3 Types of Medicaid Long-Term Care: Nursing Home, HCBS Waivers & ABD

There are 3 different types of Medicaid programs that provide long-term care. These programs provide different types of care services, in different locations and they have different eligibility requirements.

1. Nursing Home Medicaid – provides the highest level of care and is available only to persons who reside in nursing homes.
2. Home and Community Based Services (HCBS) Waivers – offers long-term care services to individuals that require a “Nursing Facility Level of Care” but live at home or in a “community” such as an assisted living residence.
3. Aged, Blind, and Disabled (ABD) Medicaid – delivers long-term care services at home or in the community but to a lesser extent than HCBS Waivers.

Note that while these 3 programs exist in every state, there are large differences between the states in how they work, the benefits they offer and their eligibility requirements.

 

 

1) Nursing Home / Institutional Medicaid

In a lot of ways, “Nursing Home Medicaid” is exactly what it sounds like, and it’s what most of us think of when we think of a nursing home, or of Medicaid. It’s long-term care that is provided in an institutionalized setting. Nursing home Medicaid covers:

  • Room and board at the facility
  • Personal help as needed with everyday activities, often referred to as the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
  • Administration of daily medications
  • Skilled nursing services as necessary

Nursing Home Medicaid is for anyone who is in significant need of assistance with the Activities of Daily Living, can not afford the care and can demonstrate that fact with a deep-dive look into their finances. Medicaid beneficiaries have to meet income limits and asset limits that are set by their state of residence. States can have different financial requirements, but in general they are all low since Medicaid is meant for people with limited financial resources. While the income limit for Nursing Home Medicaid in most states in 2024 is $2,829/month, Nursing Home Medicaid beneficiaries are only allowed to keep a small portion (between $30 and $100 in most states) of their monthly income as a personal needs allowance and must give most of it to the state to help cover the cost of care.

Nursing Home Medicaid is an entitlement, and that simply means that if you meet the requirements, you are guaranteed by law to receive the benefits without wait. But it’s important to note that some nursing homes might have waitlists for available beds, which means a Nursing Home Medicaid beneficiary might be put on a waitlist for that specific nursing home. Medicaid will still pay for their benefits, but they need to find a nursing home with available space.

Nursing Home Medicaid must be provided in a Medicaid-certified nursing home facility, meaning the facility has to accept Medicaid. More on Nursing Home Medicaid eligibility.

 

2) Home and Community Based Services (HCBS) Waivers

Nursing home care is extremely expensive, and the administrators of Medicaid programs know that care at home can be less expensive and preferred by many individuals. Medicaid has expanded in certain ways to help facilitate that in-home care, and Home and Community Based Services (HCBS) Waivers, are one such way.

HCBS Waivers will provide in-home long-term care services and supports to help people who require a “Nursing Facility Level of Care” but want to remain living at home (or somewhere else in the community). The long-term care benefits provided by HCBS Waivers are intended to delay nursing home placement for as long possible. Some of those benefits include:

  • Adult day care
  • In-home assistance with Activities of Daily Living (ADLs)
  • Homemaker services
  • Home health care services
  • Home modifications for accessibility and safety
  • Medical alert services
  • Respite care for unpaid caregivers (such as family members)

Most HCBS Waivers programs will deliver their long-term care services and supports to program participants in their own home or the home of a family member or friend if that’s where the Waiver beneficiary lives. Some HCBS Waivers will also deliver their benefits in other settings “in the community,” like assisted living facilities, adult foster care homes, adult day centers and specialized memory care units for people with Alzheimer’s disease and other dementias. While HCBS Waivers may pay for benefits in multiple locations, they will not cover room and board expenses in any of them.

As with Nursing Home Medicaid programs, HCBS Waivers have state-specific financial requirements. However, while Nursing Home Medicaid beneficiaries must give almost of their income to the state, HCBS Waiver beneficiaries can keep their income to cover their cost of living expenses like mortgages, rent, food, car payments and other costs people residing in a nursing home would not have.

HCBS Waivers are not entitlements. Instead, there are a limited number of enrollment spots in most Waiver programs. Once those spots are full, additional applicants are placed on a waitlist before receiving benefits. Waiting times can range from a few months to a few years. How waitlists are organized and prioritized depends on the state and the program. Some waitlists work on a first-come, first-serve basis, others prioritize people with the greatest need. More on HCBS waivers eligibility.

 

3) Aged, Blind, and Disabled (ABD) Medicaid

Where Nursing Home Medicaid offers full-time care in an appropriate facility, and HCBS Waivers allow you to receive that level of care outside of a nursing home, ABD (Aged, Blind, Disabled) Medicaid can best be thought of as an expansion of regular Medicaid. Think Medicaid health insurance expanded for aged, blind of disabled persons. One qualifies for each service and support separately as opposed to the suite of services one receives in a nursing home.

ABD Medicaid is not referred to by the same name in every state, but states typically use a variation such as Aged & Disabled (AD) or Elderly, Blind and Disabled (EBD). Although some states us other names, like Medi-Cal in California, and MassHealth in Massachusetts.

Typically, ABD Medicaid programs do not offer the same wide range of services and supports that are provided under Nursing Home Medicaid or HCBS Waivers. In most states, ABD Medicaid’s long-term care is limited to home health care and personal care assistance or attendant care.

Every state’s ABD Medicaid program is an entitlement, just like with the Nursing Home Medicaid. Again, this means if you meet the eligibility requirements, the state must pay for the benefits. It’s not like HCBS Waiver programs that have a cap on the number of participants. More on ABD Medicaid eligibility.

 

Quick Comparison Table

Comparing 3 Types of Medicaid Long Term Care Programs
Type of Medicaid Long Term Care Program Entitlement? Care Locations Level of Care Eligibility Criteria
Nursing Home Yes Nursing homes only All care needs and room and board Permits higher income limits but income must be surrendered to Medicaid
HCBS Waiver No State-dependent but typically at home, in assisted living or adult day care Most care needs but no room and board Permits higher income limits with allowances for room and board
Aged, Blind or Disabled Yes State-dependent but typically at home only Limited care needs Most restrictive income limits