Medicaid Long Term Care Benefits: Locations & Care Providers

Many people think of Medicaid Long Term Care as just financial help to live in a nursing home, but it is also a series of programs with benefits for people who live in their own homes or in assisted living communities. Therefore, what is covered by Medicaid Long Term Care depends on the type of Medicaid program in which a beneficiary is enrolled.

Medicaid LTC helps pay for ongoing needs that are not necessarily medical. In nursing homes, it covers almost all costs, including room and board. For those who live in their own homes or communities (including assisted living), there are many other benefits such as assistance with activities of daily living like eating and bathing. In some states, there are even programs that will pay spouses or adult children to be their loved one’s caregiver.


Medicaid Benefits for Long Term Care

Medicaid Long Term Care is for people with limited financial resources who cannot live independently in their own homes. The Centers for Medicare and Medicaid Services says LTC helps Americans who “need long-term care services because of disabling conditions and chronic illnesses.” This means healthcare needs are ongoing and not necessarily medical in nature, 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 are an inability to perform “activities of daily living,” like eating and bathing, or the need for a “nursing facility level of care.”

There are three types of Medicaid Long Term Care programs.

Nursing Home Medicaid

Nursing home Medicaid is also called Institutional Medicaid, and for most recipients it covers 100% of the costs of nursing home care. These are the services that must be provided at nursing homes and covered under the Medicaid LTC benefit:
– 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 medical) must be covered. It is important to note, however, that the requirements to receive Medicaid are not the same in every state.

Nursing home billing is different from assisted living and other communities—in nursing homes the services are not itemized. Medical and personal care, room and board, meals, laundry, etc., all fall under a daily rate, and Medicaid LTC will pay enough to cover that rate.

Most nursing homes accept Medicaid, but they limit the number of “Medicaid beds,” meaning there is a cap on the number of residents they will accept who pay with their Medicaid LTC benefits. This is because people who pay privately usually pay a little more than those who pay through Medicaid. So while the state must provide coverage for anyone who qualifies, the individual nursing homes do not have to admit these people if they don’t take Medicaid or have reached their cap on Medicaid beds.

 Medicaid LTC 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.

These are the services often received in nursing homes that typically will not be covered under Medicaid LTC (though different states have different coverages):
– 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 Waiver Benefits

Home and Community Based Services (HCBS) waivers are for people who need a nursing home level of care but want to stay in their own home or assisted living community. HCBS waivers, in fact, are designed to prevent or delay the move into a nursing home for someone with a disability or chronic illness. HCBS waivers also give unpaid caregivers (usually a spouse or other family member) relief from the hard duty of caregiving. The specifics vary from state to state, but these waivers sometimes allow the recipient to choose who delivers their services and may even allow a family member to be paid for caregiving.

Benefits provided under HCBS waivers will be different in different states, but generally speaking a person who qualifies financially and medically for HCBS waivers can expect to receive a mix of medical and non-medical services. These services can be received in a person’s own home, the home of a caregiver, or in an assisted living community (including memory care and board and care homes). Typically included is:

– Case management (help with determining and receiving support)
– Homemaker services (like laundry and tidying up)
– Home health aides (provide personal or custodial care, meaning help with activities of daily living)
– Adult day care
– Respite care (temporary care to give caregivers a break)
– Medical supplies and equipment
– Counselling services
– Vehicle and home modifications
– Transportation to doctor’s appointments
– Mobility help like walkers and wheelchairs
– Hot meal delivery

HCBS waivers are not an entitlement like Nursing Home Medicaid described above, which means states have enrollment caps for the waivers and your loved one may have to go on a wait list. Wait lists for HCBS waivers can be several months or even several years long.

 Nursing Home or Institutional Medicaid will pay for room and board while waivers will not.

Among the benefits not covered under HCBS waivers is room and board (rent) costs for assisted living and other types of communities. This is a crucial difference between Medicaid LTC assistance for a person in a nursing home and those who live in their own home or in a community: Nursing Home or Institutional Medicaid will pay for room and board while waivers will not.

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


ABD / Regular Medicaid’s Benefits for Long Term Care

Aged Blind and Disabled Medicaid is also referred to as Regular Medicaid. The purpose of long term care coverage through ABD Medicaid is the same as the HCBS waivers described above: To provide services that will keep someone who needs nursing home care in their own home or community rather than having to move into a more expensive nursing home. ABD offers fewer actual benefits and services than HCBS waivers and has more restrictive financial eligibility criteria but less restrictive medical requirements. Unlike Waivers, ABD Medicaid is an entitlement, so anyone who is eligible must be given these services, and there are not wait lists.

The exact types of benefits vary considerably by state even more so than with HCBS Waivers. It is rare any one state will cover all the following, but this is the range of ABD Medicaid benefits for long term care across the states. Benefits under ABD Medicaid are approved on a case-by-case basis.

– Adult Day Care
– Family & Caregiver Support
– Environmental Accessibility Modifications
– Home Health Care
– Homemaker Services
– Hospice Care
– Medical Equipment & Supplies
– Medical Alerts Devices & Services
– Nutrition Services
– Personal Care
– Transportation Assistance

More on ABD Medicaid benefits here and 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 pay 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 a state’s Aged Blind and Disabled / Regular 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 follow in the section below.

Which of the 3 types of care provider a beneficiary receives depends on the specific HCBS Waiver or ABD Medicaid program in which they are enrolled.

Need assessments are made after one applies for Medicaid and is approved. The process of assessing usually involves a healthcare professional coming to the home or community and determining the level of care required. Which specific activities of daily living (ADLs), like eating and bathing, does your loved one need help with? The method of measuring needs (behavior and cognition might also be rated) 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 every state offer some form of Consumer Direction, which means the person receiving the benefits can select their own care providers, often within a budget determined by assessing care needs and factoring in the average wage of a home care aide in your area. Consumer direction gives freedom to receive long term care outside the state’s approved list of providers (and saves the state money by eliminating its need to manage your loved one’s healthcare).

One of the best parts of Consumer Direction is the option to pay a member of the family to provide caregiving. In other words, an unpaid caregiver can get paid. Many states, including California, Florida, and Minnesota, even allow for a spouse to be paid for caregiving duties. Otherwise, the caregiver could be an adult child, sibling, or a close friend. Caregivers might also receive training to learn techniques for communicating with their loved one and helping with activities of daily living like getting dressed or bathing.

Consumer Direction (also called “cash and counselling,” “self administration,” and “participant directed” care) is usually part of your state’s Home and Community Based Services (HCBS) Medicaid waiver program. These are popular because the family has control over care, and there are so many unpaid caregivers (more than 50 million!) who would like to keep things the way they are in their home but just need some financial help. Unfortunately, these waivers are not entitlements, which means there are often long wait lists. Some states also allow for consumer direction through their regular / ABD Medicaid programs.

Some states, including Texas and Massachusetts, allow the person who needs care to move into the home of a friend or relative (like an adult child). That home is considered “adult foster care” or a foster home. Funding for caregiving is then paid out by the program. This foster care program is available through HCBS waivers and also through regular ABD Medicaid in some states.