Wisconsin Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid’s rules, benefits and name can all vary by state. In Wisconsin, Medicaid is sometimes called BadgerCare. This article focuses on Wisconsin Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or Medicaid for the Elderly, Blind, or Disabled. This is different than regular Medicaid, which is for financially limited people of all ages.

Wisconsin Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Wisconsin Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited Wisconsin seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:

• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Skilled nursing care
• Physician’s visits
• Prescription medication
• Medication management
• Mental health counseling
• Social activities

Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.

Wisconsin Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $45/month (as of 2023), which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.

Wisconsin Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.

Home and Community Based Services (HCBS) Waivers

Wisconsin Home and Community Based Service (HCBS) Waivers will pay for long-term care services and supports that help Wisconsin Medicaid recipients who require a Nursing Facility Level of Care, but choose to remain living in the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for Wisconsin residents who live in their home, the home of a loved one, a boarding house, an adult family home (adult foster care), a community-based residential facility or a residential care apartment complex (assisted living facility). While Wisconsin’s HCBS Waivers will provide long-term care benefits in those settings, it will not pay for room and board costs.

There are three HCBS Waivers programs relevant to seniors in Wisconsin:

1. Family Care – provides non-medical long-term care services and supports to Wisconsin Medicaid beneficiaries across the state
2. Family Care Partnership – coordinates medical, vision, dental and non-medical benefits and services into one plan for Wisconsin Medicaid beneficiaries in 14 counties
3. Include, Respect, I Self-Direct (IRIS) – gives Wisconsin Medicaid beneficiaries an individualized budget to spend on long-term care services, supports and caregivers of their choice

1. Family Care
Wisconsin’s Family Care program provides non-medical, long-term care services and supports to Wisconsin Medicaid beneficiaries who live in their own home, the home of a loved a one, an adult family home (adult foster care), a community-based residential facility or a residential care apartment complex (assisted living residence). While the Family Care program will provide benefits in any of those settings, but it will not pay for room and board.

Family Care benefits include adult day care, care management, meal delivery, transportation and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Program participants will receive services and supports through an individualized care plan that is based on their needs and circumstances.

Family Care benefits are delivered through a single Medicaid health plan from a managed care organization (MCO) which has a network of care providers. However, Family Care program participants also have the ability to choose their own caregivers through the self-directed supports (SDS) option. Relatives, including spouses and adult children, can be hired as caregivers.

Unlike most HCBS Waivers, Family Care is considered an entitlement program. This means that all eligible applicants are guaranteed to receive benefits.

2. Family Care Partnership
Wisconsin’s Family Care Partnership, which is often called just Partnership or the Partnership Program, is available in the following counties: Waupaca, Outagamie, Calumet, Sauk, Columbia, Dodge, Washington, Ozaukee, Dane, Jefferson, Waukesha, Milwaukee, Racine and Kenosha. Program participants must live in their own home, the home of a loved a one, an adult family home (adult foster care), a community-based residential facility or a residential care apartment complex (assisted living residence). The Partnership program will provide long-term care services and supports in these settings, but it will not pay for room and board.

The Partnership program integrates medical, vision, dental and non-medical benefits and services into one heath plan for Wisconsin Medicaid beneficiaries. This includes both Medicaid and Medicare benefits for individuals who are eligible for both (dual eligible). The health plan is delivered by a managed care organization (MCO) and its network of care providers. However, Partnership program participants can also choose their own caregivers through the self-directed supports (SDS) option. Relatives, including spouses and adult children, can be hired as caregivers.

Partnership Program benefits include adult day health care, assistive technology, care management, durable medical equipment, home modifications, mental health services, Personal Emergency Response Systems and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Program participants will receive services and supports through an individualized care plan that is based on their needs and circumstances.

Like most HCBS Waivers, the Partnership Program is not an entitlement. Instead, there are a limited number of enrollment spots, and once those spots are full, any additional eligible applicants will be placed on a waitlist. However, as of 2022 there was not a waitlist for Wisconsin’s Partnership Program.

3. Include, Respect, I Self-Direct (IRIS)
Wisconsin’s Include, Respect, I Self-Direct (IRIS) program allows Wisconsin Medicaid beneficiaries to self-direct their long-term care services and supports through an individualized budget. With the help of an IRIS program consultant, program participants decide which benefits best meet their needs, who will provide these benefits and where they will be provided. The consultant will also help the program participant with the financial aspect of the budget as well as locating and hiring / acquiring any necessary caregivers or long term care goods and equipment.

Friends and relatives can be hired as caregivers through the IRIS program. Program participants who are unable to make their own decisions can choose someone else to make decisions for them. IRIS program participants must live in their own home, the home a loved one, a boarding house, an adult family home (adult foster care) or a residential care apartment complex.

IRIS program benefits include live-in caregiver, adult day care, meal delivery, nursing services, home modifications, vehicle modifications, non-medical transportation and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Unlike most HCBS Waivers, IRIS is considered an entitlement program. This means that all eligible applicants are guaranteed to receive benefits.

Medicaid for the Elderly, Blind, or Disabled

Wisconsin’s Medicaid for the Elderly, Blind, or Disabled (EBD) provides healthcare coverage and long-term care services and supports to financially limited Wisconsin residents who are aged (65 or over), blind or disabled and live in the community. Medicaid for the Elderly, Blind, or Disabled is comparable to ABD Medicaid in other states. It can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages. EBD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via EBD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.

1. EBD Long Term Care Benefits
Eligible Wisconsin seniors who show a medical need for long-term care services can receive those services through EBD Medicaid. These benefits can include in-home personal care, adult day care, meal delivery, home modifications and Personal Emergency Response Systems (PERS). EBD recipients qualify for these benefits one at a time. This is different from Nursing Home Medicaid, which makes all of its benefits immediately available for anyone who qualifies. Instead, Wisconsin seniors will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.

2. Program of All-Inclusive Care for the Elderly (PACE)
Wisconsin residents who are age 55 or older and have Medicaid for the Elderly, Blind, or Disabled can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Wisconsin’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Wisconsin’s PACE program is located in Brookfield  and called Community Care. To learn more about PACE, click here.

Eligibility Criteria For Wisconsin Medicaid Long Term Care Programs

To be eligible for Wisconsin Medicaid, a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Medicaid for the Elderly, Blind, or Disabled.

Wisconsin Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Wisconsin residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through Wisconsin Medicaid. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for Wisconsin Nursing Home Medicaid for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Wisconsin Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $45/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.

For married applicants with both spouses applying, the 2024 asset limit for nursing home coverage through Wisconsin Medicaid is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

Functional Requirements
The functional, or medical, criteria for nursing home coverage through Wisconsin Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if the Nursing Facility Level of Care requirement is for Medicaid purposes, Wisconsin uses its Functional Screen. This tool takes into consideration the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognitive ability.

Wisconsin Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
Wisconsin residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2024, the asset limit for HCBS Waivers in Wisconsin is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for HCBS Waivers in Wisconsin for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2024 asset limit for HCBS Waivers in Wisconsin is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Services (HCBS) Waivers through Wisconsin Medicaid is needing a Nursing Facility Level of Care, which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if the Nursing Facility Level of Care requirement is met for HCBS Waivers, Wisconsin uses its Functional Screen. This tool takes into consideration the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning and taking medications), as well as cognitive ability.

Wisconsin Medicaid for the Elderly, Blind, or Disabled Eligibility Criteria

Financial Requirements
Wisconsin residents have to meet an asset limit and an income limit in order to be financially eligible for Medicaid for the Elderly, Blind or Disabled (EBD). For a single applicant, the 2024 asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for Wisconsin’s EBD Medicaid for a single applicant is $1,026.78/month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.

For married applicants in 2024, the asset limit for Medicaid for the Elderly, Blind, or Disabled is a combined $3,000, and the income limit is a combined $1,547.05/month. These limits apply to married couples with both spouses applying and married couples with just one spouse applying.

Functional Requirements
The only functional requirements for receiving basic healthcare coverage through Medicaid for the Elderly, Blind or Disabled (EBD) is being aged (65 or over), blind or disabled. For EBD recipients who need long-term care, the state will conduct an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as their cognitive abilities, to determine the kind of long-term care services Wisconsin Medicaid will cover.

How Medicaid Treats the Home

One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:

• If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage/debt) is less than $750,000 (as of 2023) then the home is exempt.
• If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives.
• If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $750,000.

These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.

Wisconsin Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Wisconsin and how you can protect your home from it, click here.

Applying For Wisconsin Medicaid Long Term Care Programs

The first step in applying for Wisconsin Medicaid Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Medicaid for the Elderly, Blind, and Disabled (EBD).

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that program. Applying for Wisconsin Medicaid when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Wisconsin Medicaid applicant. These documents will be needed for the official Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Wisconsin residents can apply for Wisconsin Medicaid online at ACCESS. They can also find apply in person at their local Income Maintenance and Tribal Agency, or by submitting a completed paper application.

To apply for any of the HCBS Waivers programs in Wisconsin (Family Care, Partnership or IRIS), individuals should contact their local Aging and Disability Resource Center.

For a comprehensive guide that will take you through the application process for all three types of Medicaid Long Term Care, click on the program you want: 1) Nursing Home Medicaid 2) HCBS Waivers 3) EBD Medicaid.

Choosing a Wisconsin Medicaid Nursing Home

After being approved for nursing home coverage through Wisconsin Medicaid, seniors have to choose which Medicaid-accepting nursing home best meets their needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes accept Medicaid, and those that do may not have available space. Finding the right nursing home can be time-consuming and challenging, especially if you’re looking in a specific location.

Wisconsin has roughly 340 nursing homes, and most of them accept Medicaid. There are about 50 nursing homes that accept Medicaid in Greater Milwaukee. The Lake Winnebago Region has 25 nursing homes, and there are a dozen around Green Bay. There are nearly 25 facilities around Madison, and nine in the Wisconsin Dells area. In the western part of the state, Eau Claire has about 20 nursing homes that take Medicaid, and there are roughly a dozen in La Crosse.

Residents in some Wisconsin communities regularly travel across state lines for business and personal reasons, including healthcare. Medicaid coverage, however, does not cross state lines. So, someone with Wisconsin Medicaid would not be covered for nursing homes in Minnesota or Illinois, even if facilities in those places were well-suited and convenient for the Wisconsin resident.

When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. You can also contact your local Area Agency on Aging to find more information about nursing homes in Wisconsin.

After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.

CMS data collected from 2019-2022 shows that Wisconsin nursing homes are on par with the national average when it comes to health standards, fire safety and resident well-being