How does the look-back period affect a person’s eligibility for Medi-Cal benefits?

Monday, Jan. 25th 2021 3:26 PM

In California, any transfer of a non-exempt asset (also called “countable”) within 30 months of an individual’s application for Medi-Cal for nursing facility level of care may result in a period of ineligibility. This period of ineligibility will only apply to the nursing facility level of care and, if
otherwise eligible, the individual would be eligible for all other Medi-Cal covered services. Remember, the look-back period does not apply to those assets that are exempt (also called “not countable”). The most common exempt asset is the individual’s principal residence. The period of ineligibility is determined by dividing the average private pay rate (APPR) in California, currently $4,322, into the value of the transferred non-exempt asset. Let us take a look at the following example:

Ten months prior to Ms. Peabody’s (a single individual) application to Medi-Cal to pay for her stay at Sunnyside Nursing Facility, she transferred $200,000 from her bank account to her son John. She meets all other eligibility requirements for Medi-Cal. Would Ms. Peabody have a period of ineligibility for payment to the nursing facility as determined by her eligibility worker? If so, what would be the period of ineligibility?

Yes, Ms. Peabody would have a period of ineligibility of 21 months. Here is how it is calculated:

The first step taken by the eligibility worker would be to determine the maximum period of ineligibility. This is accomplished by dividing the value of the $200,000 non-exempt transfer by the APPR for 2002, which is $4,322. For this example, the calculation results in 46 months. OBRA 93 (Omnibus Budget Reconciliation Act) lifted the ceiling on the maximum period of ineligibility. Remember, however, that the maximum period of ineligibility in California is still 30 months. In this example, the transfer took place 10 months prior to Ms. Peabody’s application for Medi-Cal. In determining the actual period of ineligibility, the eligibility worker would start counting beginning with the 10th month and continue through the 30th month. The ineligibility period would thus be 21 months. Medi-Cal would not begin to
pay for Ms. Peabody’s nursing facility costs until another 21 months had passed.

The period of ineligibility is always the lesser of one of the following: – 30 months; or – the number of months obtained by dividing the value of the transfer by the APPR; or – the difference between 30 months from the date of the transfer and the date of application for Medi-Cal benefits, inclusive. In other states, the look-back period and the period of ineligibility may differ from that used in California.

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Posted on Monday, Jan. 25th 2021 3:26 PM | by Share of Cost | in Medi-Cal, Share of Cost | No Comments »

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