Wisconsin Long-Term Care Partnership Policies Supplemental

Wisconsin Long-Term Care

Insurance Partnership Program

WI Medicaid Training

PART I

Introduction to the WI Long-Term Care Insurance Partnership Program

and

The Wisconsin Medicaid Program: An Overview

The information contained in this training material is current as of June 2, 2008 (it has been provided by the state of Wisconsin).

Contents

Introduction to the

WI Long-Term Care Insurance Partnership Program and

The Wisconsin Medicaid Program: An Overview

Why is this training important to me?

This training is important to you because

The WI Long-Term Care Insurance Partnership (LTCIP) program creates a new role for you to play relative to your clients and the WI Medicaid program.

This training is intended to help you learn that role by gaining an understanding of WI Medicaid and

How WI Medicaid relates to the WI Long-Term Care Insurance Partnership (LTCIP) program.

Becoming familiar with this relationship is the key to knowing how low income WI residents can benefit most from participating in the WI LTCIP program.

Introduction to the WI Long-Term Care Insurance Partnership Program

The WI Long Term Care Insurance Partnership (LTCIP) Program is a joint effort between the federal Medicaid Program, long-term care insurers, and the State of Wisconsin.

The Purpose of the WI LTCIP program is to encourage people to plan for future long-term care needs, such as:

1. Residing in a nursing facility

OR

2. Receiving long-term care services in one's home or another community-based setting.

In Wisconsin, the LTCIP Program Includes:

• Private Long-Term Care Insurers
• Long-Term Care Insurance Producers (agents and brokers)
• The Department of Health and Family Services (DHFS)
• The Office of the Commissioner of Insurance (OCI)

At the federal level, the LTCIP program is overseen by the federal Centers for Medicare and Medicaid Services (CMS).

Under the WI LTCIP program, an amount equal to the amount of benefits that an individual receives under a qualifying LTCIP insurance policy is excluded when determining:

• The individual's resources for purposes of determining WI Medicaid eligibility and
• The amount to be recovered from the individual's estate if the individual receives WI Medicaid benefits.

Intro RECAP

• Participation in the WI LTCIP program can affect the low income person's WI Medicaid eligibility and estate planning.
• Some low income people who wish to participate in the WI LTCIP program may already be eligible for WI Medicaid.
• Some will become eligible for WI Medicaid at some point after they begin participating in the WI LTCIP program.

It is important to understand the precise relationship between the WI LTCIP program and WI Medicaid so that:

• You can provide sound advice to low income people who inquire about the WI LTCIP program and
• You can also accurately explain to low income people the potential benefit of participating in the WI LTCIP program relative to qualifying for WI Medicaid and protecting their estate.

Wisconsin Long-Term Care Insurance

Partnership Program WI Medicaid Training

PART II

WI Medicaid Eligibility

The information contained in this training material is current as of June 2, 2008 (it was supplied by the state of WI).

Contents

• General Eligibility Requirements for WI Medicaid
• Detailed Eligibility Requirements for WI Medicaid Payment of Long-Term Care
• WI Estate Recovery
• How Asset Protection Works under WI LTCIP Program
• How to Apply for WI Medicaid

Why is it important for you to know about WI Medicaid?

It is important for you to know about WI Medicaid because

1. Wisconsin statute intends that you gain a thorough understanding of the relationship between the qualified WI LTVIP policies that you market and the WI Medicaid program. [s. 49.45(32) (c)]
2. This relationship is grounded in WI Medicaid eligibility and estate recovery policy.
3. You need this understanding to fulfill your obligation to explain to consumers the protections offered by qualified WI LTCIP policies.

WI Medicaid Eligibility

General Eligibility Requirements for WI Medicaid

To Be Eligible for WI Medicaid:

• A person must meet both non-financial and financial requirements.
• A person must fit into a general eligibility group and meet specific requirements relating to residency, citizenship, immigration status, third party liability, income and assets.

General WI Medicaid Eligibility groups include the following:

• People age 65 or older
• People who are blind
• People with a certified disability

A person must be a Wisconsin resident to be eligible for WI Medicaid. He or she must:

• Be physically present in Wisconsin (there is no required length of time the person has to have been physically present), and
• Express intent to reside in Wisconsin.

Federal Citizenship and Immigration Status rules require a person to be either a U.S. citizen or a non-citizen with a qualified immigration status.

WI Medicaid Third Party Liability rules state:

• People must provide information about possible payment sources, such as other health insurance, Medicare or another liable third party (such as a qualified WI LTCIP policy).
• Other payment source pays their portion of medical expenses before WI Medicaid payments are made.

General Eligibility Requirements for WI Medicaid RECAP

• WI Medicaid eligibility policy is complicated, but it can be viewed as having two distinct components: financial and non-financial requirements.
• Together, WI Medicaid's financial and non-financial requirements dictate whether a person will qualify to receive the WI Medicaid benefit.
• WI Medicaid's financial requirements relate to the maximum amount of income and assets a person may have and still be found eligible for the program.

• Non-financial requirements relate to things such as the person's age, disability status, living arrangement, residency, citizenship, etc.
• Understanding this general framework will allow long-term care insurers to better grasp key details associated with WI Medicaid eligibility policy and its relationship to the WI LTCIP program.

QUICK QUIZ

True or False

1. The WI Medicaid program is governed by both state and federal laws.

True or False

2. The general WI Medicaid eligibility groups most likely to benefit from long-term care insurance partnership policies include elderly, blind, and disabled persons.

True or False

3. Persons must have resided in Wisconsin for a minimum of six months before they can meet the WI Medicaid program's residency requirement.

True or False

QUICK QUIZ ANSWERS

True or False

1. The WI Medicaid program is governed by both state and federal laws. True
2. The general WI Medicaid eligibility groups most likely to benefit from long-term care insurance partnership policies include elderly, blind, and disabled persons. True
3. Persons must have resided in Wisconsin for a minimum of six months before they can meet the WI Medicaid program's residency requirement. False

There are financial basics that establish the necessary groundwork to grasp the asst protection provisions of the WI LTCIP program.

The Basics:

Are Functional Requirements Met?	The Long-Term subprograms of WI Medicaid generally have functional eligibility requirements. Does the individual meet these functional requirements?
If yes, then
Are Non-financial Requirements Met?	Non-financial factors (such as citizenship, WI residency, age, etc.) will be tested. Does the individual meet the non-financial requirements?
If yes, then
Are Financial Requirements Met?	Financial factors (assets, income, cost share) will be tested. If the individual is functionally, non-financially, and financially eligible
Then
Is the Individual Eligible for WI Medicaid?	The individual can have their care paid for by WI Medicaid.

Key Points:

• The relationship between the WI LTCIP program and WI Medicaid is grounded in WI Medicaid financial eligibility requirements and, ultimately, in WI Estate Recovery policy.
• Therefore, some background information on both WI Medicaid financial eligibility and estate recovery is necessary.

To receive comprehensive long-term care benefits through WI Medicaid, the individual must:

• Meet the program's functional requirements
• Meet the program's non-financial requirements
• Meet the program's financial requirements
• Contribute toward cost of care

The WI LTCIP program directly affects WI Medicaid financial requirements (i.e. the income test, the asset test and the cost share calculation).

Financial Requirements: Income Test

• When looking at WI Medicaid eligibility for payment of long-term care services, only the income of the elderly or disabled applicant is counted in determining his or her budget.
• The income of that person's spouse or parent is not counted.

An applicant's gross monthly income, minus certain "credits" is compared to the income limit associated with the program for which the person is applying.

Under certain circumstances, the premium associated with the qualified WI LTCIP policy could be one of the "credits" deducted from gross income to help the person qualify for WI Medicaid payment of long-term care.

Financial Requirements: Income Test

If the person qualifies on the basis of his/her income, a separate calculation is performed to determine the amount the individual must contribute toward the cost of his or her long-term care services each month.

Financial Requirements: Cost Share

The cost share calculation starts with the applicant's gross monthly income and subtracts various deductions or credits. Each possible deduction is not allowed for each person.

General deductions include:

• Medicare premiums and health insurance premiums not paid by Medicaid (this includes WI LTCIP policy premiums)
• An income allocation to a spouse who is living in the community, if it is determined that the spouse has a financial need.
• An income allocation to certain other family members (subject to specific limitations)
• Personal needs (an amount which changes annually)
• Health care expenses not paid by WI Medicaid or a third party

After allowing applicable income deductions, the result is the amount a person must contribute toward the cost of his or her services monthly. It is typically paid to the WI Family Care (or WI Family Care Partnership) managed care organization, or the medical care facility (for Institutional Medicaid).

Financial Requirements: Asset Test

Asset Limit:

The asset limit for a person applying for WI Medicaid payment of LTC services is $2,000. If the person applying has a spouse living in the community, the spouse will be able to keep assets substantially above the $2,000 limit without affecting the applicant's eligibility. This policy is often referred to as "Spousal Impoverishment Protection."

Countable Assets:

• Countable assets are those which are available to the person and are not specifically excluded by the WI Medicaid program.
• Not all assets are countable.

Countable Assets include:

• cash
• checking accounts
• savings accounts
• certificates of deposit
• life insurance policies
• stocks
• bonds
• non-homestead real
• property agreements like contracts-for-deed
• other liquid assets

Excluded Assets include:

• homestead property in which the person or spouse or certain other family members live
• some trusts
• certain funds set aside for burial expenses
• one vehicle
• some federal payments
• household goods
• personal items (such as clothing and jewelry)

The county agency will review all verified assets and determine the amount:

• Counted toward WI Medicaid eligibility
• Excluded and not counted toward WI Medicaid eligibility (including the amount of verified benefits paid out by a qualified WI LTCIP policy)
• Determined to be protected for the community spouse, if married

Spousal Impoverishment Asset Protections:

WI Medicaid provides special financial protection to allow the spouse and dependent children of the applicant for LTC Services to retain both assets and income that are above regular WI Medicaid financial limits.

Spousal Impoverishment Asset Protections:

• For long-term care cases where one spouse is still living in the community, special asset protection provisions apply at application.
• An Asset Assessment is conducted by the county agency to establish the asset limit/test that the person will have to pass when applying for WI Medicaid.

Asset Assessment:

• Person is required to provide documentation of assets that s/he owned with his/her spouse on the date of first continuous period of institutionalization for 30 days or more OR
• The date of initial request for WI Family Care (including WI Family Care Partnership), whichever occurs earlier.

Eligibility Requirements for WI Medicaid Payment of Long-Term Care

CSAS

Based on the documentation provided, the county agency will determine the total assets of the couple and the community spouse asset share (CSAS).

• The CSAS is the amount of countable assets above $2,000 that the community spouse, the applicant, or both can have at the time of application and still be found eligible for WI Medicaid. CSAS is based on policy (explained later).
• The long-term care applicant must transfer his/her assets to the community spouse by the next regularly scheduled review (12 months).

If a person's assets are above $2,000 on the date of the next scheduled WI Medicaid review, s/he will be determined ineligible and will remain ineligible until his/her assets no longer exceed the $2,000 WI Medicaid asset limit.

Once the applicant is enrolled in a long-term care WI Medicaid program, the assets of the community spouse are considered unavailable to the enrollee for the purpose of his/her WI Medicaid eligibility.

Eligibility Requirements for WI Medicaid Payment of Long-Term Care

CSAS and Excess Assets:

The amount of assets above the asset limit can be reduced to allowable limits if they are used to pay for:

• Nursing home or home care costs
• Other costs such as home repairs or improvements, vehicle repair or replacement, clothing or other household expenses

The asset limit for the long-term care WI Medicaid applicant is $2,000 plus the CSAS:

• If the total countable assets of the couple are $208,800 or more, then the CSAS is $104,400. The WI Medicaid asset limit is $106,400, that is, CSAS plus $2,000.
• If the total countable assets of the couple are less than $208,800 but greater than $100,00, then the CSAS is 1/2 of the countable assets plus $2,000.
• If the total countable assets of the couple are $100,000 or less, then the CSAS is $50,000 and the WI Medicaid asset limit is $52,000.

**The above amounts are based on federal guidelines which change each year.

Spousal Impoverishment Asset Protections Example:

Robert was first institutionalized September 2003. Lucinda, Robert's wife, remained in the community. The couple passed the joint asset test and Robert was determined eligible in September 2003. The couple had total combined assets of $42,000, $32,000 of which was owned solely by Robert.

Robert had until the next scheduled review (September 2004) to get his total assets under the $2,000 WI Medicaid asset limit. By September 2004 Robert had only transferred $23,000 to Lucinda.

Robert still had $9,000 in assets. Robert became ineligible October 2004, and will remain ineligible as long as his assets remain over $2,000.

Eligibility Requirements for WI Medicaid Payment of Long-Term Care

Divestment

• Divestment is giving away resources, such as income, non-exempt assets and property for less than fair market value to become eligible for WI Medicaid.
• Fair market value is an estimate of the price for which an asset could have been sold on the open market at the time it was given away.

Divestment is also an action taken by a person to avoid receiving income or assets to which the person is entitled.

• Divesting financial resources within 60 months of the application for WI Medicaid, or institutionalization, may result in a divestment penalty period.
• WI Medicaid will not pay for long-term care benefits through WI Family Care, WI Family Care Partnership, or Institutional Medicaid during a divestment penalty period.

• The divestment penalty period begins with the month in which the divestment occurred.
• The amount divested is divided by the average monthly private pay nursing home cost to arrive at the number of months of the divestment penalty period.

Eligibility Requirements for WI Medicaid Payment of

Long-Term Care RECAP

• Institutional Medicaid, the WI Medicaid Home-and Community-Based Waiver programs (which are being replaced by), WI Family Care, and WI Family Care Partnership comprise four ways that WI Medicaid delivers long-term care to eligible persons.
• WI LTCIP program participants are most likely to access WI Medicaid long-term care services through one of these programs.

Each of these programs:

• Serves individuals requiring a nursing home level of care
• Applies an income limit that is significantly higher than the limits associated with other kinds of WI Medicaid
• Requires the eligible person to contribute toward the cost of his/her long-term care, based on his/her income
• Offers significant asset protections for the community spouse
• Includes penalties for those who dispose of assets for less than fair market value

QUICK QUIZ

True or False

1. When WI Medicaid pays for long-term care services, it is generally accomplished through one of the following WI long-term care WI Medicaid programs: Institutional Medicaid, Home- and Community-Based Waiver Medicaid, WI Family Care, or WI Family Care Partnership.

True or False

2. The asset limit for persons applying for WI Medicaid long-term care benefits is $2,000, irrespective of whether or not the person has a spouse living in the community.

True or False

3. WI Medicaid will not pay for long-term care, but will pay for acute and primary care during a divestment penalty period.

True or False

QUICK QUIZ ANSWERS

True or False

1. When WI Medicaid pays for long-term care services, it is generally accomplished through one of the following WI long-term care WI Medicaid programs: Institutional Medicaid, Home- and Community-Based Waiver Medicaid, WI Family Care, or WI Family Care Partnership. True
2. The asset limit for persons applying for WI Medicaid long-term care benefits is $2,000, irrespective of whether or not the person has a spouse living in the community. False
3. WI Medicaid will not pay for long-term care, but will pay for acute and primary care during a divestment penalty period. True

How Asset Protection Works under the WI LTCIP Program

Overview

Inquiry about WI LTCIP	Explain LTCIP & WI Medicaid	Person purchases WI LTCIP policy	WI LTCIP Policy Payouts
Person eligible for WI Medicaid	Payout amount disregarded	WI LTCIP Carrier verifies payouts	Person applies for WI Medicaid
Person dies	WI LTCIP Carrier verifies payouts	Payout amount Protected from WI Estate Recovery

A WI LTCIP program participant receives the following benefits

during his or her lifetime:

Assets may be disregarded up to the total amount of long-term care services paid by the qualified WI LTCIP policy. The disregarded amount is not counted toward the WI Medicaid asset limit.

• The amount paid out under a qualified WI LTCIP policy must be verified before it can be disregarded for Medicaid eligibility (or estate recovery) purposes.
• Adequate verification consists of documentation from the qualified WI LTCIP policy carrier specifying the amount paid in benefits as of the date of the documentation (on carrier letterhead, signed by a carrier representative).
• The carrier must provide adequate verification to the client, the client's representative, or the county agency, or DHFS upon request.

After the WI LTCIP program participant is deceased:

The maximum amount that can be protected from estate recovery under the WI LTCIP program is the verified amount of benefits paid out by the qualified WI LTCIP policy.

When the amount of assets disregarded during the person's lifetime due to verified payouts under a qualified WI LTCIP policy is less than total benefits paid by the qualified WI LTCIP policy, additional assets may be protected in the estate recovery process - up to the verified total amount paid by the qualified WI LTCIP policy.

Following are some examples that depict the interaction between the following programs:

• WI LTCIP program,
• WI Medicaid
• WI Estate Recovery

WI LTCIP Asset Protection for WI Medicaid Eligibility

Example 1: "WI LTCIP Policy Benefits Not Exhausted"

Ruth is a resident of a medical care facility. She has no spouse. Her qualified $90,000 LTCIP policy has been paying for her care. When Ruth applies for WI Medicaid payment of long-term care services, she verifies that her qualified WI LTCIP policy has paid out $80,000 in policy benefits.

Ruth owns the following countable assets:

$5,000 savings account

$6,000 checking account

$70,000 equity value in recreational lakeshore property

The worker determines that Ruth's total countable assets equal $81,000 ($5,000 + $6,000 + $70,000). Her WI Medicaid asset limit is $2,000; however, because $80,000 has been paid out by Ruth's qualified WI LTCIP policy, an additional $80,000 in countable assets may be disregarded.

In essence then, Ruth's WI Medicaid asset limit is $82,000. Ruth passes the asset test for WI Medicaid because, at $81,000, the value of her countable assets totals less than her asset limit. (Of course, Ruth's income would still need to be tested.)

If Ruth were to pass away the next day, $80,000 of her assets would be protected from estate recovery. The $2,000 basic asset allowance/limit does NOT apply after death and the $2,000 is subject to recovery.

Example 2: "WI LTCIP Policy Benefits Not Exhausted"

A year later, Ruth's eligibility for WI Medicaid is reviewed. At that time, she verifies that she has exhausted her qualified LTCIP policy benefit, which has paid out the full $90,000.

Ruth owns the following countable assets:

• $4,000 savings account
• $7,000 checking account
• $80,000 equity value in recreational lakeshore property

The worker determines that Ruth's total countable assets equal $91,000 ($4,000 + $7,000 + $80,000). Her WI Medicaid asset limit is $2,000; however, because $90,000 has been paid out by Ruth's qualified LTCIP policy, an additional $90,000 in countable assets may be disregarded.

In essence then, Ruth's WI Medicaid asset limit is $92,000. Ruth continues to qualify for WI Medicaid because, at $91,000, the value of her countable assets totals less than her asset limit.

If Ruth were to pass away the next day, $90,000 of her assets would be protected from estate recovery. The $2,000 basic asset allowance/limit does not apply after death and is subject to recovery.

Example 3: "WI LTCIP and Spousal Impoverishment Protections"

Ruth is applying for WI Family Care benefits. She and her spouse reside in their home and have $100,000 in countable assets. Her qualified $80,000 LTCIP policy has been paying for long-term care she has received in her home and is now exhausted. When Ruth applies for WI Family Care payment of long-term care services, she verifies that her LTCIP policy has paid out $80,000 on benefits.

Because Ruth is living with her husband, Spousal Impoverishment Protections apply. Under Spousal Impoverishment policy, Ruth's WI Medicaid asset limit is $52,000 (i.e., CSAS plus $2000see earlier slides). However, $80,000 is added to this to reflect the amount of benefits paid by her qualified LTCIP policy. Therefore, when Ruth applies for WI Family Care, her asset limit is $132,000.

Within one year of applying, Ruth must transfer her assets to her spouse sufficient to allow her to qualify at an asset limit of $82,000 (i.e., the LTCIP policy pay out amount plus the regular WI Medicaid asset limit of $2000).

WI LTCIP Asset Protection for Estate Recovery

Example 4:

Ruth is a WI Medicaid eligible resident of a medical care facility. Her qualified $90,000 LTCIP policy has been paying for her care. As of her last WI Medicaid review, the policy had paid out $70,000, an amount disregarded in determining her continued WI Medicaid eligibility.

Ten months after her last WI Medicaid review, Ruth dies. Ruth's representatives verify that, during those ten months, her qualified LTCIP policy paid out an additional $10,000 toward her long-term care.

Ruth's estate can protect a total of $80,000 (i.e., the total amount paid out by the qualified policy) from estate recovery.

How Asset Protection Works under the WI LTCIP Program RECAP

• When determining WI Medicaid eligibility, assets may be disregarded in an amount equal to the verified total amount of long-term care services paid by the qualified WI LTCIP policy.
• These disregarded assets are not counted toward the WI Medicaid asset limit.
• Assets may be protected from estate recovery in an amount equal to the verified total amount of long-term care services paid by the qualified WI LTCIP policy.

At the request of the WI Medicaid recipient or their representative, the WI LTCIP policy carrier must provide documentation which details date(s) and amount(s) paid in benefits by the policy. The WI Medicaid recipient or his/her representative must provide this documentation to the income maintenance agency worker or estate recovery staff to determine and verify the asset disregard/protection.

QUICK QUIZ

True or False

1. Benefits from the qualified WI LTCIP policy must be exhausted before the pay out amount can be disregarded for the purpose of WI Medicaid eligibility.

True or False

2. The WI LTCIP policy carrier must provide the WI Medicaid applicant with documentation verifying the amount of benefits paid as of the date of the documentation.

True or False

3. The verified WI LTCIP benefit pay out amount represents the maximum amount which can be disregarded when determining WI Medicaid eligibility, or protected from estate recovery purposes.

True or False

QUICK QUIZ ANSWERS

True or False

1. Benefits from the qualified WI LTCIP policy must be exhausted before the pay out amount can be disregarded for the purpose of WI Medicaid eligibility. False
2. The WI LTCIP policy carrier must provide the WI Medicaid applicant with documentation verifying the amount of benefits paid as of the date of the documentation. True
3. The verified WI LTCIP benefit pay out amount represents the maximum amount which can be disregarded when determining WI Medicaid eligibility, or protected from estate recovery purposes. True

How to Apply for WI Medicaid Programs

A person can apply for WI Medicaid in person, by mail, by telephone, or using a web-based internet application. Application forms and instructions are available on-line through the following link:

http://dhfs.wisconsin.gov/medicaid1/applications.htm

People who are age 65 or older, blind, or disabled should use form HCF 10101 to apply for WI Medicaid. Completed forms should be returned to the applicant's local county/tribal human or social services agency.

ACCESS is an online tool that allows people to apply for benefits, check the status of benefits, or report changes in circumstances to their worker. ACCESS is available online at:

www.access.wisconsin.gov

An online ACCESS application is the same as a paper application.

How to Apply for Wisconsin Medicaid Programs RECAP

Application forms and instructions are available on-line through the following link:

http://dhfs.wisconsin.gov/medicaid1/applications.htm

Wisconsin Long-Term Care Insurance Partnership Program

WI Medicaid Training

PART III

WI ESTATE RECOVERY

The information contained in this training material is current as of June 2, 2008 (it is supplied by the state of WI).

WI Estate Recovery

For current information regarding the Wisconsin Estate Recovery, access the internet at:

Http://dhfs.wisconsin.gov/medicaid1/recpubs/erp/phc13032.htm

Contents

• What is WI Estate Recovery?
• What Services Does Wisconsin Recover?
• When Does the State Not Recover Medicaid Benefits?

What is WI Estate Recovery?

• Wisconsin Medicaid Estate Recovery seeks repayment for the cost of certain long term care services paid for by Medicaid on behalf of recipients.
• Recovery is made from the estate of recipients and from liens placed on their homes.
• The money recovered is returned to the WI Medicaid Program and used to pay for care for other WI Medicaid recipients.

• Note that Wisconsin, unlike some other states, does not recover for ALL services that are paid by WI Medicaid.
• The amount Wisconsin can recover is limited to the amount paid by WI Medicaid for Certain Long-term care services.

• The amount of assets disregarded for WI Medicaid eligibility purposes due to verified payouts under a qualified WI LTCIP policy are protected from estate recovery except for the basic $2,000 asset allowance/limit that all persons receive while they are alive.
• This $2,000 asset disregard may be subject to recovery when the person is no longer alive.

The long-term care services for which the program seeks repayment mainly include nursing home services, community-based waiver services and certain other long-term care services received in the community by a person at least age 55 or older.

With the new WI LTCIP qualifying policies, the amount of assets that are protected due to verified payouts are not subject to estate recovery.

What is WI Estate Recovery? RECAP

• The Wisconsin Medicaid Estate Recovery Program seeks repayment for the cost of certain long term care services paid for by Medicaid on behalf of recipients.
• Recovery is made from the estates of recipients and from liens placed on their homes.
• The money recovered is returned to the WI Medicaid Program and used to pay for care for other WI Medicaid recipients.

The amount of assets that are protected due to verified payouts from a qualified WI LTCIP policy are also protected from estate recovery.

What Services Does Wisconsin Recover?

As noted previously, Wisconsin does not recover for all services provided to a WI Medicaid recipient.

Wisconsin recovers all the costs for a recipient (of any age) for the period of time in a nursing home or inpatient (more than 30 days) in a hospital, as long as the recipient was considered permanently institutionalized. Wisconsin also recovers all costs from any nursing home for a recipient over the age of 55, even if it was a short-term stay in a nursing home.

Wisconsin seeks to recover services that are generally thought of as "long-term care services" for anyone 55 and older, living in the community.

Services that a recipient age 55 and older may receive in the community, subject to recovery, include the following:

• Skilled nursing services
• Home health aide services
• Home health therapy and speech pathology services
• Private duty nursing services
• Personal care services

Wisconsin also seeks to recover benefits paid for any recipient age 55 and older in a WI Medicaid Waiver program, including but not limited to WI Family Care, WI Family Care Partnership, Community Options Waiver, Community Integration Programs IA, IB, and II, Brain Injury Waiver and Community Supported Living Arrangements.

The benefits recovered for a Medicaid Waiver recipient age 55 and older are:

• All services received through the home and community-based Waiver program (i.e. WI Family Care and WI Family Care Partnership).
• All inpatient hospital services and all prescription drugs received while the recipient was eligible for a Waiver program.

An individual who receives all or a combination of the services listed previously may have the amount paid by WI Medicaid for those services recovered from his or her estate, or through a lien while the recipient is alive except for an amount equal to the verified payouts under a qualified WI LTCIP policy.

Example 1:

Ruth was in the WI Family Care Program. She received services through Family Care that were not eligible for payment by her qualified WI LTCIP policy (worth $100,000). She passed away and WI Family Care had paid out $50,000 in services over the course of three years. WI Estate recovery would file a claim against her estate which includes her home valued at over $100,000.

When the home in her estate sells, the state would collect on its $50,000 claim, assuming sufficient funds were available to first pay other priority claims. She was not able to protect any assets as the qualified WI LTCIP policy did not pay out any benefits to protect her assets.

Example 2:

Millie was also in the WI Family Care Program. At the time she applied for WI Family Care, $25,000 had been paid out in benefits by her qualifying WI LTCIP program policy; hence $25,000 of her countable assets was disregarded. She owned her own home worth $150,000. Because she lived in her home, the home remained an exempt asset for purposes of eligibility.

At the time of Millies death, $60,000 had been paid out by the WI LTCIP program policy. However, WI Family Care had paid out $90,000 in WI Medicaid benefits. WI Estate recovery would file a claim on her estate for $90,000; however, $60,000 would be protected from recovery. Annie had a qualified WI LTCIP policy worth $200,000.

Example 3:

Annie had a qualified WI LTCIP policy worth $200,000. She had cash assets of $50,000 and a home valued at $150,000 that she lived in. She received $50,000 in benefits from her qualified WI LTCIP policy and then applied for WI Medicaid in a Home-and-Community Based Waiver program. Her qualified WI LTCIP policy had verified payouts of $50,000 at the time of her initial eligibility determination for the Waiver program.

The policy continued to pay benefits while she lived in the community and then she moved into the nursing home. While she was in the nursing home, the qualified policy had verified pay-outs to the maximum benefits - $200,000. Hence, the verified $200,000 would be exempted at the time of recovery from her estate.

What Services Does Wisconsin Recover? RECAP.

WI Medicaid recipients who are any of the following may be subject to WI estate recovery provisions:

• Nursing home residents
• Institutionalized persons who received inpatient hospital benefits
• Persons age 55 and older who reside in the community

QUICK QUIZ

True or False

1. Recovery is made from the estates of recipients and from liens placed on their homes. The money recovered is returned to the WI Medicaid Program and used to pay for care for other WI Medicaid recipients.

True or False

2. The amount recovered may not exceed the amount paid in WI Medicaid benefits.

True or False

3. WI Estate recovery does not apply to persons under age 55 who live in the community (i.e. who do not reside in a medical facility).

True or False

QUICK QUIZ ANSWERS

1. Recovery is made from the estates of recipients and from liens placed on their homes. The money recovered is returned to the WI Medicaid Program and used to pay for care for other WI Medicaid recipients. True
2. The amount recovered may not exceed the amount paid in WI Medicaid benefits. True
3. WI Estate recovery does not apply to persons under age 55 who live in the community (i.e. who do not reside in a medical facility). True

When Does the State Not Recover Benefits?

• The state may not seek recovery of any WI Medicaid benefits from a recipients liquid estate assets while the recipients spouse or a minor or disabled, or blind child survives the recipient, regardless of any qualified WI LTCIP policy. However, if the recipients estate includes a home, the state will receive a lien for the amount that exceeds the verified payouts under a qualified WI LTCIP policy.
• Repayment form the lien will be delayed until after the death of the surviving spouse and any minor, disabled, or blind children.

If the state is granted a lien as noted above, through the estate on the home of a surviving spouse, minor, disabled or blind child of a WI Medicaid recipient and if that property is sold for fair market value while the spouse, minor, disabled or blind child lives, the state will release its lien and no recovery will be made, regardless of the existence of a qualified WI LTCIP policy.

The state may not file a claim on the estate of the surviving spouse to recover WI Medicaid benefits paid on behalf of the pre-deceased recipient.

If a qualified policy has paid out verified benefits in an amount that is equal to or more than the remaining assets of a deceased WI Medicaid recipient, then the state can make no recovery as the assets are protected because of the WI LTCIP policy.

Example 4:

Maynard lived in a nursing home. His wife, Millie, continues to live in their jointly owned home. At the time he applied for WI Medicaid, he had only $2,000 in cash which was exempted for eligibility purposes. Within one year of becoming eligible for MA, their home was transferred solely to Millie. Maynard had a WI LTCIP qualifying policy worth $100,000 that paid most of the cost of the nursing home until it was exhausted.

Then, WI Medicaid paid for his nursing home care for the next two years until he passed away (WI Medicaid paid $150,000). The state would file a claim against his estate assets (which are minimal) for $150,000; however, because there is no home in his estate and only liquid assets, the state would make no recovery because Millie is a surviving spouse.

When Does the State Not Recover Benefits? RECAP

• The state may not seek recovery of any WI Medicaid benefits from a recipients estate while the recipients souse or a minor, disabled, or blind child survives the recipient.
• The state may not file a claim on the estate of the surviving spouse to recover WI Medicaid benefits paid on behalf of the recipient.

The verified amounts of benefits paid by the qualified WI LTCIP policy are protected from estate recovery. The WI LTCIP policy carrier must provide documentation which specifies the amount paid in benefits as of the date of the documentation.

QUICK QUIZ

True or False

1. The WI Estate Recovery Program uses two methods, claims in probate estates and liens, to recover the cost of WI Medicaid benefits.

True or False

2. The state may seek recovery of any WI Medicaid benefits from a recipients estate while the recipients spouse or a minor, disabled, or blind child survives the recipient.

True or False

3. The state may not file a claim on the estate of the surviving spouse to recover WI Medicaid benefits paid on behalf of the recipient.

True or False

QUICK QUIZ ANSWERS

1. The WI Estate Recovery Program uses two methods, claims in probate estates and liens, to recover the cost of WI Medicaid benefits. True
2. The state may seek recovery of any WI Medicaid benefits from a recipients estate while the recipients spouse or a minor, disabled, or blind child survives the recipient. False
3. The state may not file a claim on the estate of the surviving spouse to recover WI Medicaid benefits paid on behalf of the recipient. True

This completes your WI supplemental to the Long-Term Care Partnership Policies course.

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