oversight

Medicaid Long-Term Care: Information Obtained by States about Applicants' Assets Varies and May Be Insufficient

Published by the Government Accountability Office on 2012-07-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Requesters




July 2012
                             MEDICAID
                             LONG-TERM CARE
                             Information Obtained
                             by States about
                             Applicants’ Assets
                             Varies and May Be
                             Insufficient



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GAO-12-749
                                             July 2012

                                             MEDICAID LONG-TERM CARE
                                             Information Obtained by States about Applicants’
                                             Assets Varies and May Be Insufficient
Highlights of GAO-12-749, a report to
congressional requesters




Why GAO Did This Study                       What GAO Found
Medicaid—a joint federal-state health        States reported requiring applicants to provide documentation for most of the
care financing program for certain low-      13 types of assets included in GAO’s survey.
income individuals—paid for nearly half
of the nation’s $263 billion long-term       Number of States That Reported Requiring Documentation, by Type of Asset
care expenditures in 2010. To be
                                              Asset type           Description                                                           Number of states
financially eligible for Medicaid
                                              Income               Earned income                                                                       50
coverage for long-term care, applicants
cannot have assets—income and                                      Unearned income                                                                     49
resources—above certain limits.               Resources            Annuity, burial contract and prepaid funeral, financial and
                                                                   investment, life estate, and trust                                                  51
Federal law discourages individuals
                                                                   Life insurance, promissory note or loan, and real property other
from artificially impoverishing                                    than primary residence                                                              50
themselves in order to establish                                   Continuing care retirement community entrance fee                                   46
financial eligibility for Medicaid.
                                                                   Vehicle                                                                             38
Specifically, those who transfer assets
for less than fair market value during a                           Primary residence                                                                   37
specified time period—or “look-back”         Source: GAO web-based survey administered to state Medicaid officials.

period—before applying for Medicaid
may be ineligible for coverage for long-     States varied in the extent to which they obtained information from third parties to
term care for a period of time. The          verify applicants’ assets. For example, all states conducted data matches with
DRA extended the look-back period to         the Social Security Administration but used other sources to a lesser extent.
60 months and introduced new                 While states’ implementation of an electronic asset verification system (AVS) was
requirements for the treatment of            required on a rolling basis beginning in 2009, no state had fully implemented an
certain types of assets, such as             AVS at the time of GAO’s survey. Among the implementation challenges
annuities, in determining eligibility.       reported by states were lack of resources and getting financial institutions to
States are responsible for assessing         participate. Officials from the Centers for Medicare & Medicaid Services (CMS)
applicants’ eligibility for Medicaid, the    were aware of states’ progress and challenges and told GAO that they regularly
criteria for which varies by state.          communicated with states on AVS implementation.
GAO was asked to provide information         On the basis of states’ responses to questions about the extent of documentation
on states’ requirements and practices        required from applicants and information obtained from third parties, it is unclear
for assessing the financial eligibility of   whether some states obtain sufficient information to implement certain provisions
applicants for Medicaid long-term care       of the Deficit Reduction Act of 2005 (DRA). For example, 31 states reported
coverage. GAO examined the extent to         requiring less than 60 months of documentation from applicants and financial
which states (1) require documentation       institutions. The results of GAO’s survey raise questions about states’
of assets from applicants, (2) obtain
                                             implementation of the DRA, but are not conclusive. CMS officials said that it is
information from third parties to verify
                                             reasonable for states to only conduct reviews when there is reason to believe a
applicants’ assets, and (3) obtain
information about applicants’ assets         transfer of assets occurred. GAO has additional work planned related to
that could be used to implement              Medicaid long-term care financial eligibility.
eligibility-related DRA provisions. From     States must balance the costs of eligibility determination efforts with the need to
October 2011 to November 2011, GAO           ensure that those efforts provide sufficient information to implement federal
surveyed Medicaid officials from each        requirements. Given the complexities involved, it may be reasonable for states to
of the 50 states and the District of         adhere to a risk-based approach and focus their eligibility determination efforts
Columbia. GAO also interviewed
                                             on applicants who appear to be more likely to have assets or to have transferred
officials from CMS, the agency within
                                             assets that would make them ineligible. It is too early to assess the effectiveness
HHS that oversees Medicaid.
                                             of the AVS; its utility will ultimately depend on the breadth of the financial
                                             institutions participating and the depth of the information obtained.
View GAO-12-749. For more information,
contact Carolyn L. Yocom at (202) 512-7114   The Department of Health and Human Services (HHS) concurred with GAO’s
or yocomc@gao.gov.                           findings and commented that GAO’s comprehensive report will serve as a helpful
                                             resource for CMS and other interested parties.
                                                                                                            United States Government Accountability Office
Contents


Letter                                                                                      1
               Background                                                                   5
               States Required Applicants to Document Most Assets, but What
                   Was Considered Acceptable Proof Varied                                 10
               All States Obtained Some Amount of Asset Information from Third
                   Parties, and No State Had Implemented an Asset Verification
                   System                                                                 15
               It Is Unclear Whether Some States Obtain Sufficient Information to
                   Implement Certain DRA Provisions                                       22
               Concluding Observations                                                    26
               Agency Comments                                                            26

Appendix I     GAO Analysis of State Applications                                         28



Appendix II    States’ Asset Documentation Requirements                                   32



Appendix III   States’ Use of Data Matches to Verify Applicants’ Assets                   64



Appendix IV    States’ Contact with Financial Institutions to Verify Applicants’
               Assets                                                                     72



Appendix V     States’ Use of Property Records Searches to Verify Applicants’
               Assets                                                                     77



Appendix VI    States’ Use of Vehicle Records Searches to Verify Applicants’
               Assets                                                                     83



Appendix VII   States’ Collection of Third-Party Information to Identify Transfers
               of Assets                                                                  89




               Page i                                       GAO-12-749 Medicaid Long-Term Care
Appendix VIII   GAO Analysis of Annuity Language Contained in States’
                Application Forms                                                         91



Appendix IX     Comments from the Department of Health and Human Services                 94



Appendix X      GAO Contact and Staff Acknowledgments                                     96



Tables
                Table 1: Types of Assets and Examples                                       6
                Table 2: Summary of Selected Provisions in the Deficit Reduction
                         Act of 2005 (DRA) Related to Medicaid Eligibility for Long-
                         Term Care and Asset Transfers                                      8
                Table 3: Asset Verification System Implementation Timeline, by
                         Fiscal Year                                                      10
                Table 4: Example of States’ Variation in Treatment of Earned
                         Income Documentation, by Type of Documentation                   13
                Table 5: Number of States That Reported Conducting Data Matches
                         with Other Sources, the Proportion of Applicants
                         Screened, and When Screened in Relation to Eligibility
                         Determination, by Source of Data Match, 2011                     17
                Table 6: Number of States That Contact Financial Institutions to
                         Verify Applicants’ Assets, by Financial Institutions
                         Contacted and Proportion of Applicants, 2011 (n=24)              18
                Table 7: Number of States That Conduct Property Searches to
                         Verify Applicants’ Assets, by Geographic Area Covered and
                         Proportion of Applicants, 2011 (n=35)                            20
                Table 8: Characteristics of Medicaid Long-Term Care Application
                         Processes, by State, 2011                                        28
                Table 9: Time Frame of Information on Transfers of Assets
                         Requested in Medicaid Long-Term Care Application
                         Forms, by State, 2011                                            30
                Table 10a: Applicant Documentation Requirements for Medicaid
                         Long-Term Care, by State and Type of Asset, 2011                 32
                Table 10b: Applicant Documentation Requirements for Medicaid
                         Long-Term Care, by State and Type of Asset, 2011
                         (continued)                                                      35



                Page ii                                     GAO-12-749 Medicaid Long-Term Care
Table 11: States’ Treatment of Earned Income Documentation, by
        Type of Documentation, 2011                                      37
Table 12: States’ Treatment of Earned Income Documentation, by
        State and Type of Documentation, 2011                            38
Table 13: States’ Treatment of Unearned Income Documentation,
        by Type of Documentation, 2011                                   40
Table 14a: States’ Treatment of Unearned Income Documentation,
        by State and Type of Documentation, 2011                         41
Table 14b: States’ Treatment of Unearned Income Documentation,
        by State and Type of Documentation, 2011 (continued)             43
Table 15: States’ Treatment of Financial and Investment Resources
        Documentation, by Type of Documentation, 2011                    45
Table 16: States’ Treatment of Financial and Investment Resources
        Documentation, by State and Type of Documentation, 2011          46
Table 17: States’ Treatment of Life Insurance Documentation, by
        Type of Documentation, 2011                                      48
Table 18: States’ Treatment of Life Insurance Documentation, by
        State and Type of Documentation, 2011                            49
Table 19: States’ Treatment of Primary Residence Documentation,
        by Type of Documentation, 2011                                   51
Table 20: States’ Treatment of Primary Residence Documentation,
        by State and Type of Documentation, 2011                         52
Table 21: States’ Treatment of Documentation of Real Property
        other than Primary Residence, by Type of Documentation,
        2011                                                             54
Table 22: States’ Treatment of Documentation of Real Property
        other than Primary Residence, by State and Type of
        Documentation, 2011                                              55
Table 23: States’ Treatment of Vehicle Documentation, by Type of
        Documentation, 2011                                              57
Table 24: States’ Treatment of Vehicle Documentation, by State and
        Type of Documentation, 2011                                      58
Table 25: Amount of Required Documentation for Financial and
        Investment Resources, by State, 2011                             60
Table 26: Proportion of Applicants for Which States Require
        Additional Documentation to Identify Assets Transferred
        for Less Than Fair Market Value, by State, 2011                  62
Table 27a: Proportion of Applicants for which States Conduct Data
        Matches with Third Parties to Verify Applicants’ Assets, by
        State and Source of Data Match, 2011                             64




Page iii                                   GAO-12-749 Medicaid Long-Term Care
Table 27b: Proportion of Applicants for which States Conduct Data
        Matches with Third Parties to Verify Applicants’ Assets, by
        State and Source of Data Match, 2011 (continued)                   66
Table 28a: Timing of State Data Matches in Relation to Eligibility
        Determination, by State and Source of Data Match, 2011             68
Table 28b: Timing of State Data Matches in Relation to Eligibility
        Determination, by State and Source of Data Match, 2011
        (continued)                                                        70
Table 29: Proportion of Applicants for which States Contact
        Financial Institutions to Verify Applicants’ Assets, by State
        and Type of Financial Institution, 2011                            72
Table 30: Types and Number of Months of Information Requested
        from Financial Institutions, by State, 2011                        74
Table 31: Timing of States’ Contacts with Financial Institutions in
        Relation to Eligibility Determination, by State, 2011              76
Table 32: Proportion of Applicants for which States Conduct
        Property Records Searches to Verify Applicants’ Assets, by
        State and Geographic Area of Property Search Conducted,
        2011                                                               77
Table 33: Types of Information That Can Be Used to Conduct
        Property Records Searches, by State, 2011                          79
Table 34: Timing of States’ Property Records Searches in Relation
        to Eligibility Determination, by State, 2011                       81
Table 35: Proportion of Applicants for Which States Conduct
        Records Searches with the Department of Motor Vehicles
        to Verify Applicants’ Assets, by State, 2011                       83
Table 36: Types of Information That Can Be Used to Conduct
        Vehicle Records Searches, by State, 2011                           85
Table 37: Timing of States’ Record Searches with the Department
        of Motor Vehicles in Relation to Eligibility Determination,
        by State, 2011                                                     87
Table 38: Proportion of Applicants for Which States Take
        Additional Steps to Obtain Information from Third Parties
        to Identify Assets Transferred for Less Than Fair Market
        Value, by State, 2011                                              89
Table 39: Characteristics of Medicaid Long-Term Care Application
        Forms Related to Deficit Reduction Act of 2005 (DRA)
        Annuity Provisions, by State, 2011                                 91




Page iv                                      GAO-12-749 Medicaid Long-Term Care
Figures
          Figure 1: Asset Documentation Requirements, by State, 2011                                12
          Figure 2: Number of States That Require Financial and Investment
                   Resources Documentation, by Number of Months of
                   Documentation Required, 2011                                                     14
          Figure 3: Number of States Requesting Applicant Asset Information
                   from Financial Institutions, by Number of Months and
                   Type of Information Requested, 2011 (n=24)                                       19




          Abbreviations

          ADL               activities of daily living
          AVS               asset verification system
          CCRC              continuing care retirement community
          CMS               Centers for Medicare & Medicaid Services
          DMV               Department of Motor Vehicles
          DRA               Deficit Reduction Act of 2005
          FMV               fair market value
          HHS               Department of Health and Human Services
          IADL              instrumental activities of daily living
          IEVS              Income and Eligibility Verification System
          PARIS             Public Assistance Reporting Information System



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          Page v                                               GAO-12-749 Medicaid Long-Term Care
United States Government Accountability Office
Washington, DC 20548




                                   July 26, 2012

                                   The Honorable Orrin G. Hatch
                                   Ranking Member
                                   Committee on Finance
                                   United States Senate

                                   The Honorable Tom Coburn, M.D.
                                   Ranking Member
                                   Permanent Subcommittee on Investigations
                                   Committee on Homeland Security and Governmental Affairs
                                   United States Senate

                                   Long-term care, particularly nursing home care, can be costly; in 2010,
                                   the average annual cost for care in a nursing home was about $79,000. 1
                                   Nearly half of the nation’s $263 billion long-term care expenditures in
                                   2010 were paid by Medicaid, a joint federal-state health care financing
                                   program that covers certain categories of low-income individuals. Long-
                                   term care expenditures represent a significant portion of total Medicaid
                                   expenditures, comprising over one-quarter of the total $401 billion spent
                                   in fiscal year 2010. As the number of elderly Americans continues to grow
                                   and more individuals are likely to need long-term care, Medicaid spending
                                   for long-term care services is projected to increase. In light of the
                                   increased demand and associated burden that this places on already
                                   strained federal and state resources, it is important to ensure that only
                                   eligible individuals receive Medicaid coverage for long-term care.

                                   Individuals applying for Medicaid coverage for long-term care must meet
                                   certain financial and functional eligibility criteria. 2 To meet the financial


                                   1
                                    Metlife Mature Market Institute, The 2011 MetLife Market Survey of Nursing Home,
                                   Assisted Living, Adult Day Services, and Home Care Costs (Westport, Conn.: October
                                   2011).
                                   2
                                     For this report, we focus on financial eligibility—specifically financial eligibility for
                                   Medicaid coverage for long-term care. However, individuals applying for Medicaid
                                   coverage for long-term care must also meet functional eligibility criteria that are
                                   established by each state and generally involve a degree of impairment measured by
                                   limitations in an individual’s ability to carry out activities of daily living—eating, bathing,
                                   dressing, using the toilet, getting in and out of bed, and getting around the house—and
                                   instrumental activities of daily living, such as preparing meals, shopping for groceries, and
                                   getting around outside.




                                   Page 1                                                  GAO-12-749 Medicaid Long-Term Care
eligibility criteria, individuals must have assets that fall below established
levels, which vary by state, but are within standards set by the federal
government. Within the Medicaid program, assets have two broad
categories: income, which includes any funds received during a calendar
month that are used or could be used to meet food, clothing, or shelter
needs; and resources, which include anything owned, such as savings
accounts, stocks, or property, that can be converted to cash. 3 Not all
assets are counted in determining financial eligibility for Medicaid. For
example, states generally exclude—within specified limits—the value of
an individual’s primary residence, car, and prepaid burial arrangements.
Additionally, federal law includes provisions to discourage individuals
from artificially impoverishing themselves—for example, by transferring
their assets to certain family members—in order to establish financial
eligibility for Medicaid. Specifically, those who transfer assets for less
than fair market value (FMV) during a specified “look-back” period—a
period of time before application in which an individual’s assets are
reviewed—may be deemed ineligible for Medicaid coverage for long-term
care for a period of time. The Deficit Reduction Act of 2005 (DRA), which
was enacted in February 2006, amended certain existing provisions
regarding asset transfers for less than FMV and introduced new
requirements related to financial eligibility for Medicaid coverage for long-
term care. 4 For example, the DRA extended the look-back period from
36 months to 60 months for transfers occurring on or after its enactment
and introduced new requirements regarding how certain types of assets,
such as an individual’s home, should be considered when determining
Medicaid eligibility.

As the day-to-day administrators of the Medicaid program, states are
responsible for assessing applicants’ financial eligibility for Medicaid
coverage for long-term care; that is, determining whether an applicant’s
income and resources are below the state-established standards, and
whether an applicant transferred assets for less than FMV during the
look-back period. Our prior work and the work of others found that the




3
 This terminology is based on definitions provided in The State Medicaid Manual issued
by the Centers for Medicare & Medicaid Services (CMS), which specifies that assets
include both income and resources.
4
See Pub. L. No. 109-171, §§ 6011-6016, 120 Stat. 4, 61-67 (2006).




Page 2                                              GAO-12-749 Medicaid Long-Term Care
proportion of applicants deemed to be financially eligible for Medicaid
coverage for long-term care varied both across and within states. 5

Given the potential for state variation, you asked us for information on
states’ requirements and practices for assessing the financial eligibility of
individuals applying for Medicaid coverage for long-term care, including
states’ implementation of relevant DRA provisions. In this report, we
provide details on the extent to which states: (1) require individuals to
document assets when applying for Medicaid coverage for long-term
care; (2) obtain information from third parties to verify applicants’ assets;
and (3) obtain information about applicants’ assets that could be used to
implement DRA provisions related to eligibility for Medicaid coverage for
long-term care.

To address all three objectives, from October 2011 through November
2011, we administered a web-based survey to Medicaid officials from
each of the 50 states and the District of Columbia. 6 To ensure the clarity
and precision of our survey questions, we interviewed officials from the
Centers for Medicare & Medicaid Services (CMS), the agency within the
Department of Health and Human Services (HHS) that oversees
Medicaid; interviewed Medicaid officials from 3 states; reviewed states’
Medicaid applications for long-term care coverage; and pretested the
survey with Medicaid officials from 3 states. The survey requested
information about the types of documentation, if any, that states require
applicants for Medicaid coverage for long-term care to submit for 13 types
of assets: earned income, unearned income, financial and investment
resources, life insurance, primary residence, real property other than
primary residence, vehicles, annuities, burial contracts and prepaid
funeral arrangements, continuing care retirement community (CCRC)




5
 GAO, Medicaid Long-Term Care: Few Transferred Assets before Applying for Nursing
Home Coverage; Impact of Deficit Reduction Act on Eligibility Is Uncertain, GAO-07-280
(Washington, D.C.: Mar. 26, 2007); Nelson A. Rockefeller Institute of Government,
Assessing Asset Transfer for Medicaid Eligibility in New York State (March 2009).
6
 Throughout this document, the term state refers to the 50 states and the District of
Columbia.




Page 3                                                GAO-12-749 Medicaid Long-Term Care
entrance fees, life estates, promissory notes or loans, and trusts. 7 In
addition, the survey asked about the number of months of documentation
states required for earned income, unearned income, and financial and
investment resources. 8 The survey also asked about states’ practices to
obtain information from third parties to verify applicants’ assets, such as
whether, and to what extent, states conduct data matches with
10 sources, including the Social Security Administration and the Internal
Revenue Service, which primarily allow states to verify applicants’
income. Finally, the survey asked about any additional documentation
states require or additional steps states take to determine whether
applicants transferred assets for less than FMV during the 60-month look-
back period. We received survey responses from officials from all
51 states, although not every official responded to every question. We
relied on the data as reported by the state officials who were identified as
the primary contact for states’ documentation requirements and practices
for verifying the financial eligibility of applicants for Medicaid coverage for
long-term care. We did not independently verify these data; however, we
reviewed all responses for reasonableness and internal consistency, and
followed up with state officials for clarification where necessary. On the
basis of these activities, we determined these data were sufficiently
reliable for the purposes of our report. In addition to administering a
survey, we collected states’ application forms for Medicaid coverage for
long-term care to assess the types of asset information asked about on
the applications. 9 Finally, we interviewed CMS officials about federal
requirements related to eligibility determinations for Medicaid coverage
for long-term care, including the DRA provisions.



7
  A CCRC is generally a residential facility established in a campus-like setting that
provides access for older individuals to three levels of housing and care: independent
homes or apartments where residents live much as they did in their own homes; assisted
living, which provides help with the daily tasks of living; and skilled nursing care for those
with greater physical needs. Most residents must be able to live independently when they
enter into a contract with a CCRC, with the intent of moving through the three levels of
care as their needs change. A life estate is an interest in real property that gives the owner
of the interest the right to use and possess the property only for the duration of the life of a
person, usually the person who occupies the premises.
8
 The survey did not ask about the number of months of documentation required for other
types of assets, such as real property and trusts, as the documentation and value of these
assets are less likely to fluctuate over time.
9
 The application forms reviewed were those provided by the state officials who were
identified as the contacts for our survey. See app. I for information on states’ application
forms for Medicaid coverage for long-term care.




Page 4                                                  GAO-12-749 Medicaid Long-Term Care
                            We conducted this performance audit from July 2011 to July 2012 in
                            accordance with generally accepted government auditing standards.
                            Those standards require that we plan and perform the audit to obtain
                            sufficient, appropriate evidence to provide a reasonable basis for our
                            findings and conclusions based on our audit objectives. We believe that
                            the evidence obtained provides a reasonable basis for our findings and
                            conclusions based on our audit objectives.


                            Long-term care includes many types of services needed by individuals
Background                  who have a physical disability, a mental disability, or both. Long-term care
                            services can be provided in a variety of settings, including an individual’s
                            home or an institution, such as a nursing home. To be eligible for
                            Medicaid coverage for long-term care, individuals must be within certain
                            eligibility categories—such as those that are aged or disabled—and meet
                            functional and financial criteria. Within broad federal standards, states
                            determine whether an individual meets the functional criteria for long-term
                            care coverage by assessing an individual’s ability to carry out activities of
                            daily living (ADL), such as eating and getting around the house; and
                            instrumental activities of daily living (IADL), such as preparing meals and
                            shopping for groceries. The financial eligibility criteria are based on
                            individuals’ assets—income and resources together. States are
                            responsible for determining whether applicants meet the financial and
                            other eligibility criteria for Medicaid coverage for long-term care.


Financial Eligibility for   To qualify for Medicaid coverage for long-term care, individuals must
Medicaid Coverage for       have assets that fall below established standards, which vary by state,
Long-Term Care              but are within standards set by the federal government. The Medicaid
                            program bases its characterization of assets—income and resources—on
                            that used in the Supplemental Security Income program. 10 Income is
                            something received during a calendar month, paid either in cash or in-
                            kind, that is used or could be used to meet food or shelter needs;
                            resources are cash or real or personal property that are owned that can
                            be converted to cash and be used for food or shelter. (See table 1 for
                            examples of different types of income and resources.) In establishing
                            policy for determining financial eligibility for Medicaid coverage for long-



                            10
                              The Supplemental Security Income program provides cash assistance to aged, blind, or
                            disabled individuals with limited income and resources. 42 U.S.C. §§1381-1383f.




                            Page 5                                             GAO-12-749 Medicaid Long-Term Care
term care, states can decide, within federal standards, which assets are
countable. For example, states may disregard certain types or amounts of
income, and may elect not to count certain resources. 11 In most states, to
be financially eligible for Medicaid coverage for long-term care, individuals
must have $2,000 or less in countable resources ($3,000 for a married
couple). 12

Table 1: Types of Assets and Examples

 Type of asset Examples
 Income                 •     Money earned from work
                        •     Money generated from resources, such as interest, dividends, and
                              annuity payments
                        •     Money received from other sources, such as Social Security,
                              worker’s compensation, and unemployment benefits
 Resources              •     Cash
                        •     Financial and investment resources, such as bank accounts, stocks,
                              and bonds
                        •     Trusts
                        •     Annuities
                        •     Real property
                        •     Vehicles, such as automobiles and boats
                        •     Life insurance
Source: GAO analysis of Supplemental Security Income requirements.




11
  Although noncountable resources vary by state, for purposes of determining Medicaid
eligibility for long-term care, they generally include an individual’s home (typically if the
individual expresses the intent to return home), an automobile, household goods and
personal effects, burial spaces, and life insurance and burial arrangements up to a certain
value, among other things.
12
  For married couples, the Medicaid statute requires states to use specific minimum and
maximum resource standards in determining eligibility when one spouse is in an
institution, such as a nursing home, and the other remains in the community (referred to
as the community spouse). 42 U.S.C. § 1396r-5. The community spouse may retain an
amount equal to one-half of the couple’s combined countable resources, up to a
state-specified maximum level. States’ maximum resource levels cannot exceed the
maximum federal standard ($113,640 in 2012). If one-half of the couple’s combined
resources is less than a state-specified minimum resource level (which has to be at least
$22,728 in 2012), then the community spouse may retain resources up to that minimum
level.




Page 6                                                               GAO-12-749 Medicaid Long-Term Care
Transfers of Assets and the   Federal law limits Medicaid payment for long-term care services for
DRA                           persons who divest themselves of—or “transfer”—their assets for less
                              than FMV within a specified time period. 13 As a result, when an individual
                              applies for Medicaid coverage for long-term care, states conduct a
                              review, or “look back,” to determine whether the applicant (or his or her
                              spouse, if married) transferred assets to another person or party. If the
                              state determines an applicant transferred an asset for less than FMV
                              during the look-back period, the individual may be ineligible for Medicaid
                              coverage for long-term care for a period of time, called the penalty period.
                              The DRA extended the look-back period for transfers made on or after
                              February 8, 2006, to 60 months; prior to that, it was generally
                              36 months. 14

                              The DRA also specified circumstances under which the purchase of
                              certain assets—such as an annuity, promissory note or loan, or life
                              estate—is considered a transfer for less than FMV, and when entrance
                              fees for CCRCs are countable for purposes of determining Medicaid
                              eligibility. Additionally, while an individual’s primary residence is generally
                              not a countable resource for determining Medicaid eligibility, the DRA
                              specified when an individual with substantial equity interest in his or her
                              home is to be excluded from eligibility for Medicaid payment for long-term
                              care; the amount of allowable equity interest is established by each state
                              within federal guidelines. 15 See table 2 for a summary of these DRA



                              13
                                Federal law requires states to apply the transfer of asset provisions to institutionalized
                              individuals, who are defined in the Social Security Act as individuals who are inpatients in
                              a nursing facility or in a medical institution that is being paid based on a level of care
                              received in a nursing home, or certain recipients of home and community-based services.
                              42 U.S.C. § 1396p(h)(3). States have the option to apply such provisions to
                              noninstitutionalized individuals.
                              14
                                Among other things, the DRA also changed the beginning date of the penalty period;
                              included provisions regarding how the penalty period was to be calculated; and
                              established criteria and application, notice, and appeal requirements for undue hardship
                              waivers. Undue hardship exists when the application of a penalty period would deprive an
                              individual of (1) medical care such that the individual’s health or life would be endangered
                              or (2) food, clothing, shelter, or other necessities of life. Prior to the DRA, the criteria for
                              determining undue hardship had been established by the Secretary of HHS in Medicaid
                              guidance, namely The State Medicaid Manual. These provisions regarding the penalty
                              period and undue hardship are outside the scope of our study.
                              15
                                The DRA also included a provision regarding how a married applicant’s income should
                              be treated when determining how much of the applicant’s resources the community
                              spouse is entitled to retain. This provision is outside the scope of our study.




                              Page 7                                                  GAO-12-749 Medicaid Long-Term Care
                                             provisions. Most, but not all, of these DRA provisions became applicable
                                             on the date the law was enacted, February 8, 2006.

Table 2: Summary of Selected Provisions in the Deficit Reduction Act of 2005 (DRA) Related to Medicaid Eligibility for Long-
Term Care and Asset Transfers

DRA provision                            Description
Annuities                                •        States are required to treat the purchase of an annuity as a transfer for less than fair
                                                  market value (FMV) unless the annuity names the state as either (1) the remainder
                                                  beneficiary in the first position for at least the total amount of Medicaid expenditures
                                                  paid on behalf of the annuitant, or (2) a remainder beneficiary in the second position
                                                  after the community spouse, or minor or disabled child (or in the first position if any of
                                                  those individuals transfer the remainder of the annuity for less than FMV).
                                         •        Annuities purchased by or on the behalf of an individual who applied for Medicaid
                                                  coverage for long-term care shall be treated as a transfer of assets for less than FMV
                                                  unless the annuity is irrevocable, nonassignable, actuarially sound, and provides for
                                                  payments in equal amounts during the term of the annuity, with no deferral and no
                                                  balloon payments.
                                         •        Annuities purchased by or on the behalf of an individual who applied for Medicaid
                                                  coverage for long-term care services that are defined as individual retirement
                                                  accounts under federal tax code or purchased with the proceeds of certain retirement
                                                  accounts and meet certain federal tax code requirements are not considered transfers
                                                  for less than FMV.
                                         •        Applications for Medicaid coverage for long-term care shall: (1) describe any interest
                                                  an applicant or community spouse may have in an annuity, regardless of whether the
                                                  annuity is irrevocable or treated as an asset, and (2) include a statement that the
                                                  state becomes a remainder beneficiary of an annuity purchased on or after enactment
                                                  by virtue of the applicant’s receipt of Medicaid assistance for long-term care.
Continuing care retirement communities   States are required to consider certain entrance fees for continuing care retirement
                                         communities or life care communities as countable resources.
Home equity                              An individual with an equity interest in his or her home of more than $500,000 is excluded
                                         from eligibility for Medicaid payment for long-term care unless his/her spouse, child under
                                         age 21, or child who is considered blind or disabled lives in the home. A state can elect to
                                         increase this value up to $750,000. Beginning in 2011, the limit was to be increased each
                                         year based on the percentage increase in the consumer price index for all urban
                                                      a
                                         consumers.
Life estates                             States are required to consider a purchase of a life estate interest in another person’s
                                         home as a transfer of assets for less than FMV unless the purchaser lived in the home for
                                         at least 1 year after the date of purchase.
Promissory notes and loans               States are required to consider funds used to purchase a promissory note, loan, or
                                         mortgage as a transfer of assets for less than FMV unless the repayment terms are
                                         actuarially sound, provide for payments to be made in equal amounts during the term of
                                         the loan with no deferral or balloon payments, and prohibit the cancellation of the balance
                                         upon the death of the lender.
                                             Source: GAO analysis of the DRA.
                                             a
                                             In 2012, states’ home equity limits could range from $525,000 through $786,000.




                                             Page 8                                                   GAO-12-749 Medicaid Long-Term Care
States’ Determination of   To assess applicants’ financial eligibility for Medicaid coverage for long-
Applicants’ Financial      term care, and to determine whether they transferred assets for less than
Eligibility                FMV, states generally require applicants to submit applications and to
                           provide documentation of certain assets reported on the applications.
                           State Medicaid programs may also obtain information from third parties,
                           such as financial institutions or other government agencies, such as the
                           Social Security Administration. Such information helps states verify the
                           accuracy of applicants’ reported assets, as well as determine whether
                           applicants have assets they failed to report or transferred for less than
                           FMV during the look-back period. The processing of Medicaid
                           applications—including the collection of documentation and information
                           from applicants and third parties—is generally performed by local or
                           county-based eligibility workers.

                           In 2008, Congress passed legislation that required states to implement
                           electronic asset verification systems (AVS) to verify the assets of aged,
                           blind, or disabled applicants for Medicaid, including those seeking
                           Medicaid coverage for long-term care, with financial institutions. 16 An AVS
                           would provide states with an electronic mechanism to contact multiple
                           financial institutions, including those not reported by an applicant, to
                           determine if an applicant has, or had, an account and the value of any
                           existing accounts. 17 The law provides for states’ implementation of these
                           systems to occur on a rolling basis; the first systems were to be
                           implemented by the end of fiscal year 2009, with all states implementing
                           systems by the end of fiscal year 2013. 18 (See table 3.)




                           16
                             Supplemental Appropriations Act, 2008, Pub. L. No. 110-252, § 7001(d)(1), 122 Stat.
                           2323, 2391 (codified at 42 U.S.C. § 1396w).
                           17
                             According to guidance issued by CMS, verification requests through a state’s AVS must
                           be sent to financial institutions not identified by applicants based on some logic, such as
                           geographic proximity to the applicant’s home address, or other reasonable factors
                           whenever the state determines that such requests are needed for eligibility determination.
                           Additionally, per CMS guidance, the verification requests must include a request for
                           information on both open and closed accounts, going back for a period up to 5 years, as
                           determined by the state.
                           18
                             The Supplemental Appropriations Act, 2008, required California, New Jersey, and New
                           York to implement an AVS for aged, blind, and disabled applicants by the end of fiscal
                           year 2009 and directed the Secretary of HHS to require the remaining states to implement
                           their systems in a manner that results in a specified percentage of aged, blind, and
                           disabled Medicaid applicants being subject to this type of asset verification each year over
                           the 5-year period of fiscal year 2009 through fiscal year 2013.




                           Page 9                                                GAO-12-749 Medicaid Long-Term Care
                       Table 3: Asset Verification System Implementation Timeline, by Fiscal Year

                                               Number
                        Fiscal year           of states          States
                        2009                              9      California, Missouri, New Hampshire, New Jersey, New
                                                                 Mexico, New York, Oregon, South Carolina, Washington
                        2010                              9      Connecticut, Georgia, Kentucky, Mississippi, Nevada,
                                                                 Oklahoma, Rhode Island, Vermont, Wisconsin
                        2011                              7      Hawaii, Indiana, Michigan, Maryland, North Carolina, Ohio,
                                                                 Wyoming
                        2012                            11       Alaska, Arizona, Florida, Iowa, Illinois, North Dakota, South
                                                                 Dakota, Tennessee, Texas, Utah, West Virginia
                        2013                            15       Alabama, Arkansas, Colorado, District of Columbia,
                                                                 Delaware, Idaho, Kansas, Louisiana, Massachusetts, Maine,
                                                                 Minnesota, Montana, Nebraska, Pennsylvania, Virginia
                       Source: Supplemental Appropriations Act, 2008, Pub. L. No. 110-252, § 7001(d)(1), 122 Stat. 2323, 2391 (codified at 42 U.S.C.
                       § 1396w) and the Centers for Medicare & Medicaid Services.

                       Note: The Supplemental Appropriations Act, 2008, required California, New Jersey, and New York to
                       implement an asset verification system for aged, blind, and disabled applicants by the end of fiscal
                       year 2009 and directed the Secretary of the Department of Health and Human Services to require the
                       remaining states to implement their systems in a manner that results in a specified percentage of
                       aged, blind, and disabled Medicaid applicants being subject to this type of asset verification each year
                       over the 5-year period of fiscal year 2009 through fiscal year 2013.


                       States reported requiring applicants to provide documentation for most of
States Required        the 13 types of assets contained in our survey; however, the types and
Applicants to          number of months of documentation that the states considered to be
                       acceptable proof for determining an applicant’s financial eligibility for
Document Most          Medicaid coverage for long-term care varied. 19 Specifically, 44 states
Assets, but What Was   required documentation for at least 12 of the 13 types of assets. All states
Considered             reported requiring documentation of annuities, burial contracts and
                       prepaid funeral arrangements, financial and investment resources, life
Acceptable Proof       estates, and trusts, while fewer states reported requiring documentation
Varied                 of other types of assets. States were least likely to require documentation
                       of vehicles (38 states) and primary residence (37 states), resources that




                       19
                         As previously noted, the 13 types of assets included in our survey were: earned income,
                       unearned income, financial and investment resources, life insurance, primary residence,
                       real property other than primary residence, vehicles, annuities, burial contracts and
                       prepaid funeral arrangements, CCRC entrance fees, life estates, promissory notes or
                       loans, and trusts.




                       Page 10                                                                       GAO-12-749 Medicaid Long-Term Care
states may choose not to count for purposes of determining financial
eligibility for Medicaid coverage for long-term care. 20 (See fig. 1.)




20
  Officials from several states reported not requiring documentation of an applicant’s
vehicle, primary residence, or both because the state does not count them for purposes of
determining financial eligibility for Medicaid coverage for long-term care.




Page 11                                             GAO-12-749 Medicaid Long-Term Care
Figure 1: Asset Documentation Requirements, by State, 2011



                      WA
                      12
                                                                                                                                                                  ME      VT - 12
                                                     MT
                                                                            ND                                                                                     12
                                                     12
                                                                            12              MN                                                                            NH - 13
                 OR
                 13                                                                         12
                                  ID
                                                                                                                                                       NY                 MA - 13
                                  12                                       SD                              WI
                                                                            12                                                                         12
                                                                                                           13            MI                                               RI - 12
                                                      WY
                                                      13                                                                 13
                                                                                                 IA                                               PA                      CT - 12
                                                                            NE                   10                                               13
                      NV
                                                                            13                                  IL     IN         OH                                      NJ - 13
                      13                UT
            CA                                                                                                  13     13         13
                                       12                  CO                                                                           WV                                DE - 12
            11                                             12                      KS                                                   13        VA
                                                                                                      MO                     KY
                                                                                   12                                                             11                      MD - 13
                                                                                                      13                     13
                                                                                                                                                  NC                      DC - 9
                                                                                                                        TN                        13
                                   AZ                                               OK                                 11
                                   13                 NM                            12                AR                                  SC
                                                      12                                              12                                     13
                                                                                                                MS     AL          GA                              INTERACTIVE
            HI                                                                                                  12    13           13                             INSTRUCTIONS
                                                                             TX                       LA
            13                                                                                                                                                  Roll your mouse over
                                                                             13                       9
                                                                                                                                                                the state name to see
                                         AK                                                                                                                       more information.
                                         11                                                                                                                       To print expanded
                                                                                                                                             FL                    information, see
                                                                                                                                             13                       appendix II.




                           Total number of states that require
 Type of asset              documentation for this asset type
 Income
 Earned                                                    50
 Unearned                                                  49
                                                                   Number of asset types
 Resources                                                         that require documentation
 Annuity                                                   51
 Burial contract and pre-paid funeral                      51
                                                                              9
 Financial and investment                                  51
 Life estate                                               51
 Trust                                                     51                 10
 Life insurance                                            50
 Promissory note or loana                                  50                 11
 Real property other than primary residence                50
 Continuing care retirement community entrance fee         46                 12
 Vehicle                                                   38
 Primary residence                                         37                 13


                                                                   Source: GAO web-based survey administered to state Medicaid officials (data); Map Resources (map).

                                                                   aThe District of Columbia did not respond to the question about whether or not documentation of
                                                                   promissory notes or loans is required.




                                                                 Page L2
                                                                      12                                                                       GAO-12-749 Medicaid Long-Term Care
                                                                                                                                                                      GAO-12-749
Officials from several states reported not requiring documentation for a
particular type of asset because the state was able to obtain the
necessary information from a third party. For example, while 50 states
reported requiring applicants to submit documentation of earned income,
one state did not have such a requirement because the amount of earned
income was verified through an interface with the state’s Department of
Labor. It was less clear how states assessed other assets—such as
vehicles or CCRC entrance fees—absent documentation.

Our survey also showed that states varied in how they treated specific
types of documentation; that is, whether the documentation was required,
acceptable as proof by itself, acceptable as proof with other
documentation, or not acceptable as proof of an applicant’s assets. For
example, while states generally found a written statement of earnings
from an employer as acceptable documentation of earned income, there
was more variation in how they treated other types of documentation.
(See table 4.)

Table 4: Example of States’ Variation in Treatment of Earned Income
Documentation, by Type of Documentation

                                                                         Number of states
                                                                                    Acceptable
                                                   Acceptable as                     with other          Not
    Type of documentation                 Required    proof itself               documentation    acceptable
    Copy of check or check
         a
    stub                                              3                     33                9             4
                                     a
    Itemized bank statement                           1                      6               20            22
    Written statement of
    earnings from employer                            0                     49                1             0
Source: GAO web-based survey administered to state Medicaid officials.

Notes: This table only includes responses from the 50 states that required documentation of earned
income.
a
 One state did not specify the level of acceptability for this type of documentation.


States also varied in the number of months of documentation required
from applicants, especially as it related to financial and investment
resources. Although all 51 states reported requiring documentation of
financial and investment resources, 27 required only current
documentation, while the remaining 24 required both current and past
documentation. Of the 24 states that required documentation of both
current and past financial and investment resources, most required
60 months of documentation, while the remaining states required fewer



Page 13                                                                     GAO-12-749 Medicaid Long-Term Care
months of documentation. (See fig. 2.) There was some variation, but to a
lesser extent, in the amount of documentation of earned and unearned
income that states required from applicants. Of the 50 states that required
applicants to provide earned income documentation, 47 required only
current documentation. Of the 3 remaining states, 2 required 3 months of
documentation and 1 required 2 months of documentation. 21 Of the
49 states that required unearned income documentation, 47 only required
documentation of current unearned income. The other 2 states required
3 months of documentation. 22

Figure 2: Number of States That Require Financial and Investment Resources
Documentation, by Number of Months of Documentation Required, 2011




a
 One state reported it required both current and past documentation for financial and investment
resources, but did not specify the number of months of documentation required because it is
determined on a case-by-case basis. In some cases, the state may require up to 60 months of
documentation.




21
 Missouri and Montana required 3 months of earned income documentation and
Tennessee required 2 months of earned income documentation.
22
    The 2 states are New Hampshire and Vermont.




Page 14                                                    GAO-12-749 Medicaid Long-Term Care
                              In addition to the documentation required to assess whether applicants’
                              assets were within state financial eligibility levels, 38 states reported
                              requiring additional documentation from at least some applicants to
                              identify assets transferred for less than FMV. Of these 38 states,
                              16 indicated they required additional documentation only if an applicant
                              reported making a transfer, 5 reported doing so only if an applicant’s
                              information was questionable, and 8 reported both of these reasons. Of
                              the remaining 9 states, 7 required additional documentation from all
                              applicants, and 2 did not specify the circumstances that would result in a
                              request for additional documentation.

                              Appendix II provides additional information on states’ asset
                              documentation requirements for individuals applying for Medicaid
                              coverage for long-term care.


                              All 51 states reported that they obtained some amount of asset
All States Obtained           information from third parties, although the extent of the screenings
Some Amount of                conducted varied by state. No state had implemented an electronic AVS,
                              which would allow them to contact multiple financial institutions—
Asset Information             including those not reported by an applicant—to determine the existence
from Third Parties,           and value of any accounts belonging to an applicant. States reported
and No State Had              challenges to implementing an AVS including not having sufficient
                              resources.
Implemented an Asset
Verification System

States Varied in the Extent   To varying degrees, states reported obtaining information from third
to Which They Obtained        parties through a variety of mechanisms, including data matches, direct
Information from Third        contact with financial institutions, and property and vehicle records
                              searches. Some states also reported taking additional verification steps to
Parties                       determine if an applicant transferred assets for less than FMV during the
                              look-back period.




                              Page 15                                     GAO-12-749 Medicaid Long-Term Care
Conduct Data Matches   All 51 states reported that they conduct data matches with the Social
                       Security Administration to verify at least some applicants’ assets.
                       However, states’ use of data matches with other sources of asset
                       information—primarily related to income—varied, ranging from 48 states
                       reporting data matches with state unemployment records, to as few as
                       6 states reporting data matches with state tax records. On average,
                       states conducted data matches with 6 of the 10 sources included in our
                       survey; the number of sources states reported using ranged from 1 to 9. 23
                       In addition to variations in the use of data match sources, states varied in
                       terms of the proportion of applicants screened, and when during the
                       eligibility process the state conducted the screen. For example, most
                       states reported conducting a data match with the Social Security
                       Administration generally before determining an applicant’s eligibility. In
                       contrast, of the 30 states that reported conducting a data match with the
                       Internal Revenue Service for at least some applicants, 21 reported doing
                       so generally after determining eligibility. (See table 5 for summary
                       information and app. III for more detailed information about the data
                       matches conducted by states.)




                       23
                         While all states provided some information about their use of data matches, some states
                       did not provide responses about their use of all 10 of the sources included in our survey.




                       Page 16                                              GAO-12-749 Medicaid Long-Term Care
Table 5: Number of States That Reported Conducting Data Matches with Other Sources, the Proportion of Applicants
Screened, and When Screened in Relation to Eligibility Determination, by Source of Data Match, 2011

                                                                                                                          When screened in relation to
                                                                                                           b                                         c
                                                                      Proportion of applicants                             eligibility determination
                                            States that
                                          conduct data                                                                   Generally                Generally
                                                      a                             d                                                         e
Source of the data match                        match              All       Most         Some             None            before    Varied           after
Social Security Administration                            51       43               6            2                  0           40         6             2
State unemployment records                                48       31               5          12                   2           29         7             6
Income and Eligibility Verification                       44       36               4            4                  6           21         6            14
       f
System
Public Assistance Reporting                               42       31               2            9                  6            4         6            30
                   g
Information System
State wage files/directory of new hires                   41       26               7            8                  8           20         9             8
Internal Revenue Service                                  30       22               1            7              20               6         2            21
Department of Veterans Affairs                            22         9              0          13               26              11         6             3
State workman’s compensation                              17         7              1            9             30                6         5             4
records
                                  h
National Directory of New Hires                           14         9              2            3             33                7         3             4
State tax records                                          6         2              1            3             42                3         1             2
                                           Source: GAO web-based survey administered to state Medicaid officials.
                                           a
                                            Represents the number of states that reported conducting the data match for at least some
                                           applicants.
                                           b
                                            In each row, the number of states may not add to 51 because not all states answered the question
                                           regarding the proportion of applicants, if any, for the respective data match source.
                                           c
                                             In each row, the number of states may not add to the total number that conduct a data match with
                                           that source because not all states specified when the screening occurred in relation to eligibility
                                           determination.
                                           d
                                               “Most” is more than half of applicants.
                                           e
                                               “Varied” is sometimes before and sometimes after eligibility determination.
                                           f
                                            Each state is required to operate an Income and Eligibility Verification System that allows the state to
                                           match applicant-reported income information with data from the Internal Revenue Service, the Social
                                           Security Administration, and state wage and unemployment insurance benefit records. States that
                                           reported using this system to verify applicants’ assets may use some or all of the data available.
                                           g
                                            The Public Assistance Reporting Information System (PARIS) is an electronic data matching and
                                           information exchange system that is designed to match state enrollment information, including
                                           Medicaid enrollment, with data from other participating states and from a selected group of federal
                                           databases. The federal databases include, among other things, information on individuals’ receipt of
                                           income from the Department of Veterans Affairs, the Department of Defense, and the Office of
                                           Personnel Management. States that reported conducting a PARIS data match may use some or all of
                                           the data available.
                                           h
                                            The National Directory of New Hires is a national database of employment wage and unemployment
                                           insurance information for use by federal and state agencies.




                                           Page 17                                                                      GAO-12-749 Medicaid Long-Term Care
Contact Financial Institutions   Twenty-four states reported that they contact financial institutions to verify
                                 at least some applicants’ financial and investment resources, while the
                                 remaining 27 did not. However, these 24 states varied in terms of the
                                 range of financial institutions they contacted and the proportion of
                                 applicants about whom they inquired. (See table 6.)

                                 Table 6: Number of States That Contact Financial Institutions to Verify Applicants’
                                 Assets, by Financial Institutions Contacted and Proportion of Applicants, 2011
                                 (n=24)

                                                                                                                     Proportion of applicants
                                  Type of financial institution                                              Total        All   Most    Some
                                  Institutions with accounts reported by applicant                              24         11       0      13
                                  Local institutions that were not reported by applicant                        11          4       1       6
                                  Statewide institutions that were not reported by
                                  applicant                                                                      7          3       1       3
                                  National institutions that were not reported by
                                  applicant                                                                      5          1       2       2
                                 Source: GAO web-based survey administered to state Medicaid officials.



                                 Some states reported contacting multiple types of financial institutions,
                                 such as institutions applicants reported having accounts with, and some
                                 that applicants did not report. However, 13 of the 24 states reported
                                 contacting only financial institutions with whom the applicant reported
                                 having an account; of these 13 states, 3 states contacted financial
                                 institutions for all applicants, while the other 10 states did so for some
                                 applicants. These 13 states, and the 27 that reported not contacting any
                                 financial institutions, are unlikely to identify accounts that an applicant
                                 failed to report. Of the remaining 11 states that reported contacting
                                 financial institutions not reported by an applicant, 3 reported contacting
                                 only local institutions, whereas the other 8 contacted a combination of
                                 local, statewide, and national institutions. Regarding the proportion of
                                 applicants for which states contact financial institutions, half of the
                                 24 states reported they only contact financial institutions if an applicant
                                 submits insufficient information or provides questionable information.

                                 Of the 24 states that reported they contact financial institutions to request
                                 information, the type of information—account balances or itemized
                                 statements—and the number of months they request varied. (See fig. 3.)
                                 Specifically, half of these states requested itemized statements that
                                 include information on each transaction, while the other half requested
                                 monthly account balances. Most of the states that requested account
                                 balances did so for 3 or fewer months. Of the 12 states that requested


                                 Page 18                                                                  GAO-12-749 Medicaid Long-Term Care
itemized statements, 5 requested 60 months of statements, 3 requested
only the statement for the current month, and the other 4 states requested
between 3 and 36 months of information.

Figure 3: Number of States Requesting Applicant Asset Information from Financial
Institutions, by Number of Months and Type of Information Requested, 2011 (n=24)




a
 One state reported that it requests the current balance for any open accounts and the closing
balance for any accounts that were closed within the past 60 months.
b
 Twelve states reported that they request account balances from financial institutions; however, one
of these states did not specify the number of months of information it requested and noted it would
request whatever amount is needed.


Most of the states (20 of 24) reported that they contact financial
institutions for asset information before determining eligibility. Appendix IV
provides additional information about states’ contact with financial
institutions to verify applicants’ assets.




Page 19                                                     GAO-12-749 Medicaid Long-Term Care
Search Property Records   Thirty-five states reported that they conduct some type of property
                          records search to verify at least some applicants’ real property. The
                          extent of the searches varied in terms of the geographic area covered
                          and the proportion of applicants for which property searches were
                          conducted. (See table 7.)

                          Table 7: Number of States That Conduct Property Searches to Verify Applicants’
                          Assets, by Geographic Area Covered and Proportion of Applicants, 2011 (n=35)

                                                                                                                  Proportion of
                                                                                                                   applicants
                           Geographic area of property search conducted                              Total       All   Most    Some
                           Applicant’s county of residence                                              34        16       7      11
                           Some other counties in state                                                 31         6       3      22
                           All counties in state                                                        19         6       1      12
                           Locations in other states                                                    16         2       0      14
                          Source: GAO web-based survey administered to state Medicaid officials.



                          Of the 35 states that reported conducting property searches, 2 states
                          conduct property searches only within an applicant’s county of residence.
                          Of the 33 states that reported conducting property searches beyond an
                          applicant’s county of residence, 8 do so only if they have reason to
                          believe the applicant lived in another county or state. Additionally, 12 of
                          the 35 states indicated they conduct property searches only when an
                          applicant submits questionable or insufficient information, an applicant
                          reports the property, or a combination of both factors.

                          States reported being able to conduct property searches using several
                          types of information, including an applicant’s name (33 states), property
                          address (32 states), property zip code (12 states), or an applicant’s Social
                          Security number (10 states). Most of the states (29 of the 35) reported
                          that they generally conduct property searches before determining
                          eligibility. Appendix V provides additional information about the property
                          searches conducted by states.

Search Vehicle Records    Thirty states reported that they conduct searches of Department of Motor
                          Vehicles’ (DMV) records to verify at least some applicants’ vehicles.
                          Specifically, 14 states reported conducting vehicle searches for all
                          applicants and 1 state reported conducting searches for most of its
                          applicants. The remaining 15 reported conducting such searches for less
                          than half of their applicants; of these 15 states, 6 indicated that they only
                          conduct searches of vehicle records if they receive information from an



                          Page 20                                                                  GAO-12-749 Medicaid Long-Term Care
                             applicant that they deem questionable. States reported being able to
                             search these records using several types of information, including an
                             applicant’s name (29 states), a vehicle identification number (20 states),
                             and an applicant’s driver’s license or license plate number (18 states
                             each). Most of the states (25 of the 30 states) reported that they generally
                             conduct DMV searches before determining eligibility. Appendix VI
                             provides additional information about the vehicle searches conducted by
                             states.

Take Additional Steps to     Twenty-two states reported taking additional steps to obtain information
Identify Asset Transfers     from third parties, such as conducting additional property searches, to
                             identify assets transferred for less than FMV; 7 states reported doing this
                             for all applicants; and 15 states reported doing this for some applicants.
                             Of the 15 states that reported taking additional verification steps for just
                             some applicants, most of them indicated they do so only if they question
                             the information provided by applicants or have reason to believe a
                             transfer may have occurred, such as if an applicant reported making a
                             transfer. Appendix VII provides information on the proportion of applicants
                             for which each state reported taking additional verification steps to identify
                             assets transferred for less than FMV during the look-back period.


No State Had Implemented     Although 25 states were supposed to have implemented their electronic
an Asset Verification        AVS to obtain information from financial institutions by the end of fiscal
System to Obtain             year 2011, no state had implemented one at the time of our survey.
                             Eighteen states reported that they were in the process of implementing an
Information from Financial   AVS, while the remaining 33 states had yet to begin implementation.
Institutions
                             When asked about the challenges to implementing an AVS, 32 states
                             reported that they did not have enough resources—such as money, staff,
                             or time—required to implement such a system, and 18 states reported
                             that it had been or would be challenging to get financial institutions to
                             participate and provide information. One state reported that it had initially
                             planned to have its AVS implemented by December 2011, but was unable
                             to do so because financial institutions in the state were unwilling to
                             participate in the AVS until state legislation is passed that releases the
                             financial institutions from any liability, ensures they are fairly reimbursed
                             for their services, and makes the process voluntary. The state Medicaid
                             program is seeking such legislation during the state’s 2012 legislative
                             session and then plans to proceed with implementing its AVS.




                             Page 21                                      GAO-12-749 Medicaid Long-Term Care
                         CMS acknowledged that states may have challenges that could affect
                         their ability to implement an AVS as scheduled. CMS officials were aware
                         of states’ progress in implementing the AVS and told us that the agency
                         was regularly communicating with states regarding AVS implementation.


                         On the basis of states’ responses to questions about the documentation
It Is Unclear Whether    required from applicants and the asset information obtained from third
Some States Obtain       parties, it is unclear whether some states obtain sufficient information to
                         implement certain DRA provisions, particularly the provisions related to
Sufficient Information   the look-back period and home equity. The results of our survey raise
to Implement Certain     questions about some states’ implementation of the DRA, but are not
DRA Provisions           conclusive, and we have additional work planned related to Medicaid
                         long-term care financial eligibility.

                         •     Look-back Period. We asked states about (1) the number of months
                               of financial and investment resources documentation required to
                               determine eligibility, (2) additional documentation required to identify
                               assets transferred for less than fair market value, and (3) number of
                               months of documentation obtained directly from financial institutions.
                               When considering states’ responses to those questions, we found that
                               31 states reported obtaining less than 60 months of information about
                               at least some applicants’ assets. 24 Three of the 31 states reported
                               requiring a single month of documentation from applicants and did not
                               obtain any information from financial institutions. 25 CMS officials noted
                               that it is costly and time consuming to conduct a review for the
                               60 month look-back period. Thus, these officials stated, it was
                               understandable for states to use discretion and only conduct reviews
                               when there is reason to believe that a transfer could have been made
                               during the look-back period. For example, a state might determine the
                               need to conduct a more thorough review as a result of red flags found


                         24
                           The 31 states are: Alaska, Arizona, Arkansas, California, Colorado, District of Columbia,
                         Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts,
                         Michigan, Minnesota, Nebraska, New Mexico, North Dakota, Oklahoma, Pennsylvania,
                         Rhode Island, South Dakota, Tennessee, Texas, Virginia, Washington, West Virginia,
                         Wisconsin, and Wyoming. Ten of these states reported they may require up to 60 months
                         of additional documentation from at least some applicants to identify assets that were
                         transferred for less than FMV or may request additional information from financial
                         institutions or a combination of both factors, in situations where, for example, an applicant
                         reported making a transfer or submitted insufficient information.
                         25
                             The 3 states are: Arkansas, District of Columbia, and Minnesota.




                         Page 22                                               GAO-12-749 Medicaid Long-Term Care
      through other checks, such as when an applicant has very high
      income and no resources. However, the application forms in 6 of the
      31 states did not ask about transfers made during the entire look-back
      period. 26 Thus, it is unclear how these 6 states would know whether
      assets were transferred for less than FMV in the 60 months prior to
      application, and how all 31 states would be able to detect unreported
      transfers of assets made during the entire look-back period. In
      contrast, 20 states reported requiring 60 months of documentation
      from all applicants, 5 of which also requested 60 months of
      information from financial institutions for at least some applicants. 27

•     Home Equity. Fourteen states reported not requiring documentation
      of a primary residence. Of these 14 states, 8 indicated that they
      conduct property record searches in the county of residence for at
      least some applicants to try to obtain information about property the
      applicant may own. 28 Additionally, 1 state indicated that it could obtain
      information about an applicant’s primary residence from a third
      party. 29 The remaining 5 states reported they did not conduct property
      records searches; as such, it is unclear how these states would
      determine if an applicant owns a home that he or she failed to report,




26
  The 6 states are: Arizona, Arkansas, California, District of Columbia, Georgia, and
Indiana. These states’ application forms either did not ask about transfers of assets or
asked about transfers made for a period of time less than 60 months. Our review was
limited to state application forms for Medicaid coverage for long-term care provided to us
by state officials. Some states might ask about transfers made during the look-back period
through other means, such as a form other than the long-term care application form or
through an interview conducted as part of the application process.
27
 The 20 states are: Alabama, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland,
Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North
Carolina, Ohio, Oregon, South Carolina, Utah, and Vermont.
28
  Of the 8 states, 4 conduct searches of property records from the county of residence for
all applicants (Louisiana, Maine, Montana, and Oklahoma); 1 conducts such searches for
most applicants (Iowa); and 3 do so for less than half of applicants (Alaska, New York,
and Vermont). Additionally, although Vermont reported not requiring documentation of a
primary residence, the state indicated that documentation would be required if it appeared
as though an applicant’s equity interest in his or her primary residence might exceed the
allowable amount.
29
    The state is Minnesota.




Page 23                                              GAO-12-749 Medicaid Long-Term Care
     and the value of an applicant’s equity interest in the home. 30 Of the
     37 states that reported requiring applicants to submit documentation
     of a primary residence, only 3 reported requiring documentation that
     could provide the state with information on the value of the home or
     an applicant’s equity interest in the home. 31 The remaining
     34 states reported requiring documentation about applicants’ primary
     residence, but the documentation received may not provide all of the
     information necessary to determine if applicants’ equity interest in
     their homes exceeds the state’s allowable amount.

•    Life Estates. Among the 32 states that provided information on our
     survey about life estates, 2 states reported not assessing the length of
     time an applicant with a life estate resided in the property. 32 The
     remaining 30 states reported requiring some type of proof in order to
     determine the amount of time an applicant resided in the property
     after the purchase of the life estate interest. 33 On the basis of our
     analysis of state responses, 7 of the 30 states reported relying only on
     a statement from an applicant or another person who owns the
     residence to determine the length of time an applicant resided in the
     property; however, 2 of these 7 states said that they would require
     more documentation if they determined that the information they
     received was questionable. The remaining 23 states reported relying
     on documentation, such as a utility bill; a statement from an applicant;


30
   The 5 states are: Arkansas, California, District of Columbia, Tennessee, and Virginia.
Although Arkansas reported not requiring documentation of a primary residence and not
conducting property searches, the state indicated that documentation would be required if
it appeared as though an applicant’s equity interest in his or her primary residence might
exceed the allowable amount.
31
  The 3 states are: Delaware, Indiana, and Nebraska. Delaware and Indiana reported
requiring applicants to provide documentation of the current assessed value of their
primary residence; this documentation should provide the states with sufficient information
to know if a home is valued above the states’ home equity limit and thus whether
additional information about an applicant’s equity interest is needed. Nebraska required
applicants to submit mortgage statements and property tax assessments; this combination
of documentation should provide the state with sufficient information to determine if an
applicant’s equity interest exceeds the state-specified maximum level.
32
  The 2 states are Iowa and Maine; it is unclear how these 2 states would have the
necessary information to implement the DRA provision that life estates are to be
considered a transfer for less than FMV unless the purchaser resided in the home for at
least a year after the date of purchase.
33
  Nineteen states either did not provide an answer to this question or they did not provide
a response that adequately answered the question.




Page 24                                               GAO-12-749 Medicaid Long-Term Care
     a statement from a third party; or some combination of these sources
     to determine the length of time an applicant lived in the property.

•    CCRCs. On the basis of our survey results, most states—46 of
     51—reported requiring applicants to provide documentation of CCRC
     or life care community entrance fees, such as a copy of the contract
     or agreement. Thus, these states should have sufficient information to
     determine if, under the DRA, an applicant’s entrance fees should be
     countable resources for determining Medicaid eligibility. However, it is
     unclear how the remaining 5 states would be able to determine if an
     applicant has paid such fees, and whether they should be counted
     toward the applicant’s Medicaid long-term care eligibility
     determination.

•    Promissory Notes. Fifty states reported on our survey that they
     require applicants to provide documentation of promissory notes or
     loans; such documentation should allow the state to determine if a
     note meets the requirements specified in the DRA, such as providing
     for payments to be made in equal installments throughout the course
     of the loan, or if a note should be treated as a transfer of assets for
     less than FMV. 34

•    Annuities. In responding to our survey, all states reported requiring
     documentation of annuities and thus should have sufficient
     information to determine whether an annuity should be considered a
     transfer of assets for less than FMV under the DRA. Additionally, our
     review of 49 states’ long-term care application forms found that
     45 required the disclosure of any interest the applicant or spouse has
     in an annuity and 27 contained statements regarding the state
     becoming a remainder beneficiary of such annuities. (See app. VIII.) 35




34
  One state, the District of Columbia, did not indicate whether documentation of
promissory notes was required.
35
  Two states, Arizona and Kentucky, collected information from applicants through an
interview rather than a paper application form and, as such, were not included in our
analysis. Our review was limited to state application forms for Medicaid coverage for long-
term care provided to us by state officials. Some states might require disclosure of an
interest in an annuity or include a statement regarding the need to name the state as a
remainder beneficiary through other means, such as a form other than the long-term care
application form or through an interview conducted as part of the application process.




Page 25                                              GAO-12-749 Medicaid Long-Term Care
                  As the demand for long-term care services increases and federal and
Concluding        state resources continue to be strained, it is important to ensure that only
Observations      eligible individuals receive Medicaid coverage for long-term care. Since
                  each state is responsible for day-to-day implementation of its Medicaid
                  program, variation in policies and practices for determining financial
                  eligibility is expected. However, some of the variation we found may raise
                  questions regarding how states determine Medicaid eligibility for long-
                  term care and enforce certain provisions of the DRA.

                  States must balance the costs of eligibility determination efforts with the
                  need to ensure that those efforts provide sufficient information to
                  implement federal requirements. While third-party verification of
                  applicants’ financial information likely provides states with the best
                  assurance of having a complete picture of an applicant’s financial status,
                  it can be a complex and costly process that requires a significant amount
                  of information and review. Given the complexities involved, it may be
                  reasonable for states to adhere to a risk-based approach and focus their
                  eligibility determination efforts on applicants who appear to be more likely
                  to have assets or to have transferred assets that would make them
                  ineligible. The electronic AVS that is required by law may help states
                  identify some unreported or transferred assets. However, it is too early to
                  assess its overall effectiveness, which will ultimately depend on the
                  breadth of the financial institutions participating and the depth of the
                  information obtained.


                  We provided a draft of this report to HHS for its review, and HHS provided
Agency Comments   written comments (see app. IX). HHS concurred with our findings and
                  noted that the results of our comprehensive report will serve as a
                  resource for all interested parties. Further, HHS indicated that the report
                  will be helpful for targeting CMS’s ongoing technical assistance and
                  oversight efforts with states.


                  As agreed with your offices, unless you publicly announce the contents of
                  this report earlier, we plan no further distribution until 30 days from the
                  report date. At that time, we will send copies to the Administrator of CMS
                  and other interested parties. In addition, the report will be available at no
                  charge on the GAO website at http://www.gao.gov.




                  Page 26                                      GAO-12-749 Medicaid Long-Term Care
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made key contributions to this report
are listed in appendix X.




Carolyn L. Yocom
Director, Health Care




Page 27                                    GAO-12-749 Medicaid Long-Term Care
Appendix I: GAO Analysis of State
              Appendix I: GAO Analysis of State
              Applications



Applications

              Table 8: Characteristics of Medicaid Long-Term Care Application Processes, by
              State, 2011

                                   Level of information on
                                    assets requested on              Whether interviews are
                                      application form                  conducted for
                                                                                      Some
                                                  a
               State             Comprehensive        General    All applicants     applicants
               Alabama                   ●                             ●
               Alaska                    ●                             ●
                                          b
               Arizona                                                 ●
               Arkansas                  ●                             ●
               California                ●                                              ●
               Colorado                  ●                                              ●
               Connecticut               ●
               Delaware                  ●                             ●
               District of                              ●
               Columbia
               Florida                   ●                                              ●
               Georgia                                  ●              ●
               Hawaii                    ●                             ●
               Idaho                     ●                                              ●
               Illinois                  ●
               Indiana                                  ●              ●
               Iowa                      ●                                              ●
               Kansas                    ●
                                          c              c
               Kentucky                                                ●
               Louisiana                 ●                                              ●
               Maine                     ●                             ●
               Maryland                  ●                                              ●
               Massachusetts             ●                                              ●
               Michigan                  ●                                              ●
               Minnesota                 ●                                              ●
               Mississippi               ●                             ●
               Missouri                  ●                                              ●
               Montana                   ●                                              ●
               Nebraska                  ●                             ●
               Nevada                    ●
               New Hampshire                            ●              ●
               New Jersey                ●                             ●




              Page 28                                           GAO-12-749 Medicaid Long-Term Care
Appendix I: GAO Analysis of State
Applications




                              Level of information on
                               assets requested on                                  Whether interviews are
                                 application form                                      conducted for
                                                                                                              Some
                                                    a
    State                   Comprehensive               General               All applicants                applicants
    New Mexico                         ●                                                ●
    New York                           ●
    North Carolina                     ●
    North Dakota                       ●                                                                           ●
    Ohio                                                     ●                                                     ●
    Oklahoma                           ●                                                ●
    Oregon                             ●                                                ●
    Pennsylvania                       ●                                                                           ●
    Rhode Island                       ●                                                ●
    South Carolina                     ●                                                                           ●
    South Dakota                       ●                                                                           ●
    Tennessee                          ●                                                ●
    Texas                              ●                                                                           ●
    Utah                               ●                                                                           ●
    Vermont                            ●                                                ●
    Virginia                           ●                                                                           ●
    Washington                         ●                                                ●
    West Virginia                      ●                                                ●
    Wisconsin                          ●                                                                           ●
    Wyoming                            ●                                                ●
    Total                              44                    5                         23                          21
Source: GAO analysis of state application forms for Medicaid coverage for long-term care and GAO web-based survey administered to
state Medicaid officials.
a
 Application forms requesting comprehensive information on assets asked applicants to provide
detailed information on several types of assets, such as specifically requesting or referencing
checking and savings accounts, stocks and bonds, retirement accounts, burial insurance, real
property, and vehicles.
b
 State collected information from applicants through an interview rather than a paper application form.
A state official provided the form eligibility workers use during their interviews with applicants, and this
form requests comprehensive information on applicants’ assets.
c
 State collected information from applicants through an interview rather than a paper application form.




Page 29                                                                     GAO-12-749 Medicaid Long-Term Care
Appendix I: GAO Analysis of State
Applications




Table 9: Time Frame of Information on Transfers of Assets Requested in Medicaid
Long-Term Care Application Forms, by State, 2011

                            Application form requested information on transfers
State                     Within previous 60 months      Within another time frame
Alabama                               ●
Alaska                                ●
                                                                      a
Arizona
                                       b                              b
Arkansas
                                                                          c
California                                                           ●
Colorado                              ●
                                                                          d
Connecticut                                                          ●
Delaware                              ●
                                                                          e
District of Columbia                                                 ●
Florida                               ●
                                       f                              f
Georgia
Hawaii                                ●
Idaho                                 ●
                                                                          d
Illinois                                                             ●
                                       f                              f
Indiana
Iowa                                  ●
Kansas                                ●
                                       g                              g
Kentucky
                                                                          h
Louisiana                                                            ●
Maine                                 ●
Maryland                              ●
Massachusetts                         ●
Michigan                              ●
Minnesota                             ●
Mississippi                           ●
Missouri                              ●
Montana                               ●
Nebraska                              ●
Nevada                                ●
New Hampshire                         ●
                                                                          i
New Jersey                                                           ●
New Mexico                            ●
New York                              ●




Page 30                                           GAO-12-749 Medicaid Long-Term Care
Appendix I: GAO Analysis of State
Applications




                                          Application form requested information on transfers
    State                              Within previous 60 months                            Within another time frame
                                                                                                            d
    North Carolina                                                                                     ●
    North Dakota                                            ●
                                                            f                                           f
    Ohio
    Oklahoma                                                ●
    Oregon                                                  ●
    Pennsylvania                                            ●
    Rhode Island                                            ●
    South Carolina                                          ●
    South Dakota                                            ●
    Tennessee                                               ●
    Texas                                                   ●
    Utah                                                    ●
    Vermont                                                 ●
    Virginia                                                ●
    Washington                                              ●
    West Virginia                                           ●
    Wisconsin                                               ●
    Wyoming                                                 ●
    Total                                                  38                                          7
Source: GAO analysis of state application forms for Medicaid coverage for long-term care.

Notes: Our review was limited to state application forms for Medicaid coverage for long-term care
provided to us by state officials. Some states might ask about transfers of assets through other
means, such as a form other than the long-term care application form or through an interview
conducted as part of the application process.
a
 State collected information from applicants through an interview rather than a paper application form.
A state official provided the form eligibility workers use during their interviews with applicants, and this
form asked about transfers made in the last 36 months; 60 months for trusts.
b
 State’s application form did not ask about transfers, but did ask whether the applicant or his/her
spouse sold or gave away a home or other real property.
c
    State’s application form asked about transfers made in the last 30 months; 60 months for trusts.
d
    State’s application form asked about transfers made in the last 36 months; 60 months for trusts.
e
 State’s application form asked about transfers greater than $1,000 that were made during the last
36 months.
f
    State’s application form did not ask about transfers.
g
    State collected information from applicants through an interview rather than a paper application form.
h
    State’s application form asked about transfers ever made.
i
    State’s application form asked about transfers made in the last 36 months.




Page 31                                                                       GAO-12-749 Medicaid Long-Term Care
Appendix II: States’ Asset Documentation
                                       Appendix II: States’ Asset Documentation
                                       Requirements



Requirements

Table 10a: Applicant Documentation Requirements for Medicaid Long-Term Care, by State and Type of Asset, 2011

                                                  Financial and
                       Earned      Unearned        investment            Life       Primary       Other real
                       income       income          resources         insurance    residence      property      Vehicles
Alabama                  ●             ●                 ●                 ●           ●              ●            ●
                                           a                                           b
Alaska                   ●            ●                  ●                 ●                          ●
Arizona                  ●             ●                 ●                 ●           ●              ●            ●
                                                                                       c
Arkansas                 ●             ●                 ●                 ●                          ●            ●
                                                                                       d
California               ●             ●                 ●                 ●                          ●            ●
                         e
Colorado                               ●                 ●                 ●           ●              ●            ●
Connecticut              ●             ●                 ●                 ●           ●              ●            ●
Delaware                 ●             ●                 ●                 ●           ●              ●            ●
                                                          f                            g
District of Columbia     ●             ●                 ●                 ●                          ●
Florida                  ●             ●                 ●                 ●           ●              ●            ●
Georgia                  ●             ●                 ●                 ●           ●              ●            ●
Hawaii                   ●             ●                 ●                 ●           ●              ●            ●
                                           a              f                                                        h
Idaho                    ●            ●                  ●                 ●           ●              ●
                                           a
Illinois                 ●            ●                  ●                 ●           ●              ●            ●
Indiana                  ●             ●                 ●                 ●           ●              ●            ●
                                                                                       i              i
Iowa                     ●             ●                 ●                 ●
Kansas                   ●             ●                 ●                 ●           ●              ●
Kentucky                 ●             ●                 ●                 ●           ●              ●            ●
                                       i                                    j
Louisiana                ●                               ●                                            ●
Maine                    ●             ●                 ●                 ●                          ●            ●
                                                                                           i                        k
Maryland                 ●             ●                 ●                 ●           ●              ●            ●
Massachusetts            ●             ●                 ●                 ●           ●              ●            ●
                                           a
Michigan                 ●            ●                  ●                 ●           ●              ●            ●
                                                                                       i
Minnesota                ●             ●                 ●                 ●                          ●            ●
                                           a
Mississippi              ●            ●                  ●                 ●           ●              ●
Missouri                 ●             ●                 ●                 ●           ●              ●            ●
                                                                                       i
Montana                  ●             ●                 ●                 ●                          ●            ●
Nebraska                 ●             ●                 ●                 ●           ●              ●            ●
Nevada                   ●             ●                 ●                 ●           ●              ●            ●
New Hampshire            ●             ●                 ●                 ●           ●              ●            ●
New Jersey               ●             ●                 ●                 ●           ●              ●            ●
                                       i
New Mexico               ●                               ●                 ●           ●              ●            ●
                                                                                       d
New York                 ●             ●                 ●                 ●                          ●            ●
North Carolina           ●             ●                 ●                 ●           ●              ●            ●




                                       Page 32                                        GAO-12-749 Medicaid Long-Term Care
                             Appendix II: States’ Asset Documentation
                             Requirements




                                              Financial and
                 Earned   Unearned             investment                     Life                     Primary      Other real
                 income    income               resources                  insurance                  residence     property     Vehicles
North Dakota       ●         ●                         ●                         ●                       ●              ●
Ohio               ●         ●                         ●                         ●                       ●              ●            ●
                                                                                                          i
Oklahoma           ●         ●                         ●                         ●                                      ●            ●
Oregon             ●         ●                         ●                         ●                       ●              ●            ●
Pennsylvania       ●         ●                         ●                         ●                       ●              ●            ●
Rhode Island       ●         ●                         ●                         ●                       ●              ●            ●
South Carolina     ●         ●                         ●                         ●                       ●              ●            ●
South Dakota       ●         ●                         ●                         ●                       ●              ●
                                 a                                                                        c
Tennessee          ●         ●                         ●                         ●                                      ●
Texas              ●         ●                         ●                         ●                       ●              ●            ●
                                                          l
Utah               ●         ●                         ●                         ●                       ●              ●
                                                                                     m                    n
Vermont            ●         ●                         ●                         ●                                      ●            ●
                                 a                                                                        b
Virginia           ●         ●                         ●                         ●                                      ●
                                                        o
Washington         ●         ●                        ●                          ●                       ●              ●
West Virginia      ●         ●                         ●                         ●                       ●              ●            ●
                                 i
Wisconsin          ●         ●                         ●                         ●                       ●              ●            ●
Wyoming            ●         ●                         ●                         ●                       ●              ●            ●
Total              50        49                       51                         50                      37             50          38
                             Source: GAO web-based survey administered to state Medicaid officials.
                             a
                              State reported it did not require documentation of at least some types of unearned income that could
                             be verified with third parties.
                             b
                              State reported it did not count a primary residence when determining an applicant’s eligibility—and
                             therefore did not require documentation—if an applicant was living in the home or intended to return
                             home.
                             c
                              State reported it did not require documentation of primary residence unless it appeared as though
                             the primary residence could exceed the allowable amount of equity interest.
                             d
                             State reported it did not require documentation of primary residence because it was not countable
                             when determining an applicant’s eligibility.
                             e
                              State reported it did not require documentation of earned income because it was verified through an
                             interface with the state’s Department of Labor.
                             f
                              State reported it did not require documentation of financial and investment resources if reported
                             resources were below a designated level.
                             g
                              State reported it did not count a primary residence when determining an applicant’s eligibility—and
                             therefore did not require documentation—if an applicant’s spouse, child under 20 years old, or
                             disabled child was living in the home.
                             h
                              State reported requiring documentation of vehicle loan value only if it affected eligibility
                             determination.
                             i
                             State reported it did not require documentation of this type of asset if it could be verified with a third
                             party.
                             j
                              State reported requiring documentation of a life insurance policy if the applicant reported that it had a
                             face value of $10,000 or more.
                             k
                                 State reported only requiring documentation of vehicles other than automobiles.




                             Page 33                                                                     GAO-12-749 Medicaid Long-Term Care
Appendix II: States’ Asset Documentation
Requirements




l
State reported it may not require documentation of financial and investment resources if applicant
reported having resources valued at well below the standard.
m
 State reported it did not require documentation of term life insurance policies. State also did not
require documentation of a life insurance policy if the applicant reported that it had a face value of
$1,500 or less.
n
 State reported it did not require documentation of primary residence unless the applicant reported
the value of the residence was within $200,000 of the allowable amount of equity interest.
o
 State reported requiring documentation of financial and investment resources if the applicant was
applying for the first time, was previously denied coverage, had not received benefits in many years,
or if the applicant’s reported resources were deemed questionable; otherwise, state did not require
documentation.




Page 34                                                       GAO-12-749 Medicaid Long-Term Care
                                         Appendix II: States’ Asset Documentation
                                         Requirements




Table 10b: Applicant Documentation Requirements for Medicaid Long-Term Care, by State and Type of Asset, 2011
(continued)
                                                   a                       b                 c
State                  Annuity   Burial contract       CCRC entrance fee       Life estate       Promissory note or loan    Trust
Alabama                  ●              ●                      ●                    ●                       ●                 ●
Alaska                   ●              ●                      ●                    ●                       ●                 ●
Arizona                  ●              ●                      ●                    ●                       ●                 ●
Arkansas                 ●              ●                      ●                    ●                       ●                 ●
California               ●              ●                                           ●                       ●                 ●
Colorado                 ●              ●                      ●                    ●                       ●                 ●
Connecticut              ●              ●                                           ●                       ●                 ●
Delaware                 ●              ●                                           ●                       ●                 ●
District of Columbia     ●              ●                                           ●                       —                 ●
Florida                  ●              ●                      ●                    ●                       ●                 ●
Georgia                  ●              ●                      ●                    ●                       ●                 ●
Hawaii                   ●              ●                      ●                    ●                       ●                 ●
Idaho                    ●              ●                      ●                    ●                       ●                 ●
Illinois                 ●              ●                      ●                    ●                       ●                 ●
Indiana                  ●              ●                      ●                    ●                       ●                 ●
Iowa                     ●              ●                      ●                    ●                       ●                 ●
Kansas                   ●              ●                      ●                    ●                       ●                 ●
Kentucky                 ●              ●                      ●                    ●                       ●                 ●
Louisiana                ●              ●                      ●                    ●                       ●                 ●
Maine                    ●              ●                      ●                    ●                       ●                 ●
Maryland                 ●              ●                      ●                    ●                       ●                 ●
Massachusetts            ●              ●                      ●                    ●                       ●                 ●
Michigan                 ●              ●                      ●                    ●                       ●                 ●
Minnesota                ●              ●                      ●                    ●                       ●                 ●
Mississippi              ●              ●                      ●                    ●                       ●                 ●
Missouri                 ●              ●                      ●                    ●                       ●                 ●
Montana                  ●              ●                      ●                    ●                       ●                 ●
Nebraska                 ●              ●                      ●                    ●                       ●                 ●
Nevada                   ●              ●                      ●                    ●                       ●                 ●
New Hampshire            ●              ●                      ●                    ●                       ●                 ●
New Jersey               ●              ●                      ●                    ●                       ●                 ●
New Mexico               ●              ●                      ●                    ●                       ●                 ●
New York                 ●              ●                      ●                    ●                       ●                 ●
North Carolina           ●              ●                      ●                    ●                       ●                 ●
North Dakota             ●              ●                      ●                    ●                       ●                 ●



                                         Page 35                                                 GAO-12-749 Medicaid Long-Term Care
                                   Appendix II: States’ Asset Documentation
                                   Requirements




                                              a                                   b                         c
State            Annuity   Burial contract          CCRC entrance fee                    Life estate            Promissory note or loan    Trust
Ohio               ●              ●                                ●                             ●                         ●                 ●
Oklahoma           ●              ●                                ●                             ●                         ●                 ●
Oregon             ●              ●                                ●                             ●                         ●                 ●
Pennsylvania       ●              ●                                ●                             ●                         ●                 ●
Rhode Island       ●              ●                                                              ●                         ●                 ●
South Carolina     ●              ●                                ●                             ●                         ●                 ●
South Dakota       ●              ●                                ●                             ●                         ●                 ●
Tennessee          ●              ●                                ●                             ●                         ●                 ●
Texas              ●              ●                                ●                             ●                         ●                 ●
Utah               ●              ●                                ●                             ●                         ●                 ●
Vermont            ●              ●                                ●                             ●                         ●                 ●
Virginia           ●              ●                                ●                             ●                         ●                 ●
Washington         ●              ●                                ●                             ●                         ●                 ●
West Virginia      ●              ●                                ●                             ●                         ●                 ●
Wisconsin          ●              ●                                ●                             ●                         ●                 ●
Wyoming            ●              ●                                ●                             ●                         ●                 ●
Total              51            51                               46                            51                         50               51
                                   Source: GAO web-based survey administered to state Medicaid officials.

                                   Legend:
                                   — = Response not provided.
                                   a
                                       Includes burial contracts and prepaid funeral arrangements.
                                   b
                                       CCRC is an abbreviation for continuing care retirement community.
                                   c
                                    A life estate is an interest in real property that gives the owner of the interest the right to use and
                                   possess the property only for the duration of the life of a person, usually the person who occupies the
                                   premises.




                                   Page 36                                                                      GAO-12-749 Medicaid Long-Term Care
                                          Appendix II: States’ Asset Documentation
                                          Requirements




Table 11: States’ Treatment of Earned Income Documentation, by Type of Documentation, 2011

                                                                                                 Number of states
                                                                                                                      Acceptable
                                                                                       Acceptable as                   with other
Type of documentation                                           Required                  proof itself             documentation      Not acceptable
Earning statement or pay stub                                               4                             45                   1                   0
                               a
Copy of check or check stub                                                 3                             33                   9                   4
                           a
Itemized bank statement                                                     1                              6                  20                  22
                       a
Income tax return                                                           0                             20                  25                   4
               a
W-2 tax form                                                                0                             17                  16                  16
                   b
1099 tax form                                                               0                             16                  17                  15
Written statement of earnings from employer                                 0                             49                   1                   0
                                          Source: GAO web-based survey administered to state Medicaid officials.

                                          Notes: This table only includes responses from the 50 states that reported requiring documentation of
                                          earned income. In each row, the number of states may not add to 50 because not all states specified
                                          the level of acceptability for the respective type of documentation.
                                          a
                                              One state did not specify the level of acceptability for this type of documentation.
                                          b
                                              Two states did not specify the level of acceptability for this type of documentation.




                                          Page 37                                                                  GAO-12-749 Medicaid Long-Term Care
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                                                   Requirements




Table 12: States’ Treatment of Earned Income Documentation, by State and Type of Documentation, 2011

                                                                                                                             Written
                                   Earning       Copy of        Itemized                                                  statement of
                                 statement or    check or         bank          Income                         1099      earnings from
State                              pay stub     check stub     statement       tax return     W-2 tax form   tax form       employer
Alabama                                                                                                                  
               a,b
Alaska                                                                                                                   
                a,b
Arizona                                                                                                                  
Arkansas                                                                                                                 
                     c
California                                                                                                               
Connecticut                                                                                                              
Delaware                                                                                                                 
District of Columbia                                                                                                     
               d
Florida                                                                                                                  
                   a,d
Georgia                                                                                                                  
Hawaii                                                                                                                   
           d
Idaho                                                                                                                    
Illinois                                                                                                                 
Indiana                                                                                                                  
       b
Iowa                                                                                                                     
Kansas                                                                                                                   
                     a
Kentucky                                                         —               —              —                           
Louisiana                                                                                                                
Maine                                                                                                                    
Maryland                                                                                                                 
Massachusetts                                                                                                            
                     a,b
Michigan                                                                                                                 
                         d
Minnesota                                                                                                                
Mississippi                                                                                                              
Missouri                                                                                                                 
Montana                                                                                                                  
Nebraska                                                                                                                 
Nevada                                                                                                                   
New Hampshire                                                                                                            
New Jersey                                                                                                               
New Mexico                                                                                                               
                      c
New York                                                                                                                 
                             c
North Carolina                                                                                                           




                                                   Page 38                                             GAO-12-749 Medicaid Long-Term Care
                                              Appendix II: States’ Asset Documentation
                                              Requirements




                                                                                                                                                 Written
                              Earning       Copy of             Itemized                                                                      statement of
                            statement or    check or              bank                  Income                                     1099      earnings from
State                         pay stub     check stub          statement               tax return           W-2 tax form         tax form       employer
North Dakota                                                                                                                                 
Ohio                                                                                                                                         
Oklahoma                                                                                                                                     
Oregon                                                                                                                         —              
Pennsylvania                                                                                                                                 
Rhode Island                                                                                                                                 
South Carolina                                                                                                                 —              
South Dakota                                                                                                                                 
                        d
Tennessee                                                                                                                                    
        c
Texas                                                                                                                                        
Utah                                                                                                                                         
                d
Vermont                                                                                                                                      
            d
Virginia                                      —                                                                                               
Washington                                                                                                                                   
West Virginia                                                                                                                                
                    b
Wisconsin                                                                                                                                    
Wyoming                                                                                                                                      
                                              Source: GAO web-based survey administered to state Medicaid officials.

                                              Legend:
                                               = Required.
                                               = Acceptable as proof by itself.
                                               = Acceptable as proof with other documentation.
                                               = Not acceptable as proof.
                                              — = Response not provided.
                                              Notes: This table only includes responses from the 50 states that reported requiring documentation of
                                              earned income. One state—Colorado—reported it did not require documentation of earned income.
                                              a
                                               State reported that it verified applicants’ earned income using The Work Number, which is a national
                                              database of employment and income information contributed directly by over 2,200 employers. The
                                              state considered The Work Number acceptable as proof by itself for documenting earned income.
                                              b
                                               State reported that it verified applicants’ earned income by contacting the employer directly, which it
                                              considered acceptable as proof by itself for documenting earned income.
                                              c
                                               State reported that it may accept applicants’ self-attestation in lieu of earned income documentation.
                                              d
                                               State reported that tax forms are acceptable only to show proof of earned income for self-employed
                                              applicants.




                                              Page 39                                                                      GAO-12-749 Medicaid Long-Term Care
                                             Appendix II: States’ Asset Documentation
                                             Requirements




Table 13: States’ Treatment of Unearned Income Documentation, by Type of Documentation, 2011

                                                                                                          Number of states
                                                                                                                               Acceptable
                                                                                                 Acceptable as                  with other
Type of documentation                                                        Required               proof itself            documentation    Not acceptable
                                                           a
Statement or letter from Social Security Administration                                  1                            45                 0                 1
Statement or letter from Veterans Administration                                         4                            45                 0                 0
Pension statement                                                                        3                            44                 2                 0
Retirement statement                                                                     3                            41                 5                 0
Statement of investment earnings                                                         3                            40                 5                 1
                              b
Copy of check or check stub                                                              1                            25                16                 6
Itemized bank statement                                                                  1                            10                23                15
Income tax return                                                                        0                            13                27                 9
Tax form showing interest, dividends, etc.                                               1                            18                21                 9
Annuity schedule of payments                                                             3                            33                11                 2
                                                 b
Promissory note schedule of payments/interest                                            2                            30                15                 1
Copy of court documents                                                                  2                            30                17                 0
                                             Source: GAO web-based survey administered to state Medicaid officials.

                                             Notes: This table only includes responses from the 49 states that reported requiring documentation of
                                             unearned income. In each row, the number of states may not add to 49 because not all states
                                             specified the level of acceptability for the respective type of documentation.
                                             a
                                              Two states did not specify the level of acceptability for this type of documentation.
                                             b
                                              One state did not specify the level of acceptability for this type of documentation.




                                             Page 40                                                                       GAO-12-749 Medicaid Long-Term Care
                                          Appendix II: States’ Asset Documentation
                                          Requirements




Table 14a: States’ Treatment of Unearned Income Documentation, by State and Type of Documentation, 2011

                                                                                             Statement of
                         Statement or      Statement or        Pension         Retirement     investment      Copy of check
                                      a                 b
State                  letter from SSA    letter from VA      statement        statement       earnings       or check stub
Alabama                                                                                                        
Alaska                                                                                                         
Arizona                                                                                                        
Arkansas                                                                                                       
California                                                                                                     
Colorado                                                                                                       
Connecticut                                                                                                    
Delaware                                                                                                       
District of Columbia                                                                                           
Florida                                                                                                        
Georgia                                                                                                        
Hawaii                                                                                                         
Idaho                                                                                                          
Illinois                                                                                                       
Indiana                      —                                                                                  
Iowa                                                                                                           
Kansas                                                                                                         
Kentucky                                                                                                       
Maine                                                                                                          
Maryland                                                                                                       
Massachusetts                                                                                                  
Michigan                                                                                                       
Minnesota                                                                                                      
Mississippi                                                                                                    
Missouri                                                                                                       
Montana                                                                                                        
Nebraska                                                                                                       
Nevada                                                                                                         
New Hampshire                                                                                                  
New Jersey                                                                                                     
New York                                                                                                       
North Carolina                                                                                                 
North Dakota                 —                                                                                  
Ohio                                                                                                           




                                          Page 41                                           GAO-12-749 Medicaid Long-Term Care
                                    Appendix II: States’ Asset Documentation
                                    Requirements




                                                                                                              Statement of
                   Statement or      Statement or                 Pension                Retirement            investment      Copy of check
                                a                 b
State            letter from SSA    letter from VA               statement               statement              earnings       or check stub
Oklahoma                                                                                                                        
Oregon                                                                                                                          
Pennsylvania                                                                                                                    
Rhode Island                                                                                                                    
South Carolina                                                                                                                  —
South Dakota                                                                                                                    
Tennessee                                                                                                                       
Texas                                                                                                                           
Utah                                                                                                                            
Vermont                                                                                                                         
Virginia                                                                                                                        
Washington                                                                                                                      
West Virginia                                                                                                                   
Wisconsin                                                                                                                       
Wyoming                                                                                                                         
                                    Source: GAO web-based survey administered to state Medicaid officials.

                                    Legend:
                                     = Required.
                                     = Acceptable as proof by itself.
                                     = Acceptable as proof with other documentation.
                                     = Not acceptable as proof.
                                    — = Response not provided.
                                    Notes: This table only includes responses from the 49 states that reported requiring documentation of
                                    unearned income. The two states that reported they generally did not require documentation of
                                    unearned income were Louisiana and New Mexico.
                                    a
                                     SSA is an abbreviation for the Social Security Administration.
                                    b
                                     VA is an abbreviation for the Veterans Administration.




                                    Page 42                                                                  GAO-12-749 Medicaid Long-Term Care
                                       Appendix II: States’ Asset Documentation
                                       Requirements




Table 14b: States’ Treatment of Unearned Income Documentation, by State and Type of Documentation, 2011 (continued)

                                                         Tax form                         Promissory
                                                          showing            Annuity     note schedule
                       Itemized bank     Income tax       interest/        schedule of   of payments/      Copy of court
State                     statement        return        dividends          payments        interest        documents
Alabama                                                                                                     
Alaska                                                                                                      
Arizona                                                                                                     
Arkansas                                                                                                    
California                                                                                                  
Colorado                                                                                                    
Connecticut                                                                                                 
Delaware                                                                                                    
District of Columbia                                                                                        
Florida                                                                                                     
Georgia                                                                                                     
Hawaii                                                                                                      
Idaho                                                                                                       
Illinois                                                                                                    
Indiana                                                                                                     
Iowa                                                                                                        
Kansas                                                                                                      
Kentucky                                                                                                    
Maine                                                                                                       
Maryland                                                                                   —                 
Massachusetts                                                                                               
Michigan                                                                                                    
Minnesota                                                                                                   
Mississippi                                                                                                 
Missouri                                                                                                    
Montana                                                                                                     
Nebraska                                                                                                    
Nevada                                                                                                      
New Hampshire                                                                                               
New Jersey                                                                                                  
New York                                                                                                    
North Carolina                                                                                              
North Dakota                                                                                                




                                       Page 43                                           GAO-12-749 Medicaid Long-Term Care
                                 Appendix II: States’ Asset Documentation
                                 Requirements




                                                           Tax form                                        Promissory
                                                            showing                    Annuity            note schedule
                 Itemized bank     Income tax               interest/                schedule of          of payments/      Copy of court
State               statement        return                dividends                  payments               interest        documents
Ohio                                                                                                                         
Oklahoma                                                                                                                     
Oregon                                                                                                                       
Pennsylvania                                                                                                                 
Rhode Island                                                                                                                 
South Carolina                                                                                                               
South Dakota                                                                                                                 
Tennessee                                                                                                                    
Texas                                                                                                                        
Utah                                                                                                                         
Vermont                                                                                                                      
Virginia                                                                                                                     
Washington                                                                                                                   
West Virginia                                                                                                                
Wisconsin                                                                                                                    
Wyoming                                                                                                                      
                                 Source: GAO web-based survey administered to state Medicaid officials.

                                 Legend:
                                  = Required.
                                  = Acceptable as proof by itself.
                                  = Acceptable as proof with other documentation.
                                  = Not acceptable as proof.
                                 — = Response not provided.
                                 Note: This table only includes responses from the 49 states that reported requiring documentation of
                                 unearned income. The two states that reported they generally did not require documentation of
                                 unearned income were Louisiana and New Mexico.




                                 Page 44                                                                  GAO-12-749 Medicaid Long-Term Care
                                           Appendix II: States’ Asset Documentation
                                           Requirements




Table 15: States’ Treatment of Financial and Investment Resources Documentation, by Type of Documentation, 2011

                                                                                                        Number of states
                                                                                                                            Acceptable
                                                                                              Acceptable as                  with other
Type of documentation                                                     Required               proof itself            documentation     Not acceptable
Bank statement showing monthly balance                                                 7                            31                 8                 5
Itemized bank statement                                                                4                            41                 4                 2
                    a
Income tax return                                                                      1                            10                21                18
Retirement account statement                                                           7                            39                 5                 0
Retirement account award letter                                                        1                            30                16                 4
                                                 a
Statement or letter from investment brokerages                                         1                            40                 8                 1
Certificate of stock or bond ownership                                                 4                            29                16                 2
                                           Source: GAO web-based survey administered to state Medicaid officials.
                                           a
                                            One state did not specify the level of acceptability for this type of documentation.




                                           Page 45                                                                       GAO-12-749 Medicaid Long-Term Care
                                        Appendix II: States’ Asset Documentation
                                        Requirements




Table 16: States’ Treatment of Financial and Investment Resources Documentation, by State and Type of Documentation,
2011

                         Bank
                       statement                                                                  Statement or
                        showing      Itemized                     Retirement       Retirement       letter from   Certificate of
                        monthly        bank       Income tax       account          account        investment     stock or bond
State                   balance     statement       return        statement        award letter    brokerages       ownership
Alabama                                                                                                           
Alaska                                                                                                            
Arizona                                                                                                           
Arkansas                                                                                                          
California                                                                                        —                
Colorado                                                                                                          
Connecticut                                                                                                       
Delaware                                                                                                          
District of Columbia                                                                                              
Florida                                                                                                           
Georgia                                                                                                           
Hawaii                                                                                                            
Idaho                                                                                                             
Illinois                                                                                                          
Indiana                                                                                                           
Iowa                                                                                                              
Kansas                                                                                                            
Kentucky                                                                                                          
Louisiana                                                                                                         
Maine                                                                                                             
Maryland                                                                                                          
Massachusetts                                                                                                     
Michigan                                                                                                          
Minnesota                                                                                                         
Mississippi                                                                                                       
Missouri                                                                                                          
Montana                                                                                                           
Nebraska                                                                                                          
Nevada                                                                                                            
New Hampshire                                                                                                     
New Jersey                                                                                                        
New Mexico                                                                                                        




                                        Page 46                                               GAO-12-749 Medicaid Long-Term Care
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                               Requirements




                   Bank
                 statement                                                                                 Statement or
                  showing     Itemized                              Retirement            Retirement         letter from   Certificate of
                  monthly       bank          Income tax             account               account          investment     stock or bond
State             balance    statement          return              statement             award letter      brokerages       ownership
New York                                                                                                                   
North Carolina                                                                                                             
North Dakota                                                                                                               
Ohio                                                                                                                       
Oklahoma                                                                                                                   
Oregon                                                                                                                     
Pennsylvania                                                                                                               
Rhode Island                                                                                                               
South Carolina                                     —                                                                        
South Dakota                                                                                                               
Tennessee                                                                                                                  
Texas                                                                                                                      
Utah                                                                                                                       
Vermont                                                                                                                    
Virginia                                                                                                                   
Washington                                                                                                                 
West Virginia                                                                                                              
Wisconsin                                                                                                                  
Wyoming                                                                                                                    
                               Source: GAO web-based survey administered to state Medicaid officials.

                               Legend:
                                = Required.
                                = Acceptable as proof by itself.
                                = Acceptable as proof with other documentation.
                                = Not acceptable as proof.
                               — = Response not provided.




                               Page 47                                                                  GAO-12-749 Medicaid Long-Term Care
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                                         Requirements




Table 17: States’ Treatment of Life Insurance Documentation, by Type of Documentation, 2011

                                                                                                      Number of states
                                                                                                                      Acceptable
                                                                                            Acceptable as              with other
Type of documentation                                                  Required                proof itself        documentation     Not acceptable
                            a
Copy of life insurance policy                                                       4                         33                12                 0
Written statement from insurance company showing
current/face value of life insurance policy                                         5                         39                 6                 0
                                         Source: GAO web-based survey administered to state Medicaid officials.

                                         Notes: This table only includes responses from the 50 states that reported requiring documentation of
                                         life insurance. In each row, the number of states may not add to 50 because not all states specified
                                         the level of acceptability for the respective type of documentation.
                                         a
                                          One state did not specify the level of acceptability for this type of documentation.




                                         Page 48                                                                   GAO-12-749 Medicaid Long-Term Care
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Table 18: States’ Treatment of Life Insurance Documentation, by State and Type of
Documentation, 2011

                                                            Written statement from
                                                         insurance company showing
                             Copy of life insurance        current/face value of life
State                               policy                     insurance policy
Alabama                                                               
Alaska                                                                
           a
Arizona                                                               
Arkansas                                                              
California                                                            
Colorado                                                              
Connecticut                                                           
Delaware                                                              
District of Columbia                                                  
Florida                                                               
Georgia                                                               
Hawaii                                                                
Idaho                                                                 
Illinois                                                              
Indiana                                                               
Iowa                                                                  
Kansas                                                                
Kentucky                                                              
Maine                                                                 
Maryland                                                              
Massachusetts                                                         
               a
Michigan                                                              
Minnesota                                                             
Mississippi                                                           
Missouri                                                              
Montana                                                               
Nebraska                                                              
Nevada                                                                
New Hampshire                                                         
New Jersey                                                            
New Mexico                                                            
New York                                                              




Page 49                                               GAO-12-749 Medicaid Long-Term Care
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                                                                               Written statement from
                                                                            insurance company showing
                                          Copy of life insurance              current/face value of life
    State                                        policy                           insurance policy
    North Carolina                                                                       
    North Dakota                                                                         
    Ohio                                                                                 
    Oklahoma                                                                             
    Oregon                                                                               
    Pennsylvania                                                                         
    Rhode Island                                                                         
                      a
    South Carolina                                                                       
    South Dakota                                                                         
    Tennessee                                                                            
            a
    Texas                                                                                
    Utah                                                                                 
                a
    Vermont                                               —                               
    Virginia                                                                             
    Washington                                                                           
    West Virginia                                                                        
    Wisconsin                                                                            
    Wyoming                                                                              
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = Required.
 = Acceptable as proof by itself.
 = Acceptable as proof with other documentation.
— = Response not provided.
Notes: This table only includes responses from the 50 states that reported requiring documentation of
life insurance. One state—Louisiana—reported it generally did not require documentation of life
insurance.
a
 State reported it would contact insurance companies directly to verify ownership and value of life
insurance.




Page 50                                                                  GAO-12-749 Medicaid Long-Term Care
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                                                Requirements




Table 19: States’ Treatment of Primary Residence Documentation, by Type of Documentation, 2011

                                                                                                     Number of states
                                                                                                                            Acceptable
                                                                                           Acceptable as                     with other
Type of documentation                                              Required                   proof itself               documentation      Not acceptable
Property deed                                                                   3                             20                    13                    1
                                            a
Property tax assessment statement or bill                                       1                             23                    12                    0
                              a
Assessment of current value                                                     2                             26                      8                   0
                        a
Mortgage statement                                                              1                             14                    15                    6
                    b
Income tax return                                                               0                               4                     9                  21
Purchase or sale agreement                                                      1                             16                    16                    4
                                                Source: GAO web-based survey administered to state Medicaid officials.

                                                Notes: This table only includes responses from the 37 states that reported requiring documentation of
                                                a primary residence. In each row, the number of states may not add to 37 because not all states
                                                specified the level of acceptability for the respective type of documentation.
                                                a
                                                 One state did not specify the level of acceptability for this type of documentation.
                                                b
                                                 Three states did not specify the level of acceptability for this type of documentation.




                                                Page 51                                                                   GAO-12-749 Medicaid Long-Term Care
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                                        Requirements




Table 20: States’ Treatment of Primary Residence Documentation, by State and Type of Documentation, 2011

                                        Property tax
                                        assessment         Assessment of       Mortgage      Income tax    Purchase or sale
State               Property deed     statement or bill     current value      statement       return         agreement
Alabama                                                                                                      
Arizona                                                                                                      
Colorado                                                                                                     
Connecticut                                                                                                  
Delaware                                                                                                     
Florida                                                                                                      
Georgia                                                                                                      
Hawaii                                                                                                       
Idaho                                                                                                        
Illinois                                                                                                     
Indiana                                                                                      —                
Kansas                                                                                                       
Kentucky                                                                                                     
Maryland                                                                                                     
Massachusetts                                                                                                
Michigan                                                                                                     
Mississippi                                                                                                  
Missouri                                                                                                     
Nebraska                                                                                                     
Nevada                                                                                                       
New Hampshire                                                                                                
New Jersey                                                                                                   
New Mexico                                                                                                   
North Carolina                                                                                               
North Dakota                                                                                                 
Ohio                                                                                                         
Oregon                                                                                                       
Pennsylvania                                                                                                 
Rhode Island                                —                    —                —             —                
South Carolina                                                                               —                
South Dakota                                                                                                 
Texas                                                                                                        
Utah                                                                                                         
Washington                                                                                                   




                                        Page 52                                            GAO-12-749 Medicaid Long-Term Care
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                                 Requirements




                                  Property tax
                                  assessment                Assessment of                Mortgage           Income tax    Purchase or sale
State           Property deed   statement or bill            current value               statement            return         agreement
West Virginia                                                                                                               
Wisconsin                                                                                                                   
Wyoming                                                                                                                     
                                 Source: GAO web-based survey administered to state Medicaid officials.

                                 Legend:
                                  = Required.
                                  = Acceptable as proof by itself.
                                  = Acceptable as proof with other documentation.
                                  = Not acceptable as proof.
                                 — = Response not provided.
                                 Note: This table only includes responses from the 37 states that reported requiring documentation of
                                 a primary residence. The following 14 states reported they generally did not require documentation of
                                 a primary residence: Alaska, Arkansas, California, District of Columbia, Iowa, Louisiana, Maine,
                                 Minnesota, Montana, New York, Oklahoma, Tennessee, Vermont, and Virginia.




                                 Page 53                                                                  GAO-12-749 Medicaid Long-Term Care
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                                                Requirements




Table 21: States’ Treatment of Documentation of Real Property other than Primary Residence, by Type of Documentation,
2011

                                                                                                      Number of states
                                                                                                                            Acceptable
                                                                                            Acceptable as                    with other
Type of documentation                                                Required                  proof itself              documentation      Not acceptable
Property deed                                                                    7                             24                    16                   3
                                            a
Property tax assessment statement or bill                                        2                             32                    14                   1
Assessment of current value                                                      4                             34                    10                   2
                        b
Mortgage statement                                                               1                             13                    23                  11
                    c
Income tax return                                                                0                               3                   14                  30
                             a
Purchase or sale agreement                                                       3                             20                    25                   1
                                                Source: GAO web-based survey administered to state Medicaid officials.

                                                Notes: This table only includes responses from the 50 states that reported requiring documentation
                                                of real property other than a primary residence. In each row, the number of states may not add to
                                                50 because not all states specified the level of acceptability for the respective type of documentation.
                                                a
                                                    One state did not specify the level of acceptability for this type of documentation.
                                                b
                                                    Two states did not specify the level of acceptability for this type of documentation.
                                                c
                                                 Three states did not specify the level of acceptability for this type of documentation.




                                                Page 54                                                                   GAO-12-749 Medicaid Long-Term Care
                                        Appendix II: States’ Asset Documentation
                                        Requirements




Table 22: States’ Treatment of Documentation of Real Property other than Primary Residence, by State and Type of
Documentation, 2011

                                          Property tax
                                          assessment         Assessment of         Mortgage       Income tax     Purchase or
State                  Property deed    statement or bill     current value        statement         return     sale agreement
Alabama                                                                                                           
Alaska                                                                                                            
Arizona                                                                                                           
Arkansas                                                                                                          
California                                                                                                        
Colorado                                                                                                          
Connecticut                                                                                                       
Delaware                                                                                                          
District of Columbia                                                               —                               
Florida                                                                                                           
Georgia                                                                                                           
Hawaii                                                                                                            
Idaho                                                                                                             
Illinois                                                                                                          
Indiana                                       —                                     —               —                
Kansas                                                                                                            
Kentucky                                                                                          —               —
Louisiana                                                                                                         
Maine                                                                                                             
Maryland                                                                                                          
Massachusetts                                                                                                     
Michigan                                                                                                          
               a
Minnesota                                                                                                         
Mississippi                                                                                                       
Missouri                                                                                                          
           b
Montana                                                                                                           
Nebraska                                                                                                          
Nevada                                                                                                            
New Hampshire                                                                                                     
New Jersey                                                                                                        
New Mexico                                                                                                        
New York                                                                                                          
North Carolina                                                                                                    




                                        Page 55                                                GAO-12-749 Medicaid Long-Term Care
                                 Appendix II: States’ Asset Documentation
                                 Requirements




                                   Property tax
                                   assessment                  Assessment of                 Mortgage        Income tax     Purchase or
State            Property deed   statement or bill              current value                statement          return     sale agreement
North Dakota                                                                                                                 
Ohio                                                                                                                         
Oklahoma                                                                                                                     
Oregon                                                                                                                       
Pennsylvania                                                                                                                 
Rhode Island                                                                                                                 
South Carolina                                                                                               —                
South Dakota                                                                                                                 
Tennessee                                                                                                                    
Texas                                                                                                                        
Utah                                                                                                                         
Vermont                                                                                                                      
           c
Virginia                                                                                                                     
Washington                                                                                                                   
West Virginia                                                                                                                
Wisconsin                                                                                                                    
Wyoming                                                                                                                      
                                 Source: GAO web-based survey administered to state Medicaid officials.

                                 Legend:
                                  = Required.
                                  = Acceptable as proof by itself.
                                  = Acceptable as proof with other documentation.
                                  = Not acceptable as proof.
                                 — = Response not provided.
                                 Notes: This table only includes responses from the 50 states that reported requiring documentation of
                                 real property other than a primary residence. One state—Iowa—generally did not require
                                 documentation of real property other than the primary residence.
                                 a
                                  State reported requiring a statement from a licensed appraiser if there was no online access to
                                 property tax statements or if the applicant disputed the property tax value.
                                 b
                                     State reported requiring documentation of value, but verified ownership of property with a third party.
                                 c
                                  State reported requiring a purchase or sale agreement only if the applicant sold the property.




                                 Page 56                                                                  GAO-12-749 Medicaid Long-Term Care
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                                           Requirements




Table 23: States’ Treatment of Vehicle Documentation, by Type of Documentation, 2011

                                                                                                           Number of states
                                                                                                                             Acceptable
                                                                                                Acceptable as                 with other
Type of documentation                                                       Required               proof itself           documentation     Not acceptable
Vehicle title                                                                           3                           25                  8                2
                                a
Vehicle registration document                                                           1                           25                  9                1
Statement of vehicle loan balance                                                       2                           13                 17                6
Written assessment of vehicle value from vehicle dealer                                 2                           23                 12                1
                                           Source: GAO web-based survey administered to state Medicaid officials.

                                           Notes: This table only includes responses from the 38 states that reported requiring documentation of
                                           vehicles. In each row, the number of states may not add to 38 because not all states specified the
                                           level of acceptability for the respective type of documentation.
                                           a
                                            Two states did not specify the level of acceptability for this type of documentation.




                                           Page 57                                                                       GAO-12-749 Medicaid Long-Term Care
                                          Appendix II: States’ Asset Documentation
                                          Requirements




Table 24: States’ Treatment of Vehicle Documentation, by State and Type of Documentation, 2011

                                                                                                        Written assessment of
                                                        Vehicle registration     Statement of vehicle    vehicle value from
State                            Vehicle title              document                 loan balance           vehicle dealer
Alabama                                                                                                        
Arizona                                                                                                        
Arkansas                                                                                                       
California                                                                                                     
Colorado                                                                                                       
Connecticut                                                                                                    
Delaware                                                                                                       
Florida                                                                                                        
Georgia                                                                                                        
Hawaii                                                                                                         
Illinois                                                                                                       
Indiana                                                         —                                               
Kentucky                                                                                                       
Maine                                                                                                          
Maryland                                                                                                       
Massachusetts                                                                                                  
Michigan                                                                                                       
Minnesota                                                                                                      
Missouri                                                                                                       
Montana                                                                                                        
Nebraska                                                        —                                               
Nevada                                                                                                         
New Hampshire                                                                                                  
New Jersey                                                                                                     
New Mexico                                                                                                     
New York                                                                                                       
North Carolina                                                                                                 
Ohio                                                                                                           
Oklahoma                                                                                                       
Oregon                                                                                                         
Pennsylvania                                                                                                   
Rhode Island                                                                                                   
South Carolina                                                                                                 
Texas                                                                                                          




                                          Page 58                                             GAO-12-749 Medicaid Long-Term Care
                         Appendix II: States’ Asset Documentation
                         Requirements




                                                                                                                Written assessment of
                                             Vehicle registration                 Statement of vehicle           vehicle value from
State           Vehicle title                    document                             loan balance                  vehicle dealer
Vermont                                                                                                                
West Virginia                                                                                                          
Wisconsin                                                                                                              
Wyoming                                                                                                                
                         Source: GAO web-based survey administered to state Medicaid officials.

                         Legend:
                          = Required.
                          = Acceptable as proof by itself.
                          = Acceptable as proof with other documentation.
                          = Not acceptable as proof.
                         — = Response not provided.
                         Note: This table only includes responses from the 38 states that reported requiring documentation of
                         vehicles. The following 13 states reported they generally did not require documentation of vehicles:
                         Alaska, District of Columbia, Idaho, Iowa, Kansas, Louisiana, Mississippi, North Dakota, South
                         Dakota, Tennessee, Utah, Virginia, and Washington.




                         Page 59                                                                      GAO-12-749 Medicaid Long-Term Care
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Requirements




Table 25: Amount of Required Documentation for Financial and Investment
Resources, by State, 2011

                                               Current and past months
                        Current
State                   month       2 months   3 months   36 months      60 months
Alabama                                                                      ●
Alaska                     ●
Arizona                    ●
Arkansas                   ●
California                 ●
Colorado                   ●
Connecticut                                                                  ●
Delaware                                                                     ●
District of Columbia       ●
Florida                    ●
Georgia                    ●
Hawaii                                                                       ●
Idaho                      ●
Illinois                                                                     ●
           a
Indiana
Iowa                                              ●
Kansas                     ●
Kentucky                                          ●
Louisiana                  ●
Maine                                                                        ●
Maryland                   ●
Massachusetts              ●
Michigan                   ●
Minnesota                  ●
Mississippi                                                                  ●
Missouri                                                                     ●
Montana                                                                      ●
Nebraska                   ●
Nevada                                                                       ●
New Hampshire                                                                ●
New Jersey                                                                   ●
New Mexico                 ●
New York                   ●




Page 60                                           GAO-12-749 Medicaid Long-Term Care
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Requirements




                                                                         Current and past months
                                   Current
    State                          month            2 months             3 months   36 months      60 months
    North Carolina                     ●
    North Dakota                       ●
    Ohio                                                                                               ●
    Oklahoma                           ●
    Oregon                                                                                             ●
    Pennsylvania                       ●
    Rhode Island                       ●
    South Carolina                                                                                     ●
    South Dakota                       ●
    Tennessee                                              ●
    Texas                                                                   ●
    Utah                                                                                               ●
    Vermont                                                                                            ●
    Virginia                           ●
    Washington                                                              ●
    West Virginia                      ●
    Wisconsin                                                                            ●
    Wyoming                            ●
    Total                              27                  1                4            1            17
Source: GAO web-based survey administered to state Medicaid officials.
a
 State reported it required both current and past documentation for financial and investment
resources, but did not specify the number of months of documentation required because it is
determined on a case-by-case basis. In some cases, the state may require up to 60 months of
documentation.




Page 61                                                                     GAO-12-749 Medicaid Long-Term Care
Appendix II: States’ Asset Documentation
Requirements




Table 26: Proportion of Applicants for Which States Require Additional
Documentation to Identify Assets Transferred for Less Than Fair Market Value, by
State, 2011

State                                          Proportion of applicants
Alabama                                                   
            a
Alaska                                                    
Arizona                                                   
Arkansas                                                  
                       a
California                                                
                     a
Colorado                                                  
Connecticut                                               
Delaware                                                  
District of Columbia                                      
             a
Florida                                                   
                 a
Georgia                                                   
Hawaii                                                    
        a
Idaho                                                     
           b
Illinois                                                  
Indiana                                                   —
       a,b
Iowa                                                      
               a
Kansas                                                    
                       a,b
Kentucky                                                  
                       a
Louisiana                                                 
Maine                                                     
Maryland                                                  
Massachusetts                                             
                     a,b
Michigan                                                  
Minnesota                                                 
Mississippi                                               
                   a
Missouri                                                  
                     a,b
Montana                                                   
                       a,b
Nebraska                                                  
                 b
Nevada                                                    
New Hampshire                                             
New Jersey                                                
                             a
New Mexico                                                
New York                                                  
North Carolina                                            




Page 62                                         GAO-12-749 Medicaid Long-Term Care
Appendix II: States’ Asset Documentation
Requirements




    State                                                                Proportion of applicants
                                 b
    North Dakota                                                                    
    Ohio                                                                            
    Oklahoma                                                                        
    Oregon                                                                          
                                 a
    Pennsylvania                                                                    
                                 a,b
    Rhode Island                                                                    
    South Carolina                                                                  
                                 a
    South Dakota                                                                    
                             b
    Tennessee                                                                       
               a,b
    Texas                                                                           
           a
    Utah                                                                            
    Vermont                                                                         
                 a
    Virginia                                                                        
                             b
    Washington                                                                      
                                 a,b
    West Virginia                                                                   
                         a
    Wisconsin                                                                       
                     a
    Wyoming                                                                         
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = All applicants.
 = Some applicants.
 = No applicants.
— = Response not provided.
a
 State reported requiring additional documentation only if an applicant reported a transfer.
b
 State reported requiring additional documentation only if it questioned the applicant’s information or
had reason to believe a transfer may have occurred.




Page 63                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix III: States’ Use of Data Matches to
                                         Appendix III: States’ Use of Data Matches to
                                         Verify Applicants’ Assets



Verify Applicants’ Assets

Table 27a: Proportion of Applicants for which States Conduct Data Matches with Third Parties to Verify Applicants’ Assets, by
State and Source of Data Match, 2011

                                                               State                                                 State wage
                                    Social Security        unemployment                                          files/directory of
                                                                                             a              b
State                               Administration            records                   IEVS         PARIS           new hires
Alabama                                                                                                             
Alaska                                                                                                              
Arizona                                                                                                             
Arkansas                                                                                             —               
California                                                                                                          
Colorado                                                                                                            
Connecticut                                                                                                         
Delaware                                                          —                     —              —               —
District of Columbia                                                                                                
Florida                                                                                                             
Georgia                                                                                                             
Hawaii                                                                                                              
Idaho                                                                                                               
Illinois                                                                                                            
Indiana                                                                                              —               
Iowa                                                                                                                
Kansas                                                                                                              
Kentucky                                                                                                            
Louisiana                                                                                                           
Maine                                                                                                               
Maryland                                                                                                            
Massachusetts                                                                                                       —
Michigan                                                                                                            
Minnesota                                                                                                           
Mississippi                                                                                                         
Missouri                                                                                                            
Montana                                                                                                             
Nebraska                                                                                                            
Nevada                                                                                                              
New Hampshire                                                                                                       
New Jersey                                                                                                          
New Mexico                                                                                                          
New York                                                                                                            




                                         Page 64                                                 GAO-12-749 Medicaid Long-Term Care
                     Appendix III: States’ Use of Data Matches to
                     Verify Applicants’ Assets




                                                   State                                                          State wage
                 Social Security               unemployment                                                   files/directory of
                                                                                          a              b
State            Administration                   records                         IEVS            PARIS           new hires
North Carolina                                                                                                   
North Dakota                                                                                                     
Ohio                                                                                                             
Oklahoma                                                                                                         
Oregon                                                                                                           
Pennsylvania                                                                                                     
Rhode Island                                                                                                     
South Carolina                                                                                                   
South Dakota                                                                                                     
Tennessee                                                                                                        
                                                            c                                                            c
Texas                                                                                                            
Utah                                                                                                             
Vermont                                                                                                          
Virginia                                                                                                         
Washington                                                                                                       
West Virginia                                                                                                    
Wisconsin                                                                                                        
Wyoming                                                                                                          
                     Source: GAO web-based survey administered to state Medicaid officials.

                     Legend:
                      = All applicants.
                      = Most (more than half) applicants.
                      = Some applicants.
                      = No applicants.
                     — = Response not provided.
                     a
                      IEVS is an abbreviation for Income and Eligibility Verification System; this system allows a state to
                     match applicant-reported income information with data from the Internal Revenue Service, the Social
                     Security Administration, and state wage and unemployment insurance benefit records. States that
                     reported using this system to verify applicants’ assets may use some or all of the data available.
                     b
                      PARIS is an abbreviation for Public Assistance Reporting Information System. PARIS is an
                     electronic data matching and information exchange system that is designed to match state enrollment
                     information, including Medicaid enrollment, with data from other participating states and from a
                     selected group of federal databases. The federal databases include, among other things, information
                     on individuals’ receipt of income from the Department of Veterans Affairs, the Department of Defense,
                     and the Office of Personnel Management. States that reported conducting a PARIS data match may
                     use some or all of the data available.
                     c
                     State contracted with a data broker to perform various data matches including matches with state
                     wage, unemployment, and workman’s compensation sources.




                     Page 65                                                                  GAO-12-749 Medicaid Long-Term Care
                                         Appendix III: States’ Use of Data Matches to
                                         Verify Applicants’ Assets




Table 27b: Proportion of Applicants for which States Conduct Data Matches with Third Parties to Verify Applicants’ Assets,
by State and Source of Data Match, 2011 (continued)

                                                                      State workman’s
                            Internal Revenue     Department of         compensation     National Directory
                                                                                                       a
State                            Service        Veterans Affairs          records         of New Hires     State tax records
Alabama                                                                                                        
Alaska                                                                                                         
Arizona                                                                                                        
Arkansas                                                                                    —                   
California                                                                                                     
Colorado                                                                                                       
Connecticut                                                                                                    
Delaware                           —                    —                     —                —                   —
District of Columbia                                                                                           
Florida                                                                                                        
Georgia                                                                                                        
Hawaii                                                                                                         
Idaho                                                                                                          
Illinois                                                                                                       
Indiana                                                                                                        
Iowa                                                   —                     —                —                   —
Kansas                                                                                                         
Kentucky                                                                                                       
Louisiana                                                                                                      
Maine                                                                                                          
Maryland                                                                                                       
Massachusetts                                                               —                                   —
Michigan                                                                                                       
Minnesota                                                                                                      
Mississippi                                                                                                    
Missouri                                                                                                       
Montana                                                                                                        
Nebraska                                                                                                       
Nevada                                                                                                         
New Hampshire                                                                                                  
New Jersey                                             —                     —                                   
New Mexico                                                                                                     
New York                                                                                                       




                                         Page 66                                            GAO-12-749 Medicaid Long-Term Care
                             Appendix III: States’ Use of Data Matches to
                             Verify Applicants’ Assets




                                                                     State workman’s
                 Internal Revenue       Department of                 compensation                    National Directory
                                                                                                                     a
State                 Service          Veterans Affairs                  records                        of New Hires     State tax records
North Carolina                                                                                                               
North Dakota                                                                                                                 
Ohio                                                                                                                         
Oklahoma                                                                                                                     
Oregon                                                                                                                       
Pennsylvania                                                                                                                 
Rhode Island                                                                                                                 
South Carolina                                                                                                               
South Dakota                                                                                                                 
Tennessee                                                                                                                    
                                                                                    b
Texas                                                                                                                        
Utah                                                                                                                         
Vermont                                                                                                   —                   
Virginia                                                                                                                     
Washington                                                                                                                   
West Virginia                                                                                                                
Wisconsin                                                                                                                    
Wyoming                                                                                                                      
                             Source: GAO web-based survey administered to state Medicaid officials.

                             Legend:
                              = All applicants.
                              = Most (more than half) applicants.
                              = Some applicants.
                              = No applicants.
                             — = Response not provided.
                             a
                              The National Directory of New Hires is a national database of employment wage and unemployment
                             insurance information for use by federal and state agencies.
                             b
                              State contracted with a data broker to perform various data matches including matches with state
                             wage, unemployment, and workman’s compensation sources.




                             Page 67                                                                      GAO-12-749 Medicaid Long-Term Care
                                          Appendix III: States’ Use of Data Matches to
                                          Verify Applicants’ Assets




Table 28a: Timing of State Data Matches in Relation to Eligibility Determination, by State and Source of Data Match, 2011

                                                        State                                                  State wage
                              Social Security       unemployment                                             files/directory
                                                                                     a               b
State                         Administration           records                IEVS           PARIS            of new hires
Alabama                                                  —                                                      —
Alaska                                                                                                       —
Arizona                                                                       —                                 
Arkansas                                                                                    N/A                 
California                                                                                                     
Colorado                                                N/A                                                     
Connecticut                                                                                 —                   —
Delaware                                                 —                     —              —                   —
District of Columbia                                                                                           —
Florida                                                  —                                                      
Georgia                                                                                     —                   
Hawaii                                                                                                      
Idaho                                                                                                          
Illinois                                                                     N/A                                
Indiana                                                  —                     —                                 —
Iowa                                                                                                           
Kansas                                                                       N/A                                
Kentucky                                                                                                       
Louisiana                                                                                                      
Maine                                —                    —                     —              —                   —
Maryland                             —                                                                         
Massachusetts                                                                                                 N/A
Michigan                                                                     N/A                               
Minnesota                                                                                                    
Mississippi                                              —                                                      —
Missouri                                                                                    N/A                 
Montana                                                                                                      —
Nebraska                             —                    —                     —              —                   —
Nevada                                                                                                       
New Hampshire                                                                                                  
New Jersey                                                                                                    
New Mexico                                                                                                   
New York                                                                      —                                 
North Carolina                                                                             —                   




                                          Page 68                                          GAO-12-749 Medicaid Long-Term Care
                            Appendix III: States’ Use of Data Matches to
                            Verify Applicants’ Assets




                                            State                                                                       State wage
                 Social Security        unemployment                                                                  files/directory
                                                                                     a                       b
State            Administration            records                            IEVS                    PARIS            of new hires
North Dakota                                                                                                            
Ohio                                                                                                                  
Oklahoma                                                                                                              
Oregon                                                                                                                  
Pennsylvania                                                                                                            
Rhode Island                                     —                                                                      —
South Carolina                                                                                        —                  —
South Dakota                                                                                                         
Tennessee                                                                      —                       —                  
Texas                                                                                                                   
Utah                                                                                                                   
Vermont                                                                                                              
Virginia                                                                                                                —
Washington                                                                                                             
West Virginia                                                                                       —                 
Wisconsin                                                                                                               
Wyoming                                                                                                                
                            Source: GAO web-based survey administered to state Medicaid officials.

                            Legend:
                             = Generally before eligibility determination.
                             = Sometimes before and sometimes after eligibility determination.
                             = Generally after eligibility determination.
                            N/A = Not applicable, state did not conduct data match with respective source.
                            — = Response not provided.
                            a
                             IEVS is an abbreviation for Income and Eligibility Verification System; this system allows a state to
                            match applicant-reported income information with data from the Internal Revenue Service, the Social
                            Security Administration, and state wage and unemployment insurance benefit records. States that
                            reported using this system to verify applicants’ assets may use some or all of the data available.
                            b
                             PARIS is an abbreviation for Public Assistance Reporting Information System. PARIS is an
                            electronic data matching and information exchange system that is designed to match state enrollment
                            information, including Medicaid enrollment, with data from other participating states and from a
                            selected group of federal databases. The federal databases include, among other things, information
                            on individuals’ receipt of income from the Department of Veterans Affairs, the Department of Defense,
                            and the Office of Personnel Management. States that reported conducting a PARIS data match may
                            use some or all of the data available.




                            Page 69                                                                  GAO-12-749 Medicaid Long-Term Care
                                          Appendix III: States’ Use of Data Matches to
                                          Verify Applicants’ Assets




Table 28b: Timing of State Data Matches in Relation to Eligibility Determination, by State and Source of Data Match, 2011
(continued)

                                                                     State workman’s
                       Internal Revenue       Department of           compensation       National Directory     State tax
                                                                                                        a
State                       Service          Veterans Affairs            records           of New Hires         records
Alabama                       —                                              —                 —                   —
Alaska                                              —                        —                 —                   —
Arizona                       —                                              —                 —                   —
Arkansas                                                                    —                 N/A                 —
California                    —                                             —                 —                   
Colorado                     N/A                    N/A                      N/A                N/A                N/A
Connecticut                                                               —                 —                   —
Delaware                      —                      —                        —                 —                   —
District of Columbia          —                      —                        —                                    —
Florida                                            N/A                       —                                    —
Georgia                                                                                      —                   —
Hawaii                                                                    —                 —                   —
Idaho                                               —                        —                 —                   —
Illinois                                           N/A                      N/A                                  N/A
Indiana                                             —                        —                                    
Iowa                                                —                        —                 —                   —
Kansas                       N/A                    N/A                      N/A                N/A                N/A
Kentucky                                           N/A                      N/A                                  N/A
Louisiana                    N/A                    N/A                      N/A                N/A                N/A
Maine                         —                      —                        —                 —                   —
Maryland                      —                      —                        —                                   —
Massachusetts                 —                      —                       N/A                —                  N/A
Michigan                                            —                       N/A                N/A                N/A
Minnesota                     —                      —                                                            
Mississippi                   —                      —                        —                 —                   —
Missouri                                                                                     —                   —
Montana                                             —                        —                 —                   —
Nebraska                      —                      —                        —                 N/A                 —
Nevada                       N/A                                                                                —
New Hampshire                                                                                N/A                N/A
New Jersey                                          —                        —                                  
New Mexico                    —                                                                                —
New York                      —                      —                        —                 —                   —




                                          Page 70                                           GAO-12-749 Medicaid Long-Term Care
                                    Appendix III: States’ Use of Data Matches to
                                    Verify Applicants’ Assets




                                                                          State workman’s
                 Internal Revenue        Department of                     compensation                      National Directory     State tax
                                                                                                                            a
State                 Service           Veterans Affairs                      records                          of New Hires         records
North Carolina         N/A                                                                                                          N/A
North Dakota                                     N/A                               N/A                             N/A                N/A
Ohio                                              —                                                               N/A                —
Oklahoma                                                                                                                         —
Oregon                                                                                                           N/A                
Pennsylvania                                                                      N/A                                               N/A
Rhode Island            —                          —                                 —                              —                  —
South Carolina                                                                                                   —                  —
South Dakota                                     N/A                                                             N/A                N/A
Tennessee                                         —                                 —                                                —
Texas                   —                                                                                         —                  —
Utah                                             N/A                               N/A                             N/A                N/A
Vermont                                                                           —                              —                  —
Virginia                —                          —                                 —                              —                  —
Washington                                                                                                      —                  —
West Virginia                                     —                                 —                              —                  
Wisconsin                                         —                                 —                              —                  —
Wyoming                N/A                                                                                       N/A                N/A
                                    Source: GAO web-based survey administered to state Medicaid officials.

                                    Legend:
                                     = Generally before eligibility determination.
                                     = Sometimes before and sometimes after eligibility determination.
                                     = Generally after eligibility determination.
                                    N/A = Not applicable, state did not conduct data match with respective source.
                                    — = Response not provided.
                                    a
                                     The National Directory of New Hires is a national database of employment wage and unemployment
                                    insurance information for use by federal and state agencies.




                                    Page 71                                                                     GAO-12-749 Medicaid Long-Term Care
Appendix IV: States’ Contact with Financial
               Appendix IV: States’ Contact with Financial
               Institutions to Verify Applicants’ Assets



Institutions to Verify Applicants’ Assets

               Table 29: Proportion of Applicants for which States Contact Financial Institutions to
               Verify Applicants’ Assets, by State and Type of Financial Institution, 2011

                                                                                 Institutions not reported by applicant
                                                    Institutions with
                                                   accounts reported
                State                                 by applicant                 Local           Statewide      National
                           a
                Alaska                                                                                            
                               a
                Arizona                                                                                           
                Connecticut                                                                                       
                           a
                Illinois                                                                                          
                               a
                Indiana                                                                             —              —
                Kentucky                                                                                          
                                   a
                Louisiana                                                                                         
                Maine                                                                                             
                                   a
                Maryland                                                                                          
                                   a
                Michigan                                                                                          
                Missouri                                                                                          
                                           a
                New Jersey                                                                                        
                New York                                                                                          
                North Carolina                                                                                    
                Oklahoma                                                                                          
                Pennsylvania                                                                                      
                Rhode Island                                                                                      
                                               a
                South Carolina                                                                                    
                        a
                Texas                                                                                             
                Vermont                                                                                           
                Virginia                                                                                          
                                           a
                Washington                                                                                        
                                       a
                Wisconsin                                                                                         
                Wyoming                                                                                           
               Source: GAO web-based survey administered to state Medicaid officials.

               Legend:
                = All applicants.
                = Most (more than half) applicants.
                = Some applicants.
                = No applicants.
               — = Response not provided.




               Page 72                                                                      GAO-12-749 Medicaid Long-Term Care
Appendix IV: States’ Contact with Financial
Institutions to Verify Applicants’ Assets




Notes: This table only includes responses from the 24 states that reported contacting financial
institutions. The following 27 states reported they did not contact financial institutions: Alabama,
Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa,
Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New
Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia. Although
Oregon reported that it generally did not contact financial institutions, the state noted it may request
information from financial institutions with which an applicant reported having an account if an
applicant did not provide sufficient documentation.
a
 State reported only contacting financial institutions if an applicant submitted questionable or
insufficient information.




Page 73                                                       GAO-12-749 Medicaid Long-Term Care
Appendix IV: States’ Contact with Financial
Institutions to Verify Applicants’ Assets




Table 30: Types and Number of Months of Information Requested from Financial
Institutions, by State, 2011

                                      Type of information requested
                                                                                              Number of
 State                      Itemized statements                    Account balances     months requested
 Alaska                                   ●                                                              3
 Arizona                                                                   ●                             1
 Connecticut                              ●                                                             60
 Illinois                                 ●                                                             60
 Indiana                                                                   ●                             3
 Kentucky                                                                  ●                             3
 Louisiana                                                                 ●                             3
 Maine                                    ●                                                             60
 Maryland                                 ●                                                             60
 Michigan                                 ●                                                              1
 Missouri                                                                  ●                             3
 New Jersey                               ●                                                             60
 New York                                                                  ●                             1
 North Carolina                                                            ●                             1
 Oklahoma                                 ●                                                             12
 Pennsylvania                             ●                                                              1
 Rhode Island                             ●                                                              6
 South Carolina                                                            ●                            12
 Texas                                                                     ●                             3
                                                                                                            a
 Vermont                                                                   ●                            1
 Virginia                                                                  ●                             3
                                                                                                            b
 Washington                                                                ●                           —
 Wisconsin                                ●                                                             36
 Wyoming                                  ●                                                              1
 Total                                   12                               12
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
— = Response not provided.




Page 74                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix IV: States’ Contact with Financial
Institutions to Verify Applicants’ Assets




Notes: This table only includes responses from the 24 states that reported contacting financial
institutions. The following 27 states reported they did not contact financial institutions: Alabama,
Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa,
Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New
Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia.
a
 State reported that it requested the current balance for any open accounts and the closing balance
for any accounts that were closed within the past 60 months.
b
State did not specify the number of months of information it requested and noted it would request
whatever amount is needed.




Page 75                                                     GAO-12-749 Medicaid Long-Term Care
Appendix IV: States’ Contact with Financial
Institutions to Verify Applicants’ Assets




Table 31: Timing of States’ Contacts with Financial Institutions in Relation to
Eligibility Determination, by State, 2011


 State                                                    Point during eligibility determination process
 Alaska                                                                          
 Arizona                                                                          
 Connecticut                                                                      
 Illinois                                                                        
 Indiana                                                                          
 Kentucky                                                                         
 Louisiana                                                                        
 Maine                                                                            
 Maryland                                                                         
 Michigan                                                                         
 Missouri                                                                         
 New Jersey                                                                      
 New York                                                                         
 North Carolina                                                                   
 Oklahoma                                                                         
 Pennsylvania                                                                     
 Rhode Island                                                                     
 South Carolina                                                                   
 Vermont                                                                          
 Virginia                                                                         
 Texas                                                                            
 Washington                                                                       
 Wisconsin                                                                        
 Wyoming                                                                          
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = Generally before eligibility determination.
 = Sometimes before and sometimes after eligibility determination.
 = Generally after eligibility determination.
Note: This table only includes responses from the 24 states that reported contacting financial
institutions. The following 27 states reported they did not contact financial institutions: Alabama,
Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa,
Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New
Mexico, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Utah, and West Virginia.




Page 76                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
              Appendix V: States’ Use of Property Records
              Searches to Verify Applicants’ Assets



Searches to Verify Applicants’ Assets

              Table 32: Proportion of Applicants for which States Conduct Property Records
              Searches to Verify Applicants’ Assets, by State and Geographic Area of Property
              Search Conducted, 2011

                                                     Applicant’s   Some other
                                                      county of    counties in   All counties   Locations in
              State                                   residence       state        in state     other states
              Alabama                                                                             
                         a
              Alaska                                                                              
                             b
              Arizona                                                                             
                                 a
              Colorado                                                                            
                                         a
              Connecticut                                                                         
              Delaware                                                                            
              Georgia                                                                             
              Hawaii                                                                              
                         a
              Illinois                                                                            
                     c
              Iowa                                                                                
                             a,b
              Kansas                                                                              —
              Kentucky                                                              —              —
                                     a
              Louisiana                                                                           
              Maine                                                                               
              Maryland                                                                            
                                 a
              Michigan                                                                            
              Mississippi                                                                         
                                 a
              Missouri                                                                            
              Montana                                                                             
                             d
              Nevada                                                                              
                                                 e
              New Hampshire                                                                       
              New York                                                                            
              North Carolina                                                        —              —
                     a
              Ohio                                                                                
              Oklahoma                                                                            
                             b
              Oregon                                                                              
                                             a
              Pennsylvania                                                                        
              Rhode Island                                                                        
              South Carolina                                                        —              
              South Dakota                                                                        
              Texas                                                                               
              Vermont                                                                             




              Page 77                                                       GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
Searches to Verify Applicants’ Assets




                                    Applicant’s               Some other
                                     county of                counties in     All counties   Locations in
    State                            residence                   state          in state     other states
    Washington                                                                                 
    Wisconsin                                                                                  
    Wyoming                                                                                    
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = All applicants.
 = Most (more than half) applicants.
 = Some applicants.
 = No applicants.
— = Response not provided.
Notes: This table only includes responses from the 35 states that reported conducting property
searches. The following 16 states reported they did not conduct property searches: Arkansas,
California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New
Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.
a
 State reported conducting a property search only if an applicant submits questionable or insufficient
information.
b
    State reported conducting a property search only if an applicant reports a property.
c
 State reported it did not conduct a property search when an applicant intended to return home, was
receiving Supplemental Security Income, or was already receiving Medicaid and had an apartment as
a home address.
d
State reported it did not conduct a property search when an applicant was already receiving
Medicaid or other government assistance.
e
    State contracted with a company that conducted nationwide property searches.




Page 78                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
Searches to Verify Applicants’ Assets




Table 33: Types of Information That Can Be Used to Conduct Property Records
Searches, by State, 2011

                                     Applicant’s
                    Applicant’s     Social Security Property street     Property
State                 name             number          address          zip code
Alabama                  ●                    ●            ●
Alaska                   ●                                 ●
Arizona                  ●                    —            ●               —
Colorado                 ●                    —            ●               —
Connecticut              ●                                 ●
Delaware                 ●                                 ●                ●
Georgia                  ●                                 ●
Hawaii                                                     ●
Illinois                 ●                    ●            ●                ●
Iowa                     ●                                 ●
Kansas                   ●                                 ●
Kentucky                 ●                    —            ●               —
Louisiana                ●                                 ●
Maine                    ●                    ●            ●                ●
Maryland                 ●                    ●            ●
Michigan                 ●                    ●            ●                ●
Mississippi              ●                                 ●
Missouri                 ●                                 ●                ●
Montana                  ●
Nevada                   ●                                 ●
New                      ●                    ●            ●                ●
Hampshire
New York                 ●                    —           —                —
North Carolina           ●                                 ●
Ohio                     ●                                 ●                ●
Oklahoma                 ●                    ●            ●
Oregon                   ●                                 ●
Pennsylvania             ●                    —            ●               —
Rhode Island             ●                    ●            ●
South Carolina           ●                    —            ●                ●
South Dakota             ●                    ●            ●                ●
Texas                    ●                                 ●                ●
Vermont                 —                     —           —                —




Page 79                                            GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
Searches to Verify Applicants’ Assets




                                                     Applicant’s
                            Applicant’s             Social Security Property street           Property
 State                        name                     number          address                zip code
 Washington                         ●                                            ●
 Wisconsin                          ●                          ●                 ●                ●
 Wyoming                            ●                                            ●                ●
 Total                              33                        10                32               12
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
— = Response not provided.
Note: This table only includes responses from the 35 states that reported conducting property
searches. The following 16 states reported they did not conduct property searches: Arkansas,
California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New
Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.




Page 80                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
Searches to Verify Applicants’ Assets




Table 34: Timing of States’ Property Records Searches in Relation to Eligibility
Determination, by State, 2011

State                                   Point during eligibility determination process
Alabama                                                       
Alaska                                                       
Arizona                                                       
Colorado                                                     
Connecticut                                                   
Delaware                                                      
Georgia                                                       
Hawaii                                                        
Illinois                                                     
Iowa                                                          
Kansas                                                        
Kentucky                                                      
Louisiana                                                     
Maine                                                         
Maryland                                                      
Michigan                                                     
Mississippi                                                   
Missouri                                                     
Montana                                                       
Nevada                                                       
New Hampshire                                                 
New York                                                      
North Carolina                                                
Ohio                                                          
Oklahoma                                                      
Oregon                                                        
Pennsylvania                                                  
Rhode Island                                                  
South Carolina                                                
South Dakota                                                  
Texas                                                         
Vermont                                                       
Washington                                                    




Page 81                                            GAO-12-749 Medicaid Long-Term Care
Appendix V: States’ Use of Property Records
Searches to Verify Applicants’ Assets




 State                                                    Point during eligibility determination process
 Wisconsin                                                                        
 Wyoming                                                                          
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = Generally before eligibility determination.
 = Sometimes before and sometimes after eligibility determination.
 = Generally after eligibility determination.
Note: This table only includes responses from the 35 states that reported conducting property
searches. The following 16 states reported they did not conduct property searches: Arkansas,
California, District of Columbia, Florida, Idaho, Indiana, Massachusetts, Minnesota, Nebraska, New
Jersey, New Mexico, North Dakota, Tennessee, Utah, Virginia, and West Virginia.




Page 82                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix VI: States’ Use of Vehicle Records
              Appendix VI: States’ Use of Vehicle Records
              Searches to Verify Applicants’ Assets



Searches to Verify Applicants’ Assets

              Table 35: Proportion of Applicants for Which States Conduct Records Searches
              with the Department of Motor Vehicles to Verify Applicants’ Assets, by State, 2011

               State                                                Proportion of applicants
               Alabama                                                         
                          a
               Alaska                                                          
               Arizona                                                         
               Arkansas                                                        
               California                                                      
               Colorado                                                        
               Connecticut                                                     
               Delaware                                                        
               District of Columbia                                            
               Florida                                                         
               Georgia                                                         
               Hawaii                                                          
               Idaho                                                           
               Illinois                                                        
               Indiana                                                         
               Iowa                                                            
               Kansas                                                          
               Kentucky                                                        
               Louisiana                                                       
               Maine                                                           
               Maryland                                                        
               Massachusetts                                                   
                                  a
               Michigan                                                        
               Minnesota                                                       
               Mississippi                                                     
                              a
               Missouri                                                        
               Montana                                                         
               Nebraska                                                        
                              a
               Nevada                                                          
               New Hampshire                                                   
               New Jersey                                                      
               New Mexico                                                      
               New York                                                        
               North Carolina                                                  




              Page 83                                          GAO-12-749 Medicaid Long-Term Care
Appendix VI: States’ Use of Vehicle Records
Searches to Verify Applicants’ Assets




    State                                                                    Proportion of applicants
    North Dakota                                                                        
    Ohio                                                                                
    Oklahoma                                                                            
    Oregon                                                                              
    Pennsylvania                                                                        
                    a
    Rhode Island                                                                        
    South Carolina                                                                      
    South Dakota                                                                        
    Tennessee                                                                           
    Texas                                                                               
    Utah                                                                                
               a
    Vermont                                                                             
    Virginia                                                                            
    Washington                                                                          
    West Virginia                                                                       
    Wisconsin                                                                           
    Wyoming                                                                             
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = All applicants.
 = Most (more than half) applicants.
 = Some applicants.
 = No applicants.
a
 State reported conducting vehicle searches only if an applicant submitted questionable information.




Page 84                                                                  GAO-12-749 Medicaid Long-Term Care
                                        Appendix VI: States’ Use of Vehicle Records
                                        Searches to Verify Applicants’ Assets




Table 36: Types of Information That Can Be Used to Conduct Vehicle Records Searches, by State, 2011

                                          Applicant’s                        Applicant’s                    Applicant’s
                       Applicant’s       driver license                     license plate                  Social Security   Vehicle identification
State                    name               number                             number                         number               number
Alaska                      ●
Colorado                    —                     —                                 —                            —                     ●
Connecticut                 ●                                                        ●
Delaware                    ●                      ●                                 ●                                                 ●
Florida                     ●                      ●                                 ●                           ●                     ●
Kansas                      ●                      ●                                 ●                           ●
Kentucky                    ●                     —                                 —                            —                    —
Maine                       ●
Maryland                    ●                      ●                                 ●                                                 ●
Michigan                    ●                      ●                                 ●                           ●                     ●
Missouri                    ●
Montana                     ●                                                        ●                                                 ●
Nebraska                    ●                      ●                                 ●                                                 ●
Nevada                      ●                      ●                                 ●                           ●                     ●
New Mexico                  ●                      ●                                 ●                           ●                     ●
North Carolina              ●                      ●                                 ●                                                 ●
North Dakota                ●
Ohio                        ●                      ●                                 ●                                                 ●
Oregon                      ●                      ●                                 ●                                                 ●
Pennsylvania                ●                                                                                    ●
Rhode Island                ●                      ●                                —                            —                     ●
South Carolina              ●                      ●                                 ●                           —                     ●
South Dakota                ●                      ●                                                             ●                     ●
Utah                        ●                                                        ●                           ●                     ●
Vermont                     ●                      ●                                 ●                           ●
Virginia                    ●                                                                                    ●
Washington                  ●                                                                                                          ●
West Virginia               ●                      ●                                 ●                                                 ●
Wisconsin                   ●                      ●                                 ●                           ●                     ●
Wyoming                     ●                      ●                                                             ●                     ●
Total                      29                     18                                18                           12                   20
                                        Source: GAO web-based survey administered to state Medicaid officials.




                                        Page 85                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix VI: States’ Use of Vehicle Records
Searches to Verify Applicants’ Assets




Legend:
— = Response not provided.
Note: This table only includes responses from the 30 states that reported conducting vehicle
searches. The following 21 states reported they did not conduct vehicle searches: Alabama, Arizona,
Arkansas, California, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana,
Massachusetts, Minnesota, Mississippi, New Hampshire, New Jersey, New York, Oklahoma,
Tennessee, and Texas.




Page 86                                                      GAO-12-749 Medicaid Long-Term Care
Appendix VI: States’ Use of Vehicle Records
Searches to Verify Applicants’ Assets




Table 37: Timing of States’ Record Searches with the Department of Motor Vehicles
in Relation to Eligibility Determination, by State, 2011

 State                                                    Point during eligibility determination process
 Alaska                                                                          
 Colorado                                                                         
 Connecticut                                                                      
 Delaware                                                                         
 Florida                                                                          
 Kansas                                                                           
 Kentucky                                                                         
 Maine                                                                            
 Maryland                                                                         
 Michigan                                                                         
 Missouri                                                                        
 Montana                                                                          
 Nebraska                                                                         
 Nevada                                                                          
 New Mexico                                                                      
 North Carolina                                                                   
 North Dakota                                                                     
 Ohio                                                                             
 Oregon                                                                           
 Pennsylvania                                                                     
 Rhode Island                                                                     
 South Carolina                                                                   
 South Dakota                                                                     
 Utah                                                                             
 Vermont                                                                         
 Virginia                                                                         
 Washington                                                                       
 West Virginia                                                                    
 Wisconsin                                                                        
 Wyoming                                                                          
Source: GAO web-based survey administered to state Medicaid officials.




Page 87                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix VI: States’ Use of Vehicle Records
Searches to Verify Applicants’ Assets




Legend:
 = Generally before eligibility determination.
 = Sometimes before and sometimes after eligibility determination.
 = Generally after eligibility determination.
Note: This table only includes responses from the 30 states that reported conducting vehicle
searches. The following 21 states reported they did not conduct vehicle searches: Alabama, Arizona,
Arkansas, California, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Louisiana,
Massachusetts, Minnesota, Mississippi, New Hampshire, New Jersey, New York, Oklahoma,
Tennessee, and Texas.




Page 88                                                      GAO-12-749 Medicaid Long-Term Care
Appendix VII: States’ Collection of Third-
               Appendix VII: States’ Collection of Third-Party
               Information to Identify Transfers of Assets



Party Information to Identify Transfers of
Assets
               Table 38: Proportion of Applicants for Which States Take Additional Steps to Obtain
               Information from Third Parties to Identify Assets Transferred for Less Than Fair
               Market Value, by State, 2011

               State                                                Proportion of applicants
               Alabama                                                         
                          a
               Alaska                                                          
               Arizona                                                         
               Arkansas                                                        
               California                                                      
               Colorado                                                        
               Connecticut                                                     
               Delaware                                                        
               District of Columbia                                            
               Florida                                                         
               Georgia                                                         
               Hawaii                                                          
               Idaho                                                           
               Illinois                                                        
               Indiana                                                         —
               Iowa                                                            
               Kansas                                                          
                                  a,b
               Kentucky                                                        
                                      a
               Louisiana                                                       
               Maine                                                           
                                  b
               Maryland                                                        
               Massachusetts                                                   
                                  a
               Michigan                                                        
               Minnesota                                                       
               Mississippi                                                     
               Missouri                                                        
                                  a
               Montana                                                         
               Nebraska                                                        
                              a
               Nevada                                                          
               New Hampshire                                                   
                                          a
               New Jersey                                                      
               New Mexico                                                      
               New York                                                        
               North Carolina                                                  




               Page 89                                           GAO-12-749 Medicaid Long-Term Care
Appendix VII: States’ Collection of Third-Party
Information to Identify Transfers of Assets




    State                                                                   Proportion of applicants
    North Dakota                                                                       
    Ohio                                                                               
    Oklahoma                                                                           
    Oregon                                                                             
    Pennsylvania                                                                       
    Rhode Island                                                                       
                           b
    South Carolina                                                                     
    South Dakota                                                                       
                       a
    Tennessee                                                                          
    Texas                                                                              
    Utah                                                                               
    Vermont                                                                            
    Virginia                                                                           
    Washington                                                                         
    West Virginia                                                                      
                   a
    Wisconsin                                                                          
               a
    Wyoming                                                                            
Source: GAO web-based survey administered to state Medicaid officials.

Legend:
 = All applicants.
 = Some applicants.
 = No applicants.
— = Response not provided.
a
 State reported taking additional steps only if it questioned the applicant’s information or had reason
to believe a transfer may have occurred.
b
 State reported taking additional steps only if an applicant reported a transfer.




Page 90                                                                  GAO-12-749 Medicaid Long-Term Care
Appendix VIII: GAO Analysis of Annuity
              Appendix VIII: GAO Analysis of Annuity
              Language Contained in States’ Application
              Forms


Language Contained in States’ Application
Forms
              Table 39: Characteristics of Medicaid Long-Term Care Application Forms Related to
              Deficit Reduction Act of 2005 (DRA) Annuity Provisions, by State, 2011

                                              Application form contained language regarding
                                                             requirements to
                                         Disclose interest in an     Name the state as a remainder
               State                            annuity                      beneficiary
               Alabama                              ●                              ●
               Alaska                               ●                              ●
                                                     a                             a
               Arizona
                                                     b
               Arkansas                                                            ●
               California                           ●
                                                     c
               Colorado                             ●
               Connecticut                          ●
               Delaware                             ●                              ●
               District of Columbia
                                                                                    d
               Florida                              ●                              ●
               Georgia
               Hawaii                               ●                              ●
               Idaho
               Illinois                             ●
                                                     c                              e
               Indiana                              ●                              ●
                                                     c                                 f
               Iowa                                 ●                              ●
               Kansas                               ●                              ●
                                                     g                             g
               Kentucky
               Louisiana                            ●                              ●
               Maine                                ●                              ●
               Maryland                             ●                              ●
                                                                                    h
               Massachusetts                        ●                              ●
               Michigan                             ●
               Minnesota                            ●
               Mississippi                          ●
               Missouri                             ●
               Montana                              ●                              ●
               Nebraska                             ●                              ●
               Nevada                               ●
               New Hampshire                        ●                              ●
               New Jersey                           ●
               New Mexico                           ●




              Page 91                                              GAO-12-749 Medicaid Long-Term Care
Appendix VIII: GAO Analysis of Annuity
Language Contained in States’ Application
Forms




                                               Application form contained language regarding
                                                              requirements to
                                        Disclose interest in an                   Name the state as a remainder
    State                                      annuity                                    beneficiary
    New York                                             ●                                     ●
                                                                                                d
    North Carolina                                       ●                                     ●
    North Dakota                                         ●
    Ohio                                                 ●
                                                          c
    Oklahoma                                            ●
    Oregon                                               ●                                     ●
    Pennsylvania                                         ●
    Rhode Island                                         ●                                     ●
    South Carolina                                       ●                                     ●
    South Dakota                                         ●                                     ●
    Tennessee                                            ●                                     ●
    Texas                                                ●                                     ●
    Utah                                                 ●
    Vermont                                              ●
    Virginia                                             ●                                     ●
    Washington                                           ●                                     ●
    West Virginia                                        ●
                                                                                                   i
    Wisconsin                                            ●                                     ●
    Wyoming                                              ●
    Total                                               45                                     27
Source: GAO analysis of state application forms for Medicaid coverage for long-term care.

Notes: Our review was limited to state application forms for Medicaid coverage for long-term care
provided to us by state officials. Some states might require disclosure of an interest in an annuity and
include a statement regarding the state becoming a remainder beneficiary through another means,
such as a form other than the long-term care application form or through an interview conducted as
part of the application process.
a
 State collected information from applicants through an interview rather than a paper application form.
A state official provided the form eligibility workers use during their interviews with applicants and this
form contained language regarding requirements to disclose interest in an annuity. It also contained
language regarding the state becoming a remainder beneficiary, but specified this was for annuities
purchased on or after July 1, 2006 (rather than the date included in the DRA provision—February 8,
2006).
b
 State’s application form included a statement regarding having to disclose interest in an annuity, but
the sections of the application form that ask applicants to list their income or resources did not
mention annuities.
c
 State’s application form did not specify that annuities must be disclosed for the applicant’s spouse.
d
 State’s application form contained language regarding the state becoming a remainder beneficiary,
but specified this was for annuities purchased on or after November 1, 2007 (rather than the date
included in the DRA provision—February 8, 2006).




Page 92                                                                       GAO-12-749 Medicaid Long-Term Care
Appendix VIII: GAO Analysis of Annuity
Language Contained in States’ Application
Forms




e
 State’s application form contained language regarding the state becoming a remainder beneficiary,
but specified this was for annuities purchased on or after November 1, 2009 (rather than the date
included in the DRA provision—February 8, 2006).
f
State’s application form contained language regarding the state becoming a remainder beneficiary,
but did not indicate that this is a requirement.
g
    State collected information from applicants through an interview rather than a paper application form.
h
 State’s application form specified that the applicant may be required to name the state as a
remainder beneficiary, and referred the applicant to a booklet for more information.
i
  State’s application form contained language regarding the state becoming a remainder beneficiary,
but specified this was for annuities purchased on or after January 1, 2009 (rather than the date
included in the DRA provision—February 8, 2006).




Page 93                                                        GAO-12-749 Medicaid Long-Term Care
Appendix IX: Comments from the
             Appendix IX: Comments from the Department
             of Health and Human Services



Department of Health and Human Services




             Page 94                                     GAO-12-749 Medicaid Long-Term Care
Appendix IX: Comments from the Department
of Health and Human Services




Page 95                                     GAO-12-749 Medicaid Long-Term Care
Appendix X: GAO Contact and Staff
                  Appendix X: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov
GAO Contact
                  In addition to the contact named above, Michelle B. Rosenberg, Assistant
Staff             Director; Emily Binek; Julianne Flowers; Kaycee M. Glavich; Shirin
Acknowledgments   Hormozi; Emily Loriso; Christina Ritchie; and Phillip J. Stadler made key
                  contributions to this report.




(290953)
                  Page 96                                    GAO-12-749 Medicaid Long-Term Care
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