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Excerpts

GRANDMOTHER
When income does not count as an asset

FOR YOUR GRANDMOTHER TO QUALIFY for Medi-Cal benefits for her nursing home care, her end-of-month bank balance must be under $2,000. She must also be over age 65, or blind, or disabled, and have a medical need for nursing home care. You receive her latest bank statement and your stomach knots when you see an ending balance of $2,800. “ Blast it!” you mutter: “Now she won’t qualify and I’ll have to pay the nursing home out of my pocket!”

Maybe not. Think about this: when you balance your checkbook, do you accept the balance printed on your statement as the current balance in your check register? Probably not, since you likely wrote checks during the period between the closing date of the bank balance and the date you balance your checkbook.

Medi-Cal determines eligibility from month to month. If Grandmother qualifies for benefits on the last day of the month, she qualifies for the entire month. Now consider your Grandmother’s checking account. Suppose you wrote checks for $300 on her account during the month of application that were not posted to the account by the last day of the month. Subtracting these outstanding checks of $300 from $2,800 brings her closing balance to $2,500.

“So what?” you reply: “She still has more than $2,000. She has too much money to qualify.”

Maybe not. Grandmother receives $820 each month from Social Security. She also receives $180 pension income every month. Here is an important and often overlooked fact about Medi-Cal eligibility requirements: Income does not count as an asset in the month of receipt; income becomes an asset the month after it is received. Therefore, to calculate Grandmother’s non-exempt countable resources for any month, her income received that month must be deducted from the balance.

Grandmother’s non-exempt countable resources are calculated thusly:

Voila! Her assets are below $2,000. Grandmother qualifies. Your worries are over.

Maybe not. My first appeal of a Medi-Cal denial of benefits featured miscalculation of a checking account end-of-month balance by a county eligibility worker. When I called her supervisor, I received the same answer: Your client is overproperty.

When my client heard of the denial of benefits, she was upset and mistrustful of my assurances that Medi-Cal was wrong and I was right. I filled out the back of the denial notice and filed an appeal. I began researching regulations and sought counsel from my informal network of Medi-Cal consultants and attorneys to prepare for a hearing before an administrative law judge.

The case never reached the hearing level. I received a call from a county appeals specialist to discuss the case. When I explained the calculation errors of the eligibility worker and her supervisor, the appeals specialist asked if I would agree to a conditional withdrawal of my hearing request. If I agreed to withdraw my appeal request, the specialist would send the case back to the field office for re-processing. I was not relinquishing any of my client’s rights to appeal. I was simply giving Medi-Cal a second chance to get it right.

I agreed to withdraw my hearing request. The case was sent back to the field office. Shortly thereafter my client received a Notice of Action stating her application for benefits had been approved.

Medi-Cal operates under regulations and rules that often confuse consumers and professionals. Standard rules that apply in other areas of taxes, finances and law often are often disregarded under Medi-Cal regulations.

For example, many California residents know we live in a community property state, where property acquired during a marriage is deemed owned equally. An exception to this rule concerns inheritances. A married person may keep an inheritance as ‘separate property,’ distinct from the family’s community property. This distinction is disregarded by Medi-Cal. If a married woman has $100,000 of inheritance owned as her separate property, her inheritance is counted with the family’s community property when applying for Medi-Cal benefits for her husband.

Another Excerpt...Chapter 8