The District of Columbia (DC) Medicaid program is one of the most complex in the nation, in part because DC is not a state and the DC Government is not the most organized or efficient of local governments. The program is a procedural nightmare in many ways: eligibility rules are largely incomprehensible to the uninitiated, and even some experienced attorneys find it difficult to decipher the cryptic and often contradictory regulations vs. rules. The DC Medicaid Manual, which is supposed to be relied on by Medicaid Case Workers and attorneys, is online, but is not kept up-to-date. For example, DC Medicaid regulations were changed drastically in 2016, but as of 2020 the DC Medicaid Manual has still not been updated to reflect the changes in these regulations, so deciphering the exact state of DC Medicaid rules, where the new regulations often contradict the Medicaid Manual, and vice versa, is an exercise of enormous complexity.
DC Penalty Divisor: $12,883.74
Minimum Community Spouse Resource Allowance: $25,728
Maximum Community Spouse Resource Allowance: $128,640
Maximum Allowed under Federal Law in DC: $3,216
In DC, an unmarried applicant for Medicaid long-term care assistance may have no more than the Individual Resource Allowance set forth above in "countable resources" in his or her name in order to be "resource eligible" for Medicaid.
DC is what is known as a "medically needy" state, which is distinct from an "income cap" state. If an applicant is medically in need of nursing home care, the applicant will qualify for Medicaid benefits (as long as the applicant is otherwise eligible) as long as the applicant's gross income is less than the private cost of the long term care. As a result, a Miller Trust or Qualified Income Trust is unnecessary in DC. The nursing home resident is still required to pay all of his or her income, less certain deductions, to the nursing home. The deductions include the Resource Allowance set forth above, a deduction for any uncovered medical costs (including medical insurance premiums), and, if the applicant is married, an allowance which in some cases may be paid to the spouse that continues to live at home (the Community Spouse).
Fortunately, an experienced elder law attorney can help a married couple shift income from the nursing home spouse to the community spouse.
DC has unlimited Community-Based Care (CBC) Waiver services for the elderly (called the EPD Waiver), which can be authorized as an alternative to nursing facility care when the individual meets the clinical criteria for needing nursing home level-of-care. It covers up to 17 hours per day of in-home care. Most of the financial eligibility requirements for CBC applicants are the same as the requirements for nursing home applicants. This includes resource eligibility, income eligibility, and transfer eligibility. However, the income eligibility rules are more complex for the EPD Waiver than for nursing home Medicaid.
For Medicaid payment of nursing home long-term care, the rules are different depending on whether you read the regulations or the Medicaid Manual. In the Medicaid Manual, the applicant's principal residence is excluded from countable resources only for the first six months of continuous institutionalization, provided the applicant intends to return home and provided the equity in the home property does not exceed the home equity limit stated above. Regardless of the amount of home equity, after six months of continuous institutionalization, technically the nursing home resident's home will become a countable resource, unless the home is occupied by a spouse, dependent child under age 21, or a blind or disabled child.
However, DC has never in fact applied the above rule rendering home property available after six months; caseworkers have simply ignored the home after initial eligibility and on re-certification, so that the home is simply disregarded. And the regulations enacted in 2016 simply state that the house is an exempt asset.
DC has an aggressive estate recovery program, but as a practical matter there are ways to protect the home from Estate Recovery using an experienced Elder Law Attorney.
All countable assets owned by the married couple as of the first day of the month that the applicant becomes institutionalized, regardless of how the assets are titled, are divided, for purpose of calculation, into equal halves. One-half of the countable assets, up to the maximum Community Spouse Resource Allowance (CSRA) and subject to the minimum CSRA, is allocated to the community spouse. The other half of the countable assets is allocated to the nursing home spouse, and must be spent (or protected) until only the Individual Resource Allowance remains, at which time the nursing home spouse will then qualify for Medicaid.
Fortunately, an experienced Elder Law attorney can typically vastly increase the value of assets that a married couple can protect by using a variety of asset protection strategies.
The MMNA (Monthly Maintenance Needs Allowance) in DC is called the Community Spouse Monthly Income Allowance.
DC permits all spouses to have the maximum spousal income allowance permitted under Federal law, which is listed above.
DC Medicaid allows spousal refusal, disregarding all assets of the Community Spouse so long as the Community Spouse assigns all support rights to the District.
DC has no policy on the treatment of annuities. Because of its generous application of “just say no,” annuities are not needed to enable married individuals to qualify for benefits. And notwithstanding the Deficit Reduction Act of 2005, DC appears to accept balloon annuities and does not require that it be named a contingent beneficiary after a spouse or disabled child.
DC routinely filed claims for all services, but withdraws inappropriate claims when challenged. DC does not pursue estate recovery if there is a surviving spouse or disabled child, or where recovery would result in undue hardship. DC has a hardship standard that is strict and somewhat incomprehensible. It also has draconian deadline requirements that may trip up the unwary personal representative or estate planning lawyer. Under federal law, DC is required to make a claim against a deceased enrollee’s estate provided the individual was age 55 or over; however, DC also makes claims against estates of individuals who receive Medicaid services while under age 55.
In reality, working with an experienced Elder Law Attorney, there are several ways to avoid DC Medicaid Estate Recovery.
Social Security Act Title XIX, 42 USC § 1396 et seq.
42 USC § 1396p (transfer of assets / estate recovery / trusts).
42 USC § 1396r-5 (special rules applicable to an institutionalized spouse who has a "community spouse").
Deficit Reduction Act of 2005, Pub. L. No. 109-171 ("DRA"), signed into law on February 8, 2006. The provisions of DRA dealing with the changes to eligibility for Medicaid long-term care are contained at §§ 6011 - 6021, and 6036 of the DRA.
42 CFR 430 et seq.
DC’s Medicaid Rules and Regulations are set forth in the DC Regulations at https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?ChapterNum=29-98, and the Policy Manual at https://dhs.dc.gov/publication/esa-policy-manual.