The Deficit Reduction Act of 2005 (DRA, enacted in 2006, made major changes to the transfer penalty rules for eligibility for Medicaid to pay for nursing home care. At the time, and until now, nursing home care was the only Medicaid service that had a lookback and transfer penalty.See GIS 06 MA/016.
Change Coming in January 2022 - New Lookback for MLTC & Other Home Care and Assisted Living Program (unless further postponed - stay tuned)
Until now, there has been NO transfer penalty for applying for Medicaid for Managed Long Term Care or other home care services, or for the Assisted Living Program, In the April 2020 NYS FY 20-21 Budget, NY enacted for the first time a transfer penalty for COMMUNITY long-term care coverage, The lookback will not apply to the waiver programs (TBI NHTDW, and OPWDD), or to Medicaid for primary or acute care - only long-term care.
The State has not proposed regulations but it did submit a request to CMS to modify the 1115 waiver, which governs the Managed Long Term Care program, giving some insight about how the lookback will be implemented. NYLAG filed these comments expressing concerns about these proposed procedures. In March 2021, the state amended its requrest to CMS. (Web) - (PDF) .
See webinar conducted April 15, 2021 with the latest on the lookback
In discussions with elder law attorneys in the NYSBA, DOH administrators provided this informal information:
Lookback for Nursing Home Care - Rules since 2006
Because the DRA is a Federal law, it was implemented differently in each State. CMS, the Federal agency administering Medicaid, issued guidance to the States on implementing the DRA (see State Medicaid Director Letter #06-018, and enclosures).
Two key New York State Department of Health directives give NYS policy on transfers of assets:
NOTE that these rules on transfer penalties apply to people who are Disabled, Aged 65+ or Blind (DAB). People who are not in this category or who do not have Medicare are in the "MAGI" Medicaid category. If they need nursing home care, they do have a "lookback" and transfer penalty, but the rules are slightly different. See this link below.
The Evelyn Frank Legal Resources Program published these training materials explaining the effects of the DRA on New York State's Medicaid program, including strategies for avoiding or minimizing transfer penalties:
Calculating the Look-Back Period
One of the changes in the DRA was to lengthen the look-back period for transfers of assets for nursing home Medicaid applications. When you apply for Medicaid coverage of a nursing home stay, the old rule was that you would be asked for the last 36 months (3 years) of financial documentation (bank statements, etc.) Transfers to a trust were subject to a 60-month (5-year) look-back period. The local district would review these to find any uncompensated transfers of assets (aka "gifts"), which are presumed to have been made in order to qualify for Medicaid. The total amount of transfers found is divided by the monthly regional nursing home rate (determined by the State DOH), and the quotient is the number of months that Medicaid will not pay for your nursing home stay (aka "the transfer penalty").
The DRA lengthened the look-back period from 36 months to 60 months for all transfers (not just to trusts). However, when the lookback is implemented for community-based care in January 2021, it will be 30 months.
Applying the Transfer Penalty
In addition, the DRA changed how the transfer penalty itself is imposed. It used to be that the penalty period would begin to run at the date of the transfer (which may have occurred long before the applicant is in the nursing home and applying for Medicaid). With the DRA, the penalty period does not begin to run until the applicant is in the nursing home, is otherwise eligible for Medicaid (i.e., is below the asset limit), and has submitted an application for Medicaid (which will inevitably be denied, because of the transfers). This new rule only applies for transfers that occurred after the effective date of the DRA. This table attempts to illustrate which penalty period rule applies, based on the date of the transfer:
The regional nursing home transfer penalty rates change annually in "General Information System" (GIS) messages posted at http://www.health.ny.gov/health_care/medicaid/publications/index.htm. The 2020 rates are published in
The general exceptions to the transfer penalty are as follows. For more detailed information consult an elder law attorney.
TRANSFER OF A HOME
Transfer of the home by applicant or spouse in 5-Year Lookback Period triggers a transfer penalty for NH Medicaid unless home transferred to:
TRANSFERS OF PROPERTY OTHER THAN THE HOME
Transfer of asset penalties are not imposed when an asset other than the individual’s home is transferred by the applicant or spouse to
A. Otherwise eligible for Medicaid (citizenship, assets within limits, etc.);
B. Unable to have the resources returned despite his/her best efforts, or to obtain fair market value for them, or to void a trust (if transfer was to a trust)(FH No. 6660774R, Suffolk Co. 3/12/2014 an undue hardship exemption was granted when, the Appellant’s representatives were in close contact with the DSS, apprising them of all developments and difficulties encountered in obtaining the Appellant's spousal financial documentation. AND
C. EITHER (1) Unable to obtain appropriate medical care such that the individual’s health or life would be endangered without Medicaid for nursing home services; OR (2) The transfer of assets penalty would deprive the individual of food, clothing, shelter, or other necessities of life.
EXAMPLES: No hardship found where Appellant not threatened with discharge from nursing home. FH No. 6657601M Albany Co. 3/10/2014, FH No. 67841713Z, Schenectady Co. 7/21/2014;
1996-ADM-08 Provisions on Transfers & Trusts at 23; 2006 OMM/ADM-5 at 19-20;
Impact of the Affordable Care Act on Transfer Penalties, Medicaid Liens and other Medicaid Rules - for "MAGI" Recipients (Under 65, without Medicare)
The Affordable Care Act (ACA) did not change the rules on transfer penalties described above for most people who need institutional (nursing home) Medicaid, since most people needing nursing home care are "Disabled, Aged 65+ or Blind" (known as "DAB.") The DAB budgeting rules were not changed by the ACA. This category is also known as "non-MAGI," as opposed to the "MAGI" category whose eligibility for Medicaid was significantly changed by the ACA. Generally, the "MAGI" are people who are not on Medicare. See articles on MAGI here. Even MAGI people -- those under age 65 who do not have Medicare and who are not disabled -- sometimes need nursing home care. For them, the State issued special rules on asset transfers, liens, and institutional budgeting. See NYS DOH GIS 14 MA/016: Long Term Care Eligibility Rules and Estate Recovery Provisions for MAGI Individuals -- PDF
Under the GIS, MAGI individuals who are "medically frail" may receive coverage for medically necessary nursing facility services. The need for nursing facility services qualifies the individual as "medically frail" and no further documentation is required. Individuals whose eligibility is determined under MAGI rules are not subject to a resource test for purposes of determining Medicaid eligibility.” However, MAGI Medicaid recipients are still subject to the transfer penalty, home equity limit, and estate recovery (but only for “the cost of nursing facility services, home and community-based services, and related hospital and prescription drug services received on or after the MAGI individual's 55th birthday”). However, they do NOT have to pay a NAMI, and a lien cannot be placed on their home.
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.