The Spouse at Home Keeps a Share: Size the Community Spouse's Allowances Before the Medicaid Application
When one spouse needs nursing facility care, Medicaid sets aside a protected share of the couple's money and income for the spouse who stays home, and that share has to be sized from the published figures rather than from memory or a neighbor's story.
Medicaid for nursing facility care does not treat a married couple as two separate people. When one spouse applies, the countable resources of both spouses are assessed together, and the rules then protect a share for the spouse who remains at home. The protected share is called the community spouse resource allowance, and the couple's income is handled by separate rules. Size the share before you fill out the application, because the numbers decide how much of the family's money must be spent down and which side of the line the household falls on.
Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.
Understand the two-household count
Medicaid.gov describes the spousal impoverishment rules as a way to keep the spouse at home from being left with nothing while the other spouse receives care. In general, the couple's countable resources are totaled, the community spouse keeps an allowance up to a set maximum, and the remainder is what the institutionalized spouse must reduce before eligibility. The home is generally excluded from the count when the spouse at home lives in it, subject to equity limits. The details are set in federal law and adjusted periodically, and Missouri DSS applies them to your case.
List every countable asset before the count
Make a list of every account, title and beneficiary designation, and write down the balance of each one on the day the count is taken. Include checking and savings accounts, investment and retirement accounts, vehicles, life insurance cash values, burial arrangements and any real estate other than the home. Note which accounts are in one spouse's name and which are joint, because the caseworker will ask. Do not guess at a balance you have not verified, and do not leave out an account because it seems small.
Fit the allowance to the published figures
The minimum and maximum community spouse allowances and the income allowance are set federally and adjusted periodically, and Missouri DSS publishes the figures in force for each period. Use the figures on Medicaid.gov and the DSS publication for the period in which you apply, not a number from an old printout or a letter from a friend. Subtract the allowance the spouse at home is entitled to from the couple's total countable resources, then look at what remains. That remainder is the amount the family must reduce before the nursing facility spouse can become eligible, and it is the number that should drive the planning conversation.
Ask the caseworker for the count in writing
Ask the Missouri DSS caseworker to name the community spouse allowance and the income allowance in writing, and ask which valuation method and which snapshot the agency uses to total the resources. Ask how the home is treated in your specific case and what documents the agency needs to verify the figures. Keep copies of everything you send and everything you receive. Aging Ahead can point you to free counseling in the St. Louis region, listed on the Local Help page, and a counselor can help you assemble the list, but a counselor does not decide eligibility.
Look-back and transfers stop here
Federal law sets a look-back period, generally five years, during which gifts or transfers for less than fair market value can delay Medicaid eligibility. Medicaid.gov describes the rule in general terms, but whether a particular transfer was made properly, whether it can be undone, and how it affects the spend-down plan are questions for an attorney. The same is true of annuities, trusts, estate recovery after death, and any appeal of a denial. The Missouri Bar can point you to elder law attorneys, and the lawyer decides the points that turn on your facts.
What to bring to the lawyer
Bring the asset list, the DSS notice of the allowances that apply, any transfers made in the look-back period with their paperwork, the deed for the home, and the application as filed. The lawyer's job begins where the count ends. Your job before that meeting is to make sure the numbers are the published ones and the list is complete.