Finding the right assisted living center or nursing home for you or a loved one can feel overwhelming. This is especially true for those on Medicaid who may have a tighter budget. There’s a lot you need to know, from which health care services Medicaid covers to how much you might have to pay out of pocket, eligibility requirements and more.
Being informed can help you make the best decision. Read on to learn about Medicaid coverage and eligibility for long-term health care facilities.
What is long-term care and what will Medicaid cover?
Long-term care includes a variety of health and personal services that support those who can’t do everyday activities safely by themselves. While people of all ages with chronic conditions, illnesses, or disabilities can benefit from long-term care, it is most commonly associated with seniors.
Long-term care options like nursing homes and assisted living are generally expensive. Medicaid helps cover certain long-term care services. The extent and type of coverage depend on your individual situation, the specific care services you need, and the state you live in. In Minnesota, the state Medicaid program is called Medical Assistance, and it covers many services associated with long-term care.
Medicaid coverage and assisted living services
Assisted living facilities provide housing, meals, nursing care, custodial services, laundry, transportation and on-site social activities for seniors and those with disabilities. They have trained staff who help residents with personal care and health management.
For those who are eligible, Medicaid will help cover certain aspects of assisted living care, including:
- Skilled nursing care
- Personal care assistance
- Home services
- Memory and dementia care
- Emergency response systems
Not all assisted living facilities accept Medicaid. When applying to live at an assisted living home, make sure the facility accepts Medicaid.
Medicaid will not cover assisted living room and board fees
Medicaid does not pay for room and board at an assisted living center. Instead, the program allocates resources toward medical expenses. Residents pay room and board expenses out of pocket.
The national average monthly cost at an assisted living facility is $5,676. However, this amount covers more than room and board, and it includes things that Medicaid may cover. And there are many things that can impact this cost, including where you live, extra amenities and whether you live in a single unit.
How to get additional help paying for assisted living costs
Some states offer Medicaid waiver programs to help cover costs associated with assisted living. These programs are designed to prevent or delay the need for a nursing home for individuals on Medicaid. They can help cover costs for assistance with eating, grooming, bathing, hygiene, dressing and bathroom services, and medication management – services Medicaid does not cover without a waiver.
To see what kind of waivers your state’s Medicaid program offers, you can visit each state’s coverage on the Medicaid.gov website.
Can a facility that accepts Medicaid refuse or evict an assisted living resident?
This is something many people worry about – can I or my loved one be rejected or evicted from an assisted living center because of Medicaid? The answer isn’t a simple yes or no.
Federal Home and Community-Based Services regulations offer some protection for assisted living residents on Medicaid. If an assisted living facility accepts Medicaid, it’s considered to be a “home and community-based setting” (HCBS). Under HCBS provisions, assisted living centers providing home care to residents with Medicaid coverage must provide “comparable protections” to what tenants have under local landlord-tenant laws.
Landlord-tenant eviction laws vary by state, county and city. However, generally, an assisted living resident on Medicaid cannot be evicted without written notice and without legal processes.
Medicaid coverage and skilled nursing facilities
Also called nursing homes, skilled nursing facilities are long-term care residences for seniors who don’t need immediate hospital care but may not be able to live safely independently. They provide 24/7 supervision and nursing care, meals, personal care assistance, therapy, social activities and more. Stays in a skilled nursing facility can be temporary (like if you’re recovering after a hospital visit) or permanent if you need long-term assistance.
For those who meet the financial and medical eligibility requirements, Medicaid will pay 100% of nursing home costs – this means no out-of-pocket expenses for you, including:
- Room and board
- Skilled nursing care
- Personal hygiene care and supplies
- Meals
- Medications
- Rehab and therapy services
- Medically necessary social services
- Emergency dental care
However, you may need to pay for extra amenities and services that aren’t considered “medically necessary,” like a private room or special food, out of your own pocket.
Nursing home eligibility for those on Medicaid
Every state Medicaid program has its own requirements and coverage limitations for nursing home eligibility. First, you must qualify for Medicaid itself, which is typically based on income. Many states will consider your income and total assets from the last five years. Once you qualify for Medicaid, you will be eligible for residency at a skilled nursing facility based on your nursing home levels of care (NHLOC).
NHLOC measures the type and intensity of care someone needs to gauge whether they are eligible for nursing home coverage through Medicaid. Medicaid won’t pay for nursing home coverage if a recipient is determined not to need nursing home levels of care. NHLOC eligibility varies by state, typically assessing physical and cognitive function, medical needs and behavioral health.
Nursing home care eligibility: The Medicaid spend down
In some states, you may become eligible for nursing home care once you spend your own countable assets on medical expenses to reach your state’s Medicaid income limit on health care. After you reach that limit, Medicaid will cover the rest of your nursing home costs.
How much do Medicare and Medicaid pay for assisted living?
Most people enroll in Medicare when they turn 65, but it’s possible to keep your Medicaid after you turn 65 and to have dual coverage for both programs at the same time. But Medicare and Medicaid are different, and you might have questions about whether you can get more assisted living coverage options when you’re dually eligible.
Like Medicaid, Medicare does not pay for room and board expenses at assisted living facilities. It will, however, cover some medically necessary home health care and hospice care alongside Medicare-approved services under Medicare Parts A and B, such as doctor visits, hospital stays, diagnostics and testing, and more.
A dual-eligible Medical Assistance (Medicaid) and Medicare plan: How Minnesotans can get help with assisted living coverage
If you are dual eligible for both Medicare and Medicaid, you may qualify to enroll in a Dual Special Needs Plan (D-SNP). This plan option combines Medicare and Medicaid benefits into one.
For Minnesotans on Medicare and Medical Assistance (Medicaid), you can look into a Minnesota Senior Health Options (MSHO) plan which includes coverage for home and community-based services like assisted living.
To find out if you’re eligible for an MSHO plan, you can get information from:
Learn about MSHO
Our experts are here to help you find the best Medicare plan for the way you live. Learn more about Minnesota Senior Health Options.
