Medicaid Benefits for In-Home Care: What’s Covered & Not Covered
In every state, Medicaid will cover the costs of Long Term Care (LTC) in the beneficiary’s home if they meet certain financial and medical qualifications. Americans often think of Medicaid as coverage for living in a nursing home only, but there are programs designed to keep persons with high levels of care needs in their homes. However, unlike nursing home care, many Medicaid home care programs are not entitlements meaning beneficiaries may be wait-listed to receive services. Additionally, the services and support provided under Medicaid Home Care are not as broad as those provided in a Medicaid Nursing Home.
Types of Medicaid Programs That Provide Long Term Care at Home
Medicaid Long Term Care at home is provided under 1 of 2 Medicaid sub-programs:
1) Aged, Blind, and Disabled Medicaid (ABD or regular Medicaid)
2) Home and Community Benefits Services (HCBS) Waivers
An important difference is that HCBS waivers are not entitlements, but ABD Medicaid is an entitlement. This means there is a limit or cap on the number of people who can receive HCBS waivers, and qualified individuals then go on a waiting list that can last as long as several years. ABD Medicaid, on the other hand, is considered an entitlement because everyone who is eligible must be covered, so there is no cap or waiting lists.
Another difference between the HCBS waivers and ABD Medicaid, even for long term care, is that financial eligibility criteria vary, not just from state to state but even within regions of the same state and with marital status. One can obtain their specific Medicaid eligibility criteria here.
Medicaid will pay for long term care at home if the recipient is financially and medically qualified, but the cost cannot be more expensive than the cost of living in a nursing home. This is why most people receiving Medicaid Long Term Care at home also get care assistance from their spouse, relatives, or other unpaid caregivers (though these caregivers can receive payment under Medicaid Consumer Direction described below).
1) Aged, Blind and Disabled (Regular) Medicaid
Through their regular state-run Medicaid programs, states must make benefits available in the homes of people who need long term care, which usually means help with activities of daily living (ADLs) like eating and bathing. Regular Medicaid for people who are older or have chronic illness is also called Aged, Blind, and Disabled Medicaid.
In-home assistance from a trained attendant is an option under several states’ Medicaid plans that offer the Community First Choice option. Since the Affordable Care Act made federal dollars available for this program, nine states have launched a CFC program: Alaska, California, Connecticut, Maryland, Montana, New York, Oregon, Texas, and Washington. Someone who might require placement in a nursing home can instead receive help with ADLs and IADLs from a visiting attendant through CFC. Respite care, when someone visits to provide companionship while caregivers take a break, and home modifications like grab bars and wheelchair ramps would also be covered through CFC.
These ABD Medicaid options do not necessarily require someone to show they need nursing-home-level care, unlike the Medicaid waivers described below. Additionally, there is no waitlist to receive ABD Medicaid services, unlike waivers.
2) Medicaid HCBS Waivers
Home and Community Based Services (HCBS) Waivers
Waivers are for people on Medicaid who would need to move into a nursing home if they did not receive more support in their own homes. The idea is to save money, because living in your own house, even with support and assistance, is less expensive than moving into a nursing home as well as more desirable for the beneficiary.
Home and Community Based Services (HCBS) waivers offer more benefits for getting care at home than regular Aged, Blind and Disabled Medicaid. Every state offers an HCBS waiver in some form or another, though specific benefits and eligibility criteria will vary.
HCBS waivers might be harder to get, however, because they are not entitlement programs like ABD Medicaid. Whereas with entitlements every person who is eligible must be covered, the waivers have a cap or limit on the number of people who can receive their benefits. This means there may be a waiting list to receive HCBS waivers in your state.
Section 1115 Demonstration Waivers
The section 1115 Demonstration Waivers are pilot programs meant to test innovative ways for local areas to provide services to residents on Medicaid. If local health officials come up with an idea that aligns with the goals of Medicaid—providing care while saving money—it would be offered through these Section 1115 Demonstration waivers. Options like acupuncture and chiropractic services, for example, might be among the benefits of a Section 1115 waiver.
Section 1115 Demonstration Waivers are usually approved for 5 years at a time, and then renewed if they demonstrate effectiveness.
What Benefits Does Medicaid Long Term Care Covers In-Home?
For people who need full-time nursing care, or close to it, but want to remain in their own home rather than moving into a more expensive nursing home, Medicaid Long Term Care offers extensive benefits through the normal Aged, Blind and Disabled (ABD) Medicaid and the waivers described in the section above. Broadly speaking, if a service keeps someone healthy and taken care of in their own home, it is likely that Medicaid offers a program to help cover the costs.
Benefits vary by state, but these are the at-home services you can probably expect to find for your loved one through Medicaid Long Term Care:
– Help with Activities of Daily Living (ADLs) like eating, bathing, dressing, etc.
– Help with Instrumental Activities of Daily Living (IADLs) like cooking, money management, medication management, shopping, etc.
– Home modifications like grab bars, wheelchair ramps, etc.
– Vehicle modifications like wheelchair lifts, hand controls, etc.
– Skilled nursing care
– Respite care (short-term breaks for caregivers)
– Transportation (both medical and non-medical)
– Physical therapy
– Occupational therapy
– Meal delivery
– Personal Emergency Response Systems (PERS) also known as Medical Alert Devices
Another very popular part of Medicaid Long Term Care is consumer direction of personal care, also called attendant care services, which allow the recipient to hire a person of their choosing to be paid as caregiver. This means that the spouse (in some states) or a close relative can be hired (and paid) as caregiver. For more, see below.
Care Providers & Consumer Direction
Not all providers of Long Term Care at home will accept Medicaid payments. You can find a list of medical professionals who do accept Medicaid by checking with your local State Medicaid Agency office (see How To Find, below). Fortunately, Medicaid recipients who receive Consumer Directed Care (CDC) are not limited only to providers who accept Medicaid.
Consumer Directed Care means that the beneficiary, or close relative, has control over which services are provided through Medicaid Long Term Care, and by whom. Care providers are managed by the recipient, in other words, and payments to those providers are made by the recipient out of a predetermined budget.
This option allows people who need long-term care services to look outside the lists of Medicaid-approved providers, allowing for more options and control. Recipients would also determine for themselves which services they require. Another very popular part of CDC, available in many states, allows a person to pay their spouse or close relative some money to serve as caretaker. The amount a person can be paid to serve as their loved one’s caretaker under these Medicaid programs is determined by Medicaid and is usually below the market value for those services in their area from private pay providers.
Other names for consumer directed care include consumer-directed services, participant direction, self-directed care, self-administered services, and Cash and Counselling. There are also different terms for this type of program depending in which state you live.
Financial & Functional Eligibility for Medicaid In-Home Care
For all types of Medicaid, including Long Term Care at home, there are two criteria that determine if someone can receive these benefits: A person must have limited financial resources and a documented need for care.
Financial eligibility depends on monthly income (usually less than $2,523 in 2022) and the value of someone’s assets (usually less than $2,000 in 2022). There is a lot of wiggle room, especially when it comes to assets, and limits also vary based on other factors including state of residence, home ownership, marital status, and which Medicaid program is best suited to you or your loved one. Also note that the limits will change annually. Finally, Waivers have different financial criteria than does ABD / Regular Medicaid.
Medical or functional eligibility is different depending on the state and type of Medicaid program. Often for at-home care, a medical professional is sent to someone’s home to make an assessment of their needs based on a number of factors including which specific Activities of Daily Living a person cannot accomplish alone. In other words, someone working with Medicaid will visit and see whether a potential recipient needs help with mobility, eating, getting dressed, etc. Because programs differ, it is possible there are a set number of ADLs someone with which someone needs assistance in order to receive Medicaid benefits.
Whereas Aged, Blind and Disabled Medicaid benefits may be available to someone who does not quite need nursing-home-level care, in order to receive HCBS waiver funds in most states a person must prove to a medical professional that they would need to move into a nursing home without the benefits.
Find Medicaid In-Home Care Providers
Medicaid has a detailed list of the waivers offered in every state at this link. When searching, be sure to filter for the relevant state and deselect “terminated” waivers.
Regarding providers for ABD Medicaid, typically once the applicant has been approved for Medicaid and the specific services, Medicaid will either designated a care provider, offer a list of providers from which the beneficiary can choose or provide details of hiring one’s own care providers.
For general care provider questions, contact your local Medicaid Office. A complete list of State Medicaid Agency offices is available at this link.