For better and for worse, Medicaid is the primary method of paying for nursing home care in the United States. But navigating the Medicaid system is complicated and confusing. Here are the basics.
Medicaid (sometimes called by other names, such as “Medi-Cal” in California, “MassHealth” in Massachusetts, and “TennCare” in Tennessee) is a joint federal-state program that provides health insurance coverage to low-income children, seniors, and people with disabilities. In addition, it covers long-term care for those who qualify. This coverage has traditionally meant care in a nursing home, although coverage of care in an assisted living facility or at home are possible (see below).
In the absence of any other public program covering long-term care (Medicare provides only limited nursing home coverage), Medicaid has become the default nursing home insurance of the middle class. Lacking access to alternatives such as paying privately or being covered by a long-term care insurance policy, most people pay out of their own pockets for long-term care until they become eligible for Medicaid.
Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive federal money, which pays for about half the state’s Medicaid costs. (The state picks up the rest of the tab.) This complicates matters, since the Medicaid eligibility rules are somewhat different from state to state and they keep changing. To be certain of your rights, consult an elder law attorney in your state who can guide you through the complicated rules of the different programs and help you plan ahead.
While the majority of nursing homes accept Medicaid patients, there are some that do not. Even nursing homes that accept Medicaid recipients may only have a limited number of Medicaid beds available. Nursing homes must be certified by the state in order to accept Medicaid payments. Check with the facility before applying for admittance.
To qualify for coverage, applicants must have limited assets and income. You typically cannot have more than $2,000 in assets; the figure may be slightly higher in some states. To lower your assets, you need to spend them down by paying for things that benefit the Medicaid applicant. You cannot simply give away your resources in order to qualify for Medicaid. Income limits vary by state. In some states you can keep excess income in trust; in other states you must pay your excess income to the nursing home.
In addition to the strict income and asset limits, you must meet level of care requirements in order to qualify for nursing home coverage. Each state sets its own level of care criteria and the criteria is not always clear. The state looks at an applicants’ functional, medical, and cognitive abilities to determine if they need care in a nursing home. You are usually determined to need long-term care if you need help with two or more “activities of daily living” (such as bathing, dressing, eating, moving, and going to the bathroom). But to need a nursing home level of care, you may also need frequent medical care, such as assistance with medication, injections, IVs, or other medical treatment. The state may also consider your cognitive abilities—i.e., whether you have the ability to make decisions on your own.
Once you qualify for Medicaid, the program pays for all your basic expenses, but nursing home residents may be charged extra for certain amenities, like a private room, comfort items, or specially prepared food.
In addition to nursing home care, Medicaid may cover some home care services or in limited circumstances care in an assisted living. Home care is typically provided through home- and community-based services “waiver” programs to individuals who need a high level of care, but who would like to remain at home. States vary widely on how to qualify and what is covered. Almost all state Medicaid programs will cover at least some assisted living costs for eligible residents.