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Elder care in South Dakota
Do I (or a relative) qualify for Medicaid? Quick check
A yes or no to each question gives a rough first answer. The figures are South Dakota's.
Each question shows what either answer means.
Not legal advice. Figures are for 2026. The state makes the final decision: South Dakota Department of Social Services (DSS), Division of Economic Assistance; Department of Human Services, Division of Long Term Services and Supports (LTSS). The requirements in full: Qualifying for Medicaid in South Dakota.
Check these first
Nursing homes can sue adult children - after a 90-day written notice
SDCL 25-7-27 makes financially able adult children liable for a parent's necessary care. The SD Supreme Court enforced it against a son for his mother's nursing home bill (Americana Healthcare Center v. Randall, 1994). A claim requires written notice within 90 days after care began - take any such notice seriously and push the Medicaid application.
Source and exact words
appeals the trial court's judgment in favor of Americana Healthcare Center
Source page · Court opinion · as of 1994 · retrieved 2026-11-04
Full opinion behind paywall; holding summarized from secondary sources.
Moving into a nursing home makes the house countable unless you prove the stay is temporary
SD presumes admission to a long-term care facility establishes a new residence. Without convincing evidence (e.g., physician's statement) that the stay is temporary - renewed every 12 months - the home becomes a countable resource and can block eligibility.
Source and exact words
Temporary absence must be reestablished at 12-month intervals.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Estate recovery reaches joint accounts, life estates and living trusts
SD defines the recoverable estate to include assets passing by joint tenancy, survivorship, life estate, living trust or other arrangement, plus leftover prepaid burial funds. Surviving joint owners are liable for the decedent's debts. Probate avoidance does not avoid recovery.
Source and exact words
including any funds remaining in an individual's prepaid burial trust or prepaid burial account after the individual's reasonable burial expenses are paid
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Recovery from the surviving spouse's estate
After the Medicaid recipient dies, recovery is deferred while the spouse lives - but SD can then claim against the spouse's estate. The spouse has only 6 months after the recipient's death to petition to cap that liability at the spouse's estate value at that time.
Source and exact words
The petition for financial responsibility shall be filed with the Department of Social Services within six months of the date of death of the medical assistance recipient.
Source page · Official code · as of 2026 · retrieved 2026-11-04
Lifetime lien on real estate
Medicaid paid for a nursing-home resident creates a lien on any real property they own an interest in (SDCL 28-6-24), so the house can't be sold cleanly without paying DSS.
Source and exact words
creates a medical assistance lien against any real property in which the individual has any ownership interest.
Source page · Official code · as of 2026 · retrieved 2026-11-04
Ground ambulance bills: no protection - bill failed by one vote
SB 211 (2026) to ban ambulance balance billing failed 17-16. Out-of-network ground ambulance bills remain unrestricted for commercial plans; federal No Surprises Act excludes ground ambulances.
Source and exact words
The bill failed to pass the Senate by a vote of 17-16!
Source page · Secondary source · as of 2026 · retrieved 2026-11-04
Handbook figures are stale
DSS's Spousal Care Handbook still shows 2024 figures (e.g., $60 personal needs; the rule is $100 since June 30, 2024; $30,828/$154,140 CSRA). Use the rules and current federal figures.
Source and exact words
A deduction of one hundred dollars per month to cover personal needs
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
At a glance
Calculators for South Dakota Compare states
Common mistakes
These are the mistakes that most often cost families coverage. They apply in every state.
1. Moving money out of the account or giving it to the children
You can't simply give money away (or move it to a child's account) to get under the asset limit. Any transfer for less than fair market value within the 60-month look-back makes the person ineligible for nursing-home and waiver coverage for a penalty period: the total given away divided by the state's penalty divisor (its average monthly private-pay nursing-home cost).
Worked example for South Dakota
Giving away $50,000 in South Dakota: we won't estimate the penalty. Not confirmed for South Dakota: the penalty divisor is not something we could find, so we won't calculate with it.
Source and exact words
ARSD 67:46:05:09
The period of ineligibility is determined by dividing the uncompensated value of the transferred assets by the monthly state-wide average of long-term care costs for private pay individuals for the state's current fiscal year.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Method confirmed; dollar figure not found on an official SD page. Secondary sources conflict: medicaidplanningassistance.org $9,749.92/mo; medicareresources.org ~$9,291.62 (2026). Partial-month penalties imposed.
Source and exact words
42 U.S.C. 1396p(c)(1)(A)
disposes of assets for less than fair market value on or after the look-back date specified in subparagraph (B)(i), the individual is ineligible for medical assistance
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(1)(E)(i)
the total, cumulative uncompensated value of all assets transferred by the individual (or individual's spouse) on or after the look-back date specified in subparagraph (B)(i), divided by (II) the average monthly cost to a private patient of nursing facility services in the State
Source page · Official code · as of current statute · retrieved 2026-11-04
2. Giving money away first, then spending the rest down
The penalty clock doesn't start on the day of the gift. It starts only when the person is in a nursing home (or needs that level of care), has spent down to the asset limit, has applied, and would be approved but for the penalty. So giving money away and then spending down is the worst order: the penalty starts exactly when there is no money left to pay the nursing home.
Source and exact words
42 U.S.C. 1396p(c)(1)(D)(ii)
the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care described in subparagraph (C) based on an approved application for such care but for the application of the penalty period, whichever is later
Source page · Official code · as of current statute · retrieved 2026-11-04
3. Adding a child to the bank account
Putting a child's name on the account doesn't protect the money: the whole joint account is generally counted as the applicant's. And when the child (or anyone) takes money out, that can count as a transfer by the applicant, with a penalty.
Source and exact words
SSA POMS SI 01140.205C.2
When a claimant or recipient co-owns an account with someone who is not eligible for SSI benefits, we assume that all the funds in the account belong to the SSI claimant or recipient.
Source page · Agency guidance · as of 2023-12-27 · retrieved 2026-11-04
SSI rule. Medicaid for people 65+, blind or disabled generally uses SSI income and resource methods (42 CFR 435.601), but 209(b) states and states with less restrictive methods can differ: check the state.
Source and exact words
42 U.S.C. 1396p(c)(3)
the asset (or the affected portion of such asset) shall be considered to be transferred by such individual when any action is taken, either by such individual or by any other person, that reduces or eliminates such individual's ownership or control of such asset.
Source page · Official code · as of current statute · retrieved 2026-11-04
4. Paying family for care without a written agreement
Relatives can be paid for caregiving, but care given for free is presumed to have been free. Paying a child afterwards for past care, or paying without a written agreement made at the time the care was given, is treated as a gift. Put a written agreement in place before the care starts, pay a fair market rate as the care is given, and keep records.
Source and exact words
CMS State Medicaid Manual § 3258.1.A.1 (Rev. 64)
Also, while relatives and family members legitimately can be paid for care they provide to the individual, HCFA presumes that services provided for free at the time were intended to be provided without compensation. Thus, a transfer to a relative for care provided for free in the past is a transfer of assets for less than fair market value. However, an individual can rebut this presumption with tangible evidence that is acceptable to the State. For example, you may require that a payback arrangement had been agreed to in writing at the time services were provided.
Source page · Agency guidance · as of 1994-11 · retrieved 2026-11-04
CMS State Medicaid Manual, Chapter 3 (download p45_03.zip, file "sm 03 3 325 to 3259.8.doc"), Transmittal 64, November 1994. Still the posted federal manual; many states have since adopted stricter written personal-care-agreement rules, so check the state.
5. Giving away or underselling the home
Deeding the house to the kids, or selling it to them for less than it's worth, is a transfer with a penalty. The only home transfers that are allowed without penalty are to: a spouse; a child under 21 or a blind or disabled child; a sibling with an equity interest who lived there at least a year before the move to a nursing home; or a son or daughter who lived there at least two years and whose care kept the parent out of a nursing home.
Source and exact words
42 U.S.C. 1396p(c)(2)(A)
(A) the assets transferred were a home and title to the home was transferred to— (i) the spouse of such individual; (ii) a child of such individual who (I) is under age 21, or (II) (with respect to States eligible to participate in the State program established under subchapter XVI) is blind or permanently and totally disabled
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(2)(A)(iv)
a son or daughter of such individual (other than a child described in clause (ii)) who was residing in such individual's home for a period of at least two years immediately before the date the individual becomes an institutionalized individual, and who (as determined by the State) provided care to such individual which permitted such individual to reside at home rather than in such an institution or facility
Source page · Official code · as of current statute · retrieved 2026-11-04
6. Annuities, promissory notes and life estates that don't meet the rules
Buying an annuity, lending money to family on a note, or buying a life estate in a child's home all count as gifts unless they meet strict federal rules: annuities must name the state as remainder beneficiary and be irrevocable, non-assignable, actuarially sound and paid in equal amounts; notes must be actuarially sound, paid in equal amounts and not forgiven at death; a life-estate buyer must live in the home for at least a year after buying.
Source and exact words
42 U.S.C. 1396p(c)(1)(F)
the purchase of an annuity shall be treated as the disposal of an asset for less than fair market value unless— (i) the State is named as the remainder beneficiary in the first position
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(1)(I)
the term "assets" includes funds used to purchase a promissory note, loan, or mortgage unless such note, loan, or mortgage— (i) has a repayment term that is actuarially sound
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(1)(J)
the term "assets" includes the purchase of a life estate interest in another individual's home unless the purchaser resides in the home for a period of at least 1 year after the date of the purchase.
Source page · Official code · as of current statute · retrieved 2026-11-04
7. Forgetting estate recovery after death
After a person who got Medicaid at 55 or older dies, the state must try to recover what it paid for nursing-home and home-care services from the estate, usually the house. Recovery waits while a spouse, a child under 21 or a blind or disabled child survives. Some states also reach assets that skip probate (joint accounts, life estates, living trusts).
Source and exact words
42 U.S.C. 1396p(b)(4)(B)
any other real and personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of such interest), including such assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
Medicaid.gov, Estate Recovery
For individuals age 55 or older, states are required to seek recovery of payments from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services.
Source page · Agency guidance · as of 2026-11-04 · retrieved 2026-11-04
8. Missing records for the look-back
States typically ask for up to five years (60 months) of statements for every account, including closed ones. Money that left an account for less than fair value is presumed to be a penalized transfer unless you can show what it was for, so withdrawals you can't explain can be treated as gifts. Keep receipts and statements from the start.
Source and exact words
Oklahoma Human Services, Long-Term Care
We will need the last sixty (60) months of statements on all accounts held in the past 60 months. If any asset has been sold, traded, or given away within the last 60 months prior to entry into the nursing home and application for Medicaid, we will require documentation of the transfer.
Source page · Agency guidance · as of 2026-11-04 · retrieved 2026-11-04
A state example, not a federal rule: we found no federal source setting how many months of statements states must request. Other states ask similar.
Source and exact words
Ohio Adm.Code 5160:1-6-06(B)
any such transfer will be presumed an improper transfer and will result in a restricted medicaid coverage period (RMCP)
Source page · Official regulation · as of 2025-10-01 · retrieved 2026-11-04
A state example of how agencies treat transfers they can't verify.
Source and exact words
42 U.S.C. 1396p(c)(2)(C)
a satisfactory showing is made to the State (in accordance with regulations promulgated by the Secretary) that (i) the individual intended to dispose of the assets either at fair market value, or for other valuable consideration, (ii) the assets were transferred exclusively for a purpose other than to qualify for medical assistance
Source page · Official code · as of current statute · retrieved 2026-11-04
In South Dakota specifically
- Nursing homes can sue adult children - after a 90-day written notice
- Moving into a nursing home makes the house countable unless you prove the stay is temporary
- Estate recovery reaches joint accounts, life estates and living trusts
- Recovery from the surviving spouse's estate
- Lifetime lien on real estate
- Ground ambulance bills: no protection - bill failed by one vote
- Handbook figures are stale
Details and sources are in the cards at the top of this page.
What you are allowed to do
Spend at fair market value, on the person who needs care
Money spent on the applicant and for full value is not a gift: paying the nursing home, paying debts, buying things the applicant needs. Keep receipts.
Source and exact words
42 U.S.C. 1396p(c)(2)(C)
the individual intended to dispose of the assets either at fair market value, or for other valuable consideration
Source page · Official code · as of current statute · retrieved 2026-11-04
Pay bills and care costs, prepay the funeral
Over-limit money can go to the cost of care, to bills the person owes, and to prepaying their funeral, as long as nothing is given away or sold for less than it's worth.
Source and exact words
Maryland Department of Health, Some Questions and Answers about Financial Eligibility (nursing home)
Resources over the $2,500 limit may be used in several ways as long as they are not given away or exchanged for something of lesser value. For example, you may use your excess resources to pay for the cost of care in the nursing home, to pay other bills that you may have, or to prepay your funeral expenses.
Source page · Agency guidance · as of 2006 · retrieved 2026-11-04
A state example (2006 publication; the $2,500 figure is Maryland's and dated). The principle (spending for fair value) is federal: 42 U.S.C. 1396p(c)(2)(C).
An irrevocable prepaid funeral
A prepaid funeral contract that can't be cancelled or sold doesn't count as an asset (a revocable one does, above small burial-fund limits). States set the maximum that can be made irrevocable.
Source and exact words
SSA POMS SI 01130.420B.2
If a burial contract cannot be revoked and cannot be sold without significant hardship, it is not a resource.
Source page · Agency guidance · as of 2011-06-17 · retrieved 2026-11-04
SSI rule. Medicaid for people 65+, blind or disabled generally uses SSI income and resource methods (42 CFR 435.601), but 209(b) states and states with less restrictive methods can differ: check the state.
Things that don't count: the home, one car, household goods
The home the person lives in (up to the equity cap), one car used for transportation, and household goods are excluded. Spending countable cash at fair value on these (for example, repairs or accessibility changes to the home the person lives in, or replacing the one car) generally turns it into an excluded asset. Check the state's rules before a large purchase.
Source and exact words
20 CFR 416.1210(a)-(c)
(a) The home (including the land appertaining thereto) to the extent its value does not exceed the amount set forth in § 416.1212; (b) Household goods and personal effects as defined in § 416.1216; (c) An automobile, if used for transportation, as provided in § 416.1218
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Text read through the eCFR API (ecfr.gov), current as of 2026-11-02. SSI rule. Medicaid for people 65+, blind or disabled generally uses SSI income and resource methods (42 CFR 435.601), but 209(b) states and states with less restrictive methods can differ: check the state.
Pay medical bills
Unpaid and current medical bills the person owes can use up excess resources. Some states count them directly against the excess.
Source and exact words
New York State Department of Health, LDSS-4321 attachment (11 ADM-4)
you may be eligible for Medicaid coverage if you have medical bills that are equal to or higher than the amount of your excess resources, or if you spend excess resources on certain expenses set aside for your and your spouse’s burial.
Source page · Agency form · as of 2011-07 · retrieved 2026-11-04
A state example (New York notice language, 2011).
Transfers to a spouse
Moving assets to a spouse (or to someone else for the spouse's sole benefit) is not penalized. It doesn't hide them at application, because both spouses' assets are counted together, but after approval the at-home spouse can keep the protected share (CSRA).
Source and exact words
42 U.S.C. 1396p(c)(2)(B)(i)
were transferred to the individual's spouse or to another for the sole benefit of the individual's spouse
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396r-5(f)(1)
An institutionalized spouse may, without regard to section 1396p(c)(1) of this title, transfer an amount equal to the community spouse resource allowance (as defined in paragraph (2)), but only to the extent the resources of the institutionalized spouse are transferred to (or for the sole benefit of) the community spouse.
Source page · Official code · as of current statute · retrieved 2026-11-04
Who to call
- Medicaid agency
South Dakota Department of Social Services (DSS), Division of Economic Assistance; Department of Human Services, Division of Long Term Services and Supports (LTSS) (South Dakota Medicaid - Long-Term Care; HOPE Waiver) - Free Medicare counseling (SHIP)
SHIINE (Senior Health Information & Insurance Education) - Aging services
SD Department of Human Services, Division of Long Term Services and Supports (Dakota at Home) - Insurance regulator
South Dakota Division of Insurance (Department of Labor and Regulation)
Eligibility figures and notes
Source and exact words
The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,982 in 2026).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Over the cap, an approved Medicaid income trust is required (ARSD 67:46:05:33.01; DSS spousal care handbook).
Source and exact words
The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,982 in 2026).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
If the income of the spouse in the facility is more than three times the SSI benefit there may still be eligibility if the income is placed in an approved income trust.
Source page · Agency guidance · as of 2024 · retrieved 2026-11-04
Source and exact words
ARSD 67:46:05:30
The resource limit, including both liquid and nonliquid resources, for long-term care assistance is $2,000 for an individual
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Source and exact words
ARSD 67:46:05:30
$3,000 for an individual with a spouse if both spouses begin receiving long-term care services in the same month.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Source and exact words
ARSD 67:46:06:05 (amended eff. June 30, 2024)
A deduction of one hundred dollars per month to cover personal needs
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Plus up to $75 of earned income. The DSS Spousal Care Handbook (2024 figures) still shows $60 - outdated.
Source and exact words
ARSD 67:46:05:15 (amended eff. July 1, 2026)
the individual's home property interest , up to an equity value of seven hundred fifty-two thousand dollars, is excluded from the individual's assets if it continues to be the individual's principal place of residence.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Equity above the limit = ineligible regardless of intent to return; limit doesn't apply if spouse or child under 21/blind/disabled lives there.
Source and exact words
ARSD 67:46:05:18-19
Admission of the individual into a long-term care facility or another change in residence, whichever occurs first, is presumed to be establishing another principal place of residence.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Source and exact words
It is better to fill this form out as soon as possible after entry because it is easier to prove your resources for the day the spouse entered the facility now than at a later date.
Source page · Agency guidance · as of 2024 · retrieved 2026-11-04
Protecting the spouse at home
Source and exact words
One-half of the total resources or $30,828*, whichever is greater, can be protected for the spouse at home.
Source page · Agency guidance · as of 2024 · retrieved 2026-11-04
Source and exact words
Minimum Resource Standard: 32,532.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
SD uses federal min/max (handbook shows 2024 figures indexed with '*'); 2026 SD-specific figure not found on an SD page.
Source and exact words
Maximum Resource Standard 162,660.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
Minimum Monthly Maintenance Needs Allowance 2,705.00 All States (Except Alaska and Hawaii)
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Federal; SD 2026 figure not confirmed on SD page (handbook shows $2,465 for 2024).
Source and exact words
Maximum Monthly Maintenance Needs Allowance: 4,066.50
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Gifts, the look-back and the penalty
Source and exact words
The look-back period extends back to the date 60 months before the first date on which the individual is institutionalized and applies for long-term care assistance
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Source and exact words
ARSD 67:46:05:09
The period of ineligibility is determined by dividing the uncompensated value of the transferred assets by the monthly state-wide average of long-term care costs for private pay individuals for the state's current fiscal year.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Method confirmed; dollar figure not found on an official SD page. Secondary sources conflict: medicaidplanningassistance.org $9,749.92/mo; medicareresources.org ~$9,291.62 (2026). Partial-month penalties imposed.
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
SD rule text on penalty start date not retrieved; federal rule (date otherwise eligible) presumed.
- spouse
- son/daughter under 21
- blind/disabled son or daughter
- caregiver son/daughter who lived in the home 2 years before admission
- sibling with equity interest who lived there 1 year
Source and exact words
ARSD 67:46:05:16
A son or daughter who has resided in the home for at least two years immediately prior to the date the applicant or recipient entered the long-term care facility and who provided care
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
After death: estate recovery and liens
Source and exact words
ARSD 67:48:02:01(2)
including such assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Includes leftover prepaid burial funds. Recovers NF, HCBS, ICF/IID, hospital and prescription drug services from age 55 (SDCL 28-6-23). DSS can also file against the surviving spouse's estate.
- Lifetime tefra liens
- Yes
- Detail
- Medicaid paid to an inpatient of a nursing facility/ICF/medical institution creates a lien against any real property the person has an ownership interest in.
Source and exact words
SDCL 28-6-24
is a debt and creates a medical assistance lien against any real property in which the individual has any ownership interest.
Source page · Official code · as of 2026 · retrieved 2026-11-04
- No recovery while
- spouse living
- child under 21
- blind or disabled child
- Spouse estate
- After the spouse dies, DSS may claim against the surviving spouse's estate; spouse may petition (within 6 months of recipient's death) to cap it at the spouse's estate value at the recipient's death (SDCL 28-6-23.1).
Source and exact words
ARSD 67:48:02:05
The department may not seek recovery from the individual's estate if the individual's spouse is still living or if the individual has a surviving child who is under age 21 or is blind or disabled.
Source page · Official regulation · as of 2026 · retrieved 2026-11-04
Source and exact words
SDCL 28-6-23
The Department of Social Services may file a claim against the estate of the surviving spouse of a medical assistance recipient to satisfy the debt established under this section.
Source page · Official code · as of 2026 · retrieved 2026-11-04
Family liability
Source and exact words
Any adult child, having the financial ability to do so, shall provide necessary food, clothing, shelter, or medical attendance for a parent who is unable to provide for oneself.
Source page · Official code · as of 2026 · retrieved 2026-11-04
Written notice to the child required within 90 days after care first provided before a claim. Americana Healthcare Center v. Randall, 513 N.W.2d 566 (S.D. 1994) held a son liable for his mother's nursing home bill. SD News Watch (2018): law 'is rarely used'. SDCL 25-7-28: contribution from siblings.
Care at home and other programs
- HOPE Waiver (Home & Community-Based Options and Person Centered Excellence)
HCBS for elderly and adults with disabilities at nursing-facility level of care, including services in assisted living and community homes
Source and exact words
It allows for home and community-based services to be provided to individuals at risk for institutionalization.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Waitlist status not found.
- Covered
- Yes
- Detail
- HOPE Waiver pays services for eligible people in assisted living or community home facilities (same $2,982 income / $2,000 resource limits).
Source and exact words
HOPE Waiver for Individuals in Assisted Living or Community Home Facilities
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Room and board not covered (general rule; not quoted).
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
No South Dakota PACE program found in sources reviewed (not confirmed).
Source and exact words
The South Dakota Long-Term Care Partnership Program, administered by the Department of Social Services and Division of Insurance, provides an alternative to spending down or transferring assets
Source page · Agency guidance · as of 2024 · retrieved 2026-11-04
Medicare and Medigap
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
No SD birthday/anniversary rule found on the Division of Insurance Medicare supplement page.
Source and exact words
For all persons on Medicare, there is a six-month open enrollment period once they reach the age of 65.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- Required
- Yes
- Detail
- Six-month open enrollment beginning at Part B enrollment for those under 65 due to disability.
Source and exact words
For those who are under age 65 and qualify for Medicare by reason of disability, there is also a six month open enrollment period beginning on the date of enrollment in Part B Medicare.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Plans/pricing rules (e.g., rate caps) not verified.
- Resource individual
- 9,950
- Resource couple
- 14,910
- Asset test eliminated
- No
Source and exact words
Resource limit is $9,950 for an individual and $14,910 for a couple.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
None researched.
Ambulance bills and rides
- Detail
- 2026 SB 211 (ban on ambulance balance billing / out-of-network reimbursement standards) failed in the Senate 17-16 on Feb. 24, 2026. No enacted SD law found.
Source and exact words
The BIG news of the week is SB 211 (ambulance bill). The bill failed to pass the Senate by a vote of 17-16!
Source page · Secondary source · as of 2026 · retrieved 2026-11-04
Source is an insurance-advisor trade group legislative report (opposed the bill). Official sdlegislature.gov bill page not fetched.
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Not researched beyond federal No Surprises Act.
- Model
- Enrolled transportation providers (no single statewide broker identified); ask if provider is Medicaid-enrolled before booking.
Source and exact words
Before booking transportation, remember to ask if the provider is enrolled in South Dakota Medicaid and if the trip will be covered by Medicaid.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
Other protections
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
SD elder abuse reporting/APS not researched.
Federal rules that apply everywhere
These federal rules apply nationwide, DC included.
Federal gotchas
Observation status can wipe out SNF coverage
A parent can spend several nights in a hospital bed 'under observation' (outpatient) and never meet the 3-day INPATIENT requirement, so Medicare pays nothing for the rehab/nursing home stay that follows. Ask every day: 'Is she inpatient or observation?' Read the MOON notice (required after 24 hours of observation), ask the doctor to reconsider admission, check if a Medicare Advantage plan or ACO waives the 3-day rule, and if a stay was switched from inpatient to observation, appeal.
Source and exact words
42 CFR 409.30(a)
This means a prior medically necessary inpatient hospital stay of at least 3 days in a row (starting the day you were admitted as an inpatient, but not including the day you leave the hospital).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'Time you spend at the hospital under observation or in the emergency room before you're admitted doesn't count toward the 3-day qualifying inpatient hospital stay, even if you're there overnight.' ACO waivers and Medicare Advantage plans may waive the 3-day rule.
Medicare does not pay for long-term nursing home care
Medicare (and Medigap) covers only short-term skilled care (max 100 days per benefit period, $217/day from day 21 in 2026, and only while daily skilled care is needed). Custodial care in a nursing home, assisted living, or at home is private-pay, LTC insurance, VA, or Medicaid. Plan for Medicaid before the money runs out.
Source and exact words
Since most long-term care is non-medical, Medicare and most health insurance, including Medicare Supplement Insurance (Medigap) , don’t pay for long-term care services, including care in a nursing home or in the community.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
SNF coverage often ends long before day 100
Coverage stops as soon as the facility decides daily skilled care is no longer needed ('plateaued'); there is no right to 100 days. Request a fast appeal from the notice of non-coverage, and remember 'improvement' isn't required: maintenance therapy can qualify.
Source and exact words
Days 21–100: You pay $217 each day. Days 101 and beyond: You pay all costs. Part A limits SNF coverage to 100 days in each benefit period.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Days 1-20: 'You pay $0 each day after you pay the $1,736 deductible' (deductible not owed again if already paid for the hospital stay in the same benefit period). CMS fact sheet: '$217.00 in 2026 ($209.50 in 2025)'. The 100 days are a maximum, not a guarantee: coverage ends when daily skilled care is no longer needed.
Gifts within 5 years delay Medicaid, and the penalty clock starts late
Any gift (cash to grandkids, deeding the house) within 60 months of applying triggers a penalty. The penalty doesn't start when the gift is made; it starts only once the parent has spent down, applied, and would otherwise be eligible, which leaves a stretch with no money and no Medicaid. Partial months can't be rounded away.
Source and exact words
42 U.S.C. 1396p(c)(1)(D)(ii)
the date specified in this subparagraph is the first day of a month during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care described in subparagraph (C) based on an approved application for such care but for the application of the penalty period, whichever is later
Source page · Official code · as of current statute · retrieved 2026-11-04
Gifting the house can cost the kids capital-gains tax
A gifted house keeps the parent's old (low) basis; an inherited house gets a stepped-up basis at death. Gifting a house to dodge Medicaid can create a large taxable gain when the child sells, plus a look-back penalty. Consider exempt transfers (caregiver child, disabled child, spouse) or other planning with an elder-law attorney.
Source and exact words
IRC 1015 (gifts), 1014 (inherited); IRS Pub. 551
If the FMV of the property is equal to or greater than the donor's adjusted basis, your basis is the donor's adjusted basis at the time you received the gift.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Inherited: 'Generally, the basis of property inherited from a decedent is one of the following. The FMV of the property at the date of the individual's death.' Why it matters: a house bought for $80k and gifted to a child while worth $400k carries the $80k basis; if the child sells, ~$320k gain is taxable (and the child usually can't use the parent's IRC 121 exclusion). If inherited instead, basis steps up to ~$400k and little or no gain results. Gifting also starts a 60-month Medicaid look-back penalty.
Joint bank accounts are treated as the parent's money
Under SSI rules (which most state Medicaid programs follow), all funds in a joint account are presumed to belong to the applicant unless rebutted with evidence. Adding a child's name doesn't protect money, and removing money from a joint account can count as a gift.
Source and exact words
SSA POMS SI 01140.205
Account holders include one or more claimants or recipients If there is more than one claimant or recipient, assume that all the funds in the account belong to the claimant(s) or recipient(s), in equal shares.
Source page · Agency guidance · as of 2023-12-27 · retrieved 2026-11-04
SSI rule; Medicaid aged/blind/disabled eligibility generally follows SSI methodology (42 CFR 435.601), but states can differ: check state files.
A power of attorney without explicit gifting power can block Medicaid planning
Under Uniform Power of Attorney Act states, an agent can make gifts, change beneficiaries, or create/change survivorship rights ONLY if the POA expressly says so. If the parent has lost capacity, the family may need a costly guardianship to do planning. Review the POA now while the parent can sign a new one.
Source and exact words
N.C. Gen. Stat. 32C-2-201 (example of UPOAA sec. 201)
An agent may do the following on behalf of the principal or with the principal's property only if the power of attorney expressly grants the agent that authority: a. Make a gift. b. Create or change rights of survivorship. c. Create or change a beneficiary designation.
Source page · Official code · as of current statute · retrieved 2026-11-04
State law, not federal; shown as a representative UPOAA enactment. Check each state's POA statute.
Don't sign the nursing home admission agreement as a guarantor
Federal rules bar Medicare/Medicaid nursing facilities from requiring a third-party guarantee of payment. Facilities still use 'Responsible Party' language. Sign only as the resident's representative/agent (using the resident's funds), cross out personal guarantees, and never agree to pay personally.
Source and exact words
42 CFR 483.15(a)(3)
The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Arbitration clauses are optional, and you can rescind within 30 days
Nursing homes may not require binding arbitration as a condition of admission or continued care, and the agreement must allow rescission within 30 calendar days. Decline or rescind to keep the right to sue over neglect or abuse.
Source and exact words
42 CFR 483.70(m)
The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Same section: 'The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.'
IRMAA surprise two years after selling the house or cashing out an IRA
Medicare premiums are based on income from 2 years earlier. A home sale gain above the $250k/$500k exclusion, a big IRA withdrawal, or a Roth conversion can raise Part B to as much as $689.90/month plus a Part D surcharge two years later. A one-time sale is NOT a life-changing event for an SSA-44 appeal (but a spouse's death, retirement, or lost pension is). Spread income across years when possible.
Source and exact words
20 CFR 418.1205; SSA POMS HI 01120.001
You or your spouse experiences a loss of income-producing property, provided the loss is not at the direction of you or your spouse (e.g., due to the sale or transfer of the property) and is not a result of the ordinary risk of investment.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Selling a house or other property is NOT a life-changing event. POMS HI 01120.001: 'the SSA-44 , Medicare Income-Related Monthly Adjustment Amount Life Changing Event is available online' and 'The SSA-44 is only for beneficiaries wishing to request a new initial determination, based on a valid LCE'.
Switching from Medicare Advantage back to Original Medicare can leave you without a Medigap
Federal Medigap guaranteed issue lasts only 6 months from Part B at 65, plus narrow situations. After the 12-month MA 'trial right' passes, a parent with health problems who leaves Medicare Advantage (e.g., to use an out-of-network specialist or nursing home) can be denied Medigap in most states. Choose carefully at 65.
Source and exact words
There’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet their medical underwriting requirements. They may deny you a policy unless you have a guaranteed issue right
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Medicare.gov 'Choosing a Medigap Policy' guide (2026 edition).
Ground ambulance bills aren't covered by the No Surprises Act
The federal No Surprises Act protects against surprise air-ambulance and ER bills, but generally not ground ambulance. Out-of-network ground ambulances can balance-bill privately insured patients unless state law protects them. With Original Medicare, the patient owes 20% coinsurance after the deductible.
Source and exact words
Generally, ground ambulance services aren't covered by billing protections in the No Surprises Act (unless a state law has different rules). They're still allowed to charge out-of-network rates.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: the NSA protects against surprise out-of-network bills from 'emergency room visits; non-emergency care related to visits at in-network hospitals, hospital outpatient departments, and ambulatory surgical centers; and air ambulance services.' NSA applies to private/commercial coverage; Medicare and Medicaid already limit balance billing by participating ambulance suppliers.
Scheduled non-emergency ambulance trips can be billed to you if prior authorization is denied
For repeated scheduled trips (e.g., dialysis), Medicare requires prior authorization by the 4th round trip in 30 days; if denied and the trips continue, the company may bill the full charge. Non-emergency trips also need a physician certification and an ABN when Medicare may not pay.
Source and exact words
If your prior authorization request isn't approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'You get scheduled, non-emergency ambulance transportation for 3 or more round trips in a 10-day period or at least once a week for 3 weeks or more You get this transportation from any ambulance company nationwide'.
Retroactive Medicaid shrinks from 3 months to 2 starting with 2027 applications
For applications made on or after Jan. 1, 2027, Medicaid for older/disabled applicants can reach back only to the 2nd month before the application month (1 month for expansion adults). Nursing home bills from earlier months may not be covered, so apply as soon as the parent might qualify.
Source and exact words
Pub. L. 119-21 sec. 71112, amending 42 U.S.C. 1396a(a)(34) and 1396d(a)
is not described in subparagraph (A), such assistance will be made available to the individual for care and services included under the plan and furnished in or after the second month before the month in which the individual made application
Source page · Official code · as of 2027 · retrieved 2026-11-04
Applies to eligibility 'based on an application made on or after the first day of the first quarter that begins after December 31, 2026' (i.e., Jan. 1, 2027). Older adults needing nursing-home Medicaid fall in the 'not described in subparagraph (A)' (2-month) group. The replaced statutory text was 'in or after the third month before the month in which the recipient makes application'.
Home equity cap drops to a flat $1,000,000 in 2028
Nursing-home Medicaid is denied if home equity exceeds the state's limit (2026: $752,000 to $1,130,000) unless a spouse or minor/disabled child lives there. From Jan. 1, 2028, the cap for non-agricultural homes can't exceed $1,000,000 and won't rise with inflation. A reverse mortgage or home equity loan can reduce equity.
Source and exact words
Pub. L. 119-21 (One Big Beautiful Bill Act) sec. 71108, amending 42 U.S.C. 1396p(f)
A State may elect, without regard to the requirements of section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to comparability), to apply subparagraph (A), in the case of an individual's home that is not described in clause (i), by substituting for the amount specified in such subparagraph, an amount that exceeds such amount, but does not exceed $1,000,000.
Source page · Official code · as of 2028 · retrieved 2026-11-04
Effective-date text: 'The amendments made by subsection (a) shall apply beginning on January 1, 2028.' Also adds: inflation-indexed amounts (other than for agricultural-lot homes) exceeding $1,000,000 'shall be deemed to be equal to $1,000,000'. States currently above $1M (2026 max is $1,130,000) will have to drop to $1M for non-agricultural homes.
Estate recovery can reach the house and more
States must recover nursing home and home-care costs from the estates of people who got Medicaid at 55+. Many states expand 'estate' beyond probate to joint property, life estates, and living trusts. Recovery waits until a surviving spouse dies and doesn't apply while a child under 21 or a blind/disabled child survives; ask about hardship waivers.
Source and exact words
42 U.S.C. 1396p(b)(4)(B)
may include, at the option of the State (and shall include, in the case of an individual to whom paragraph (1)(C)(i) applies), any other real and personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of such interest), including such assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.
Source page · Official code · as of current statute · retrieved 2026-11-04
Partnership LTC policyholders (1396p(b)(1)(C)(i)) are subject to the expanded definition for non-protected assets.
Annuities and promissory notes must meet strict rules or they count as gifts
A Medicaid-compliant annuity must name the state as remainder beneficiary and be irrevocable, nonassignable, actuarially sound, and pay equal installments. Family loans/promissory notes must be actuarially sound, pay equal installments, and can't be forgiven at death, or the money counts as a transfer.
Source and exact words
42 U.S.C. 1396p(c)(1)(I)
the term "assets" includes funds used to purchase a promissory note, loan, or mortgage unless such note, loan, or mortgage— (i) has a repayment term that is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); (ii) provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and (iii) prohibits the cancellation of the balance upon the death of the lender.
Source page · Official code · as of current statute · retrieved 2026-11-04
Caregiver-child home transfer requires 2 years of live-in care
A parent can deed the home to a child without penalty only if the child lived there for at least 2 years immediately before the parent's institutionalization and provided care that kept the parent out of a facility, as the state determines. Document the care (doctor letters, care logs) now.
Source and exact words
42 U.S.C. 1396p(c)(2)(A)-(D)
(iv) a son or daughter of such individual (other than a child described in clause (ii)) who was residing in such individual's home for a period of at least two years immediately before the date the individual becomes an institutionalized individual, and who (as determined by the State) provided care to such individual which permitted such individual to reside at home rather than in such an institution or facility
Source page · Official code · as of current statute · retrieved 2026-11-04
Quote shows the caregiver-child exemption; the other listed exemptions are in the same subsection (c)(2)(A)(i)-(iii), (B)(i)-(iv), (C)(i)-(iii), (D).
Hospice doesn't pay nursing home room and board
Choosing hospice in a nursing home or at home doesn't cover room and board. The family or Medicaid still pays the facility's daily rate.
Source and exact words
Room and board. Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).'
Income just over the cap needs a Miller trust (QIT)
In income-cap states, a parent with income even $1 over $2,982/month (2026) is ineligible for nursing-home Medicaid unless the excess goes into a Qualified Income (Miller) Trust each month. Missing a month's deposit can cause ineligibility for that month.
Source and exact words
42 U.S.C. 1396p(d)(4)(B)
A trust established in a State for the benefit of an individual if— (i) the trust is composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust), (ii) the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this subchapter; and (iii) the State makes medical assistance available to individuals described in section 1396a(a)(10)(A)(ii)(V) of this title, but does not make such assistance available to individuals for nursing facility services under section 1396a(a)(10)(C) of this title.
Source page · Official code · as of current statute · retrieved 2026-11-04
Medicare (all states)
Source and exact words
The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,736 in 2026, an increase of $60 from $1,676 in 2025.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- Days61to90
- $434/day
- Lifetime reserve per day
- $868/day
Source and exact words
In 2026, beneficiaries must pay a coinsurance amount of $434 per day for the 61 st through 90 th day of a hospitalization ($419 in 2025) in a benefit period and $868 per day for lifetime reserve days ($838 in 2025).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- Premium free if40 quarters
- $0/month
- Reduced30to39 quarters
- $311/month
- Full
- $565/month
Source and exact words
may buy into Part A at a reduced monthly premium rate, which will be $311 in 2026, a $26 increase from 2025. Certain uninsured aged individuals who have fewer than 30 quarters of coverage, and certain individuals with disabilities who have exhausted other entitlements, will pay the full premium, which will be $565 a month in 2026
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
42 CFR 409.30(a)
This means a prior medically necessary inpatient hospital stay of at least 3 days in a row (starting the day you were admitted as an inpatient, but not including the day you leave the hospital).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'Time you spend at the hospital under observation or in the emergency room before you're admitted doesn't count toward the 3-day qualifying inpatient hospital stay, even if you're there overnight.' ACO waivers and Medicare Advantage plans may waive the 3-day rule.
Source and exact words
42 CFR 409.30(a)(1)
Have been hospitalized in a participating or qualified hospital or participating CAH, for medically necessary inpatient hospital or inpatient CAH care, for at least 3 consecutive calendar days, not counting the date of discharge
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
- Days1to20
- $0/day
- Days21to100 per day
- $217/day
- After100
- beneficiary pays all costs
Source and exact words
Days 21–100: You pay $217 each day. Days 101 and beyond: You pay all costs. Part A limits SNF coverage to 100 days in each benefit period.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Days 1-20: 'You pay $0 each day after you pay the $1,736 deductible' (deductible not owed again if already paid for the hospital stay in the same benefit period). CMS fact sheet: '$217.00 in 2026 ($209.50 in 2025)'. The 100 days are a maximum, not a guarantee: coverage ends when daily skilled care is no longer needed.
Source and exact words
42 CFR 489.20(y) (NOTICE Act)
to provide notice, as specified in paragraphs (y)(1) and (2) of this section, to each individual entitled to Medicare benefits under Title XVIII of the Act when such individual receives observation services as an outpatient for more than 24 hours. Notice must be provided to the individual not later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged, or admitted.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Source and exact words
If you’re a Medicare patient who was admitted to the hospital as an inpatient, and the hospital changed your status to “outpatient getting observation services,” you may be able to appeal the denial of Part A (Hospital Insurance) inpatient coverage that came from the change in your status.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Page heading: 'You can appeal past hospital stays back to January 2009'. Appeal right applies to inpatient-then-reclassified stays, not to people who were in observation from the start.
Source and exact words
The standard monthly premium for Medicare Part B enrollees will be $202.90 for 2026, an increase of $17.90 from $185.00 in 2025.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
The annual deductible for all Medicare Part B beneficiaries will be $283 in 2026, an increase of $26 from the annual deductible of $257 in 2025.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
No quote captured.
Source page · Agency guidance · as of 2027 · retrieved 2026-11-04
CMS had not published 2027 Part A/B premiums and deductibles as of 2026-11-04 (expected fact-sheet URL returned 404). Only Trustees Report projections exist; not recorded.
- Part b
- Single
- <=109000
- Joint
- <=218000
- Total premium
- $202.90/month
- Part dadd
- $0/month
- Single
- 109001-137000
- Joint
- 218001-274000
- Total premium
- $284.10/month
- Part dadd
- $14.50/month
- Single
- 137001-171000
- Joint
- 274001-342000
- Total premium
- $405.80/month
- Part dadd
- $37.50/month
- Single
- 171001-205000
- Joint
- 342001-410000
- Total premium
- $527.50/month
- Part dadd
- $60.40/month
- Single
- 205001-499999
- Joint
- 410001-749999
- Total premium
- $649.20/month
- Part dadd
- $83.30/month
- Single
- >=500000
- Joint
- >=750000
- Total premium
- $689.90/month
- Part dadd
- $91/month
- Married filing separately
- Magi
- <=109000
- Total premium
- $202.90/month
- Part dadd
- $0/month
- Magi
- 109001-390999
- Total premium
- $649.20/month
- Part dadd
- $83.30/month
- Magi
- >=391000
- Total premium
- $689.90/month
- Part dadd
- $91/month
Source and exact words
Less than or equal to $109,000 Less than or equal to $218,000 $0.00 $202.90 Greater than $109,000 and less than or equal to $137,000 Greater than $218,000 and less than or equal to $274,000 $81.20 $284.10
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Total monthly Part B premium per person; partDAdd is the Part D income-related adjustment added to the plan premium. Full table on the CMS fact sheet; also in SSA POMS HI 01101.020.
Source and exact words
20 CFR 418.1135(a)
In general, we will use your modified adjusted gross income provided by IRS for the tax year 2 years prior to the effective year of the income-related monthly adjustment amount determination.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
SSA POMS HI 01101.020 (2026 tables): 'If MAGI in 2024 (or 2023 if 2024 is not available) was:'. MAGI = AGI plus tax-exempt interest (20 CFR 418.1010), so capital gains from selling a home (above the IRC 121 exclusion), IRA withdrawals, and Roth conversions all count.
- Form
- SSA-44
- Qualifying events
- death of spouse
- marriage
- divorce/annulment
- work stoppage
- work reduction
- loss of income-producing property (not by sale)
- loss of employer pension
- employer settlement payment
Source and exact words
20 CFR 418.1205; SSA POMS HI 01120.001
You or your spouse experiences a loss of income-producing property, provided the loss is not at the direction of you or your spouse (e.g., due to the sale or transfer of the property) and is not a result of the ordinary risk of investment.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Selling a house or other property is NOT a life-changing event. POMS HI 01120.001: 'the SSA-44 , Medicare Income-Related Monthly Adjustment Amount Life Changing Event is available online' and 'The SSA-44 is only for beneficiaries wishing to request a new initial determination, based on a valid LCE'.
- 2026
- $2,100/year
- 2027
- $2,400/year
Source and exact words
CMS CY 2027 Rate Announcement (Apr. 6, 2026), Attachment V, Table V-2
Table V-2. Updated Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy (LIS) and Retiree Drug Subsidy 2026 202713 Standard Benefit Deductible $615 $700 Out-of-Pocket Threshold $2,100 $2,400
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
'202713' in the quote is '2027' followed by footnote marker 13. Standard deductible: $615 (2026), $700 (2027).
Source and exact words
42 U.S.C. 1395ss(s)(2)(A)
The issuer of a medicare supplemental policy may not deny or condition the issuance or effectiveness of a medicare supplemental policy, or discriminate in the pricing of the policy, because of health status, claims experience, receipt of health care, or medical condition in the case of an individual for whom an application is submitted prior to or during the 6 month period beginning with the first month as of the first day on which the individual is 65 years of age or older and is enrolled for benefits under part B.
Source page · Official code · as of current statute · retrieved 2026-11-04
Medicare.gov guide: 'This is a one-time enrollment period; it doesn’t repeat every year.' Federal law gives no Medigap open enrollment to under-65 disabled beneficiaries; some states do.
- Employer/union retiree plan supplementing Medicare ends
- Medicare Advantage plan leaves the area/terminates or person moves out of service area (or PACE)
- Medigap insurer goes bankrupt/coverage ends involuntarily, or insurer violated policy or misled the person
- Trial right: dropped Medigap to join Medicare Advantage for the first time and leaves within 12 months
- Trial right: joined Medicare Advantage/PACE when first eligible at 65 and leaves within 12 months
Source and exact words
42 U.S.C. 1395ss(s)(3)(B)(i)-(vi)
The individual, upon first becoming eligible for benefits under part A at age 65, en rolls in a Medicare+Choice plan under part C or in a PACE program under section 1395eee of this title, and disenrolls from such plan or such program by not later than 12 months after the effective date of such enrollment.
Source page · Official code · as of current statute · retrieved 2026-11-04
Quote reproduces an 'en rolls' word-break artifact in the govinfo HTML. Guaranteed-issue applicants are limited to certain plans (statute lists A, B, C, F; Medicare.gov guide lists current equivalents including G for those new to Medicare after 2020). States may add rights.
Source and exact words
In most cases, you won’t have a right under federal law to switch Medigap policies, unless: You're within your 6-month Medigap open enrollment period, or You're eligible under a specific situation or guaranteed issue right (when an insurance company can’t deny you a Medigap policy).
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
There’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet their medical underwriting requirements. They may deny you a policy unless you have a guaranteed issue right
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Medicare.gov 'Choosing a Medigap Policy' guide (2026 edition).
Source and exact words
Since most long-term care is non-medical, Medicare and most health insurance, including Medicare Supplement Insurance (Medigap) , don’t pay for long-term care services, including care in a nursing home or in the community.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
Room and board. Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).'
Source and exact words
Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Listed under 'Medicare doesn't pay for:' along with '24-hour-a-day care at your home'. Same page: 'up to 8 hours a day (combined), for a maximum of 28 hours a week.'
Federal Medicaid rules (all states)
Source and exact words
CMCS Informational Bulletin, Apr. 27, 2026 (2026 SSI and Spousal Impoverishment Standards chart, effective 1-1-26)
Individual 994.00 2,000.00 2,982.00 2,073.00 1,014.00 Couple 1,491.00 3,000.00 N/A 3,067.00 1,511.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Table columns: SSI FBR, SSI resource standard, income cap limit (300%), earned and unearned income break-even points. Whitespace normalized from PDF table.
Source and exact words
CMCS Informational Bulletin, Apr. 27, 2026
Individual 994.00 2,000.00 2,982.00 2,073.00 1,014.00 Couple 1,491.00 3,000.00 N/A 3,067.00 1,511.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
SSA Notice, Cost-of-Living Increase and Other Determinations for 2027, Docket No. SSA-2026-1024 (FR Doc. 2026-21796)
The maximum Federal Supplemental Security Income (SSI) monthly payment amounts for 2027 under title XVI of the Act will be $1,029 for an eligible individual; $1,544 for an eligible individual with an eligible spouse; and $516 for an essential person.
Source page · Official regulation · as of 2027 · retrieved 2026-11-04
Federal Register public-inspection copy. 3.6% COLA. CMS has not yet (as of 2026-11-04) published its 2027 SSI and Spousal Impoverishment Standards chart.
Source and exact words
SSA Notice, Docket No. SSA-2026-1024
The maximum Federal Supplemental Security Income (SSI) monthly payment amounts for 2027 under title XVI of the Act will be $1,029 for an eligible individual; $1,544 for an eligible individual with an eligible spouse; and $516 for an essential person.
Source page · Official regulation · as of 2027 · retrieved 2026-11-04
- Individual
- $2,000
- Couple
- $3,000
Source and exact words
Individual 994.00 2,000.00 2,982.00 2,073.00 1,014.00 Couple 1,491.00 3,000.00 N/A 3,067.00 1,511.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Most states use $2,000 as the nursing-home Medicaid asset limit for a single applicant, but states vary; see state files.
Source and exact words
SSA 1902(a)(10)(A)(ii)(V); CMCS chart 'Income Cap Limit (300%)'
Individual 994.00 2,000.00 2,982.00 2,073.00 1,014.00 Couple 1,491.00 3,000.00 N/A 3,067.00 1,511.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
In income-cap states, income above this requires a Miller trust / QIT.
Source and exact words
The maximum Federal Supplemental Security Income (SSI) monthly payment amounts for 2027 under title XVI of the Act will be $1,029 for an eligible individual
Source page · Official regulation · as of 2027 · retrieved 2026-11-04
DERIVED: 3 x $1,029 = $3,087. Not yet published by CMS; confirm against the CMS 2027 SSI and Spousal Impoverishment Standards chart (normally issued in December).
- Individual
- $30/month
- Couple
- $60/month
Source and exact words
42 U.S.C. 1396a(q)(2)
is $30 for an institutionalized individual and $60 for an institutionalized couple (if both are aged, blind, or disabled, and their incomes are considered available to each other in determining eligibility)
Source page · Official code · as of current statute · retrieved 2026-11-04
Federal floor only; nearly all states set higher amounts (see state files).
Source and exact words
42 U.S.C. 1396r-5(f)(2), (g); CMCS 2026 chart
Community Spouse Resources: Minimum Resource Standard: 32,532.00 Maximum Resource Standard 162,660.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396r-5(g); CMCS 2026 chart
Community Spouse Resources: Minimum Resource Standard: 32,532.00 Maximum Resource Standard 162,660.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- From2026-07-01
- Contiguous states
- $2,705/month
- Alaska
- $3,381.25/month
- Hawaii
- $3,111.25/month
- 2026-01-01to2026-06-30
- Contiguous states
- $2,643.75/month
- Alaska
- $3,303.75/month
- Hawaii
- $3,040/month
Source and exact words
Minimum Monthly Maintenance Needs Allowance 2,705.00 All States (Except Alaska and Hawaii) (Effective 7-1-26) 3,381.25 Alaska 3,111.25 Hawaii
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
MMMNA minimum changes each July 1 with the poverty guidelines. The Dec. 9, 2025 chart (cib12092025.pdf) lists 2,643.75 / 3,303.75 / 3,040.00 '(Effective 7-1-25)' for January-June 2026.
Source and exact words
Maximum Monthly Maintenance Needs Allowance: 4,066.50
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- From2026-07-01
- Contiguous states
- $811.50/month
- Alaska
- $1,014.38/month
- Hawaii
- $933.38/month
- 2026-01-01to2026-06-30
- Contiguous states
- $793.13/month
- Alaska
- $991.13/month
- Hawaii
- $912/month
Source and exact words
Community Spouse Monthly Housing Allowance: 811.50 All States (Except Alaska and Hawaii) (Effective 7-1-26) 1,014.38 Alaska 933.38 Hawaii
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Basis for the excess shelter allowance.
Source and exact words
42 U.S.C. 1396r-5(c)(1)(A)
There shall be computed (as of the beginning of the first continuous period of institutionalization (beginning on or after September 30, 1989) of the institutionalized spouse)— (i) the total value of the resources to the extent either the institutionalized spouse or the community spouse has an ownership interest, and (ii) a spousal share which is equal to ½ of such total value.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396r-5(b)(1)
During any month in which an institutionalized spouse is in the institution, except as provided in paragraph (2), no income of the community spouse shall be deemed available to the institutionalized spouse.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(f); CMCS 2026 chart
Home Equity Limits: Minimum: 752,000.00 Maximum: 1,130,000.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(f); CMCS 2026 chart
Home Equity Limits: Minimum: 752,000.00 Maximum: 1,130,000.00
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(f)(2)
Paragraph (1) shall not apply with respect to an individual if— (A) the spouse of such individual, or (B) such individual's child who is under age 21, or (with respect to States eligible to participate in the State program established under subchapter XVI) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1382c of this title, is lawfully residing in the individual's home.
Source page · Official code · as of current statute · retrieved 2026-11-04
- Effective
- 2028-01-01
- Non agricultural home cap
- 1,000,000
- Indexed
- No
- Agricultural lot homes
- keep the existing indexed state-option range
Source and exact words
Pub. L. 119-21 (One Big Beautiful Bill Act) sec. 71108, amending 42 U.S.C. 1396p(f)
A State may elect, without regard to the requirements of section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to comparability), to apply subparagraph (A), in the case of an individual's home that is not described in clause (i), by substituting for the amount specified in such subparagraph, an amount that exceeds such amount, but does not exceed $1,000,000.
Source page · Official code · as of 2028 · retrieved 2026-11-04
Effective-date text: 'The amendments made by subsection (a) shall apply beginning on January 1, 2028.' Also adds: inflation-indexed amounts (other than for agricultural-lot homes) exceeding $1,000,000 'shall be deemed to be equal to $1,000,000'. States currently above $1M (2026 max is $1,130,000) will have to drop to $1M for non-agricultural homes.
- Before2027
- 3 months before application month
- For applications on or after2027-01-01
- Expansion adults
- 1 month before application month
- Aged_blind_disabled_and_other_non_expansion
- 2 months before application month
Source and exact words
Pub. L. 119-21 sec. 71112, amending 42 U.S.C. 1396a(a)(34) and 1396d(a)
is not described in subparagraph (A), such assistance will be made available to the individual for care and services included under the plan and furnished in or after the second month before the month in which the individual made application
Source page · Official code · as of 2027 · retrieved 2026-11-04
Applies to eligibility 'based on an application made on or after the first day of the first quarter that begins after December 31, 2026' (i.e., Jan. 1, 2027). Older adults needing nursing-home Medicaid fall in the 'not described in subparagraph (A)' (2-month) group. The replaced statutory text was 'in or after the third month before the month in which the recipient makes application'.
Source and exact words
42 U.S.C. 1396p(c)(1)(B)(i)
The look-back date specified in this subparagraph is a date that is 36 months (or, in the case of payments from a trust or portions of a trust that are treated as assets disposed of by the individual pursuant to paragraph (3)(A)(iii) or (3)(B)(ii) of subsection (d) or in the case of any other disposal of assets made on or after February 8, 2006, 60 months) before the date specified in clause (ii).
Source page · Official code · as of current statute · retrieved 2026-11-04
California has historically used a different (shorter) look-back for Medi-Cal; see state files.
Source and exact words
42 U.S.C. 1396p(c)(1)(D)(ii)
the date specified in this subparagraph is the first day of a month during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care described in subparagraph (C) based on an approved application for such care but for the application of the penalty period, whichever is later
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(1)(E)(iv)
A State shall not round down, or otherwise disregard any fractional period of ineligibility determined under clause (i) or (ii) with respect to the disposal of assets.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
No quote captured.
Source page · Official code · as of 2026 · retrieved 2026-11-04
Divisor (average monthly private-pay nursing home cost) is set by each state; there is no federal figure. See state files.
- Home to spouse
- Home to child under 21 or blind/disabled child
- Home to sibling with equity interest who lived in the home at least 1 year before institutionalization
- Home to 'caregiver child' who lived in the home at least 2 years before institutionalization and provided care that kept the parent out of a facility
- Any asset to spouse or to another for the sole benefit of spouse
- Any asset to (or trust solely for) a blind/disabled child
- Any asset to a trust solely for a disabled person under 65
- Showing that the transfer was intended for fair market value, or exclusively for a non-Medicaid purpose, or that assets were returned
- Undue hardship waiver
Source and exact words
42 U.S.C. 1396p(c)(2)(A)-(D)
(iv) a son or daughter of such individual (other than a child described in clause (ii)) who was residing in such individual's home for a period of at least two years immediately before the date the individual becomes an institutionalized individual, and who (as determined by the State) provided care to such individual which permitted such individual to reside at home rather than in such an institution or facility
Source page · Official code · as of current statute · retrieved 2026-11-04
Quote shows the caregiver-child exemption; the other listed exemptions are in the same subsection (c)(2)(A)(i)-(iii), (B)(i)-(iv), (C)(i)-(iii), (D).
- State remainder beneficiary
- State must be named remainder beneficiary in first position (or second after community spouse/minor or disabled child) for at least the Medicaid paid
- Safe harbor
- irrevocable, nonassignable, actuarially sound per SSA Chief Actuary tables, equal payments with no deferral and no balloon (or qualifying IRA/retirement annuity)
Source and exact words
42 U.S.C. 1396p(c)(1)(F)-(G) (DRA 2005)
the purchase of an annuity shall be treated as the disposal of an asset for less than fair market value unless— (i) the State is named as the remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the institutionalized individual under this subchapter
Source page · Official code · as of current statute · retrieved 2026-11-04
Related text in (G)(ii): 'the annuity— (I) is irrevocable and nonassignable; (II) is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); and (III) provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.'
Source and exact words
42 U.S.C. 1396p(c)(1)(I)
the term "assets" includes funds used to purchase a promissory note, loan, or mortgage unless such note, loan, or mortgage— (i) has a repayment term that is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); (ii) provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and (iii) prohibits the cancellation of the balance upon the death of the lender.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(c)(1)(J)
the term "assets" includes the purchase of a life estate interest in another individual's home unless the purchaser resides in the home for a period of at least 1 year after the date of the purchase.
Source page · Official code · as of current statute · retrieved 2026-11-04
Life estates retained when a parent deeds the remainder to children are still a transfer of the remainder interest (look-back applies) and may be reached by expanded estate recovery; see estateRecovery.optionalExpandedEstate.
Source and exact words
42 U.S.C. 1396p(b)(1)(B)
In the case of an individual who was 55 years of age or older when the individual received such medical assistance, the State shall seek adjustment or recovery from the individual's estate, but only for medical assistance consisting of— (i) nursing facility services, home and community-based services, and related hospital and prescription drug services, or (ii) at the option of the State, any items or services under the State plan
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(b)(4)(A)
shall include all real and personal property and other assets included within the individual's estate, as defined for purposes of State probate law
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(b)(4)(B)
may include, at the option of the State (and shall include, in the case of an individual to whom paragraph (1)(C)(i) applies), any other real and personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of such interest), including such assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.
Source page · Official code · as of current statute · retrieved 2026-11-04
Partnership LTC policyholders (1396p(b)(1)(C)(i)) are subject to the expanded definition for non-protected assets.
Source and exact words
42 U.S.C. 1396p(b)(2)-(3)
Any adjustment or recovery under paragraph (1) may be made only after the death of the individual's surviving spouse, if any, and only at a time— (A) when he has no surviving child who is under age 21, or (with respect to States eligible to participate in the State program established under subchapter XVI) is blind or per manently and totally disabled
Source page · Official code · as of current statute · retrieved 2026-11-04
Quote reproduces a line-break artifact ('per manently') present in the govinfo HTML. Hardship: '(3)(A) The State agency shall establish procedures ... under which the agency shall waive the application of this subsection (other than paragraph (1)(C)) if such application would work an undue hardship'.
Source and exact words
42 U.S.C. 1396p(d)(4)(B)
A trust established in a State for the benefit of an individual if— (i) the trust is composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust), (ii) the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this subchapter; and (iii) the State makes medical assistance available to individuals described in section 1396a(a)(10)(A)(ii)(V) of this title, but does not make such assistance available to individuals for nursing facility services under section 1396a(a)(10)(C) of this title.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(d)(4)(A)
A trust containing the assets of an individual under age 65 who is disabled (as defined in section 1382c(a)(3) of this title) and which is established for the benefit of such individual by the individual, a parent, grandparent, legal guardian of the individual, or a court if the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this subchapter.
Source page · Official code · as of current statute · retrieved 2026-11-04
Source and exact words
42 U.S.C. 1396p(d)(4)(C)
A trust containing the assets of an individual who is disabled (as defined in section 1382c(a)(3) of this title) that meets the following conditions: (i) The trust is established and managed by a non-profit association. (ii) A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of funds, the trust pools these accounts.
Source page · Official code · as of current statute · retrieved 2026-11-04
Treatment of pooled-trust funding by people 65+ varies by state; check state files.
Source and exact words
42 U.S.C. 1396p(b)(1)(C)(iii) (DRA 2005)
the term "qualified State long-term care insurance partnership" means an approved State plan amendment under this subchapter that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a long-term care insurance policy if the following requirements are met: (I) The policy covers an insured who was a resident of such State when coverage first became effective under the policy.
Source page · Official code · as of current statute · retrieved 2026-11-04
- Qmb
- Income individual
- $1,350/month (income); USD (resources)
- Income couple
- $1,824/month (income); USD (resources)
- Slmb
- Income individual
- $1,616/month (income); USD (resources)
- Income couple
- $2,184/month (income); USD (resources)
- Qi
- Income individual
- $1,816/month (income); USD (resources)
- Income couple
- $2,455/month (income); USD (resources)
- Resource individual
- $9,950/month (income); USD (resources)
- Resource couple
- $14,910/month (income); USD (resources)
- Qdwi
- Resource individual
- $4,000/month (income); USD (resources)
- Resource couple
- $6,000/month (income); USD (resources)
Source and exact words
Monthly income and resource limits for 2026: Your situation: Monthly income limit:* Resource limit: What counts in resource limits? Individual $1,350 $9,950 Married couple $1,824 $14,910
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
QMB shown in quote. Same page: SLMB 'Individual $1,616 $9,950 Married couple $2,184 $14,910'; QI 'Individual $1,816 $9,950 Married couple $2,455 $14,910'. '* Income limits slightly higher in Alaska and Hawaii.' Resource limits confirmed by CMCS CIB Dec. 9, 2025: 'Effective January 1, 2026, the resource standards for single and married QMBs, SLMBs, and QIs will be, respectively, $9,950 and $14,910.' QDWI resource standard 'remains $4,000 for a single individual and $6,000 for a married individual.' Many states use higher limits or no asset test.
Ambulance (federal)
Source and exact words
Part B covers ground ambulance transportation when traveling in any other vehicle could endanger your health, and you need medically necessary services from one of the following: A hospital A critical access hospital A rural emergency hospital A skilled nursing facility
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
42 CFR 410.40(e)(1)-(2); 410.41 (vehicle/staff)
Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
Source and exact words
42 CFR 410.40(f)
From any point of origin to the nearest hospital, CAH, rural emergency hospital (REH), or SNF that is capable of furnishing the required level and type of care for the beneficiary's illness or injury.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
If the patient chooses a farther facility, Medicare generally pays only the mileage to the nearest appropriate one.
Source and exact words
The ambulance company must give you an "Advance Beneficiary Notice of Noncoverage (ABN)" when both of these apply: You get ambulance services in a non-emergency situation. The ambulance company believes that Medicare may not pay for your specific ambulance service.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Source and exact words
If your prior authorization request isn't approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: 'You get scheduled, non-emergency ambulance transportation for 3 or more round trips in a 10-day period or at least once a week for 3 weeks or more You get this transportation from any ambulance company nationwide'.
- Air ambulance
- covered
- Ground ambulance
- NOT covered (unless state law)
Source and exact words
Generally, ground ambulance services aren't covered by billing protections in the No Surprises Act (unless a state law has different rules). They're still allowed to charge out-of-network rates.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Same page: the NSA protects against surprise out-of-network bills from 'emergency room visits; non-emergency care related to visits at in-network hospitals, hospital outpatient departments, and ambulatory surgical centers; and air ambulance services.' NSA applies to private/commercial coverage; Medicare and Medicaid already limit balance billing by participating ambulance suppliers.
- Report issued
- 2024-08-28 (report document dated March 29, 2024)
- Status
- Currently Inactive
Source and exact words
The Committee issued its Report to the Secretaries containing Recommendations on preventing balance billing for ground ambulance services and protecting consumers on August 28, 2024. Committee Status - Currently Inactive
Source page · Agency guidance · as of 2026-11 · retrieved 2026-11-04
Report PDF: https://www.cms.gov/files/document/report-advisory-committee-ground-ambulance-and-patient-billing.pdf (recommends prohibiting ground-ambulance balance billing with cost-sharing caps; not self-executing).
- Enacted
- No
Source and exact words
Committee Status - Currently Inactive
Source page · Agency guidance · as of 2026-11-04 · retrieved 2026-11-04
No enacted federal law extending NSA-style protection to ground ambulances was found as of 2026-11-04 (CMS consumer page still says ground ambulance is generally not covered). Could not confirm any pending 119th Congress consumer-protection bill; the 119th-Congress 'Protecting Access to Ground Ambulance Medical Services Act' (H.R. 2232 / S. 1643) concerns Medicare rate add-ons, not balance billing. State laws fill the gap; see state files.
Source and exact words
42 CFR 431.53; 42 U.S.C. 1396a(a)(4)(A)
A State plan must— ( a ) Specify that the Medicaid agency will ensure necessary transportation for beneficiaries to and from providers; and ( b ) Describe the methods that the agency will use to meet this requirement.
Source page · Official regulation · as of current regulation · retrieved 2026-11-04
eCFR spacing artifacts '( a )' kept as rendered. Statute 1396a(a)(4) likewise requires the state agency to 'ensure necessary transportation for beneficiaries under the State plan to and from providers'.
Taxes
Source and exact words
IRC 213(a); IRS Pub. 502 (2025)
You can deduct on Schedule A (Form 1040) only the part of your medical and dental expenses that is more than 7.5% of your adjusted gross income (AGI).
Source page · Agency guidance · as of 2025 · retrieved 2026-11-04
Pub 502 for tax year 2026 not yet published; 7.5% floor is permanent in IRC 213(a). Nursing home: 'This includes the cost of meals and lodging in the home if a principal reason for being there is to get medical care.' Qualified long-term care services for a chronically ill person are also includible.
- Age40 or less
- $500/year per person
- 41to50
- $930/year per person
- 51to60
- $1,860/year per person
- 61to70
- $4,960/year per person
- Over70
- $6,200/year per person
Source and exact words
Rev. Proc. 2025-32 sec. 4.27; IRC 213(d)(10)
Attained Age Before the Close of the Taxable Year Limitation on Premiums 40 or less $500 More than 40 but not more than 50 $930 More than 50 but not more than 60 $1,860 More than 60 but not more than 70 $4,960 More than 70 $6,200
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Only the portion within these limits counts as a medical expense (still subject to the 7.5%-of-AGI floor). 2027 limits not located as of 2026-11-04.
Source and exact words
Rev. Proc. 2025-32 sec. 4.62
For calendar year 2026, the stated dollar amount of the per diem limitation under § 7702B(d)(4), regarding periodic payments received under a qualified long-term care insurance contract or periodic payments received under a life insurance contract that are treated as paid by reason of the death of a chronically ill individual, is $430.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
- Qualifying relative gross income limit2026
- $5,300
- Parent need not live with you
- Yes
- Support test
- you must provide more than half of support (or use a multiple support agreement)
Source and exact words
Rev. Proc. 2025-32 sec. 4.23; IRC 152(d); IRS Pub. 501
For taxable years beginning in 2026, the exemption amount referred to in § 152(d)(1)(B) is $5,300.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Pub 501 lists 'Your father, mother, grandparent, or other direct ancestor, but not foster parent' among relatives who need not live with you. Social Security that is not taxable generally isn't gross income for this test (check Pub 501). Pub 502: you may deduct medical expenses paid for a parent who would be your dependent except for the gross-income test.
Source and exact words
IRS Pub. 501 (2025)
If you pay more than half the cost of keeping your parent in a rest home or home for the elderly, that counts as paying more than half the cost of keeping up your parent’s main home.
Source page · Agency guidance · as of 2025 · retrieved 2026-11-04
Source and exact words
IRS Pub. 503 (2025); IRC 21
A person who wasn't physically or mentally able to care for themselves, lived with you for more than half the year, and either: Was your dependent, or Would have been your dependent except that: They received gross income of $5,200 or more
Source page · Agency guidance · as of 2025 · retrieved 2026-11-04
2025 publication shows the 2025 gross income figure ($5,200); 2026 figure is $5,300 per Rev. Proc. 2025-32.
- Per person
- 6,000
- Married both eligible
- 12,000
- Years
- 2025-2028
Source and exact words
Pub. L. 119-21; IRS Pub. 501 (2025)
Beginning in 2025, taxpayers who are age 65 or older may be eligible for the enhanced deduction for seniors. The maximum amount of the deduction is $6,000 ($12,000 if married filing jointly and both spouses are eligible).
Source page · Agency guidance · as of 2025 · retrieved 2026-11-04
Income phase-out applies; OBBBA provides it for tax years 2025-2028 (end year not quoted from the fetched page).
- Gift
- carryover basis (donor's adjusted basis) when FMV >= donor basis
- Inheritance
- basis generally = FMV at date of death (step-up)
Source and exact words
IRC 1015 (gifts), 1014 (inherited); IRS Pub. 551
If the FMV of the property is equal to or greater than the donor's adjusted basis, your basis is the donor's adjusted basis at the time you received the gift.
Source page · Agency guidance · as of 2026 · retrieved 2026-11-04
Inherited: 'Generally, the basis of property inherited from a decedent is one of the following. The FMV of the property at the date of the individual's death.' Why it matters: a house bought for $80k and gifted to a child while worth $400k carries the $80k basis; if the child sells, ~$320k gain is taxable (and the child usually can't use the parent's IRC 121 exclusion). If inherited instead, basis steps up to ~$400k and little or no gain results. Gifting also starts a 60-month Medicaid look-back penalty.
- Single
- $250,000
- Married joint
- $500,000
Source and exact words
IRC 121; IRS Pub. 523
If you meet certain conditions, you may exclude the first $250,000 of gain from the sale of your home from your income and avoid paying taxes on it. The exclusion is increased to $500,000 for a married couple filing jointly.
Source page · Agency guidance · as of 2025 · retrieved 2026-11-04
Gain above the exclusion raises MAGI and can trigger IRMAA two years later.
Still unconfirmed
- Official SD penalty divisor (monthly state-wide average private-pay LTC cost) for FY2026/FY2027 - secondary sources conflict ($9,749.92 vs $9,291.62).
- Whether SD has a PACE program.
- HOPE waiver waitlist status.
- SHIINE phone (site fetch failed).
- SD penalty start rule text (ARSD 67:46:05:09.02) not reviewed.
- Any filial-support suits since Randall (1994) / Accounts Management v. Nelson (2003).