Medicaid Long Term Care: Definition, Programs & Locations
Medicaid Long Term Care (LTC) is a series of benefits programs for Americans with limited financial resources who can no longer live independently in their own homes. Their difficulties can be a normal part of aging or result from a chronic disease like Alzheimer’s. Medicaid LTC can be provided in a nursing home, at home, or in assisted living. Eligibility depends on state, marital status, financial resources and other factors.
What is Medicaid vs. Medicaid Long Term Care?
Medicaid is a governmental health insurance program for low-income individuals and families. It is funded both by the federal government and the individual states. The rules governing Medicaid, such as benefits and eligibility criteria, are specific to each state but must stay within certain guidelines set by the federal government.
This is different from Medicaid Long Term Care (LTC), which is a series of programs offered under Medicaid that provide long term care. Medicaid covers medical costs like doctor’s appointments and hospital bills, Medicaid Long Term Care also covers non-medical care needs. Broadly, Medicaid LTC covers the costs of living in a nursing home (including room and board). Alternatively, for people who live in their own home or an assisted living community, Medicaid LTC will pay for help with activities of daily living like eating, bathing, and mobility.
What is Long Term Care (LTC)?
The Centers for Medicare and Medicaid Services (CMS) says LTC is for Americans who “need long-term care services because of disabling conditions and chronic illnesses.” Meaning the need for assistance can be due to normal aging or illness and disability.
Long term care differs from regular care in that 1) the need is ongoing and 2) the care is not necessarily medical care. Long term care includes medical care but also includes non-medical care such as assistance with activities of daily living. Activities of Daily Living are the things we do throughout a typical day: eat, bathe, brush our teeth, walk from one room to another, go to the bathroom, get dressed, etc. Someone who cannot perform these activities of daily living is unfortunately unable to live independently.
Another term critical to understanding Long Term Care is “Nursing Facility Level of Care” (NFLOC). This is the level of care typically provided in a nursing home. For comparison purposes, this is a lower level of care than is provided in hospitals. Because Medicaid programs are provided through state offices, each state has its own definition of “Nursing Facility Level of Care.” In most states there is an NFLOC score that measures the following:
– ability to perform activities of daily living like eating and bathing
– cognition or thinking ability
– continence (going to the bathroom)
Most states use either an inability to perform several “activities of daily living” or the need for a “nursing facility level of care” as qualifying factors for Medicaid Long Term Care.
3 Types of Medicaid Programs that Provide Long Term Care
There are three types of Medicaid Long Term Care programs. They provide different services in different types of living arrangements. They also have different eligibility requirements, and determining eligibility can be a complicated process because of all these factors. The three types of Medicaid LTC are Nursing Home Medicaid, Home and Community Based Services (HCBS) waivers, and Aged Blind & Disabled (ABD) Medicaid.
1. Nursing Home Medicaid: Also called Institutional Medicaid, this is an entitlement program and covers the full cost of nursing home care. It is available in all states though eligibility criteria vary.
2. Home and Community Based Services (HCBS) Waivers: For people who need nursing home level of care, HCBS waivers allow them to stay in their home or assisted living residence and still receive medical treatment, medication management, and other services. Most waivers have enrollment caps and wait-lists are common.
3. Aged Blind & Disabled Medicaid: Also referred to as Regular Medicaid. This is an entitlement program. Care services and help with ADLs are provided in the home or assisted living community,
A big part of the Medicaid Long Term Care program is its Home and Community Based Service waivers. People who qualify for HCBS waivers live outside a nursing home, in their own home or in a community. “Community” refers to the following:
– the home of a caregiver
– the home of a family member
– board and care homes
– assisted living residences
– memory care residences
– senior living communities
– adult day care centers
In What Locations Will Medicaid Pay for Long Term Care?
Medicaid will pay for all medical care, non-medical care and room and board for a beneficiary that resides in a Medicaid nursing home. Nursing homes should not be confused with assisted living residences or memory care (for persons with dementia) as those provide a lower level of care. Most, but not all, nursing homes accept Medicaid. In almost all states, Medicaid will pay for a shared room, not a private room unless that is a medical necessity.
Medicaid nursing home care is an entitlement. If someone meets the financial and medical eligibility criteria, the state must pay for their nursing home care.
In most states, Medicaid will pay for some portion of a beneficiary’s assisted living costs. However, in no states will Medicaid pay for the room and board portion of assisted living. That said, a state may have other non-Medicaid programs that provide assistance for “rent”.
Most assisted living residences do not accept Medicaid or have a limited number of “Medicaid rooms”. However, many assisted living residences allow outside caregivers (persons who are not employed by the assisted living residence) to come in and provide care. These outside caregivers can be paid by Medicaid. Therefore, Medicaid beneficiaries who live in a non-Medicaid assisted living residence can still receive care paid for by Medicaid.
States can pay for assistance in assisted living either through a HCBS Medicaid Waiver or through their regular Aged Blind & Disabled Medicaid program. HCBS Waivers are not entitlements, but regular ABD Medicaid is an entitlement. This means if one is trying to pay for assisted living using a Medicaid Waiver, they may be placed on a wait-list.
Memory care is assisted living for people who have Alzheimer’s disease or a related dementia (like vascular, frontotemporal, and Lewy body dementias). The rules governing Medicaid payments in memory care residences are the same as for assisted living (described above). However, states may have special HCBS Waivers for persons with dementia, meaning these individuals may be eligible for benefits that are not available to persons without dementia.
Medicaid will pay for long term care at home for qualified beneficiaries. However, a rule of thumb is that the cost of the care at home cannot exceed what the cost would be were it provided in a nursing home. Therefore, most persons receiving Medicaid long term care at home also receive care assistance from family members or other unpaid caregivers.
Medicaid long term care at home is provided under 1 of 2 Medicaid sub-programs: either HCBS Waivers or ABD Medicaid. Waivers are not entitlements, but ABD Medicaid is. Therefore, persons hoping to receive care under a Waiver may experience lengthy wait-lists while those receiving care under ABD Medicaid will not. It should be noted that these programs have different financial eligibility criteria.
Adult Day Care
Adult day care is typically provided only during daytime working hours on weekdays. It is designed to allow a spouse or other family member to go to work, shop, or just take a break from their caregiving responsibilities. In almost all states Medicaid will pay for some level of adult day care. Some adult day care centers provide a level of care almost equivalent to a nursing home in which case it may be called “adult day health care”. It is more likely Medicaid will pay for this level of care.
Not all adult day care centers accept Medicaid. Like assisted living and in-home care, Medicaid pays for adult day care through 1 of 2 sub-programs: HCBS Waivers and ABD Medicaid. ABD Medicaid is an entitlement but HCBS Waivers are not.
Determining Eligibility for Medicaid Long Term Care
Regardless of the type of Medicaid 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.
From a financial perspective, typically there are limits on monthly income, total countable assets and home ownership. These limits vary based on age, marital status, number of applicants in the family, state of residence and the specific type of Medicaid program. In addition, these limits change annually and, in some cases, twice annually.
Medical or functional eligibility criteria also vary by state and by type of Medicaid program. In all cases, the individual must be determined by Medicaid to require the type of care they are seeking.