Medicaid Benefits for In-Home Care: What’s Covered & Not Covered

Summary
Americans often think of Medicaid Long Term Care as coverage for living in a nursing home only, but every state has Medicaid programs that will cover the costs of long-term care in the recipient’s home as long as they meet certain financial and medical qualifications. Medicaid’s in-home care is not as comprehensive as the care you would receiving in a nursing home, and many Medicaid in-home care programs have limited enrollment spots, which means some applicants will end up on waitlists before receiving benefits.

 

 

Types of Medicaid that Provide Long Term Care at Home

There are three types of 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 of these two programs can provide in-home care to qualified applicants: HCBS Waivers and ABD Medicaid.

ABD Medicaid and Nursing Home Medicaid are both entitlements, meaning qualified applicants are guaranteed to receive benefits without any wait. HCBS Waivers, however, are not an entitlement. Instead, most HCBS Waivers programs have a limited number of enrollment spots, and 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 Waivers and ABD Medicaid also have different financial and functional (medical) requirements. We will discuss these differences in the next section. Before we get there, you should know that ABD Medicaid is sometimes referred to as Regular Medicaid for seniors, but it should not be confused with the Regular Medicaid that is available to financially needy people of any age.

 Medicaid is not Medicare. Both are health insurance programs run by the government, but Medicare is a federal program for all Americans 65 and older while Medicaid is run by states for residents with limited income. Medicaid will pay for long-term care and Medicare will not.

 

Financial Eligibility Criteria for Medicaid In-Home Care

For all types of Medicaid coverage, including long-term care at home through either Home and Community Based Services (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid, applicants and recipients must have limited financial resources. This is measured by two criteria – an asset limit and an income limit.

Asset limit
In most states in 2024, the asset limit for both HCBS Waivers and ABD Medicaid is $2,000 for individuals and either $3,000 or $4,000 for married couples. However, these asset limits can vary by state and program. In Florida, for example, the HCBS Waivers asset limits are $2,000 for an individual and $3,000 for a couple, but the ABD Medicaid asset limits are $5,000 for an individual and $6,000 for a couple. And California will have no asset limit starting on Jan. 1, 2024. Some assets are not counted toward the limit, like the applicant’s home, as long as it meets certain conditions.

Medicaid considers the assets of a married couple jointly owned and will count all assets toward the limit, but there are exceptions for HCBS Waivers applicants who are married but only one spouse is applying. In most states in 2024, the non-applicant spouse is allowed to keep up to $154,140 in assets (depending on the state), due to the Community Spouse Resource Allowance. This allowance does not apply to ABD Medicaid.

Income limit
The income limit for HCBS Waivers in most states in 2024 is $2,829/month for an individual and $5,658/month for a married couple with both spouses applying. For a married couple with just one spouse applying for HCBS Waivers, the income limit is $2,829/month (in most states in 2024) and the income of the non-applicant spouse is not counted. The income limit for ABD Medicaid in 2024 ranges from $943/month to $1,751/month, and the income limit for a married couple is between $1,415/month and $2,593/month. ABD Medicaid counts the income of both applicants in a married couple no matter if one or both of the spouses is applying. Again, all of these limits can vary by state.

 Toolbox: To find the financial limits for your specific situation, you can use our Medicaid Eligibility Requirements Finder by clicking here.

 

Functional Eligibility Criteria for Medicaid In-Home Care

Home and Community Based Services (HCBS) Waivers applicants must meet a functional, or medical, requirement to qualify for the program and receive in-home care. In most cases, they must require a Nursing Facility Level of Care (NFLOC). This means they need the type of 24/7 care and supervision that is usually associated with a nursing home. Each state has their own method when it comes to determining what an applicant’s level of care need is, but most involve some kind of in-person evaluation and communication with the applicant’s doctors and any other relevant care providers.

ABD Medicaid applicants are not required to meet any medical needs to qualify for the program and receive basic healthcare coverage. They only need to be aged (65 or over), blind or disabled. However, for ABD Medicaid applicants to receive long-term care services and supports in their home, they have to show a medical need for those services and supports. This means they will be evaluated on a case-by-case basis to see which long-term care benefits they can receive. They may qualify for some their state’s ABD Medicaid program offers, but not others.

 

In-Home Long-Term Care Benefits Covered by Medicaid

Medicaid Long Term Care offers a wide range of in-home benefits through Home and Community Based Services (HCBS) Waivers and Aged, Blind and Disabled (ABD) Medicaid. These two programs don’t cover every long-term care service and support, and what they do cover varies by state and program, as does they amount of that service or support they might cover. That being said, if a service or support can help keep someone healthy and living in their own home, chances are good one of these two programs will help cover the cost. It’s more cost effective for the state to provide in-home care than it is to provide nursing home care, so states are motivated to do just that.

Some states have multiple HCBS Waiver programs, so you may need to apply to more than one of them to get all of the in-home coverage you need. The official Medicaid website has a detailed list of the HCBS Waivers offered in every state that you can access by clicking here. When searching, be sure to filter for the relevant state and deselect “terminated” waivers.

ABD Medicaid offers its in-home care benefits piecemeal and separately from its basic healthcare coverage, which means you may need to go through several application processes to get all the in-home services and supports you need through ABD Medicaid.

While there can be a lot of variance between states and programs, the following in-home care benefits are generally available through HCBS Waivers and/or ABD Medicaid in most states:

  • Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
  • Personal care assistance with the Instrumental Activities of Daily Living (cleaning, shopping, cooking, laundry, medication management, etc.)
  • Home modifications like grab bars, wheelchair ramps, etc.
  • Vehicle modifications like wheelchair lifts, hand controls, etc.
  • Skilled nursing and doctor’s visits
  • 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

Some of these benefits, like the personal care assistance with the Activities of Daily Living, can be provided by a family member via Consumer Directed Care. This is an appealing advantage for many people who want in-home care, and we will discuss it further in the next section.

 

Care Providers & Consumer Direction

If you qualify for a Home and Community Based Services (HCBS) Waiver, or in-home care via Aged, Blind and Disabled (ABD) Medicaid, the state will assign a care provider to deliver those benefits. You can find a list of medical professionals who are in the Medicaid network by checking with your local state Medicaid offices. To find contact information for the Medicaid office nearest you, click here and then select the “HOW TO contact your state” link.

However, if you are covered by an HCBS Waiver or ABD Medicaid program that offers Consumer Directed Care, you may be able to select a caregiver of your choice, within limits. With Consumer Directed Care, the Medicaid recipient has some decision-making power when it comes to their care, and this can include selecting (and paying) a caregiver. In most cases, this caregiver can be a family member, and some states even allow Medicaid recipients to select their spouse as a paid caregiver.

Family members may need to undergo background checks or certification classes to be approved by Medicaid as caregivers. And the amount they can be paid depends on the program and the state, but it is often not a high wage. However, many of these family members may have already been providing the care for free, so any payment is better than none.

Other names for Consumer Directed Care can have different names in different states, including Consumer Directed Services, Participant Direction, Self-Directed Care and Cash and Counseling. To learn more about Consumer Directed Care, click here.