Do Health Insurance Or Medicaid Pay For Assisted Living?
Last Updated on January 25, 2024 by Lori Pace
Having worked extensively in Medicaid planning, I can assure you that Medicaid does indeed cover assisted living costs, including memory care. It’s important to understand that Medicaid offers comprehensive support, encompassing personal care and specialized home care services, as well as coverage for skilled nursing and emergency response services.
However, it’s crucial to note that Medicaid typically does not cover accommodation and board costs. It’s essential to recognize that Medicaid programs vary from state to state, as each state has the flexibility to design its Medicaid program within federal guidelines.
Drawing from my extensive experience in Medicaid planning, it’s crucial to understand that Medicaid programs vary significantly from one state to another. This variation in eligibility criteria can make it challenging to determine if Medicaid will cover assisted living in your specific location. To illustrate this point, let’s take a closer look at two types of Medicaid programs commonly found in most states: the regular state Medicaid program and HCBS (Home and Community-Based Services). By delving into these program distinctions and their impact on eligibility, you’ll gain a deeper understanding of how Medicaid operates across the nation.
Every state must provide personal care assistance through Medicaid. Some states offer it through regular state programs, while others provide it through HCBS waivers. Many states offer it through both Medicaid and HCBS waivers. Medicaid is available in all 50 states. However, assisted living facilities are not available in all states.
What Is Regular State Medicaid?
Regular state Medicaid is an entitlement program that provides many of the Federal Government’s health care benefits.
All states, for instance, are required to pay the cost of home nursing for all residents who are eligible. Optional benefits are also included by the federal government, but they can be implemented at the state’s discretion. Assistive personal care is one such benefit.
What Are HCBS Medicaid Waivers?
Many states offer 1915(c) waivers, also known as HCBS Medicaid Waivers. These waivers allow residents to live at home or in the community without assisted living facilities placement.
This is done by waivers, which provide care and other benefits to enable independent living.
How Can You Qualify Assisted Living Coverage Under Medicaid?
Financial Need
State Medicaid programs limit recipients’ earnings to either the following:
- 100% FPL (Federal Poverty Level) = $1073/monthly
- 100% FBR (Federal Benefit Rat) = $794/monthly
The FBR must be below 300% to qualify for the HCBS waiver. Regular state Medicaid waivers and HCBS waivers usually limit assets to $2000.
Functional Need
The recipient must be able to receive nursing care or hospitalization. Each state has its own requirements which means, some states may require beneficiaries to receive assistance with two aspects of daily living, such as:
- Chop up their food and eat.
- Dressing up and down.
- Cleaning up and after going to the bathroom.
- You can move from a bed into a couch.
Some programs require that recipients have a doctor’s statement. A confirmation of Alzheimer’s disease is not an indication that you are eligible for assisted living benefits.
Which Assisted Living Service Does Medicaid Cover?
Understanding Medicaid’s impact on your financial and life decisions is paramount. The scope of Medicaid’s assisted living benefits can vary significantly based on your location and the specific Medicaid program you enroll in. Let’s delve deeper into the key assisted living services commonly covered under Medicaid:
- Personal care (assisting with dressing, cleaning, eating, and toileting)
- Home care (providing support with food preparation, grocery shopping, housecleaning, and laundry)
- Case management to ensure comprehensive care
- Emergency response personnel for immediate assistance
However, it’s crucial to note that Medicaid typically does not cover the cost of accommodation or board for assisted living. To address these expenses, many states offer an Optional States Supplement (OSS), a cash aid program designed to assist with housing and board costs. This supplemental benefit, also known as State Supplementary Benefits (SSB), is added to federal Supplemental Security Income (SSI) earnings. While the issuing agency for these federal payments varies between states, it is typically either the SSA (Social Security Administration) or DHS (Department of Human Services). You can easily access a list of all DHS outlets in your area through the Medicaid portal.
What Is the Extent of Coverage for Assisted Living Under Medicaid?
It will all depend on:
- The state in which the recipient resides.
- The state Medicaid program (Regular Medicaid, HCBS Medicaid).
- How much care the recipient needs
To determine how many hours Medicaid will pay, a needs assessment will occur. For example, beneficiaries who are dependent on assisted living will receive more caregiver hours per month.
Which Assisted Living Centers Accept Medicaid?
Some assisted living facilities are not willing to accept Medicaid coverage as payment. Therefore, you have to make sure you check if the residence is Medicaid-approved before making your decision. Even though the care center does not accept Medicaid, it may allow third-party caregivers to enter and provide assistance.
Medicaid will pay the third-party caregiver if they aren’t working for an assisted living facility. This alternative is worth considering. Make sure you inquire at the care center whether they accept third-party caregivers.
Unfortunately, there is not a national database of assisted living facilities that take Medicaid, therefore, for assistance in finding these homes, contact your local AAA (Area Agency on Aging).
AAA offices have a list of assisted living facilities that accept Medicaid. They will provide a link to a searchable database that includes a list of centers in the state if they do not have one.
Notice that assisted living facilities that accept Medicaid have a limit on the number of available beds for Medicaid-sponsored residents. This also means that there are fewer beds for Medicaid recipients.
It is best to create a list of local care centers and then call most of them. Ask them about the third-party caregivers if they do not allow Medicaid-sponsored residents.
Conclusion
Drawing on my years of experience in Medicaid planning, I can offer insights into the diverse ways states provide assistance, including through Medicaid, HSBS waivers, and state plans. If you’re considering Medicaid to cover assisted living costs, I strongly recommend consulting with a seasoned Medicaid planning specialist.
They can provide personalized guidance tailored to your specific situation, addressing the unique needs of different individuals. Additionally, it’s worth noting that if you don’t qualify for Medicaid, there are alternative options to explore, which I can elaborate on further.
