Navigating Nursing Home Care Costs: What does Medicaid Pay When you Need Care in a Nursing Home or Assisted Living?

As we age, it is important to consider the possibility of needing long-term care, especially as health changes may eventually make it challenging to live independently. Nursing homes can provide the necessary care and support, but the costs associated with nursing facilities can be overwhelming for many families.

There is an option for those concerned about the cost of long-term care and looking to protect their own or a loved one’s assets.  Medicaid, a government program, offers assistance to seniors who require nursing home care and meet specific criteria. At Friedman Elder Law Department, we can discuss with you the details of what Medicaid covers for nursing facility care, how older adults can qualify, and what expenses might not be covered.

Medicaid Coverage for Nursing Home

Medicaid is a joint federal and state program designed to provide healthcare coverage for individuals with limited income and resources. For older adults needing long-term care provided in assisted living, a nursing home, or a skilled nursing facility, Medicaid can be a lifeline, as it assists with covering substantial costs associated with long-term care services.

However, Medicaid’s coverage is subject to eligibility criteria and program guidelines, which vary from state to state.

1. Room and Board: Medicaid typically covers the cost of a semi-private room in a nursing home that accepts Medicaid. This includes accommodation, meals, and housekeeping services.
2. Medical Services: Medicaid pays for a range of medical services, such as doctor visits, nursing care, medication administration, physical therapy, and rehabilitation services.
3. Personal Care: Assistance with activities of daily living (ADLs), including bathing, dressing, eating, and toileting, is often covered by Medicaid.
4. Skilled Nursing Care: Medicaid covers skilled care for Medicaid recipients requiring medical attention, wound care, injections, and other treatments administered by licensed medical professionals.
5. Medical Equipment and Supplies: Medicaid will often pay for necessary medical equipment, such as wheelchairs, walkers, and hearing aids.
6. Therapeutic Services: Speech therapy, occupational therapy, and other therapeutic services are often covered when deemed medically necessary.

Medicaid Coverage for In-Home Care Expenses

In-home care allows seniors to receive necessary assistance while remaining in the comfort of their own homes. This option can be particularly appealing to those who wish to maintain their independence and have a preference for familiar surroundings.

Medicaid programs for home care can encompass various services:

1. Personal Care Assistance: Medicaid often covers personal care or home health care, including help with bathing, dressing, grooming, and meal preparation.
2. Homemaker Services: These services encompass light housekeeping, laundry, grocery shopping, and other tasks that help seniors maintain a clean and organized living environment.
3. Skilled Nursing: If seniors require medical attention or specialized care at home, Medicaid can cover skilled nursing services, wound care, medication administration, and more.
4. Physical, Occupational, and Speech Therapy: Medicaid services may include therapy sessions conducted at home to aid in recovery, mobility improvement, and communication skills.
5. Home Health Aide Services: Trained home health aides can provide essential assistance with various tasks, and Medicaid can cover their wages.

Does Medicaid Pay for Assisted Living?

Assisted living care offers a middle ground between independent living and skilled nursing care. These facilities provide assistance with daily activities while fostering a sense of community and social engagement.

While coverage for assisted living varies from state to state, there are common services that it often covers:

1. Room and Board: Medicaid will pay the cost of a resident’s room and board in an assisted living facility, which includes accommodation, meals, and housekeeping services.
2. Personal Care Services: Assistance with activities of daily living (ADLs), such as bathing, dressing, grooming, and eating, is often covered in assisted living.
3. Medication Management: Many assisted living homes offer medication management services, and Medicaid can cover the cost of medication administration and monitoring.
4. Health Monitoring: Medicaid can cover health monitoring services, ensuring that residents receive necessary medical attention and regular check-ups.
5. Transportation: Depending on the state, Medicaid might cover transportation services to medical appointments, allowing residents to access healthcare easily.
6. Social Activities: Assisted living homes focus on fostering social engagement, and Medicaid might cover costs related to planned social activities and programs.

Qualifying for Medicaid to Pay for Long-Term Care

Qualifying for Long-Term Care Medicaid involves meeting specific financial and medical requirements. Medicaid eligibility is complicated.

Here is an overview of eligibility requirements:

1. Income: Medicaid has income limits that applicants must meet. At its roots, it is a program meant for the needy.  If an applicant’s countable income exceeds the limit, they might need to “spend down” their assets on medical expenses before becoming eligible.
2. Assets: Medicaid has asset limits, which generally exclude a primary residence, personal belongings, and a limited amount of funds in specific accounts. Eligibility rules for assets can vary from state to state.
3. Look-Back Period: Medicaid employs a “look-back” period to prevent individuals from transferring assets to qualify for benefits. Any asset transfers made within a certain timeframe (usually five years) can impact eligibility.
4. Medical Necessity: Applicants must meet the state’s medical necessity criteria, which usually means requiring a certain level of care and need nursing home care.
5. Citizenship and Residency: Applicants must be U.S. citizens or qualified immigrants and reside in the state where they are applying for Medicaid.
6. Application Process: Applying for Medicaid involves submitting detailed financial and medical information. It’s a complex process, and seeking assistance from an elder law attorney or social worker can be immensely helpful.

Expenses Not Covered by Medicaid

While Medicaid covers growing costs of care at a care facility, there are expenses that the program generally does not cover:

1. Private Rooms: Medicaid typically covers the cost of a semi-private room, but if you prefer a private room, you might need to pay the difference in cost. Medicaid may pay for room and board at assisted living facilities, but not if those costs include additional amenities and non-medical services as they often do. 
2. Extra Amenities: Amenities beyond basic room and board, such as cable TV or personal telephone lines, are usually not covered by Medicaid.
3. Non-Medical Services: Services that aren’t medically necessary, such as beauty salon visits or personal caregivers for non-medical assistance, are not covered.
4. Advanced Planning: Costs associated with estate planning, trust creation, a long-term care plan, or other financial planning to protect assets might not be covered.
5. Certain Medications: Medicaid may not cover all prescription medications, especially if there are equivalent lower-cost alternatives available.
6. Experimental Treatments: Treatments that are experimental or not deemed medically necessary might not be covered by Medicaid.

Consult with an Elder Law Attorney to Start Medicaid Planning Today

Navigating the complexities of nursing home care costs can be overwhelming for older adults and their families. Using Medicaid for long-term care costs offers a vital safety net for those who meet the eligibility criteria, assisting with covering the substantial expenses associated with long-term care services.

Understanding what Medicaid covers and how to qualify is crucial for ensuring that older adults receive the care they need without enduring financial hardship. Download our free guide: 5 Tips to Protect Your Savings from the Nursing Home.

Consulting with an elder law attorney or social worker can provide invaluable guidance throughout the application process, making the journey toward nursing home care a more manageable one. Contact Friedman Elder Law Department at (954) 866-1055 to get started today.