This document is intended to help readers understand:
·
General eligibility policy relating to Medicaid payment of
long-term care services in South Carolina, and
·
The interaction between South Carolina Medicaid policy and
the Long-Term Care Partnership Program in South Carolina
An individual may not sell, solicit, or negotiate long term
insurance unless the individual is licensed as an insurance producer for accident and health or sickness or life. Previously licensed
may continue to sell long term care products, but must
complete a one-time training course by or before June 30, 2009 and ongoing
training every 24 months thereafter. Those who were not yet licensed producers
as of July, 2008 must obtain the initial course before
beginning to sell long term insurance products. The one- time training shall be
no less than eight hours and the ongoing training shall be no less than four
hours. Training can occur in the classroom or online. South Carolina Medicaid
eligibility policy is very complex. It incorporates special regulations and
exceptions for various situations, and changes frequently due to legislative
regulations. As a result, this document provides basic eligibility information,
but not enough for readers to determine if someone may be eligible for Medicaid
benefits.
To see how South Carolina Medicaid eligibility policy would
be applied to someone’s particular circumstances, the
person must submit an application to their South Carolina Department of Health
and Human Services (SCDHHS) Local Medicaid Eligibility office and provide all
information and verifications necessary to determine eligibility. Inquiries
about the eligibility status of current beneficiaries must be requested by the
beneficiaries or their authorized representatives, or third parties with
written consent of the beneficiary.
necessary to use this information verbatim, but the training
should address the basic elements contained in this document.
This document provides information on one of the subjects
that must be included in the training required of individuals seeking approval
to sell long-term care insurance policies in South Carolina. Training courses
must include all of the topics listed in SC Code
SECTION 38-72-69.
Information in this document is up-to-date
as of January 1, 2018 (checked in 2024 for newer version & one was not available).
The Long Term Care Partnership
(LTCP) Program is a joint effort between the federal Medicaid Program and Long
Term Care (LTC) insurers. The Long Term Care
Partnership was developed to encourage people to plan for their future
Long-Term Care (CLTC) needs, such as residing in a nursing facility or
receiving CLTC waivered services in a home or community-based setting.
The LTCP involves private LTC insurers, LTC insurance
producers (agents and brokers), the South Carolina Department of Health and
Human Services (SCDHHS) and the Department of Insurance (DOI). Although the
Partnership is overseen by the federal Centers for Medicare and Medicaid
Services (CMS), each state has a great deal of autonomy in its administration.
In South Carolina, qualified LTCP policies must provide a specific amount of
inflation protection based on the person’s age when the policy is purchased and
must meet other requirements determined by the Department of Insurance.
A person who requests Medicaid assistance of LTC services
after exhausting some or all benefits of a qualified LTCP policy may have
certain assets “disregarded” equal to the benefits paid by the qualified LTCP
policy at the time the person is determined eligible for Medicaid. These assets
are not counted when the person’s Medicaid eligibility is determined and will
not be recovered during estate recovery when the person dies.
To be eligible for Medicaid, a person must fit into an
eligibility group and meet specific requirements relating to residency,
citizenship, immigration status, third party liability, income, and asset
guidelines. General information about each item is included below, with special
emphasis on people who reside in a long-term care facility (LTCF) or receive
home and community-based services through a waiver program.
·
Children under the age of 21
·
Parents or relative caretakers of dependent children
·
Pregnant women
·
People age 65 or older
·
People who are blind
·
People with a certified disability
·
Women in need of treatment for certain cancers.
People living in a Long Term Care
Facility or receiving Home and Community-Based Services (HCBS) are generally
either disabled or are age 65 or over.
·
A child under 18 whose parent or legal guardian lives in
another state
·
A person of any age placed in the facility by another state
1.
citizen or a noncitizen with a qualified immigration status.
The following must be verified:
§ U.S. citizenship
and identity when a person declares that he or she is a U.S. citizen
§ Immigration status
when the person states that he or she has a non-citizen status. Sponsored
non-citizens must also provide information about their sponsors.
To be eligible for Medicaid payment of LTC services, a person
must:
1.
Meet the necessary Level of Care (LOC.) A Level of Care (LOC)
is a determination of medical necessity for care. A qualified individual must
meet either an Intermediate or Skilled level of care designation. Community
Long Term Care (CLTC) or its designee must certify the individual’s level of
care before Medicaid can pay for long-term care services.
2.
Reside in a Long Term Care Facility
or receive services through one of the Home and Community Based Waivers.
3.
Meet income and resource guidelines.
4.
Have home equity of $572,000 less unless a spouse, child
under the age of 21, or blind or disabled child is lawfully residing in the
home. This figure is updated annually.
5.
Disclose an interest in an annuity for self and spouse, if
married. The state must be named as remainder beneficiary of annuities by the
individual or spouse.
6.
Not be in a penalty period for an uncompensated transfer of
income or assets. A look-back is completed by SCDHHS for the five (5) year
period prior to the date of application for services. If it is determined an
uncompensated transfer occurred, a penalty period is calculated. During a
penalty period, Medicaid will not pay for any Long Term
Care services.
A person's Medicaid eligibility group determines income and
budgeting considerations for that person, including:
§ Income limits
(which are adjusted annually)
§ Income which is
counted for Medicaid eligibility and that which is excluded
§ Deductions allowed
from total gross countable income
§ Potential Medicaid
eligibility if the person's income is over the allowable limit.
Basic budgeting information provided relates specifically to
someone in a Nursing Home. People who receive HCBS through other waiver
programs may be eligible for the Partnership, but will
have different eligibility rules not addressed in this document. It is
recommended that they contact their local eligibility office for information
relating to their specific situations.
When looking at Medicaid eligibility, income of just the
individual in the Nursing Home is counted. Income of a spouse or parent is not
counted.
Deductions allowed for institutionalized individuals depend
on his or her specific situation. Every deduction is not allowed for each
person. General deductions include:
§ Health insurance
premiums
§ An income
allocation to a community spouse
§ An income
allocation to certain other family members (subject to specific limitations)
§ Personal needs
§ Home maintenance
if the person is expected to return to the home within six (6) months
§ Health care
expenses not paid by Medicaid or a third party.
After allowing applicable deductions, the result is the
amount a person must contribute toward the cost of his or her monthly LTC
services and is typically paid to the Nursing Home. Medicaid will pay for all
other covered services received by the person.
A person's eligibility group and household size determine his
or her asset limit for Medicaid. A resident of a Nursing Facility or someone
receiving HCBS is considered a household size of one. He or she has an asset
limit of $2,000 in countable assets.
The local eligibility office will review all verified assets
and determine which ones are:
·
Counted toward Medicaid eligibility
·
Excluded and not counted toward Medicaid eligibility
·
Determined to be protected for the community spouse, if
married
·
Protected because benefits of an LTCP policy have been
exhausted. (explained later)
The county will also determine if a person needs to reduce
assets to the $2,000 asset limit allowed for someone residing in a Nursing Home
or receiving HCBS.
A person residing in a Long Term
Care Facility or receiving HCBS is considered a household of one and has an
asset limit of $2,000, whether the person is married or unmarried. However,
evaluating assets of the married person is more
complicated and several questions need to be addressed.
·
Is the spouse also receiving or requesting Medicaid payment
of Nursing Home services? If yes, then each one is treated as a single
individual for purposes of the Medicaid eligibility
and each has an asset limit of $2,000 in countable assets.
·
Is the spouse living independently in the community? If yes,
then that spouse is considered a community spouse and the local
eligibility office must consider special rules of spousal impoverishment.
In an asset assessment, the married couple reports all assets
owned by either spouse individually and by both
spouses jointly. The eligibility worker then evaluates the reported assets to
determine:
·
The amount of countable assets that can be kept by the
community spouse and not counted towards the institutionalized spouse's
Medicaid eligibility and
·
When the institutionalized spouse may possibly be eligible to
receive Medicaid payment for LTC services.
A community spouse is allowed to keep up to $66,480. At the
initial determination the assets are considered together
and the couple cannot exceed $68,480 in total countable assets. Within 90 days
of approval, the assets must be separated so that the
institutionalized spouse has no more than $2,000 and the
community spouse has no more than $66,480 in countable assets.
In August of 1993, Congress passed a law that requires states
to recover amounts that Medicaid has paid for certain recipients. In South
Carolina the Estate Recovery Program went into effect on July 1, 1994. The
state will recover amounts paid by Medicaid for services received July 1, 1994 or later.
Estate recovery applies to the following beneficiaries:
·
A person who was 55 years of age or older when he or she
received medical assistance consisting of nursing facility services, home and community based service care to include prescriptions and
hospital stays associated with either of these services paid by Medicaid; or
·
A person of any age who was an inpatient in a nursing
facility, intermediate care facility for the mentally retarded, or long term care facility at the time of death; and, who was
required to pay most of his/her monthly income to the facility toward the cost
of care.
Recovery may be made only after the death of the decedent's
surviving spouse, if one exists, and only at a time when the decedent has no
surviving child under age twenty- one or no child who is blind or permanently
and totally disabled as defined in Title XVI of the Social Security Act.
Recovery must be waived by the department upon proof of undue
hardship, asserted by an heir or devisee of the property claimed pursuant to 42
U.S.C. 1396p(b)(3) and in accordance with the guidance issued by the Secretary
of the United States Department of Health and Human Services in the State
Medicaid Manual as incorporated into the state plan. The department shall
publish and maintain such guidance on the department's web site.
When a beneficiary dies, the state files a claim with the
probate court against the beneficiary’s estate to recover amounts paid by
Medicaid for the deceased beneficiary’s medical care. An estate is all real and
personal property and other assets of the deceased person (recipient) as
defined in South Carolina State Law. This claim will be similar
to claims for funeral expenses, attorney’s fees to administer the
estate, and tax. This claim will need to be satisfied in
order to close the estate; however, it may not require the selling of
the decedent’s home and land if there are other assets available to pay the
Medicaid claim. In the event other assets are insufficient to repay the
Medicaid claim and/or other expenses of the estate, the Personal Representative
(Administrator, Executor, and Executrix) may choose other options to repay the
Medicaid debt. The state is not interested in taking title to anyone’s home.
For example, John Doe was in a nursing home for the month of
July. He died August 3. Medicaid paid $2,000 for his care in July and August.
His estate is worth $50,000.
Medicaid will recover only $2,000 from his estate, after
claims with higher priority (i.e., mortgage, funeral expenses, and probate
fees) are paid.
In another example, Joe Smith has been on Medicaid for years.
Medicaid has spent
$25,000 on the medical services he received since he was age
55. His estate is worth
$20,000. The Medicaid program will recover from the remainder
of the estate, after claims with higher priority are paid.
·
Estate recovery must be deferred if the beneficiary is
survived by a spouse or a child under the age of 21, blind, or permanently
disabled.
·
Estate recovery may be waived if it would create an undue
hardship.
·
Estate recovery may exempt some or all assets of a Medicaid
beneficiary who is covered under a Qualified Long Term Care Partnership (QLTCP)
Insurance Policy. Estate recovery will not seek adjustment or recovery from the
beneficiary’s estate to the extent benefits were paid under the QLTCP policy.
1.
With respect to the decedent’s home property, if the decedent
could have transferred the home property on or after the date of his or her
Medicaid application without incurring a penalty under 42 U.S.C. Section
1396p(c) if the property could have been transferred without penalty to a:
a)
Surviving sibling of the decedent who possessed an equity
interest in the property and who lived in the home for a period of at least one
year immediately prior to the date the decedent was institutionalized; or
b)
Surviving child of the deceased who
lived in the home for a period of at least two years immediately before the
decedent became institutionalized and who provided care which allowed the
decedent to delay institutionalization. Does not apply to a child under the age
of 21, or a child who is blind or disabled.
However, hardship under this item only applies if the
individual to whom the property could have been transferred without penalty is
actually residing in the home, at the time the hardship is claimed
and this hardship status only protects a homestead of modest value. A homestead
of modest value is defined as fifty percent (50%) or less of the average price
of homes in the county where the homestead is located as of the date of the
beneficiary’s death. To the extent the value of the home property exceeds this
modest value, that portion is subject to recovery by the department.
2.
With respect to the decedent’s home and one acre of land
surrounding the house, if an immediate family member:
·
Has resided in the home for at least two years immediately
prior to the recipient’s death;
·
Is actually residing in the home at the time the hardship is claimed;
·
Owns no other real property or agrees to sell all other
interest in real property and give the proceeds to the department; and
·
Has annual gross family income that does not exceed one
hundred eighty- five percent (185%) of the federal poverty guidelines.
3.
With respect to a sole income producing asset:
a)
An immediate family member’s annual gross family income would
fall below the federal poverty guidelines or immediate family member agrees to
pay all income in excess of one hundred eighty-five
percent (185%) of the federal poverty guidelines to the department.
1.
A LTCP participant in South Carolina is someone who either:
o
Requests Medicaid payment of Long Term
Care services after exhausting all benefits of a qualified LTCP policy, or
o
Exhausts all benefits of a LTCP policy while receiving
Medicaid payment of LTC services, or
o
Receives Medicaid payment of LTC services and dies before the
LTCP policy benefits are exhausted.
2.
In determining Medicaid eligibility, SCDHHS will disregard an
individual’s assets in an amount equal to the amount of payments made by the
individual’s qualifying LTCP policy for services covered under the policy.
Documentation of the amount in benefits paid will have to be provided.
3.
A LTCP participant receives the following benefits during his
or her lifetime:
o
Assets may be designated for protection in an amount equal to
the total amount of LTC services paid by the qualified LTCP policy
o
Designated assets are not counted toward the Medicaid asset
limit
o
The designated assets may be transferred to any other person
without penalty.
4.
After the LTCP participant is deceased:
o
Assets which were designated as protected during the person's
lifetime are also protected from estate recovery
o
When the amount of assets protected during the person's
lifetime was less than total benefits paid by the LTCP policy, additional
assets may be protected in the estate recovery process - up to the total amount
paid by the LTCP policy
o
If no assets were protected during the person's lifetime, the
personal representative may designate assets to protect from estate recovery
equal to the total amount paid by the LTCP policy - even if LTCP policy
benefits were not completely exhausted.
5.
Owning a LTCP policy does not guarantee eligibility for
Medicaid, even if the policy holder exhausts all benefits. Individuals must
still meet all other Medicaid eligibility requirements. The LTCP allows policy
holders to have a portion of their assets disregarded (not counted) during the
eligibility process and subsequently protected from estate recovery. REMINDER:
Only SCDHHS can determine whether a person will qualify for Medicaid. Agents
should be careful not to advise regarding eligibility requirements or whether a
person will be eligible for Medicaid.
Two types of assets cannot be protected under the LTCP
Program. Federal Medicaid rules require that when a person dies, the following
assets must be available to reimburse SCDHHS for the amount
of Medicaid benefits paid during his or her lifetime:
o
Resources in a Special Needs Trust or a Pooled Trust and
o
Annuity interests in which South Carolina must be named as a
preferred remainder beneficiary.
·
People may request an application form by:
§
Calling the Member Services Call Center at (888) 549-0820.
§
Visiting or calling their local eligibility office
§
Visiting the
agency website at www.scdhhs.gov
·
A complete signed and dated application can be faxed or
mailed to the local eligibility office
·
People may ask the local eligibility office to help them
complete the application and contact third parties for required information
and/or verifications.
·
Health Care coverage generally begins in the month that the
county receives a completed, signed and dated application.
·
People may ask that Medical Assistance coverage begin up to
three months before the date they apply.
Updated 01/17/2018