Tiffany Huyenh-Cho: Welcome to today’s webinar, Medicaid 101: Basics and Recent Changes. My name is Tiffany Huyenh-Cho, and I’m the director of California Medicare and Medicaid Advocacy at Justice in Aging. And I’m joined by Gelila Selassie. Gelila is the Director of Health Advocacy at Justice in Aging.
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So first, a little bit about us. Justice In Aging is a national organization that uses the power of law to fight senior poverty by securing access to affordable healthcare, economic security, and the courts for older adults with limited resources. Since 1972, we focused our efforts primarily on fighting for people who have been marginalized and excluded from justice such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency.
Justice In Aging is committed to advancing equity for low-income older adults in the areas of economic security, healthcare, housing, and elder justice initiatives. We strive to address the enduring harms and inequities caused by systemic racism and other forms of discrimination that uniquely impact low-income older adults in marginalized communities.
We produce a wealth of information like the webinar you’re seeing today, along with fact sheets, issue briefs, alerts, and other materials to keep you updated on important developments. If you’re not already a member of our network, we encourage you to join by going to our website and signing up or simply emailing info@justiceinaging.org.
Okay. And with that, here is our agenda for today. First, we’ll provide an overview of Medicaid, the benefits that Medicaid includes, eligibility pathways for older adults and people with disabilities. We’ll also discuss how Medicaid works with Medicare to make Medicare more affordable and discuss Medicaid’s coverage of long-term care services. And at the end, we’ll cover some recent federal changes to Medicaid and then have time for our Q&A at the end.
So with that, let’s get started. So Medicaid basics. First, Medicaid is health insurance. Medicaid provides health insurance for people with low incomes and covers millions of people across the US, including children, adults of all ages, and people with disabilities. Every state has a Medicaid program. Medicaid is often confused with Medicare, but they are not the same. Medicaid and Medicare are two separate programs. They both do provide health insurance, but Medicare is the federal health insurance program for older adults over 65 and people with disabilities.
Medicaid was enacted in 1965, so the same year as Medicare, and is authorized by the Social Security Act. Medicaid is administered by the states while Medicare is run by the federal government. Some people are dually enrolled in Medicare and Medicaid at the same time. This group is also called dual eligibles or Medi-Medis, but for this group, they qualify for Medicare because they’re over 65 or because of a disability, and they qualify for Medicaid because they have limited income and resources.
Medicaid is a needs-based program, so eligibility is based on financial need. So to qualify, you must demonstrate that you have limited financial resources. Medicaid is also an entitlement program. Anyone who meets the eligibility rules for Medicaid is guaranteed enrollment. There are no caps on the number of individuals who can be on Medicaid, and states cannot put individuals on enrollment wait lists. There is one exception to caps and wait lists for some specific Medicaid benefits. Those are called home and community-based programs. We’ll cover this later, but overall, states cannot cap how many people can enroll in Medicaid. If you meet their requirements, you are granted coverage.
So Medicaid is funded partly by the federal government and partly by the state. The federal portion is often called the FMAP as an acronym. So the federal government sets out the basic requirements that dictate how each state must operate their Medicaid program. For example, the federal government requires states to cover specific population groups in their Medicaid program and also sets out minimum financial eligibility requirements. And because Medicaid is also state-based, each state does have the authority to administer and design its own Medicaid program. So while the federal government sets out the ground rules, states still have the authority to design their own Medicaid program and go beyond the minimum standards that the federal government sets out. So some states change the income or asset limits to be higher than the federal minimums. States can also cover additional population populations beyond what’s federally required. So the federal government requires all states to provide a basic minimum package of benefits, but states can choose to provide more than that minimum package. And we’ll discuss some of those extra optional benefits in just a bit.
And because there is a lot of discretion that states have in designing their own Medicaid program, Medicaid does vary significantly state by state. So every state has different rules to qualify, and the package of benefits may vary as well. This means someone may qualify for Medicaid in one state, but they may not in a neighboring state if there are different rules. So advocates should always pay attention to their state’s specific rules.
Many states also use what are called Medicaid waivers. Waivers allow states to waive certain federal requirements. There are several types of waivers. For example, a state could use a waiver to provide additional Medicaid services beyond the traditional set, or they could test a pilot program to see how to better deliver certain benefits. One example of a waiver was during the COVID-19 public health emergency. States temporarily waived some Medicaid eligibility requirements and paused Medicaid renewals in order to respond to the pandemic.
Okay, so those were the basics. Let’s discuss now what Medicaid actually covers. So the federal government requires all Medicaid programs to include a minimum package of benefits. So at a minimum, states must provide all of the services listed on this slide. So physician visits like primary care, care with specialists are required, care you receive in a hospital or nursing facility, home health services, lab and x-rays, and then transportation to and from medical services. Early and periodic screening diagnostic and treatment is a program for children under 21. It provides comprehensive and preventative healthcare services. You’ll note that transportation and nursing facility care provided by Medicaid are particularly important to older adults since these services are not generally covered by Medicare.
Medicare provides short-term nursing facility care while Medicaid is long-term care. That also means Medicaid is often the only option for coverage of long-term nursing facility care for older adults and people with disabilities. Even individuals who have moderate income often turn to Medicaid to access long-term care because care in a nursing facility is otherwise expensive and unaffordable for most people. So Medicaid is the primary payer for the majority of long-term nursing facility stays in the US. And then more than six in 10 nursing facility residents are on Medicaid, including those with Alzheimer’s and dementia. Home health services like personal care services are also important under Medicaid, and these are services that older adults and people with disabilities rely on.
Like I mentioned earlier, states can also choose to provide optional benefits. States are not required to provide these services, but can choose to do so. So common optional services include dental care, vision, physical, or speech therapy, as well as Home and Community-Based Services, or HCBS. HCBS are services that help older adults and people with disabilities live at home as they age. So instead of having to move to a nursing facility, you can receive HCBS that allow you to live at home and remain in your community with your friends and with your family.
HCBS services are provided to people living in the community and they are personalized to meet a person’s specific needs. Some examples include day programs, case management, as well as personal care aids. Because optional Medicaid benefits are just that optional, the downside is that states can cut these benefits during budget shortfalls. States cannot cut required Medicaid services like hospital care, but can cut optional benefits to save money. And this is especially tough because optional benefits like HCBS or transportation are the benefits that older adults and people with disabilities often rely on the most because again, they are not traditionally covered by Medicare.
HCBS are also particularly important because Medicaid is the only funder of these services to receive care in the home and community. HCBS is optional, and that means they can also be varied amongst states and states can even limit their availability throughout a state. And because HCBS is optional, that also creates a bias towards institutional care since nursing facility coverage is required and covered by all states, but HCBS is not.
States can also choose how to deliver Medicaid benefits to their state residents. So the states itself don’t provide healthcare services directly and instead use a delivery system to pay healthcare providers for covered services received by Medicaid enrollees. And there are three main systems. The first is fee-for-service. And in fee-for-service, the Medicaid agency directly pays providers a set payment for each service it provides to a Medicaid enrollee. Here, Medicaid enrollees can see any participating provider.
Another delivery system is Medicaid managed care. Managed care is increasingly more common, and most states have some form of Medicaid managed care. In managed care, care is delivered by a health insurance company similar to private insurance and managed care enrollees are limited to providers that are contracted with their specific health plan. Some states don’t have Medicaid managed care and others do. Some have managed care, but services like nursing facility care or HCBS are not part of the health plan benefits, but are instead provided on a fee-for-service basis.
Some states instead have set up managed care for those long-term services and supports like nursing facility and HCBS. And these services are provided by a Medicaid managed care plan. It’s less common, but 25 states do have this. States can also decide which Medicaid populations must join managed care. So in some states, older adults with Medicare are excluded from Medicaid managed care, but in other states it is mandatory.
And with that, I’ll turn it over to Gelila.
Gelila Selassie: Thank you so much, Tiffany. So we’ll be talking a bit about who Medicaid covers in a little bit more detail about what Medicaid covers. Next slide.
So as Tiffany mentioned, Medicaid is a very important program. It covers around 73 million people, including more than seven million older adults aged 65 and up. As you stated, there are a lot of people on Medicare who also rely on Medicaid, and about one in six Medicare recipients need Medicaid to help pay for those Medicare premiums. We’ll talk about this a bit more, but Medicaid is also the primary payer for Long-Term Services and Supports, or LTSS. As Tiffany mentioned covering more than 6 in 10 nursing home residents. This is often very surprising for people because Medicare is seen as a primary benefit for older adults who often need long-term care and nursing home care. And when they’re at that point where they need that care, it’s very difficult to find out that Medicare’s benefits are actually very limited. This is another reason why it’s really important to highlight why Medicaid is so crucial. And just overall, Medicaid is really essential and plays a huge role in providing coverage for people who traditionally face barriers when they’re trying to access coverage through other avenues. Next slide.
Medicaid is required to cover certain categories of people. And those are children under age 19, pregnant people, certain parents or caretakers, people with disabilities, and then especially notable for older adults, older people 65 and up, and individuals who are part of that Medicare buy-in group or the Medicare savings program, that’s that program we discussed that helps pays for Medicare premiums for low-income Medicare enrollees. So these are all the required populations.
On top of that, states can choose to cover additional groups. So just to clarify, the federal government, when it comes to most of a lot of these eligibility criteria, they set a floor that states have to comply with whether it’s income or who’s covered. And then for many instances, states can go above that as we’ll discuss with some of either the expanded eligibility levels like higher income or additional populations covered.
So states can choose to cover Medicaid for optional groups, and that’s the Medicaid expansion population. And this was made available to states under the Affordable Care Act. 41 states, including DC, have chosen to expand Medicaid to all individuals with low incomes, typically around 138% of the federal poverty level for those individuals who are between ages 18 to 64 and not eligible for Medicare.
So we’re going to talk a lot about the ACA expansion population or the Medicaid expansion population. And that’s who we’re referring to because as we get to the end of the webinar, we’ll discuss some of the major changes that have been implemented by Congress this past year under H.R. 1. And so yeah, just to clarify that that is the Medicaid expansion population.
And then the other optional group is the Medically Needy Program, which we’ll discuss in just a second. It’s also known as share of cost, sometimes known as a Medicaid deductible. But this is basically for people who would be eligible for Medicaid except for their income being too high. Next slide.
So focusing on the major eligibility pathways for older adults, the three biggest Medicaid programs are the SSI-based Medicaid for people receiving SSI or supplemental security income, the aged and disabled programs, and again, the medically needy program. And for the latter two programs, aged and disabled medically needy, states again have that flexibility to set in the higher income limits, but the federal government just sets the floor that says states must cover at a minimum people at this level and states can choose to cover individuals above that amount. Next slide.
So just a little bit of background about SSI. It’s a program for older adults and people with disabilities living in poverty. It’s really important to note that this is different from SSDI. They’re both programs handled by the Social Security Administration, but SSDI triggers Medicare eligibility and it’s based on work history and how much somebody has paid on their payroll taxes into the system.
SSI on the other hand is very low. It covers about 75% of the federal poverty level, which is $994 in 2026, and has a $2,000 asset limit. All states offer Medicaid for SSI enrollees. And so eligibility is usually automatic where once somebody becomes eligible for SSI, then they’re automatically enrolled in that SSI-based Medicaid. However, there are about eight states known as 209B states that can use a different criteria than SSI, as long as they are no more restrictive than the rules the states had in place in 1972. In practice, they can be a bit more restrictive, but generally confined to that 1972 criteria. And those eight 209B states are Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia. Next slide.
On top of SSI, because the SSI income is just very low, it’s well below the poverty level. So several states also offer state supplemental payments or SSP for those SSI recipients. So this is money coming from the state to help make things a little bit more affordable for those SSI recipients. SSP rates vary really widely across states from $80 to $240 plus. And they can also vary for a couple if somebody’s part of a relationship, if they’re a married couple versus if they’re living alone. And it’s really important to note a lot of states do not offer SSP at all. So again, these are state-based eligibility programs. And not only does the amount vary widely, but even if it’s available in your state, it varies widely as well. And so mandatory Medicaid eligibility is extended to these people receiving an SSP if that’s offered by the state. Next slide.
And so as we mentioned, the federal government sets a floor that states can expand on and often do for the aged and disabled populations. So states can use, they have flexibility through state plan amendments to use higher income and asset limits for these groups to go well beyond the SSI limit up to 100% and maybe even more.
So nine states cover older adults and people with disabilities between 75 to 99% of the federal poverty level, while 17 states cover older adults and people with disabilities at 100% of the federal poverty level. And then in California, they actually cover this group up to 138% of the federal poverty level. We’ve talked about in other webinars some challenges with the asset limit, especially for this population that’s typically on a fixed income. They might be retired, unable to work. That $2,000 asset limit is exceptionally low, particularly for today. It’s one car repair away from having absolutely nothing or dozens of other issues that can come up that makes it really insufficient for folks.
So for that reason, several states have expanded the asset limit for the aged and disabled enrollees beyond the $2,000 limit. And crucially, Arizona actually completely eliminated the asset limit for age and disabled programs. California briefly eliminated it and then reinstated it in 2026. And when we talk about assets, typically their primary home is exempt. So that’s not included in that $2,000 limit, the home that the individual’s living in. And then one car per couple is also usually excluded. But if a married couple each have their own car, then that second car would be counted towards that $2,000 limit. Beyond that, most liquid assets, any cash, bank accounts, certain retirement benefits, cash values on whole life insurance policies, investments, that’s all typically included as part of the asset limit for Medicaid. Next slide.
And so now I’ll talk about the medically needy program, which is a little bit wonky, but this is really useful for older adults who are over the income limit for Medicaid in order for them to become eligible after they spend down their excess income. So again, this is why sometimes it’s helpful to think of it as a Medicaid deductible. It’s how we used to refer to it when I was in practice. And the idea is that somebody has to spend a certain amount of dollars on their own healthcare and amass a certain amount of healthcare expenses. Once they reach that amount, Medicaid kicks in and pays whatever else is left for the year for the benefit period. The amount they spend is also often called the share of cost, although it varies by states. And states can set their levels. And then there’s a sort of calculation that’s involved that’s based on how much the individual is over the income limit, which we’ll do an example of this in just a second.
So just as an example of how widely these levels are set for determining if someone’s eligible under the medically needy program. In Alaska, it’s 108. California is 600, and Wisconsin is 1,255. So as we’ll discuss on the next slide, how this process comes to be. Even though it’s complicated, if it’s available in your state, it is really useful for older adults, definitely in long-term care settings and for long-term care expenses, but there are other situations where people have regular ongoing high medical needs. So things like chemotherapy or regular treatment for autoimmune diseases. These amass thousands, if not tens of thousands of dollars monthly. And in that case, it’s definitely worth looking at the medically needy program. So next slide.
So here’s an example in Maryland of an individual with accountable income of $850, and their state set their medically needy income level at 350. So we subtract the $350 from the accountable income 850 to get a monthly excess limit of $500. Since the spend down period is over six months, we multiply $500 by six to get a $3,000, six month spend down obligation. So this means that the individual must spend at least $3,000 in medical expenses and then anything beyond that $3,000 is covered by Medicaid for that spend down period. So when you’re looking at this in your own state, just factor in, replace that 350 with whatever your state’s medically needy income limit is, and then with the individual’s countable income as well and that’s how you’ll be able to determine how much they need to spend down. Next slide.
It’s really crucial to note that the money that the individual has to spend down does not have to go towards any current Medicaid covered service. So there are other healthcare services like dental or vision insurance or even some past medical bills, as long as they’re not too old, that can be used to help somebody meet that spend down limit. One thing about the old bills, however, is it can’t be years and years old, but if it’s something that occurred right before their eligibility period, and especially if it was something that occurred before their eligibility because there was some confusion or error in how the spend down was applied and how to apply for the spend down program generally, then those often can be counted as well. Next slide.
And then a big tip for people who may need this program. Again, it is really useful, especially for people with those really high ongoing healthcare expenses. However, being over the eligibility limit, the eligibility limit say for an aged or disabled program can still result in a really huge spend down or share of costs. So as a practice tip, if somebody is just a few dollars over the income limit for one of those programs, it’d be helpful for them to consider reducing their countable income. For example, having one spouse apply for coverage or purchasing supplemental insurance like dental or vision, that can reduce their accountable income that Medicaid looks at so that they are below that threshold and then don’t have to deal with a very costly spend down for just being a little bit over. Next slide.
And then lastly, we’re going to look at how Medicaid eligibility dates are determined. Medicaid coverage begins on the date of the application or at the state’s option, the first day of the month in which they applied. So if somebody applied on August 11th, in several states, their eligibility could be sort of deemed back to August 1st. So until the end of this year, states have to cover up to three months of retroactive coverage prior to the application date, as long as the individual met all the eligibility requirements during that retroactive period. However, H.R. 1, which we’ll talk about again at the end of the webinar, made several changes to this. And starting in January 2027, states must implement retroactive coverage to just one month prior to application for that ACA Medicaid expansion population, and then two months for all other Medicaid populations. So that’s starting in January.
And to be clear, this is just referring to the retro period prior to submitting the application. If an application is pending for several months, so if somebody submits an application in August and doesn’t get approved till December, that person’s still going to have Medicaid coverage August onward because the state’s application was pending. We’re talking about the months prior to this individual submitting their application. That’s that window that has been shortened. So that’s something really important to note as well. We’re talking about prior to application, not prior to approval during that pending period. And then it’s really important to note that some states have sought to eliminate or limit retroactive period. So it’s really worth checking to make sure that your state hasn’t done so as well. Next slide. And now I will turn it back over to Tiffany.
Tiffany Huyenh-Cho: Thanks, Gelila. Okay, so now we’ll cover dual eligibles. Again, this is the term that’s often used to refer to a group of people who are enrolled in Medicare and Medicaid simultaneously. Dual eligibles are also, again, known as Medi-Medis or people that are dually eligible. So this group are dually eligible for both Medicare and Medicaid. They’re enrolled in Medicare because they qualify based on age or disability, and then they qualify for Medicaid because they have limited income and assets.
Dual eligibles fall into two groups or two categories. Those who are called full dual eligibles, this means they have Medicare and full Medicaid benefits. They are eligible to receive all Medicaid services like home and community-based services and others. And they’re enrolled in a Medicaid category like aged and disabled, for example. And there are about 8.6 million people who are full dual eligibles today.
The other group is called partial dual eligibles. People in this group are also enrolled in Medicare, and then they are enrolled in a Medicare savings program only. Medicare savings programs also called MSPs are a type of Medicaid, but they only provide partial benefits. And that’s namely payment of Medicare costs. Things like Medicare premiums, cost insurance, deductibles. Medicare is not free, and you must pay monthly premiums and cost sharing. So Medicare savings programs helps pay for those Medicare costs. They make Medicare affordable, but Medicare savings programs do not provide full Medicaid coverage, so this group are called partial duals because they’re not eligible for all Medicaid benefits. They’re only eligible for the Medicare savings program and this program just provides financial assistance to cover the cost of Medicare. Still really important, it’s just that Medicare savings programs, the benefits are much more limited than full Medicaid.
Medicaid is critical to Medicare enrollees because it fills the gaps in Medicare. Both Gelila and I have talked about it, but Medicaid covers a lot of services that Medicare simply does not. Medicaid provides really vital wraparound services that are not traditionally covered by Medicare, dental, vision, transportation, long-term nursing facility care, as well as care in the community such as home and community-based services. Medicaid is important because it provides choice. It helps people age in their home instead of having to go to a long-term care facility far away from family, friends, or community. And nearly 30% of all Medicaid dollars directly support Medicare enrollees. If you want to learn more about dual eligibles and how Medicare and Medicaid coordinate with each other, we have a lot of resources on our website, and you can read more about dual eligibles.
So the Medicare savings program that we just mentioned, there are four types. They’re on this slide. Each type of Medicare savings program provides different levels of financial assistance for Medicare costs. That also means they have different income limits. So the first Medicare savings program is the qualified Medicare beneficiary or QMB. The QMB program is the most comprehensive. It pays for Medicare Part B premiums and Medicare Part A premiums if someone does not qualify for free Medicare Part A. That’s typically people who have not worked long enough in the US to get their required work history, or maybe they worked, but they could only work part-time due to caregiving. So QMB also pays beyond the Medicare Part A and B premiums. It will also pay for Medicare cost sharing in the form of co-insurance deductibles and copays. QMB, again, is the most comprehensive, but it also has the most restrictive eligibility limits. You have to have income less than 100% of the federal poverty level, which today is about $1,350 a month.
So the remaining Medicare savings programs offer less assistance and protections, but they do have higher income limits. For example, the second program Specified Low-Income Medicare beneficiary pays for Part B premiums, but it does not help with other cost sharing. But the income limit is a little higher in this second program.
So the income and asset limits for the MSPs are set by the federal government. This is the floor that all states must follow, but states can also choose to set higher levels for their Medicare savings programs with federal approval. So some states like Arizona don’t have asset limits for the Medicare savings programs at all. So advocates should look to their state’s Medicaid website for the respective limits.
And overall, it’s important to ensure that clients are enrolled in a MSP program even if ineligible for full Medicaid benefits. MSPs alone do not provide Medicaid health and medical coverage, but they can offer important protections against improper billing from Medicare providers.
In 2024, there was a new federal law that simplified enrollment into Medicaid and other programs like the MSPs. This law is called the Streamlining Rule, and many of its provisions were delayed by H.R. 1. H.R. 1 is a recent federal law that passed. So because of this delay, states do not have to implement many of the provisions in the streamlining rule for several years. States can do so voluntarily, but they are not required to implement earlier than 2034.
There is importantly one provision that did not change, which is the requirement that certain people with SSI are automatically enrolled into QMB. Like Lila mentioned before, most SSI recipients are automatically enrolled into Medicaid. It’s also called SSI linked Medicaid. And people who are eligible for SSI are generally eligible for QMB as well because the income limits are similar. So the streamlining rule requires states to directly enroll older adults with SSI linked Medicaid into QMB. There is no need for a separate application. And this is especially important because people with SSI are often the lowest income. They often do not have free Part A because they don’t have the work history. So QMB is really important because it will pay for a Part A premium so that this group qualifies for both Part A and Part B, as well as covering all those other Medicare costs.
On this slide, we have two resources linked (Final Rule to Streamline Enrollment in Medicare Savings Program; Final Rule to Streamline Access to Medicaid). We created on the streamlining rules, and we discuss many of the provisions in these rules as well as the pause that’s happening right now. And with that, I’ll pass it back to Gelila.
Gelila Selassie: Great. Thank you so much, Tiffany. We’re going to be talking about Medicaid’s role in long-term services and supports as we’ve been talking about how crucial it is. So next slide.
As you mentioned, Medicaid must cover institutional care as a mandatory benefit. So it’s required under the statute. And institutional care includes nursing facility services. To qualify, an individual’s medical needs must meet a nursing facility level of care. And that is a very specific sort of term of art that looks at how much care a person needs, typically looking at how limited they are in their activities of daily living. So that’s things like toileting, bathing, eating, meal prep, things like that, dressing. And so that’s how the state will determine if someone meets a nursing home level of care, is looking at their ability to do that. And then any other supportive records from their doctors or the medical records to show that they need pretty intense hands-on care.
Medicaid LTSS covers skilled nursing services, which includes things like having a licensed health professional like a registered nurse, a physical therapist, or a speech therapist. It can also include wound care or catheter care, which is really critical for people. And then there are personal care services or attendance services like those activities of daily living that Medicaid LTSS can cover in addition to certain supplies such as a wheelchair or supplies for incontinence. Medicare, as we’ve mentioned, only covers very limited nursing facility services just about 100 days, which is again, why Medicaid coverage is so crucial. Next slide.
So in terms of eligibility for Medicaid coverage for nursing facilities, it varies a lot on the state that you live in, which may or may not have an income cap. If your state does not have an income cap, then eligibility for nursing facilities typically looks sort of like the medically needy program where you have to spend down a certain amount of your income and only keep a personal needs allowance. So instead of having that medically needy income level, it’s usually a personal needs allowance, which again, as always with Medicaid, varies greatly by state. It can be as little as $30 a month is how much a person’s allowed to keep or as much as 200.
The rest of the income will go to the facility to pay for your care. And then after that portion is paid, then the state pays the remainder of your healthcare costs to the facility under Medicaid. So you might’ve heard nursing home residents saying that they keep $30 and then the rest of their Social Security check is going towards a nursing facility. That’s what this is. That’s where that $30 or $100 or whatever it is their personal needs allowance that they keep. Rest of it goes to the nursing home and then Medicaid covers anything else of their LTSS cost remaining beyond that. If your income is above the income cap, then you’re not financially eligible for nursing facility coverage. And 20 states have an income cap, which is typically set at three times the federal SSI rate, which is $2,982 in 2026.
And then there are some other complex rules regarding assets, transfer of assets. There’s typically a restriction on transferring assets for Medicaid long-term services and supports in nursing homes and HCBS, typically up to five years, in some instances three years, as well as some rules regarding spousal coverage as well. For this webinar, since this is a webinar basics and we’re trying to cover a whole lot, we’re just going to be looking at some of the basic income and eligibility levels, including some of the impacts on the community spouse. Next slide.
And so Medicaid, in addition to being such a huge payer for nursing facility services, it’s also a primary payer for home-based care through Medicaid home and community-based services or HCBS. As we mentioned, HCBS is an optional benefit unlike nursing home care, which is a mandatory benefit, and that’s why we often have that institutional bias. But HCBS is really crucial because individuals can often receive those nursing facility services in their own home and community, which is something that most people really want to do. They really want to age in their home or age in a community and are less interested in being in a nursing facility if they don’t have to.
As we’ve mentioned a thousand times, Medicaid programs vary so much by state. All these different Medicaid programs are often called very different things in your state, not just the Medicaid program itself, but the different programs for different populations. HCBS throws another wrench in that because HCBS is available for a variety of disabled and aging populations, so there’s even more variety and there’s very little standardization even within one state across the different HCBS programs. So that’s also something that’s really important to note as well.
So somebody who might be receiving HCBS because they have a developmental disability might be entitled to different services or have a different process for enrolling than somebody in that same state receiving HCBS under an aging waiver. So again, that’s why there’s quite a lot of complexity. And so we really just want to go through that high level process. And we strongly encourage you looking at your state plans, your state Medicaid manuals, policy guides, things like that to see what’s specifically available for your client or the people you serve. Next slide.
So as I mentioned, it varies widely, and states typically implement HCBS through waivers or state plans. The overall goal of HCBS is to rebalance some resources away from institutions into more integrated community care. This has been a long going multi-decade bipartisan effort to have, instead of most LTSS spending beyond nursing facilities, be applied in less expensive community settings, which most people prefer. And again, that’s not to say all spending needs to be taken away from nursing facility services, but the idea of rebalancing is just to create a little bit more parity for all HCBS populations, whether that’s younger people with disabilities or older adults needing these services. HCBS covers a wide range of services, including personal care, adult day health, assisted living services, meals, home modifications, and case management.
One thing as we’ve talked about what Medicare does and doesn’t offer in terms of long-term care. Not only does Medicare offer pretty limited nursing facility services, it really does not offer hardly any of these HCBS services aside from skilled nursing care. So outside of a skilled service, and skilled services, what’s the language in the statute, so things like physical therapy, occupational therapy, wound care, RN services, that’s available under a Medicare home health benefit. But these other HCBS services like assistance with the activities of daily living and adult health, that’s not available under Medicare. So that’s one reason why this is so important to make sure that Medicaid HCBS is strong and available because a lot of older adults in particular need this sort of assistance on a day-to-day basis.
And so CMS issued regulations a little over, geez, over 10 years ago, called the HCBS settings rule, to clarify what it means to have a community-based settings. And this is really important because what we didn’t want to happen is to have a lot of HCBS dollars going to certain settings that operated like a institution. The whole purpose of having HCBS is to provide that alternative for institutions. And so this isn’t a problem so much if people are receiving services in the home, but some people might be receiving assisted living services in a assisted living facility or they might be receiving services in a group home. And so those settings can feel institutional. So these settings rules have different processes and rules in place to make sure that somebody in those settings are able to be integrated with the community, have independence, have autonomy, all these things that they would get if they were in their own home, but rather just in a setting that provides a specific kind of service for them.
And then as we’ve mentioned, there are waivers to… Because there are waivers in HCBS, that also often means there are wait lists. So as Tiffany mentioned, this is really the only Medicaid program that has a waiting list of any kind and that can have caps. And this is because it is an optional program. So if it was a mandatory benefit, we wouldn’t have that problem. One big thing to note is your state may have particular waiting lists for certain HCBS waivers, but there may be informal waiting lists as well because some people will see that there’s a long wait list and might not even apply to be on the waiting list. That actually happens quite a lot where people…
Basically the waiting lists don’t fully capture the amount of people who might need HCBS because people can be turned away or made despondent by the idea of having to be put on such a long list for so long. So that’s something that’s also really important to note. We discuss a lot of these HCBS issues in our HCBS primer that we linked here. Again, varies widely, lots of variability. So I strongly recommend looking at that resource for some really finite questions you may have. Next slide.
And so since HCBS is optional, again, there’s a lot of variability in terms of income and assets. The HCBS monthly income cap is generally three times the SSI limit as well, which is $2,982 for a single person. And then the individual will also need limited resources as well, and that resource limit or asset limit varies across states as well.
The enrollee may be required to make a post-eligibility payment from his or her income towards the cost of healthcare. This post-eligibility payment will be calculated in a way that allows a recipient to retain a certain amount of income for housing and other living expenses, sort of like the nursing home personal needs allowance. But these post-eligibility payments, however, as the case for medically spend down for medically needy eligibility does not have to be directed towards current Medicaid covered healthcare expenses. So this is another similar way of doing that medically needy calculation where an individual must spend a certain amount of their dollars of their own expenses on their services, but doesn’t necessarily have to be Medicaid specific or Medicaid covered services. Next slide.
And then something that’s really important are these spousal impoverishment protections. One spouse often may be receiving LTSS and the other spouse does not need those services. So again, many people have to spend down their assets or income in order to qualify. And what we want to make sure is that that spouse that’s not receiving long-term care is not impoverished basically because they have a spouse who does need those services. And so for that reason, there are spousal impoverishment protections, which are mandatory for nursing facility residents, but only optional for HCBS enrollees through September 2027. If Congress doesn’t act to expand that requirement for HCBS spouses, then it’s only available if your state chooses it.
So the spousal impoverishment rules allows the spouse who’s not receiving LTSS, also known as the community spouse, to retain a higher income and resource so they’re not impoverished by their spouse needing Medicaid. And the amount a community spouse can retain in 2026 is up to $162,000. So this is the accountable asset limit depending on the state. And then the income the spouse can keep varies from 2,700 to $4,066. Next slide.
In some instances, the exact amount the community spouse can maintain will vary. And that’s, as you mentioned, the community spouse resource allowance. They could keep half of the joint resources up to $162,660, or they can keep a minimum amount as determined by the state between that threshold. And this amount does change a little bit every year. So it’s not like the $2,000 asset limit where it’s set in stone. It does go up a little bit based on cost of living adjustments. Next slide.
And then looking at the income, same idea. The community’s spouse can keep all of his or her own income, so the spouse not receiving LTSS, as well as 2,700 to 4,066 of their LTSS spouse’s income as determined by the state. And so with that, I’ll turn it back over to Tiffany to talk about some of the recent Medicaid cuts.
Tiffany Huyenh-Cho: Thank you. Okay, so next we’ll talk about H.R. 1. It’s also known as the One Big Beautiful Bill Act or House Resolution 1, AKA H.R. 1. We don’t have time to get into the fine details of this new law, but if you want to learn more, we have many, many resources on our website as well as a recent webinar on H.R. 1 that we’ll have linked in our resources slide.
So H.R. 1 is a federal budget bill. It was passed by Congress last year. It is law, states must comply. H.R. 1 makes significant ant sweeping eligibility and funding changes to the Medicaid program. H.R. 1 made the largest cuts to Medicaid in history with about $1 trillion in lost funding combined. Again, Medicaid is jointly funded by the state and federal government. So what H.R. 1 does is it cuts federal Medicaid funding to states, and this leaves states with gaps in funding. They have hard choices and it forces them to either make up that loss with their own state funds or to shrink their Medicaid budget to make up for the loss in federal funds. There’s also major changes to Medicaid eligibility rules, including the requirement that certain adults work, volunteer, or go to school in order to qualify for Medicaid benefits.
There’s also reduced funding for emergency Medicaid services for some immigrants as well as other changes. And it’s expected that 7.5 to 10 million people will likely lose Medicaid health insurance because of H.R. 1. And you can read our section-by-section summary of H.R. 1 at the link listed on the slide.
So most of the direct H.R. 1 eligibility changes target younger adult populations, but older adults, people with disabilities and dual eligibles are still impacted. Federal funding cuts impact these groups because states are now forced to take a variety of steps to shrink their Medicaid budget or put up their own state dollars to fill those gaps. And on top of the direct federal funding cuts, states have other rising costs that are happening at the same time, including administrative cost of implementing work requirements. There’s also changes to SNAP as well, so states are seeing reductions on many different fronts.
And because H.R. 1 saves federal dollars by shifting more costs to the states, states can reduce their Medicaid spending by either cutting services or cutting eligibility. And again, states can’t cut required services or eligibility groups, but they can cut optional Medicaid benefits or optional programs. Things like home and community-based services, dental, vision, hearing, again, are optional, and states can choose to shrink their Medicaid benefit by not offering these type of services. States that have expanded eligibility rules for Medicaid, such as the Share of Cost Medically Needy Program that Gelila covered. There’s also the special income rule program that lets some higher income people qualify for Medicaid or HCBS. These are optional eligibility categories, and they’re also at risk of being cut.
States can also reduce enrollment by eliminating any expanded aged and disabled programs and bringing it back down to the federal minimums. Same thing with Medicare savings programs, if states have increased income or asset limits for these programs, they can choose to roll those back in order to cut enrollment.
Many states have also expanded Medicaid coverage for immigrants regardless of status, and they do so using state funds only, but with these other federal cuts happening, states may choose to roll back these expansions as well in order to shrink the number of people in their program and thus save more money.
States can also choose to reduce payment rates that they pay to Medicaid providers. By doing so, this may result in fewer providers that accept Medicaid patients. This hurts everybody. It can also worsen the direct care workforce shortage. Personal care providers in Medicaid may find other work if they are not paid enough because the state has cut the provider payment rates and this also impacts older adults and people with disabilities who rely on the direct care workforce for home and community-based services. So H.R. 1, it can’t be understated the amount of changes that it makes and the threats that it provides to Medicaid all throughout the US.
Beyond those funding changes, there’s also the specific eligibility changes that H.R. 1 puts in place. We’ve already covered the moratorium or delay on certain Medicaid streamlining eligibility and enrollment rules. Some provisions are delayed until 2034. H.R. 1 also narrows Medicaid eligibility for many lawfully present immigrants, including people who are refugees, people who have been granted asylum status, as well as other humanitarian immigrants. So these folks remain lawfully present, but they’re ineligible for federally funded Medicaid and will lose Medicaid benefits. This starts October 1st, 2026. Emergency Medicaid is available, but it’s limited, so it will leave many people uninsured altogether.
And then on January 1st, work requirements go into effect. Younger adults enrolled in that ACA Medicaid expansion we covered earlier will be required to work, volunteer, or go to school to qualify for Medicaid. So not only do you have to meet the income limits for Medicaid, you also must show that you’re working, volunteering, or going to school. Not everyone is subject to this rule, and some groups are excluded, including people who are medically frail or certain caregivers. And again, this only applies to the Medicaid expansion group, so dual eligibles are not subject to work requirements.
The same group of Medicaid expansion enrollees are also now going to have to renew Medicaid every six months. So instead of annually, they will go through a Medicaid renewal every six months, and they must certify that they’re meeting work requirements as well.
And for all Medicaid enrollees, Gelila mentioned this earlier, but the Medicaid retroactive coverage period is now shortened. So for older adults and dual eligibles, it’s been shortened from three months to two months. So it’s more important than ever for people to submit their Medicaid application as soon as possible.
And then as we’ve covered, HCBS is incredibly important because they are the services and care that older adults and people with disabilities rely on to live at home and in their community. And although these benefits are optional, they are critical. And 86% of the spending that states spend on these optional services directly support older adults and people with disabilities. And over half of state spending on these services is for HCBS directly. So cutting services like this would be devastating.
And because states don’t have to provide HCBS, they are at risk. We know from past history, states have cut HCBS services during past budget downturns. This happened during the Great Recession when federal funding was cut back then as well. And then we saw what that meant, spending cuts average from 11 to 12% for waiver and personal care services programs, and then 22% for home health. And so you saw a big deduction in the number of people that were served during this time.
So states are going to make these decisions during their budget process. And one way to get involved is we recommend people pay attention, join state-based coalitions. If you can, show up at state budget hearings. You can always illustrate what the real life impact of what these cuts would mean on people in the US.
And then H.R. 1 is incredibly complicated. We didn’t have time to cover everything, but there are many, many resources out there for you to learn more. Several are listed on this slide from us at Justice in Aging, others like Kaiser Family Foundation and NHeLP. And then now we have time for questions. And if you have other things that come up, feel free to reach out to us at our emails below.
Gelila Selassie: Thank you so much, Tiffany. I’ve noticed a couple really overarching things that I wanted to address. As we’ve mentioned, these are all very specific programs, and so we might not be able to say what’s specifically available in your state or for a specific person in your state. One big thing that came up a lot is due process and appeal rights, which we didn’t really discuss. If somebody loses their Medicaid, then why if someone loses their Medicaid or is denied when they apply, they do have a right to appeal. It’s usually very quick. They can receive benefits pending for 10 days. If it’s an initial application, there’s an appeal window of usually 30 days, maybe 60. And then they can do that. Every notice is supposed to have information about appeal rights. So anytime they’re denied coverage, anytime they’re receiving a lower category of Medicaid, say they went from being enrolled in full Medicaid and are now receiving just a Medicare savings program, they have an opportunity to appeal. Local legal aids and legal services groups are often able to help as well.
So that’s something that’s really important to note. What’s appealable is when somebody did not receive, should have been covered and was not. So that’s really important to note as well is some of these major changes that we discussed like Medicaid work requirements, you can’t appeal the existence of the work requirements, but if somebody met the rules and still got denied, then that’s something that can be appealed as well.
And so with that, one question was just about what services are covered as optional versus mandatory. So one was about prescription drug coverage. And yes, so prescription drugs are covered under Medicaid. The other one was if transportation is available under Medicaid and non-emergency medical transportation is available. It’s one of those programs that very often is available to people, but very difficult to actually get because of procedural challenges. So very often there might be delays in getting it started. There could be problems getting accessible transportation. So while it is a program benefit, there are a lot of issues with how it’s actually implemented for people, unfortunately. There are things that are available on paper and then making it happen in fruition is often very, very challenging across all states.
And then we had a few questions about where people can go to know what’s available in their state. I don’t know if you have any suggestions for that, Tiffany, what’s one resource they can look to for what’s available in their state?
Tiffany Huyenh-Cho: Yeah, that’s a great question. I know we talk a lot about the variation, but there’s a lot of variation in resources. One place is to always look at your state’s Medicaid website. It could be run by different agencies. In California, it’s the Department of Healthcare Services. In others, it’s called the Health and Human Services Agency. But many states do list their Medicaid programs, the categories, the income and asset limits, as well as the type of services that are provided on their state websites. I would also turn to legal services programs in your state. They are experts on Medicaid eligibility and also can provide a lot of those answers as well. There’s also the SHIP programs, the State Health Insurance Program. They serve Medicare enrollees, but many of them are also well-versed in Medicaid rules as well. So that is another option as well.
Gelila Selassie: Thank you. There were a few questions about the different eligibility for Medicaid and Medicaid expansion. A couple questions were asking about Medicaid expansion. As you mentioned, it covers people 19 through 64 with incomes typically around 138% of a federal poverty level. These individuals are not subject under Medicaid expansion to have an asset limit. So there’s no asset limit for them. And there’s also no sort of medical determination. That’s different from Medicaid through a disability pathway where they typically need to be assessed or determined disabled based on their medical records. So there’s that. Another question was if someone who’s on SSDI can receive Medicaid if they’re also eligible for Medicare under SSDI?
Tiffany Huyenh-Cho: Sorry, can you repeat the question again?
Gelila Selassie: Oh, sorry. Can someone who’s on SSDI get Medicaid if they’re also on Medicare?
Tiffany Huyenh-Cho: Yes. You would have to meet the Medicaid rules, but yes, you can still get Medicare and Medicaid. Many dual eligibles are people who are on SSDI and qualify for Medicare based on their disability.
Gelila Selassie: That’s really helpful as well. And then there was a little bit of confusion around the Medicare savings programs. So just confirming that there are different income levels for all the MSP programs.
Tiffany Huyenh-Cho: Correct. Again, there are four different types. I covered the main one, the qualified Medicare beneficiary program. That one has the lowest income levels that are set by the federal government. And then the other three programs have higher income limits. But states, again, can choose to set higher income limits. They can also choose to set higher asset limits. So really look at your specific state to see what the specific rules are for the different programs.
Gelila Selassie: Thank you. There were a few questions about HCBS. We kept mentioning that it was an optional program. And so is there any movement to try to make that a mandatory benefit or anything like that? And very often there are bills in Congress. One is the HCBS Access Act that does try to make HCBS a mandatory benefit, but there’s nothing in place yet to actually have that implemented since it hasn’t even been passed and obviously may not be. So that’s one thing that’s really important to note.
There’s also been some guidance from the Department of Justice recently about HCBS in terms of how it’s being interpreted, particularly with respect to community integration. So a lot of our colleagues at the Bazelon Center for Mental Health Resources, we have a statement on that. And although that statement from the Department of Justice suggests that the administration is going to look at HCBS a little bit more differently based on looking differently at Supreme Court precedents, no changes have been made yet to HCBS. So it’s really important to note that what’s called the Olmsted memo has not changed HCBS at this moment. Whether it does, just depends on a lot of factors that we really can’t predict right now. So as of this moment, we are just proceeding with making sure that HCBS is available for our people.
And then there was a lot of questions about immigrant eligibility. And I just refer folks back to that link earlier that we had in the slides, which will be shared shortly. We have very detailed slides on the differences in H.R. 1 and all the different immigrant eligibility benefits.
So I believe with that, we are at time. If folks have any other questions, you’re welcome to reach out to us. Please be sure to look at all of our resources as well. And we are really appreciative of you all spending your time with us. And thank you so much for your questions.
