Medicaid Long Term Care Eligibility Requirements by Type of Program / Care Location

Summary
In all states, there are three types of Medicaid programs that offer long term care. The locations in which these programs provide care varies (in nursing homes, in assisted living and at home) and therefore the living expenses of the beneficiaries vary. Consequently, the eligibility requirements for these three programs vary. In addition, eligibility criteria vary by state, year and marital status. Find the eligibility criteria specific to the type of Medicaid and your situation using our Medicaid Eligibility Requirements Finder tool.

 

The three types of Medicaid program are Nursing Home Medicaid, Home and Community-Based Services (HCBS) Medicaid Waivers and Aged, Blind, and Disabled (ABD) Medicaid.

 

Institutional / Nursing Home Medicaid

As implied by the name, Nursing Home Medicaid is provided in and only in nursing homes. Beneficiaries reside in the nursing home on a full-time basis and all of their needs including room and board are provided and paid for by the Medicaid program.

Consequently, because Medicaid is intended for low-income persons with limited assets and because beneficiaries are provided with all their medical and personal care needs as well as room and board, the financial and medical eligibility requirements are very restrictive. While the actual dollar values change annually and by state, a rule of thumb is that applicants must have less than $2,523 / month in income and less than $2,000 in countable assets.

When moving to the nursing home, all their income except for a very small personal needs allowance must be turned over to the Medicaid program to pay the nursing home. It should be noted that there are many subtleties to these rules and this is a gross over-simplification. Eligibility details are available here.

While somewhat obvious, it is still worth noting that individuals must require a “nursing home level of care”. Applicants will be formally assessed to meet this requirement.

All nursing homes covered by Medicaid must be licensed and certified by the state in which they are located. All licensing and certifications must be according to federal standards. Every one of these institutions is subject to survey at regular intervals to maintain their certification and licensing.

 Home Ownership’s Impact on Eligibility – Homes are generally considered exempt from countable assets. However, this depends on the type of Medicaid, where the applicant lives and if married, where their spouse resides. More details.

 

Home and Community-Based Services (HCBS) Medicaid Waivers

Another type of Medicaid long term care program are Home and Community Based Services Waivers. HCBS Waivers offer Medicaid beneficiaries an alternative to living in a nursing home. Care services are provided to recipients in their homes or communities. “Communities” can include assisted living residences, memory care homes (for persons with Alzheimer’s or other dementias) and adult foster care homes. Medicaid will pay for all the beneficiary’s medical costs and much of their personal care, but Medicaid will not pay rent, mortgage, utilities or room and board fees in assisted living. Consequently, Medicaid waiver beneficiaries have higher expenses than Nursing Home Medicaid beneficiaries. It is for this reason that Waiver rules permit beneficiaries to retain much of their income, while nursing home beneficiaries must surrender their income.

For the most part, income and asset limits for Medicaid Waivers are equal to the limits for Nursing Home Medicaid. The same rule of thumb applies; less than $2,523 per month in income and less than $2,000 in countable assets for single applicants. The different being, Waiver beneficiaries are permitted to keep their income to pay their housing, food and utility costs.

The level of care requirement or “functional need” is the same for Waivers as it is for Nursing Home Medicaid. While beneficiaries will not reside in a nursing home, they still must require a “Nursing Facility Level of Care” to qualify.

 

Aged, Blind, and Disabled (ABD) Medicaid

The third type of Medicaid program is Aged, Blind, or Disabled Medicaid. Note this name may vary from state to state. It may be best thought of as regular Medicaid for aged, blind or disabled persons. Like Waivers, services provided through ABD Medicaid are provided to persons in their homes or communities. Communities can again include residential group living such as assisted living or memory care as well as daytime supervision in adult day care centers. Beneficiaries receive coverage for a broad range of health services and some non-medical, personal care but ABD is not nearly as comprehensive as Waivers or Nursing Home Medicaid.

ABD Medicaid has more restrictive financial eligibility criteria but less restrictive medical need requirements. Typically, states require income equal to or less than the federal poverty level which is approximately $841 / month, but some states may allow as much as 50% more or less than that figure. Asset limits are set at or close to $2,000 for single applicants and $3,000 for married couples. Again, some states allow more or less.

The big difference with ABD compared to Waivers and Nursing Home Medicaid is that there is no level of care / functional need requirement to be accepted into the program. Rather, healthy persons can enroll in ABD. Services are then approved on a specific need / case-by-case basis. As an example, one enrolls in the program, and 6 months later, if they require personal care, they are assessed and likely approved for the specific personal care benefit.