Medicaid Long Term Care (LTC) is for financially limited Americans who can no longer live independently. Their difficulties can be a normal part of aging, or result from a chronic medical condition like Alzheimer’s. Medicaid LTC can be provided in a nursing home, in private homes or in other locations in the community, such as assisted living facilities. Exact eligibility requirements can change depending on state, marital status and the type of Medicaid LTC.
In general terms, Medicaid refers to the government-funded healthcare coverage for financially limited people of any age and health condition, and sometimes it’s called Regular Medicaid or State Plan Medicaid. On the other hand, Medicaid Long Term Care (LTC) refers to a group of programs offered under Medicaid that provide long-term care services and supports to people who can no longer live independently due to regular aging or a chronic medical condition. Medicaid LTC can be used by people of any age, but this article and website is focused on Medicaid LTC for seniors.
Broadly speaking, Medicaid LTC will cover the cost of living in a nursing home, including room and board and all healthcare necessities, for seniors who require that level of care. It will also cover the necessary care for seniors who need help living independently but wish to remain living in their own home or somewhere else in the community instead of moving to a nursing home. Medicaid LTC will cover their doctor’s appointments and other medical bills, and it will cover non-medical care goods and services the senior needs to live independently, such as home modifications, housekeeping, meal delivery and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).
Medicaid is not Medicare – While both are government-run health insurance programs, Medicare is for all Americans 65 and older while Medicaid is for Americans with limited financial means. Medicaid will pay for long-term care and Medicare will not.
Long-term care differs from regular care in that 1) the need is ongoing and 2) the care is not necessarily medical care. Medicaid Long Term Care (LTC) benefits include medical care, and non-medical care, such as assistance with the Activities of Daily Living: mobility (moving from one room to another), bathing, dressing, eating and toileting. Someone who cannot perform these activities can not live independently. Examples of other non-medical services and supports Medicaid LTC might provide depending on the program and the beneficiary’s needs are home modifications (such as wheelchair ramps), meal delivery, housekeeping assistance and transportation.
Another term critical to understanding Medicaid LTC is “Nursing Facility Level of Care” (NFLOC). In general, this means the kind of full-time care and supervision typically provided in a nursing home. Each state has it’s own specific definition of Nursing Facility Level of Care, but they usually take into consideration the following:
Needing a Nursing Facility Level of Care is a requirement to receive nursing home care via Medicaid LTC, and to receive long-term care in the community via many Medicaid LTC programs.
There are three types of Medicaid Long Term Care programs relevant to seniors – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers and Aged, Blind, and Disabled (ABD) Medicaid. They provide different services in different settings, and they have different eligibility requirements.
1. Nursing Home Medicaid (previously called Institutional Medicaid) will cover the full cost of nursing home care for financially limited seniors who require a Nursing Facility Level of Care. It’s available in all states, although eligibility criteria does vary. Nursing Home Medicaid is an entitlement, which means all eligible applicants are guaranteed by law to receive benefits without wait.
2. Home and Community Based Services (HCBS) Waivers cover long-term care services and supports that help financially limited seniors who require a Nursing Facility Level of Care remain living in the community instead of moving to a nursing home. Long-term care benefits can include home modifications, housekeeping and personal care assistance with the Activities of Daily Living. HCBS Waivers are not an entitlement. Instead, these programs have a limited number of enrollment spots, and once those spots are full, additional applicants are placed on waitlists.
3. Aged, Blind, and Disabled (ABD) Medicaid provides basic healthcare coverage for financially limited seniors, and it will cover long-term care benefits for seniors who show a medical need for those benefits and live in the community. ABD Medicaid can also be referred to as Regular Medicaid for seniors, but it should not be confused with the Regular Medicaid for financially limited people of all ages. Like Nursing Home Medicaid, ABD Medicaid is an entitlement, which means all eligible applicants are guaranteed by law to receive benefits without wait. However, there may be a wait for certain long-term care benefits (or they may not be available at all) depending on the funds, programs and caregivers available in the beneficiary’s locale.
Both Home and Community Based Services (HCBS) Waivers and Aged, Blind, and Disabled (ABD) Medicaid can cover long-term care benefits in the community, but what does “in the community” mean? Essentially, it means anywhere outside of a nursing home, including:
However, it’s important to know that whether or not long-term care benefits are covered in these settings depends on the state and the HCBS Waivers or ABD Medicaid program. And even if a program covers long-term care benefits in a particular setting in the community, it will not cover room and board costs in that setting, such as mortgage payments, rent, facility fees, utility bills and food expenses.
More details on how Medicaid LTC covers care in various settings, including nursing homes, is provided below.
All states have HCBS Waivers or ABD Medicaid programs that will pay for long-term care services and supports in a beneficiary’s home or the home of a family member, such as an adult child or sibling. As a rule of thumb, the cost of the care in a private residence cannot exceed what the cost would be were it provided in a nursing home. Therefore, most people receiving Medicaid long-term care in their home or someone else’s home also receive care assistance from family members or other unpaid caregivers.
Some states have HCBS Waivers or ABD Medicaid programs that will cover long-term care services and supports in assisted living facilities. These Medicaid programs will not cover room and board expenses in assisted living facilities, but in many states there are other programs that will help cover room and board in assisted living for financially limited seniors.
Long-term care benefits in assisted living depend on the needs and circumstances of each individual. State Medicaid offices will conduct an assessment of the beneficiary’s medical needs, and the services already being provided by the assisted living facility, to determine what kind of long-term care benefits Medicaid will cover.
Memory care is assisted living for people who have Alzheimer’s disease or a related dementia (like vascular, frontotemporal and Lewy body dementias). Some states have HCBS Waivers or ABD Medicaid programs that are specifically designed to cover long-term care benefits for financially limited seniors who live in memory care residences. These can be standalone facilities or units inside of a larger facility or hospital.
Long-term care benefits in memory care depend on the needs and circumstances of each individual. The state will conduct an assessment of the beneficiary’s medical needs, and the services already being provided in the memory care facility, to determine what kind of long-term care benefits Medicaid will cover.
Financially limited seniors who live in adult foster care (also called board and care homes), senior community housing or other congregate living situations may be able to receive long-term care benefits through HCBS Waivers or ABD Medicaid, if there is an available program in their area.
The rules governing Medicaid LTC coverage in congregate living are the same as they are for assisted living and memory care: benefits depend on the needs and circumstances of each individual. The state will conduct an assessment of the beneficiary’s medical needs, and the services already being provided in the congregate living setting, to determine what kind of long-term care benefits Medicaid will cover.
Nursing Home Medicaid will pay for all nursing home expenses for financially limited seniors who require a Nursing Facility Level of Care. Coverage includes all medical care, non-medical care and room and board expenses. Most, but not all, nursing homes accept Medicaid. In almost all states, Medicaid will pay for a shared room but not a private room, unless that is deemed a medical necessity.
Medicaid nursing home care is an entitlement. This means if an applicant meets the financial and medical eligibility criteria, the state must pay for their nursing home care without delay. However, this does not mean beneficiaries are entitled to a bed in any nursing home they choose. As mentioned above, not all nursing homes take Medicaid, and those that do may not have any available spaces when you or your loved one needs care.
Custom Fit – The easiest way for you to find the specific eligibility criteria for your specific situation is by using our Medicaid Long Term Care Eligibility Requirements Finder.
Regardless of the type of program or the state in which a beneficiary receives it, there are two consistent eligibility criteria for Medicaid Long Term Care – the individual must have limited financial resources and a documented need for care.
The financial requirements are meeting an asset limit and an income limit. These limits vary based on state, marital status and type of Medicaid program. In addition, these limits change annually and, in some cases, twice annually. For seniors who are over the either limit, there are alternative pathways to eligibility.
Medical or functional eligibility criteria can also vary by state and by type of Medicaid program. However, Nursing Home Medicaid applicants in all states, and applicants for almost all Home and Community Based services (HCBS) Waivers, must need a Nursing Facility Level of Care. The medical requirements vary more for long-term care benefits via ABD Medicaid.
Medicaid eligibility is complicated, and the application process is full of potential pitfalls. Families should consider working with a Medicaid Planning professional when applying. These fee-based experts help people become eligible, while streamlining the application process and preserving assets for spouses and family members.
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