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Medicaid- Who Pays For What?

Medicaid-Sponsored Long-term Care: Who pays for what?

We find a major area of confusion with regards to Medicaid eligibility for senior care and how it varies within the Medicaid program. In this article we will shed light on the various Medicaid programs and waiver programs, as well as how each one interrelated with the other programs, so you or your loved one can take advantage of the senior care and senior living options that are right for you.

Medicaid Overview:

In order to understand the relationship between the various Medicaid waivers and how they work in tandem with Institutional Medicaid (nursing Home Medicaid) , it is crucial to have a fundamental understanding of how the Medicaid system works.

Seniors that require long-term care in a care facility are covered by Institutional Medicaid, as long as they meet the eligibility criteria. Institutional Medicaid will pay for the care of the individuals in a skilled nursing facility. In addition to Institutional Medicaid, Medicaid also offers long term care services in a community setting, such as an assisted living facility, as well as certain services in one’s home. One popular service offered is home care. This kind of Medicaid is often referred to as Community Medicaid. Community Medicaid services vary state to state.

For those who wish to live at home or in a community setting, such as an assisted living facility, and receive medical care, as well as, non-medical coverage, Medicaid will often pay for care in those locations if it will prevent the recipient from requiring nursing home care which would increase the cost for Medicaid. In most states, Community Medicaid services fall under the Medicaid Waiver programs, which is also called Home and Community Based Services Waivers (HCBS). In those states, HCBS waiver programs offer a host of long-term care services to pay for care in non-institutional settings.

What are Medicaid Waivers?

There are two primary types of waivers:

• Managed Care Waivers: These types of waiver, also known as Section 1915(b)waivers, were established so states can provide services through managed care delivery systems, with the intent of streamlining long-term care and cutting costs. These waivers may sometimes limit peoples choice of providers.

• Home and Community-Based Services Waivers:These waivers, known as Section 1915(c), are also state-specific, and provide funding for long-term care services in home and community settings rather than institutional settings. These waivers were established so seniors can choose to age in place, while at the same time save the government unnecessary, exorbitant nursing home coverage costs.

What are the eligibility guidelines for each of the various Medicaid-sponsored long-term care options?


Nursing Home and Assisted Living:

Medicaid eligibility for nursing home care or assisted living is based on medical and financial eligibility guidelines. Each state has its own guidelines in determining an individual’s medical eligibility. This is usually done with a physician certification or a medical screening facilitated by a nurse stating that the individual requires this service.

Income and asset Limits. Most states follow the federal SSI (Supplemental Security Income) program for both asset and income limits. You can earn up to 300% of the SSI limit and still be eligible for nursing home Medicaid. Many states offer the option of placing excess income into an income-only trust for those that exceed the income limit, so that they may still be eligible for Medicaid despite their income surplus. As for assets, the limit in many states is $2,000 for an individual receiving care. If a husband and wife are both receiving care, the limit is $3,000. Again, these guidelines are for most states that follow the SSI guidelines, but be sure to check with your state’s asset and income limits.

Medicaid ‘spend down’:

Once an individual is above the asset limit, they will not be eligible for Medicaid-sponsored coverage until they ‘spend down’ their assets below the limit in their state. This process can be tricky and the help of a Medicaid planning professional may be advisable. Certain assets, such as one’s primary residence for an individual residing in it, as well as some other assets , are ‘excludable’ assets and do not factor in for Medicaid eligibility.


Home Care:

Home care through regular Medicaid programs:

Medicaid pays for a variety of medical services that can help you continue to live in your home. Some of the covered services are: doctor and clinic services, prescription and non-prescription drugs, lab tests, transportation to medical care, home care, adult day care services, x-rays, medical equipment such as wheelchairs, orthotics and prosthetic appliances.

Eligibility for Community Medicaid varies from state to state, but here are the income and asset limits for a single applicant in NY as an example (as of 2015):

• Income limit: $845.00

• Asset limit: $14,850.00

There are options to still qualify even if one’s income exceeds the limit. One commonly used option is to utilize a pooled income trust. Some other states have similar options to deal with surplus income.

HCBS Waivers:

Home and Community-Based Services (HCBS) Waivers, as mentioned, are federal programs designed for individuals who choose to receive medical and non-medical care in the comfort of their own homes, who would have otherwise been cared for in a nursing facility, a hospital, or an intermediate care facility.

These waiver programs, unlike Institutional Medicaid, are not entitlement programs and have only a designated number of slots available for applicants. When a person’s medical condition improves, HCBS coverage doesn’t automatically terminate, but rather continues for as long as the recipient is at risk of requiring nursing home care.

States can run as many HCBS waivers as they want, and indeed there are several hundred HCBS waiver programs nationwide that cater to different target groups, such as, the elderly, people with behavioral or mental health conditions, etc. HCBS waivers generally cover; personal care services, adult day services, homemaker services, meal delivery, transportation assistance, some minor home modifications, and in some states pay family members for home care.

Types of HCBS Waiver Programs:

There are many types of HCBS programs, each catering specific services to specific demographics. Here are some of the popular HCBS waiver programs:

Medicaid Personal Care services. The Personal Care Services (PCS) program provides services such as housekeeping, meal preparation, bathing, toileting, and grooming.

Certified Home Health Agency (CHHA). This waiver provides what is commonly known as ‘visiting nurse’ services, as well as PT, OT, or speech therapy in the home,  ‘home health aide’ (HHA) services, and medical supplies.

• Consumer Directed Personal Assistance Program. CDPAP provides services to chronically ill or physically disabled individuals who have a medical need for help with activities of daily living (ADLs) or skilled nursing services. Services can include any of the services provided by a personal care aide (home attendant), home health aide, or nurse.

HCBS eligibility:

In order for an individual to be eligible for an HCBS waiver program, in general, they will need to provide verification that without these services they would be at a risk of requiring institutionalized care, and that they meet income and asset eligibility guidelines for institutionalized care in their state.

Medicaid managed care:

All of the above waivers were covered under Section 1915(c)– Home and Community-Based Services Waivers. Managed care(MLTC), on the other hand, is covered under Section 1915(b), and is a healthcare system that aims to cut spending while improving quality care by contracted arrangements between state Medicaid agencies and Managed Care Organizations (MCO). In addition to reducing Medicaid program costs, MLTCs are improving health plan performance, health care quality, access and utilization of health services, and outcomes. The state pays a monthly premium to the MCO plan “per member per month”, known as a “capitation rate.” This waiver program was established in order to provide more services to those requiring a higher level of care, while saving money on members who needed fewer services, and increasing efficiency and accountability.

MLTC is mandatory in certain states, while in others it’s a choice along with several other Medicaid home care choices. Typically, these programs follow the general Medicaid eligibility guidelines for medical and financial need, although services may not be identical to those received under the regular Fee for Service Medicaid structure. Services not covered by the MLTC plans can typically be received by either; Original Medicare, Medicare Advantage plan, or Institutional/Community Medicaid.

Does receiving some services preclude one from other services?

As we can see from the information above, each individual Medicaid program or Medicaid waiver program serves a specific demographic and fills a specific need. Obviously, one cannot receive both HCBS Waiver and nursing home care, but in general, as long as one is qualified medically and financially for a specific service, they can receive that service even while enrolled in another program. For example; if one is receiving Medicaid coverage for in-home medical care and can prove that without additional non-medical coverage they would need to be institutionalized, they would be eligible for HCBS services, as well.

In some instances, though, certain waiver program enrollees may be ineligible for another waiver program. For example; an individual who is enrolled in any one of the following waiver programs may be precluded from joining a Medicaid Managed Care waiver program. These include:

• Traumatic  Brain Injury waiver

• Persons receiving hospice services

• Nursing Home Transition & Diversion waiver

• Office for People with Developmental Disabilities waiver

• Individuals with complex mental health needs on ICF and HCBS waiver programs

• Dual eligibles who need only “housekeeping” services and not additional assistance with ADLs

• Dual eligibles who do not need long-term care services


When it comes to Medicaid coverage for long-term care, be it nursing home care, assisted living or home care, proper planning is crucial to have ‘all your ducks in a row’ and receiving the type of care you or your loved one requires. How to pay for that care is another crucial piece of that puzzle and it is a good idea to learn as much as possible about all your funding options, so you can receive the proper care and live happily – in the residence of your choice — for many years to come.