs---as a short order cook, as a day laborer, and working for a temporary agency, but he has been unable to make enough money to meet his living expenses. At most, he has earned between \$500-\$600/month in odd jobs. Mr. Lee exhausted his meager savings. Last month he was evicted from his apartment. He is currently living out of a homeless shelter. He has no other assets. To compound his other problems, Mr. Lee has developed some medical problems. He has been coughing and has had a hard time breathing. He called several of the doctors' offices in town, but they all require payment at the time services are rendered. Since Mr. Lee has little money, he decided to delay seeking care. Finally, when his breathing became so difficult, one of his friends brought him to the emergency room. The doctors diagnosed him with bronchitis, and gave him a prescription to try to clear up his cough. The medication cost \$60 to fill, but he has not had the resources to fill his prescription. In addition, the doctors have told him to have his cough checked after he finishes his prescription. You work at the shelter and have been trying to help Mr. Lee address his medical needs. The shelter has a small pool of money set aside to help provide needed medical care for the shelter residents; but you first try to exhaust all other options before using this limited pool of money. a. You are interested in finding out if Mr. Lee could qualify for Medicaid in Non Expansion State (NES). Do you think Mr. Lee can qualify? What program categories should you explore? What questions would you need to ask to find out if he qualifies for assistance? b. What if Mr. Lee lived in another state that had expanded Medicaid? Would he qualify? Why or why not? 2\. **Ms. Richardson** lives with her two children in public housing in Rural County, Non Expansion State (NES). Her children are five and eight. She recently lost a job with health insurance coverage and just found a new job working 30 hours/week for a small business (30 employees). Her employer does not offer health insurance coverage. She earns \$2,900 in modified adjusted gross income (MAGI)/month. She only has about \$1,000 in the bank and no other assets (aside from her car, which she uses to get to work). She has come to you because she needs health insurance coverage. She has been trying frantically to get a higher paid job, one with insurance, but has been unsuccessful. She also wants to keep her hours down to 30 hours per week so that she can be at home when her kids get back from school. Her oldest child, Jack, was recently diagnosed with attention deficit disorder and needs a lot of help completing his schoolwork. The costs of Jack's medications are expensive. Further, both of the kids get sick from time to time. Susan (Ms. Richardson's youngest child) has had a history of ear infections and strep throat, so Ms. Richardson wants to make sure that the children can get the medical care they need. She has been prescribed medicine for diabetes but has been unable to fill the prescription because of the costs. a. What type of coverage would she or her children be eligible for in NES? b. What if she lived in another state that expanded Medicaid? **3. The Kent Family.** Mrs. Kent lives with her husband, Clark, in their home in Non Expansion State (NES). Clark (age 73) is a retired pilot, and his wife, Lois (69) is a retired reporter. Mr. Kent receives \$1,500/month in Social Security retirement benefits, and \$1,500/month in a private pension. Mrs. Kent receives \$1,000/month in Social Security retirement benefits. Mr. Kent has been diagnosed with Alzheimers. Mrs. Kent, who is also in ill health, can no longer take care of her husband at home. She is exploring options to place her husband in a nursing home after he leaves the hospital. The Kents own their home (their mortgage and taxes amount to \$703/month). Their monthly utilities are \$350 (including electricity, water and telephone). They also have \$250,000 in the bank. Mr. Kent does not have long-term care insurance. He has Medicare and a private health insurance plan, but neither of these will cover long-term nursing home costs. A nursing home stay costs approximately \$8,000/month for private pay. Mrs. Kent is concerned that they will quickly eat through their combined assets paying the nursing home costs. She wants to keep their home and as much of her savings as possible, so that they can live leave it to their grandchildren when they die. She is also concerned that she will not have enough income to live on if Mr. Kent is forced to spend all his money on the costs of nursing home care. The hospital social worker has told her that she can apply for Medicaid to pay for the costs of Mr. Kent's nursing home care. She's heard from her friends that she may have too many assets, and that she will need to give her assets away in order to qualify. Help Mrs. Kent determine if Mr. Kent is eligible for Medicaid to help with his nursing home costs, and if so, whether any part of his income or resources can be used to support Mrs. Kent. **\ Non-Expansion State Monthly Income Eligibility Criteria (2024)** +---------+---------+---------+---------+---------+---------+---------+ | **Famil | **Famil | **Medic | **100% | **138% | **210% | **250% | | y | y/** | ally | FPL\ | FPL\ | FPL\ | FPL\ | | Size** | | needy** | ** | ** | ** | ** | | | **paren | | | | | | | | t | | - **E | - **M | - **M | **Cap | | | coverag | | lderly* | edicaid | edicaid | for | | | e | | * | chi | chi | cost | | | (37% | | | ldren | ld | sharing | | | FPL)** | | - **D | 6-1 | 0-6 | subsidi | | | | | isabled | 8)** | ** | es** | | | | | ** | | | | | | | | | - **M | - **C | | | | | | - **B | edicaid | HIP | | | | | | lind** | exp | chi | | | | | | | ansion | ld | | | | | | | adu | 6-1 | | | | | | | lts** | 8** | | +=========+=========+=========+=========+=========+=========+=========+ | **1** | \$464 | \$242 | \$1,255 | \$1,732 | \$2,636 | \$3,138 | +---------+---------+---------+---------+---------+---------+---------+ | **2** | \$630 | \$317 | \$1,703 | \$2,350 | \$3,576 | \$4,258 | +---------+---------+---------+---------+---------+---------+---------+ | **3** | \$796 | \$367 | \$2,152 | \$2,970 | \$4,519 | \$5,380 | +---------+---------+---------+---------+---------+---------+---------+ | **4** | \$962 | \$400 | \$2,600 | \$3,588 | \$5,460 | \$6,500 | +---------+---------+---------+---------+---------+---------+---------+ | **5** | \$1,128 | \$433 | \$3,048 | \$4,206 | \$6,401 | \$7,620 | +---------+---------+---------+---------+---------+---------+---------+ Resource Limits (2024) ====================== ------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------- **[Family Size]** **[SSI (Elderly & Disabled)]** **[Pregnant Women, Children, Families (and childless adults in M'aid expansion states)]** **[Families/Adults if applying under medically needy]** 1 \$2,000 NA \$3,000 2 \$3,000 NA \$3,000 3 NA \$3,000 4 NA \$3,000 ------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------- NES's maximum resource limits for Medicaid are \$2,000 for an individual, \$3,000 for a couple (for the elderly and disabled). Certain assets are exempt in determining Medicaid eligibility, including a house, one car and personal belongings. Most other assets are counted towards the resource limit. NES does not have a resource limit in their CHIP program or in the Medicaid program for pregnant women, children, or families (unless applying under the medically needy program). - **\ Subsidized Coverage in the Health Benefits Exchange (2022)** **Individual or Family Income** **Percent of family income to purchase benchmark plan (2^nd^ lowest cost silver plan)** **Out-of-pocket cost sharing for silver plan** **Out-of-pocket cost sharing limits** --------------------------------- ----------------------------------------------------------------------------------------- ------------------------------------------------ --------------------------------------- **100-133% FPL** 0.0% 6% \$3,000 (ind)/\$6,000 (fam) **133-150% FPL** 0.0% 6% \$3,000 /\$6,000 **151-200% FPL** 0.0% - 2.0% 13% \$3,150 /\$6,000 **201-250% FPL** 2.0% - 4.0% 27% \$7,250/\$14,500 **251-300% FPL** 4.0% - 6.0% 30% \$9,450/\$18,900 **301-400% FPL** 6.0% - 8.5% 30% \$9,450/\$18,900 **400% + FPL** 8.5% 30% \$9,450/\$18,900 Special Rules for Individuals in Long-Term Care (April 2023-present) ==================================================================== Income rules: - Institutionalized spouse can keep \$30/month for his or her personal needs allowance. - Institutionalized spouse at home can give some of his or her income to support the spouse at home ("community-spouse"), up to \$2,465/month. - The institutional spouse can also make additional contribution for the community spouse's "excess shelter expenses" (housing and utility expenses that exceed \$740/month). The maximum that the institutionalized spouse can contribute to the community spouse for support and excess shelter expenses is \$3,853. Resource Rules: - The community spouse can keep half of the couple's joint resources, but not less than \$30,828 (if they have that much) or more than \$154,140 (half of \$308,280). - The institutional spouse can retain \$2,000 of the assets. (Source: and https://www.medicaid.gov/media/166206) ***Medicare and SSI:*** *Substantial gainful activity* is defined as a job that pays \$1,470 per month (\$2,460 if blind) (2023). The SSI maximum payment for 2024 is: \$943/month for an individual or \$1,415/month for a couple. Individuals covered by Medicare have certain cost sharing requirements (2022), including but not limited to: - \$1,632 Part A hospital deductible per spell of illness. After the hospital deductible, Medicare covers 100% of inpatient hospital services for the first 60 days, then \$408 copayment (for days 61-90), and a \$816 copayment/day for 60 lifetime reserve days (also listed as days 91-150). - There is a \$174.70 monthly premium for Part B coverage for most people (unless their income is more than \$97,000 individual, or \$194,000 couple in which case they'll pay more); \$240 Part B deductible, and 20% coinsurance for most Part B services. - Medicare pays 100% for the first 20 days of skilled nursing home care; then there is a \$204/day copayment for days 20-100 of nursing home care (Medicare only covers 100 days of skilled nursing home care per spell of illness).