MEDICAID’S ROLE IN LONG-TERM CARE

Medicaid is a complex program, and when it comes to senior care, there are a few terms that people commonly mix up. In this blog post, we attempt to clarify any confusion between Medicaid, Medicaid Long-Term Care, and the Medicaid Waiver Program.

Medicaid

Medicaid is a social program that provides health insurance to millions of Americans including people with low income, children, pregnant women, elderly adults, and people with disabilities. It is administered by the state, according to federal requirements, but it is funded jointly by the state and the federal governments. It does not provide full coverage, meaning not all things medical are covered under Medicaid. Federal law requires that states provide certain mandatory benefits including: inpatient hospital services, outpatient hospital services, clinic visits, doctors’ office visits, and transportation to medical care. While it is common for folks to say that Medicaid does pay for a stay at a nursing home; just because someone has Medicaid doesn’t mean Medicaid will pay for his or her permanent stay at a nursing home.

Medicaid Long-Term Care

To have Medicaid pay for a permanent stay at a nursing home, a person must meet the law’s income and medical criteria, even if he or she is already covered under general Medicaid. If approved, the person is said to be covered under Medicaid Long-Term Care.

To be medically eligible for Medicaid Long-Term Care, a person must need routine skilled services or help with his or her activities of daily living (“ADLs”). Examples of skilled services include:

  • Medication management
  • Immunizations
  • IV care
  • Podiatry
  • Wound care (level 3 and 4)
  • Tube feeding
  • Assistance with breathing
  • Help with catheters

Nursing homes also provide aides that will help a patient with his or her ADLs. Transferring, walking, using the bathroom, showering, dressing, and eating are the six ADLs. The rules are vague as to how many ADLs one needs help with to qualify for Medicaid Long-Term Care, but at Senior Advisors Plus, we’ve generally seen that people who need help with three or more on their worst day would qualify for Medicaid Long-Term Care.

To financially qualify for Medicaid Long-Term Care, a person must meet two criteria, assets and income. Each state differs on its income and asset restrictions but generally the laws work like this:

  • A person can’t have more than $2,000 in countable assets to qualify.
  • A person can’t have monthly income that exceeds the average cost of a nursing home in the state.

A person who makes less than the income limit but has too many countable assets may need to spend down his or her savings to qualify for Medicaid Long-Term Care. In this situation, he or she may also benefit from talking to an elder law attorney. After spending down assets, the person should qualify for Medicaid Long-Term Care. Medicaid will then pay the difference between the person’s income and the cost of the nursing home.

Medicaid Waiver Program

A hospital is the most expensive setting of care, while nursing homes are not far behind. After a patient stabilizes following a procedure done in a hospital, he or she may be discharged to a nursing home or skilled nursing facility to recover and build strength. A skilled nursing facility’s goal is to help the patient transition back to the community. Commonly, people are forced to stay in nursing homes because they can’t afford to hire help at home. The Medicaid Waiver Program was designed to help these people transition back to the community, despite their financial constraints. The Medicaid Waiver Program may pay for home care services, assisted living, and other services that may prevent someone from returning to a nursing home. While people under the Medicaid Waiver Program do need assistance, the cost of the assistance that they need is far less than the cost that the Medicaid fund would incur if they remained in a nursing home. To be medically eligible for the Medicaid Waiver Program, a person may need help with the activities of daily living but not routine skilled services. Here’s the tricky part: it’s harder to qualify for the Medicaid Waiver Program than it is Medicaid Long-Term Care. The asset restriction is the same—$2,000—but the income limit is generally lower. We’ve generally seen the income limit to be around $2,300 per month; however, the income limit depends on the state. If a person makes over the income limit, then he or she is required to pay for assistance themselves. If a person makes less than the income limit, needs at-most intermittent skilled services, and needs help with some of their activities of daily living, then he or she may qualify for the Medicaid Waiver Program.

If you’re confused or worried about your current situation or the future, it may help to talk to someone. We offer free advice; just contact us.

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