How Does Medicaid Treat Income?

The basic Medicaid rule for nursing home residents is that they must pay all of their income, minus certain deductions, to the nursing home. The deductions include a $60-a-month personal needs allowance (this amount may be somewhat higher or lower in your state), a deduction for any uncovered medical costs (including medical insurance premiums), and, in the case of a married applicant, an allowance for the spouse who continues to live at home if he or she needs income support. A deduction may also be allowed for a dependent child living at home.

In determining how a Medicaid applicant’s income affects his or her eligibility for nursing home coverage, most states use what is known as the “medically needy” or “spend-down” approach.  These states allow the applicant to spend down their income on their care until they reach the state’s income standard for eligibility, at which point Medicaid will begin covering their care.  In this way, those with incomes that exceed Medicaid’s thresholds can still qualify if they have high medical expenses, assuming they meet Medicaid’s other requirements.

But some states set a hard limit on the income permissible to qualify for Medicaid — no spend-down is allowed.  In these states, known as “income cap” states, eligibility for Medicaid benefits is barred if the nursing home resident’s income exceeds $2,349 a month (for 2020), unless the excess income above this amount is paid into a “(d)(4)(B)” or “Miller” trust. If you live in an income cap state, contact your attorney to set up a trust. The income cap states as of this writing are: Alabama, Alaska, Arizona, Arkansas, Colorado, Delaware, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Nevada, New Mexico, New Jersey, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, and Wyoming.

For Medicaid applicants who are married, the income of the healthy spouse living in the community (the “community spouse”) is not counted in determining the Medicaid applicant’s eligibility. Only income in the applicant’s name is counted in determining his or her eligibility. Thus, even if the community spouse is still working and earning, say, $5,000 a month, he or she will not have to contribute to the cost of caring for his or her spouse in a nursing home if the spouse is covered by Medicaid.