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Benefit Questions
1. WHAT IS DIFFERENCE BETWEEN MEDICARE AND MEDICAID?
ANSWER: Medicare is a federal program without a
means test mainly for acute care; Medicaid is state/federal program with a means
test can be for long term care. Must be 65, blind or disabled for both.
2. WHAT IS MEDICAID?
ANSWER: Medicaid is state/federal program with a
means test can be for long term care. Must be 65, blind or disabled.
3. WHAT IS MEDICARE?
ANSWER: Medicare is a federal program without a
means test mainly for acute care. Must be 65, blind or disabled.
4. WHAT IS DIFFERENCE BETWEEN SSI AND SSDI?
ANSWER: Supplemental Security Income payments (SSI)
are for disabled individuals with means test and automatic right to Medicaid
medical payments. Social Security Disability Insurance payments (SSDI) are for
disabled individuals with sufficient work quarters, no means test and no
automatic right to Medicaid medical payments.
5. WHAT IS SSI?
ANSWER: Supplemental Security Income
payments (SSI) are for disabled individuals with means test and automatic right
to Medicaid medical payments.
6. WHAT IS SSDI?
ANSWER: Social Security Disability Insurance
payments (SSDI) are for disabled individuals with sufficient work quarters, no
means test and no automatic right to Medicaid medical payments.
7. WHAT IS SSA?
ANSWER: A Social Security Administration retirement
benefit based upon earned income for last countable work quarters. No means
test. Based upon attaining age 66 or over; reduced benefit for early retirement.
8. WHAT ARE THE DIFFERENT KINDS OF MEDICAID?
ANSWER: Institutional Care Program (ICP) for
nursing home long term care; waiver program for assisted living facilities and
home care; many medical payment programs. All programs are means tested.
9. WILL MEDICAID TAKE A PERSON’S HOME?
ANSWER: No. In Florida a personal residence
protected by Florida Constitution homestead exemption.
10. CAN YOUR CLIENT LOSE MEDICAID BECAUSE OF A
SETTLEMENT?
ANSWER: Yes, unless the funds are properly
transferred to an appropriate trust and the trust is administered by a
knowledgeable trustee.
11. WILL FUNDS IN YOUR ACCOUNT BE CHARGED TO CLIENT?
ANSWER: Only if the exact amount due to your is known. The date on which this
amount becomes known is the month in which the amount becomes available as
income.
12. WHEN WILL SETTLEMENT FUNDS BE CHARGED TO YOUR
CLIENT?
ANSWER: The date on which the exact amount due to the client becomes
known.
13. WHAT ARE MEDICAID MEDICAL PAYMENTS?
ANSWER: Payments made for medical expenses to
providers of medical equipment and or medical services on behalf of a Medicaid
qualified individual.
14. CAN YOUR CLIENT BECOME ELIGIBLE FOR FOOD STAMPS?
ANSWER: Yes, if your client’s recurring regular
monthly income is equal or less than the applicable federal poverty amount which
is about $620 a month.
15. WHEN CAN YOUR UNDER 65 CLIENT GET MEDICARE?
ANSWER: In order to qualify for Medicare, an
individual under age 65 must be blind or disabled for 29 months before becoming
eligible.
16. CAN SSDI CLIENT GET MEDICAID?
ANSWER: Yes, after 29 months.
17. CAN AN UNDER 65 CLIENT GET MEDICAID?
ANSWER: Yes if a financial need and or totally and
permanently disabled.
18. CAN AN SSI CLIENT GET MEDICAID?
ANSWER: Yes as it is automatically provided for ISS
recipients.
19. WHAT IS DEEMING?
ANSWER: When assets and/or income of one person are
said to be owned by another for eligibility issues. Only applies when a means
test is used.
20. IS THERE DEEMING IN SSA?
ANSWER: No. There is no means test used.
21. WHAT IS A (d)(4)(A) TRUST?
ANSWER: It is an OBRA’93 trust; an under 65
disability (special needs) self settled trust. Has a payback provision and
cannot be established by client.
22. WHAT IS A (d)(4)(C) TRUST?
ANSWER: It is an OBRA’93 pooled (special needs)
self settled trust. Can avoid payback provision and can be set up by client.
23. WHAT IS A (D)(4)(B) TRUST?
ANSWER: It is an OBRA’93 Qualified Income Trust
(Miller Trust) for use in obtaining eligibility when monthly income of Medicaid
applicant exceeds the income cap. Not for special needs purposes.
24. WHAT IS A MEDICARE SET ASIDE TRUST?
ANSWER: It used for Workers’ Compensation
settlement cases when the claimant has or will qualify for Medicare. The purpose
of the trust is to assure Medicare that the claimant’s medical bills will be
paid in accordance with the commuted value approved by CMS.
25. WHAT IS THE MEDICARE SECONDARY PAYOR ACT?
ANSWER: It is the federal law requiring that
Medicare be repaid for it payment of medical bills for an injured claimant under
Workers’ Compensation. See answer to question 24 above.
26. WHAT IS MEANT BY “COMMUTED VALUE”?
ANSWER: It is the present value of amount allocated
for the payment of medical bills by a claimant under a Workers’ Compensation
settlement. See answers to questions 24 and 25 above.
27. WILL A CLIENT LOSE MEDICARE BECAUSE OF A RECOVERY?
ANSWER: No. There is no means test for Medicare,
only age or disability.
28. CAN DIVIDENDS CAUSE A CLIENT TO LOSE SSI?
ANSWER: Yes. Dividends are unearned income and can
cause a client’s income to increase over the maximum amount for eligibility or
lower the amount of benefit received by the client.
29. CAN DIVIDENDS CAUSE A CLIENT TO LOSE SSDI?
ANSWER: No. Dividends are unearned earned and are
not counted against SSDI benefits; only earned income is counted.
30. CAN DIVIDENDS CAUSE A CLIENT TO LOSE MEDICAID?
ANSWER: Yes. Dividends are unearned income and can
client’s income to increase over the maximum amount for eligibility or lower the
amount of benefit received by the client depending upon the nature of the
Medicaid program.
31. CAN DIVIDENDS CAUSE A CLIENT TO LOSE MEDICARE?
ANSWER: No. Dividends are unearned earned and are
not counted against Medicare benefits.
32. WHAT IS EARNED INCOME?
ANSWER: Income paid for services rendered; for
example: wages, salary, commissions, etc.
33. WHAT IS UNEARNED INCOME FOR SSI OR MEDICAID
PURPOSES?
ANSWER: Dividends, interest, capital gains, gifts,
life insurance proceeds, personal injury recoveries, inheritances, alimony, etc.
34. IS A PERSONAL INJURY RECOVERY INCOME FOR SSI?
ANSWER: Yes, it is unearned income.
35. IS A PERSONAL INJURY RECOVERY INCOME FOR SSDI?
ANSWER: No. It is not relevant for eligibility.
36. IS A PERSONAL INJURY RECOVERY INCOME FOR SSA?
ANSWER: No. It is not relevant for eligibility.
37. CAN A WORKERS’ COMPENSATION CLAIMANT GET MEDICARE?
ANSWER: Yes, if 65 years of age or blind or the
claimant is totally and permanently disabled for 29 months .
38. CAN A WORKERS’ COMPENSATION CLAIMANT KEEP SSI?
ANSWER: Yes, but only if a proper SSI special needs
trust is utilized and the client otherwise meets all of the other SSI
requirements.
39. CAN A WORKERS’ COMPENSATION CLAIMANT LOSE SSI?
ANSWER: Yes, if an improper SSI special needs trust
is utilized and/or the client does not otherwise meet all of the other SSI
requirements.
40. CAN A WORKERS’ COMPENSATION CLAIMANT LOSE MEDICAID?
ANSWER: Yes, if an improper SSI or Medicaid special
needs trust is utilized and/or the client does not otherwise meet all of the
other Medicaid requirements.
41. CAN A WORKERS’ COMPENSATION CLAIMANT GET MEDICAID?
ANSWER: Yes, but only if a proper SSI or Medicaid
special needs trust is utilized and the client otherwise meets all of the other
Medicaid requirements.
42. CAN A WORKERS’ COMPENSATION CLAIMANT GET SSDI?
ANSWER: Yes, as long as the claimant is determined
to be totally and permanently disabled.
43. CAN INTEREST CAUSE A CLIENT TO LOSE MEDICARE?
ANSWER: Medicare is not a means tested benefit, it
is an entitlement.
44. CAN INTEREST CAUSE A CLIENT TO LOSE MEDICAID?
ANSWER: Yes, if it causes monthly income to exceed
the income cap and no Qualified Income Trust is used or the client’s income
exceeds the program’s income limits.
45. CAN INTEREST CAUSE A CLIENT TO LOSE SSDI?
ANSWER: No. SSDI is not means tested and interest
is unearned income.
46. CAN INTEREST CAUSE A CLIENT TO LOSE SSI?
ANSWER: Yes because interest is included in gross
income and can cause a loss or reduction in SSI benefits.
47. CAN CAPITAL GAINS CAUSE A CLIENT TO LOSE SSI?
ANSWER: Yes because capital gains are included in
gross income and can cause a loss or reduction in SSI benefits.
48. CAN CAPITAL GAINS CAUSE A CLIENT TO LOSE MEDICAID?
ANSWER: Yes, if it causes monthly income to exceed
the income cap and no Qualified Income Trust is used or the client’s income
exceeds the program’s income limits.
49. CAN CAPITAL GAINS CAUSE A CLIENT TO LOSE SSDI?
ANSWER: No. Capital gains are considered to be
unearned income and will not affect eligibility for SSDI.
50. CAN CAPITAL GAINS CAUSE A CLIENT TO LOSE MEDICARE?
ANSWER: No. Medicare is not a means tested program.
51. CAN CAPITAL GAINS CAUSE A CLIENT TO LOSE SSA?
ANSWER: No. SSA retirement benefits are not a means tested program.
52. DOES DEEMING APPLY TO MINORS?
ANSWER: Yes. The assets and income of the family
unit (usually mother and/or father) are considered to be owned or received by
the minor (under 18 years of age) which could disqualify a minor from an SSI or
Medicaid program.
53. DOES DEEMING APPLY TO
ADULTS?
ANSWER: Usually not, but can between husband and
spouse. Also possible between members of a family unit.
54. DOES DEEMING APPLY TO A HUSBAND AND WIFE?
ANSWER: Yes. The assets and income of one will be
considered to be owned or received by the other which could cause a
disqualification from an SSI or Medicaid program.
55. IS THERE DEEMING UNDER NURSING HOME MEDICAID?
ANSWER: No. No deeming, but assets between spouses
are aggregated for eligibility purposes, but not income.
56. IS THERE DEEMING UNDER MEDICAID MEDICAL PAYMENTS?
ANSWER: Yes for some programs. The assets and
income of the family unit (usually mother and/or father) are considered to be
owned or received by a minor (under 18 years of age) which could disqualify a
minor from a Medicaid program.
57. IS THERE DEEMING UNDER SSI?
ANSWER: Yes. The assets and income of one will be
considered to be owned or received by the other which could cause a
disqualification from SSI.
58. IS THERE DEEMING UNDER SSDI?
ANSWER: No. Not a means tested program.
59. WHAT DOES “PMV” MEAN?
ANSWER: PMV is used in SSI and means Presumed
Maximum Value rule. It is an alternative to the one third reduction rule. These
rules are applied when an SSI recipient receives in kind payments for food,
clothing or shelter in kind support and maintenance (ISM).
60. WHAT DOES THE ONE THIRD REDUCTION RULE MEAN?
ANSWER: The value of the one third reduction rule (VTR)
is used to determine eligibility and payment amounts under SSI. It means that
for every in kind payment, the recipient’s SSI payment will be reduced $1.00 for
every $3.00 of in kind support and maintenance payments.
61. DOES THE ONE THIRD REDUCTION RULE APPLY TO SSI?
ANSWER: Yes. It is an SSI rule. The value of the
one third reduction rule (VTR) is used to determine eligibility and payment
amounts under SSI. It means that for every in kind payment, the recipient’s SSI
payment will be reduced $1.00 for every $3.00 of in kind support and maintenance
payments.
62. DOES THE ONE THIRD REDUCTION RULE APPLY TO SSDI?
ANSWER: No. This rule applies to SSI, not SSDI.
63. DOES THE ONE THIRD REDUCTION RULE APPLY TO SSA?
ANSWER: No. This rule applies to SSI, not SSA, a
federal retirement program.
64. DOES THE ONE THIRD REDUCTION RULE APPLY TO
MEDICAID?
ANSWER: No. This rule applies to SSI, not Medicaid.
65. DOES THE “PMV” APPLY TO SSA?
ANSWER: No. This rule applies to SSI , not SSA, a
federal retirement program.
66. DOES THE “PMV” APPLY TO SSI?
ANSWER: Yes. PMV is used in SSI and means Presumed
Maximum Value rule. It is an alternative to the one third reduction rule. These
rules are applied when an SSI recipient receives in kind payments for food,
clothing or shelter in kind support and maintenance (ISM).
67. DOES THE “PMV” APPLY TO SSDI?
ANSWER: No. This rule applies to SSI, not SSDI.
68. DOES THE “PMV” APPLY TO MEDICAID?
ANSWER: No. This rule applies to SSI, not Medicaid.
69. DOES THE TERM “PAYBACK” APPLY TO A SPECIAL NEEDS
TRUST?
ANSWER: Yes to an OBRA’93 (d)(4)(A) individual
trust. and sometimes to a (d)(4)(C)pooled trust.
70. DOES THE TERM “PAYBACK” APPLY TO A POOLED TRUST?
ANSWER: No, if the tax exempt trustee retains 100%
of the trust upon the death to the trust beneficiary. Yes, if the trustee
retains less than 100%.
71. WHAT ARE IN-KIND PAYMENTS?
ANSWER: Payments made on behalf of a beneficiary to
someone other than the beneficiary for a support and maintenance (ISM) item for
the beneficiary.
77. DO IN-KIND PAYMENTS APPLY TO SSI?
ANSWER: Yes. In kind support and maintenance (ISM)
apply to SSI recipients and can result in the activation of the one-third
reduction rule.
78. DO IN-KIND PAYMENTS APPLY TO SSA?
ANSWER: No. They apply to SSI programs.
79. DO IN-KIND PAYMENTS APPLY TO SSDI?
ANSWER: No. They apply to SSI programs.
80. DO IN-KIND PAYMENTS APPLY TO MEDICAID?
ANSWER: Possibly, depending upon the Medicaid
program.
81. CAN A CLIENT SET UP (d)(4)(A)TRUST?
ANSWER: It can only be established by the client’s
parent, grandparent, guardian or by a court.
82. CAN A CLIENT SET UP A (d)(4)(C) TRUST?
ANSWER: Yes, if the client has capacity, or by the
client’s parent, grandparent, guardian or by a court.
83. CAN A CLIENT’S BROTHER SET UP A (D)(4)(A) or(C)
TRUST?
ANSWER: No. The client for a (d)(4)(C); or for a by
the client’s parent, grandparent, guardian or by a court for both the (d)(4)(A)
and (C) trusts..
84. CAN A CLIENT’S SISTER SET UP A (d)(4)(A) or(C)
TRUST?
ANSWER: No. The client for a (d)(4)(C); or by the
client’s parent, grandparent, guardian or by a court for both the (d)(4)(A) and
(C) trusts..
85. CAN YOU AVOID A MEDICAID LIEN BY PUTTING MONEY IN
TRUST?
ANSWER: No. The client for a (d)(4)(C); or by the
client’s parent, grandparent, guardian or by a court for both the (d)(4)(A) and
(C) trusts..
86. WHEN CAN A MEDICAID LIEN BE NEGOTIATED?
ANSWER: During the settlement process with the
inclusion of an AHCA representative.
87. IS A SPECIAL NEEDS TRUST A GRANTOR TRUST FOR INCOME
TAX?
ANSWER: Yes. Trust income and expenses are passed
through the trust to the grantor of the trust. An individual trust or a pooled
trust account can be a grantor trust.
88. WHAT IS A GRANTOR TRUST?
ANSWER: It is a trust where the grantor is
responsible for the income and expenses of the trust. An individual trust or a
pooled trust account can be a grantor trust.
89. WHAT IS A THIRD PARTY TRUST?
ANSWER: A trust established and funded by someone
other than the beneficiary of the trust.
90. WHAT IS A SELF SETTLED TRUST?
ANSWER: A trust in which the funds are contributed
by or on behalf of the trust beneficiary.
91. IS A (d)(4)(A) or(C) TRUST A GRANTOR TRUST?
ANSWER: Yes. Trust income and expenses are passed
through the trust to the grantor of the trust. An individual trust or a pooled
trust account can be a grantor trust.
93. CAN A PARENT ESTABLISH A (d)(4)(A) or(C) TRUST?
ANSWER: Yes. A (d)(4)(A) or(C) trust can be
established by the client’s parent, grandparent, guardian or by a court. An
individual can also be established by a client.
94. CAN A GRANDPARENT ESTABLISH A (d)(4)(A) or(C)
TRUST?
ANSWER: Yes. A (d)(4)(A) or(C) trust can be
established by the client’s parent, grandparent, guardian or by a court. An
individual can also be established by a client.
95. WHO CAN ESTABLISH A (d)(4)(A) or(C) TRUST?
ANSWER: A (d)(4)(A) or(C) trust can be established
by the client’s parent, grandparent, guardian or by a court. An individual can
also be established by a client.
96. WHO CAN ESTABLISH A THIRD PARTY TRUST?
ANSWER: Any who has legal capacity. With regard to
special needs trusts, usually a parent, grandparent, uncle, aunt, brother,
sister, friend, etc.
97. WHAT IS A POOLED TRUST UNDER OBRA’93?
ANSWER: It operates like pension plan with a master
trust and joinder agreements. A beneficiary joins the trust and has a separate
account for the contribution made to or for the benefit of a beneficiary. The
trustee must be tax exempt organization. There will be no payback to any
government agency if the trust retains the entire amount in the account of a
deceased beneficiary. The separate accounts may be pooled for investment
purposes. Special needs items can be paid from the trust without endangering the
beneficiary’s eligibility. This trust can be used as a safe harbor to protect a
beneficiary’s eligibility when a personal injury recovery is obtained.
98. WHAT IS AN INDIVIDUAL DISABILITY TRUST UNDER
OBRA’93?
ANSWER: It is an individual trust for a person
under 65 years of age. Any one can be a trustee , but should have a
knowledgeable independent trustee. There is a payback provision to the state.
Special needs items can be paid from the trust without endangering the
beneficiary’s eligibility. This trust can be used as a safe harbor to protect a
beneficiary’s eligibility when a personal injury recovery is obtained.
99. CAN AN SSI CLIENT BUY A HOUSE WITH SETTLEMENT
MONEY?
ANSWER: Yes, but the ownership, shelter expenses,
mortgage and other items will vary depending upon the circumstances and the
individuals involved in each situation.
100. WHAT IS CONSIDERED INCOME UNDER HUD SECTION 8?
ANSWER: Only regularly occurring income is
considered income for Section 8 housing subsidies.
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