Medicaid Benefits in Assisted Living & Memory Care: What Is & Isn’t Covered
Summary
Seniors in assisted living facilities can receive long-term care services and supports through Medicaid, in the right circumstances. Applicants must meet certain financial and medical requirements, and their state must offer the benefits. Medicaid won’t cover room and board expenses for assisted living, but it will cover long-term care benefits through one of two Medicaid Long Term Care programs – Home and Community Based Services (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid.
Types of Medicaid Long Term Care Programs that Cover Assisted Living
There are three Medicaid Long Term Care programs relevant to seniors – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers and Aged, Blind and Disabled (ABD) Medicaid. The latter two can provide long-term care benefits to seniors in assisted living facilities, including memory care units for people with Alzheimer’s and other dementias – HCBS Waivers and ABD Medicaid.
There are many differences between the two Medicaid Long Term Care programs, including eligibility criteria, benefits and availability. The next two sections will provide an overview of the programs, their differences and how they might be used by Medicaid recipients in assisted living.
Aged, Blind, and Disabled (ABD) Medicaid
ABD Medicaid is an entitlement. This means all qualified applicants are guaranteed by law to receive benefits without wait. This is not the case with HCBS Waivers, as you’ll see below. ABD Medicaid can sometimes be called state Medicaid or Regular Medicaid for seniors, but it should not be confused with the regular state Medicaid available to financially needy people of all ages.
There is no medical requirement to receive general healthcare coverage through ABD Medicaid other than being aged (65 and over), or blind, or disabled. However, to receive any long-term care services and supports in assisted living facilities, ABD Medicaid recipients must show a need for that particular benefit. The process to determine if an ABD Medicaid recipient needs a particular service or support will vary by state, but in general it will involve an in-person evaluation and/or communication with doctors and other relevant healthcare providers.
The long-term care benefits available in assisted living through ABD Medicaid are fully detailed below, but they can include things like medication management and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Most ABD Medicaid recipients who are in assisted living can receive some kind of long-term care benefits through the program, but they should check with their state Medicaid agency. To find contact information for the Medicaid office nearest you, click here and then select the “HOW TO contact your state” link.
ABD Medicaid applicants do have to meet two financial requirements – an asset limit and an income limit. In most states in 2024, the asset limits for ABD Medicaid are $2,000 for an individual and $3,000 combined for a married couple, but these can vary by state. In Illinois, for example, the ABD Medicaid asset limit if $17,500 for an individual and a couple, and California has no Medicaid Long Term Care asset limits. The ABD Medicaid income limits in most states in 2024 are between $943/month and $1,751/month for an individual, and between $1,415/month and $2,593/month combined for a married couple.
Home and Community Based Services (HCBS) Waivers
Unlike ABD Medicaid, HCBS Waivers are not an entitlement. Instead, each program has a limited number of enrollment spots. Once those spots are full, additional applicants will be placed on a waitlist that could last months or years. To learn more about Medicaid waitlists, click here.
HCBS Waiver applicants must meet a medical requirement to be eligible, and in most cases the requirement is needing a Nursing Facility Level of Care (NFLOC). This means the kind of constant care and supervision usually found in a nursing home. Some HCBS Waiver programs have less strict medical requirements, like being at risk of needing a NFLOC, but a significant level of care is required for all HCBS Waiver programs.
Every state has at least one HCBS Waiver, and some have several, but not all of them will cover long-term care services and supports for recipients living in assisted living facilities. To find out if your state has an HCBS Waiver that provides long-term care benefits in assisted living, contact your state Medicaid agency. Your can find contact information for the Medicaid office nearest you by clicking here and then select the “HOW TO contact your state” link. You also see a list of the HCBS Waivers available in every state by clicking here. Or you can go to our 50-State Guide.
Like ABD Medicaid, HCBS Waivers require their applicants to meet two financial criteria – an asset limit and an income limit. In most states in 2024, the HCBS Waivers asset limits are $2,000 for an individual and $3,000 combined for a married couple with both spouses applying. For married couples with just one spouse applying for HCBS Waivers, the 2024 asset limit in most states is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse. The HCBS Waivers income limits in most states in 2024 are $2,829/month for an individual and $5,658/month combined for a married couple with both spouses applying. For married couples with just one spouse applying for HCBS Waivers, the 2024 income limit is $2,829/month for the applicant (in most states) and the income of the non-applicant spouse is not counted.
Again, these limits can all vary by state. But as you can see, the HCBS Waivers financial limits are, in general, more lenient than the ABD Medicaid financial limits.
Long Term Care Benefits Covered by Medicaid in Assisted Living
The long-term care benefits that Medicaid covers in assisted living will vary depending on the state. However, they will generally include:
- Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
- Personal Care assistance with the Instrumental Activities of Daily Living (such as housekeeping, shopping, cooking, managing finances and medications, etc.)
- Transportation (medical and non-medical)
- Meal preparation and/or delivery
- Personal Emergency Response Systems (PERS) or medical alert devices
Again, it’s important to note that Medicaid Long Term Care will not cover room and board expenses in any assisted living facility, including memory care units for seniors with Alzheimer’s or other dementias. This is different from Medicaid’s nursing home coverage, which does pay the room and board fees associated with the nursing home. However, seniors in assisted living may be able to receive help with room and board expenses from other programs, including Supplemental Social Security (described below).
Finding Assisted Living Facilities that Accept or Allow Medicaid
Some assisted living facilities, including most memory care units, will arrange for long-term care services and supports for its residents, and some of those facilities may accept Medicaid payments for those services and supports. However, even if the assisted living facility doesn’t accept Medicaid or doesn’t arrange for care, it may still allow outside caregivers (including those from Medicaid) to come in and provide long-term care services and supports to its residents.
With that mind, to find assisted living facilities that will allow its residents to receive Medicaid-provided long-term care services and supports on site, you should call the facilities in your area and ask about their Medicaid policy. Ask as many questions as you want, but definitely include these two:
- Do you accept Medicaid?
- Do you allow outside caregivers to enter the residence and provide long-term care services?
A good resource for narrowing down your search is the Area Agency on Aging, which might keep a list of Medicaid-certified residences and service providers. To find your local AAA office, click here.
Non-Medicaid Assistance for Medicaid Beneficiaries
Since Medicaid Long Term Care won’t cover room and board in assisted living facilities, some Medicaid recipients who reside in assisted living may need help with those expenses. Many states offer Optional State Supplementation (OSS) to help cover these kind of expense. OSS assistance is in addition to Supplemental Security Income (SSI) and regular Social Security benefits. OSS programs vary by state, and they are out of the scope of this article and website. To see if your state offers OSS, you can contact your local Social Security Administration office by clicking here.