Medicaid Long Term Care Benefits: Locations & Care Providers

Summary
Medicaid Long Term Care covers care in a nursing home, and it covers long-term care benefits for seniors who live in their own home, the home of a loved one, assisted living residences and other places in the community. Medicaid can assign caregivers to provide these benefits, but there are some programs that let beneficiaries pick caregivers of their choice, including family members. The availability of benefits in the community depends on the individual’s needs and circumstances, and the program itself.

 

Medicaid Long Term Care Benefits

Medicaid Long Term Care is for people with limited financial resources who cannot live independently in their own homes. Their long-term care needs do not have to be medical in nature to be covered by Medicaid, and they can be due to normal aging, a disability, or a chronic health condition with no cure like Alzheimer’s or Parkinson’s disease. The functional (as opposed to financial) qualifying factors for Medicaid Long Term Care in most states is the need for a “Nursing Facility Level of Care.” This means the applicant needs the kind of full-time care usually associated with a nursing home. Exact definitions vary by state, but in general it means an inability to perform some or all of the “Activities of Daily Living,” which are mobility, bathing, dressing, eating and toileting.

There are three types of Medicaid Long Term Care relevant to seniors – Nursing Home Medicaid, Home and Community Based Services Waivers, and Aged, Blind and Disabled Medicaid.

Nursing Home Medicaid

Nursing Home Medicaid (which was formerly referred to as Institutional Medicaid) covers 100% of the costs of nursing home care, including:

  • Nursing and medical services
  • Medically related social services (counseling, conflict resolution, etc.)
  • Assistance with acquiring and administering medications
  • Meals to meet the dietary needs of each resident
  • Programs with activities that meet interests and needs for every resident
  • Emergency dental services
  • Room and bed maintenance
  • Routine hygienic items and services

Nursing Home Medicaid is available in every state and is classified as an entitlement, which means anyone who meets the eligibility criteria (financial and functional) must be covered and is guaranteed by law to receive benefits without wait. It is important to note, however, that the requirements to receive Medicaid are not the same in every state. Plus, not all nursing homes accept Medicaid, and those that do may not have available space when you or your loved one is ready for care. So, eligible Nursing Home Medicaid applicants are guaranteed nursing home coverage, but they are not guaranteed a spot in any facility they choose.

 Medicaid Long Term Care is Not for Rehabilitation: When an individual enters a nursing home for a limited time to recover after an injury, short-term disability or illness, this is considered “rehab.” If someone needs to stay in a nursing home for 100 days or fewer, Medicare is typically the program that covers those costs.

The following nursing home services are usually NOT covered by Medicaid Long Term Care:

  • A private room, unless it’s medically necessary
  • Specially prepared food beyond what the residence’s kitchen can cook
  • Phone, TV, and radio
  • Personal comfort items like tobacco or sweets
  • Cosmetics or grooming items beyond those considered routine
  • Clothing
  • Personal reading materials
  • Gifts
  • Flowers or other plants
  • Social events or activities beyond the residential activity program
  • Special care services not considered medical or necessary

More on Medicaid benefits in nursing homes.

 

Home and Community Based Services Waivers

Home and Community Based Services (HCBS) Waivers are for people who need or are at risk of needing a Nursing Facility Level of Care, but want to continue living in the community. Where “in the community” HCBS Waivers will cover long-term care benefits varies by state and program. Most states have an HCBS Waiver that will cover some long-term care benefits in the Medicaid recipient’s home or the home of a family member. Other places in the community that HCBS Waivers cover long-term care benefits can include:

  • assisted living residences
  • the home of a friend
  • adult foster homes
  • senior group homes
  • memory care units for people with Alzheimer’s and other dementias
  • adult day care centers

While HCBS Waivers will cover long-term care services and supports in multiple settings, they will not cover room and board expenses, with only a very few rare exceptions. This is different than Nursing Home Medicaid, which will pay for room and board.

Another crucial difference between HCBS Waivers and Nursing Home Medicaid is that HCBS Waivers are NOT an entitlement. Remember, entitlement means guaranteed by law to receive benefits without wait. Most HCBS Waivers, on the other hand, have a limited number of enrollment spots. Once those spots are full, additional applicants are placed on a waitlist. Applicants might be on these waitlists for a few months or even years in some cases.

The benefits provided by HCBS Waivers will vary depending on the state and program, but they can include:

  • case management
  • homemaker services (such as shopping, cooking, cleaning, laundry, etc.)
  • home health aides (to provide personal care help with the Activities of Daily Living)
  • adult day care
  • respite care for unpaid caregivers
  • medical supplies and equipment
  • counseling services
  • home and vehicle modifications for accessibility
  • transportation (medical and non-medical)
  • hot meal delivery

These HCBS Waiver benefits are provided depending on the individual needs and circumstances of the Medicaid recipient, and depending on the scope of the waiver. For example, an HCBS Waiver might cover 20 hours/week of personal care assistance for someone who needs that to keep living independently and stay out of a nursing home, but the same Waiver might not cover personal care assistance, or offer less coverage, for an individual who doesn’t need that help to keep living independently. Other HCBS Waivers might not offer personal care assistance at all.

Providing benefits “as needed” is different than Nursing Home Medicaid, which offers all of its benefits at once to anyone who qualifies.

More on Medicaid Waiver benefits at home and in assisted living.

 

Aged, Blind, and Disabled Medicaid

Aged, Blind and Disabled (ABD) Medicaid provides healthcare coverage for any U.S. citizen over age 65 who meets the financial requirements. ABD Medicaid will also cover long-term care services and supports for beneficiaries who need them to keep living independently and avoid moving into a nursing home. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially limited people of all ages.

ABD Medicaid is an entitlement, which means eligible applicants are guaranteed by law to receive benefits without wait. This is the same as Nursing Home Medicaid, but different from Home and Community Based Services (HCBS) Waivers, which have a limited number of enrollment spots and utilize waitlists once those spots are full. It should be noted that while ABD Medicaid beneficiaries are guaranteed to receive healthcare coverage, and many ABD Medicaid Long Term Care programs are also guaranteed, some are limited by factors like funding, location and availability of facilities, such as memory care units or adult day care centers.

ABD Medicaid will also cover some long-term care services and supports in the Medicaid recipient’s home or the home of a loved one. Other places in the community that ABD Medicaid programs might cover long-term care benefits can include:

  • assisted living residences
  • adult foster homes
  • senior group homes
  • memory care units for people with Alzheimer’s and other dementias
  • adult day care centers

Available long-term care benefits through ABD Medicaid vary considerably by state, and they also depend on the needs and circumstances of the beneficiary, but the following benefits are covered by various ABD Medicaid programs across the country:

  • adult day care
  • home modifications for accessibility
  • home health care (like skilled nursing visits)
  • homemaker services (such as shopping, cooking, cleaning, and laundry)
  • hospice care
  • medical equipment & supplies
  • medical alerts devices & services
  • nutrition services
  • personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
  • Transportation assistance

To learn more about ABD Medicaid benefits in the home click here, and for assisted living facilities click here.

 

Who Provides Long Term Care Services under Medicaid

In Nursing Homes

Medicaid will cover all the costs of living in a nursing home — medical care, non-medical care, and room and board. Care and support services are provided by the employees of the nursing home. The beneficiary has no say over who provides them with care in the nursing home. However, Medicaid beneficiaries can choose the specific nursing home in which they will reside. Not all nursing homes take Medicaid payments, but most do.

Keep in mind that Nursing Home Medicaid will not pay for a private room unless it is medically necessary. People who pay for nursing home care through Medicaid must share a room unless family members make additional payments so their loved one can upgrade to a private room. This is called “family supplementation” and the rules regarding it are state specific.

 

In the Home or Community

Medicaid services in a person’s home or assisted living community are most often provided through HCBS Waivers or the state’s Aged, Blind, and Disabled Medicaid program. There are 3 types of care providers.

  1. Providers approved and paid directly by Medicaid
  2. Providers that work for a Managed Care Organization (MCO) that has an agreement with Medicaid
  3. Providers chosen by the beneficiary that are paid by Medicaid. This is called Consumer Directed Care and more details on this option follow in the section below.

The type of care provider depends on the specific HCBS Waiver or ABD Medicaid program in which the Medicaid beneficiary is enrolled.

The first step in finding a care provider is usually a needs assessment administered by the state’s Medicaid offices. Most often, this process involves a healthcare professional coming to the Medicaid beneficiary’s residence for an in-person evaluation of the beneficiary’s specific needs and issues, which often include behavior and cognition as well as healthcare and personal care. The method of measuring needs varies depending on the state. In Ohio, for example, they use the Adult Comprehensive Assessment Tool (ACAT). In Texas, it’s called the Medical Necessity and Level of Care Assessment (MN/LOC).

Once need is established, the Medicaid program either assigns a care provider, offers a list of care providers from which the beneficiary can choose, or allows the beneficiary to choose any care provider and approves that individual or organization (provided they accept the rate Medicaid is willing to pay).

MCOs are often known for providing very little flexibility in care providers. However, some more progressive MCOs now allow for Consumer Direction within their service network.

 

Understanding Consumer Direction and Receiving Payment for Caregiving

Medicaid Long Term Care programs in most states offer some form of Consumer Directed Care, which means the Medicaid beneficiary has some choice when it comes to selecting a care provider. The beneficiary usually needs to stay within a budget that was determined by the state after the needs assessment and factoring in the average pay rate for a home care aide in their area. Still, Consumer Direction offers the beneficiary freedom to receive long term care outside the state’s approved list of providers, and it saves the state money by eliminating its need to manage some of your loved one’s healthcare.

One of the best parts of Consumer Direction is the option to pay a family member to provide care. In many cases, these family members are already acting as unpaid caregivers, but they can get paid through a Medicaid program with Consumer Direction. These family member caregivers can be an adult child, grandchild, niece, nephew or sibling. Many states also allow non-related loved ones and friends to be caregivers. And some states, including California, Florida and Minnesota, even allow spouses to be paid for caregiving duties.

Some states require that caregivers paid through Consumer Direction, including family members, receive some formal training and licensing. Background checks are also a common requirement for Consumer Direction caregivers.

Consumer Direction is also referred to as “Self-Directed,” “Participant Direction,” and “Cash and Counseling.” Programs that allow for Consumer Direction are usually part of a Home and Community Based Services (HCBS) Waiver, but some state’s Aged, Blind, and Disabled (ABD) Medicaid programs also offer Consumer Direction.

Some states, like Texas and Massachusetts, allow the Medicaid beneficiary to move into the home of their Consumer Direction caregiver, including friends and family members. That home is then considered an “adult foster care home” and is often eligible for additional benefits beyond the Consumer Direction pay for caregiving.