Financial Protections and Choice for Medicaid Participants and Their Families

Background

MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. coverage of long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ) provides a safety net for vulnerable older people—and younger people with disabilities—who have low incomes and few assets. It also provides coverage for those who become impoverished because of medical needs, LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. needs, or both. In fiscal year 2018, MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. paid $197 billion for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (in both institutional and home and community-based settings), or approximately 33 percent of total MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. expenditures. Institutional care accounts for the majority (roughly 55 percent) of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. spending for older people and adults with physical disabilities.

Financial Eligibility: Federal and state financial eligibility criteria effectively restrict MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. eligibility to the very poor. Criteria, as well as the complexity of the eligibility determination process, vary widely from state to state. In most states, older people who are eligible for Supplemental Security IncomeThe SSI program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. (SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled.) are considered eligible for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.. To be eligible for SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. in 2021, an individual cannot have countable income over $794 a month and more than $2,000 in assets. Certain states, known as 209(b) states, may impose even more restrictive financial eligibility rules (see also Supplemental Security Income).

In determining financial eligibility, MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. does not count an individual’s home, one car, and a modest amount of personal goods. However, in 2021, applicants’ equity value in their home must be $603,000 or less. States, however, have the option to exempt up to $906,000 in home equity.

Medically Needy Programs: States may choose to have a medically needy programA program states may use to allow people with income or assets above Medicaid limits become eligible when their medical and LTSS expenses, subtracted from income, result in net income below the Medicaid eligibility standard. that allows people over the age of 65 (and younger people receiving Supplemental Security IncomeThe SSI program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. or Social Security Disability Insurance benefits) to spend down their assets and income in order to meet their state’s financial eligibility criteria for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. coverage of nursing facility care. If states do not want to have a medically needy programA program states may use to allow people with income or assets above Medicaid limits become eligible when their medical and LTSS expenses, subtracted from income, result in net income below the Medicaid eligibility standard., they may choose to use a special income rule of 300 percent of the SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. benefit ($2,382 per month in 2021) to qualify individuals for nursing facility care and home and community-based services (HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings.) waiver programs.

In states where the eligibility of people with higher incomes is limited to those qualifying under the special income rule, individuals with too much income may still qualify for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. coverage of nursing facility care and HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. waiver programs by placing their incomes in a Miller Trust. When the person dies, the money in the trust is used to reimburse the state for the amount that MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. spent on the Miller Trust owner.

Personal Needs Allowance: In 2020, the federal personal needs allowance (PNA) for nursing facility residents who are MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.-eligible was $30 a month. The purpose of the PNA is to cover a resident’s basic expenses such as personal hygiene supplies and phone calls.

States may allow a higher amount—up to $200 a month. In 2020, only Alaska allowed a PNA of $200. The majority of states have PNAs in the $40 to $60 range.

Financial protections for spouses: MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. requires states to protect the income and assets of spouses of nursing facility residents (called the “community spouse”) to prevent spousal impoverishment. A certain amount of the couple’s combined resources is protected for the community spouse. Depending on the community spouse’s income, a certain amount of the income belonging to the spouse in a nursing home can be allocated for the community spouse.

The amount of income that a spouse may keep is called the "minimum monthly maintenance needs allowance" (MMMNA). It varies from state to state, subject to a federal minimum and a maximum. The minimum amount in 2021 is $2,155.00, and the maximum is $3,259.50. (The amount changes each year in July.) Any income above the MMMNA must be used to help cover the cost of the consumer’s nursing facility care. The amount of resources that the community spouse is allowed to keep is called the community spouse resource allowance. It also varies by state based on the federal minimum of $26,076 and the maximum of $130,380. These amounts are automatically updated annually for inflation. States can offer the same protection to spouses, including same-sex spouses, of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. recipients who receive HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. under a waiver program.

For five years, beginning in 2014, states were required to extend spousal impoverishment protections for home and community-based services (HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings.) participants as well as nursing facility residents. Congress has provided a number of extensions of the requirement for states to provide spousal impoverishment protections for HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. participants, most recently through September 30, 2023.

Estate recovery: Today, almost every state and the District of Columbia has a program for recovering MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. costs from consumers’ estates. Federal law requires all states to recover MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. costs for nursing facility or HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. care from the estates of people who received benefits at age 55 or older. The law defines “estate” to include assets that are part of the probate estate under state law. States can include other property in which the individual had any legal interest at the time of death, including property passing by joint tenancy or living trust.

Under federal law, states have the option to implement estate recovery for the receipt of primary- and acute-care services as well. Thus, individuals who enroll in the MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. expansion could be subject to estate recovery rules (see also Medicaid State Plan Amendments and Waiver Authority).

The federal government requires states to perform estate recovery as a condition of participation in the MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. program. In addition to having a disparate impact on affected families, fear of recovery causes some people to decline MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. and the vital services it provides.

Recoveries cannot be made while there is a surviving spouse or dependent child. With certain exceptions and exemptions, a number of states recover expenditures by filing liens on the homes of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. recipients. However, no recovery can be made until both the recipient and spouse die, the house is sold, and any surviving children reach the age of 21.

States may allow liens to be placed prior to an individual’s death. But federal law prohibits states from imposing pre-death liens unless the person is in a nursing facility and expected to be permanently institutionalized. Any pre-death lien must be removed if the individual is discharged from the nursing facility and returns to the community.

The look-back period for pre-eligibility transfers of assets: When determining MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. eligibility, states are required by federal law to ascertain whether an applicant transferred assets for less than fair-market value during the 60 previous months, and for California, 30 months (known as the look-back period). If an applicant is found to have gifted or transferred assets, a penalty period is imposed during which the applicant is ineligible for benefits. Although the look-back is intended to prevent people from sheltering assets in order to qualify for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. inappropriately, many transfers deemed inappropriate were done innocently before the need for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. was even apparent. The passage of the DeficitThe amount by which annual expenditures exceed annual revenues. Reduction Act in 2006 tightened the asset transfer rules. Applicants have the option of requesting a hardship waiver of the penalty period.

FINANCIAL PROTECTIONS AND CHOICE FOR MEDICAID PARTICIPANTS AND THEIR FAMILIES: Policy

FINANCIAL PROTECTIONS AND CHOICE FOR MEDICAID PARTICIPANTS AND THEIR FAMILIES: Policy

Public input

States should have an open contract development, waiver, or state plan amendmentThe state plan is a contract between a state and the federal government describing how the state administers its Medicaid program. Whenever a state makes changes to its Medicaid program, it sends state plan amendments (SPAs) to CMS for review and approval. process that provides opportunities for meaningful public input.

 

Medicaid financial eligibility criteria

All individuals with incomes at or below 100 percent of the povertyThe federal government defines “poverty” as income below specific thresholds. These thresholds are adjusted annually for inflation and vary according to family size and the age of the head of the family. line ($12,760 per year for an individual in 2020) should be considered categorically eligible for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets..

The federal government should increase the asset limitThe value of assets a person or family can have and still qualify for public assistance benefits. for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. eligibility and index it for inflation.

The federal government should allow home and community-based services (HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings.) waiver participants to keep more of their income by establishing a minimum community maintenance allowance (CMA) that states must adopt or exceed. A realistic CMA is needed to enable HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. waiver participants to remain in their homes and communities.

Transfer-of-assets look-back, penalty periods, and hardship waivers

Look-back period: Congress should repeal the five-year look-back period for asset transfers and return to the previous 36-month look-back window. Other provisions—including one that changed the start date of the penalty period to the date of application for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits (instead of date of transfer of the asset) and another that imposed a cap on home equity—should also be repealed. Congress should not modify these provisions in ways that further restrict eligibility for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.-funded long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

Federal and state regulations should define the types of transfers that will be presumed to be legitimate, such as charitable donations and contributions to relatives’ medical and educational expenses. A reasonable level of undocumented expenditures should also be deemed legitimate unless the state can demonstrate an intent to qualify for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. improperly.

Deliberately abusive practices should also be defined. Government attempts to prevent abusive asset transfers for the purpose of qualifying for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. should focus on deliberately fraudulent or abusive activities and loopholes in state laws, not the ordinary actions of typical families with moderate and low incomes. A threshold limit should be established for transfer-of-asset penalties so that those making reasonable levels of transfers for charities, religious donations, or personal gifts—or who are unable to provide documentation of all purchases over a five-year period—are not penalized. Some asset transfers should be exempt from consideration when implementing the DeficitThe amount by which annual expenditures exceed annual revenues. Reduction Act (DRA). These include:

  • those resulting from a court order because of fraud or misrepresentation; and
  • those made before the individual could reasonably have been expected to anticipate the need for long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ) within the next five years, for example, before the onset of a disabling injury or disease.

The imposition of a penalty period should be delayed until it is determined that the applicant has the income and resources sufficient to pay for all necessary medical and support care and treatment, food, housing, utilities, and other necessities of life for the duration of the penalty period.

Federal and state regulations should require monitoring during the penalty period to ensure that applicants are not deprived of care or necessities.

Prior to the imposition of a penalty, applicants seeking a hardship waiver of the penalty should receive assistance in developing a care plan and budget for medical and supportive services and necessities for the duration of the penalty period.

States should provide advance written notice to the applicant identifying the income and resources available—and the projected costs of medical and support care and treatment, food, housing, utilities, and other necessities of life—during the penalty period.

Applicants should be afforded the opportunity to appeal state determinations of support costs.

Hardship Waivers: Federal and state regulations should establish uniform criteria for evaluating whether denial of coverage under stringent DRA provisions causes hardship.

Federal and state regulations should allow for and promptly process hardship waiver requests and appeals prior to or during the penalty period.

Federal and state regulations should establish clear guidelines for defining what constitutes a hardship for determining transfer-of-asset penalties.

Hardship waivers should be granted to individuals who require LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. but would be denied MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. because of prohibited asset transfers.

Federal and state regulations should establish hardship waivers of the home equity limit in order to protect people who have no other way to pay for needed care and to ensure that people are not forced to sell their homes to get the needed care.

Federal regulations should require that states give all applicants information about the availability of hardship exceptions. They should ensure presumptive eligibility until a final decision is rendered and provide a standardized appeal process for people whose exemptionIncome that is excluded from taxation. requests are denied.

Recovery of transferred assets

States should not impose blanket requirements for applicants to seek the return of all transferred assets.

States should not mandate civil or criminal legal action to regain transferred assets. States could instead establish a minimum transfer amount for which recovery is required.

Frivolous recovery efforts lacking any lawful basis and criminal complaints motivating an applicant to file charges of malicious prosecution should be prohibited.

States should establish a hardship exception for those unable to make any recovery effort because of functional limitations.

Home equity barriers to Medicaid eligibility

Federal and state regulations should establish hardship waivers of the home equity limit that protect people who have no other way to pay for needed care.

The federal government should encourage states to provide clear information about other options to individuals who are denied MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. eligibility due to home equity under the DRA.

States should be required to use a fair process to determine an individual’s home equity (i.e., a home’s current fair-market value for property tax purposes, minus any outstanding debts against the home).

States should increase the home equity cap to the maximum permitted by federal law as permitted by the DeficitThe amount by which annual expenditures exceed annual revenues. Reduction Act.

States should not deny eligibility under the home equity provision if the individual is ineligible for a reverse mortgage A loan that allows older homeowners to tap into the equity in their home without having to make monthly mortgage payments while still living there. Homeowners can receive a single lump-sum payment, tap a credit line as needed, or receive a monthly amount. The loan becomes due and must… or unable to obtain a home equity loan.

Home equity cap

Federal and state regulations should exempt purchasers from the home equity cap established in the DRA.

Federal and state regulations should establish hardship waivers of the home equity limit to protect people who have no other way to pay for needed care.

For individuals who are found ineligible for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. due to home equity under the DRA, states should provide clear information about what other options those individuals have for securing needed LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. using private resources or through other public programs.

States should be required to use a fair process to determine an individual’s home equity. For example, obtaining a realtor’s assessment of a home’s current fair-market value, minus any outstanding debts against the home.

States should increase the home equity cap to the maximum permitted by federal law as permitted by the DRA. States should not deny eligibility under the home equity provision if the individual is ineligible for a reverse mortgage A loan that allows older homeowners to tap into the equity in their home without having to make monthly mortgage payments while still living there. Homeowners can receive a single lump-sum payment, tap a credit line as needed, or receive a monthly amount. The loan becomes due and must… or unable to obtain a home equity loan.

 

Impoverishment protection for spouses, domestic partners, and children

Unmarried domestic partners and spouses in same-sex marriages should be provided all the financial protections given to opposite-sex community spouses.

Current financial protections for spouses, caregivers, and dependent children should be retained and extended to domestic partners.

Federal and state governments should make permanent the financial protections that prevent the impoverishment of spouses of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. participants. Federal and state governments should continue prohibiting any requirement that adult children or grandchildren of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. participants receiving LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. assume financial responsibility for their parents’ or grandparents’ care.

States should set the highest community spouse resource allowance and spousal maintenance needs allowance possible under federal law to provide community spouses with the greatest financial protection.

Estate recovery programs

Heirs should have an extended period of time to reimburse the state. They should not be forced to sell the deceased person’s home. They should also be protected from coercive tactics designed to force repayment of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. expenditures.

The federal government and states should establish procedures for waiving estate recovery when undue hardship would result. States should be permitted to forego estate recovery of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. liens for families with low incomes.

Federal regulations should require states to use all money recovered from the estates of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. recipients to improve the program.

The term “estate” under the estate recovery program should be defined no more broadly than it is under state probate law.

Federal regulations should ensure public accountability by requiring estate recovery programs to provide consistent and readily available data on the total costs of the program and the numbers of participants affected. Other essential information should be included, such as the number of exemptions, deferrals, hardship waivers, liens, and contested recoveries.

Federal regulations should ensure that consumers are adequately informed about MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. estate recovery. Recovery notices should be timely, clear, and easy to read (e.g., published in an adequate type size). They should include vital information concerning exemptions, deferrals, hardship waivers, liens, and consumer obligations and rights.

Federal regulations prohibiting states from placing liens on the property of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. recipients who receive LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. in the home and community should remain in force.

Medically needy programs

The federal government should require all states to implement medically needy programs for people who need LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. in all settings.

States with medically needy programs for nursing facility residents should retain them.

States without medically needy programs should use the special income rule of 300 percent of the Supplemental Security IncomeThe SSI program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. benefit level.

Personal needs allowance (PNA)

The federal government should increase the minimum PNA for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. participants in nursing facilities and residential care settings. The allowance should be adjusted annually to account for changes in the cost of items for personal needs.