Washington, D.C. Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid’s rules, benefits and name can all vary by state, and in Washington, D.C. This article focuses on DC Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or ABD Medicaid. This is different than regular Medicaid, which is for financially limited people of all ages.

 

DC Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

DC Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited Washington, D.C. seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:

  • Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
  • Skilled nursing care
  • Physician’s visits
  • Prescription medication
  • Medication management
  • Mental health counseling
  • Social activities

Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.

DC Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $103.20/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.

DC Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.

  A Nursing Home Alternative – DC Nursing Home Medicaid beneficiaries who want to leave their nursing home and return to living “in the community” can receive financial and functional help with that transition through the Money Follows the Person program (MFP). This help can include paying for moving expenses, as well as long-term care services and supports in the new residence. MFP beneficiaries must be moving from a Medicaid-approved facility and into their own home, the home of a relative or a small group home with a maximum of four unrelated residents.

 

Home and Community Based Services (HCBS) Waivers

Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited District of Columbia seniors who require a Nursing Facility Level of Care remain living in the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for DC Medicaid recipients who live in their own home, the home of a loved one or an assisted living residence. While DC Medicaid HCBS Waivers may cover long-term care benefits in those settings, they will not pay for room and board costs.

The HCBS Waiver relevant to Washington, D.C. seniors is the Elderly and Persons with Disabilities Medicaid Waiver.

Elderly and Persons with Disabilities Medicaid Waiver
The Elderly and Persons with Disabilities (EPD) Medicaid Waiver provides long-term care benefits to District of Columbia seniors who require a Nursing Facility Level of Care but live in their own home, the home of a loved one or an assisted living residence. While the EPD Waiver will pay for long-term care services and supports in those settings, it will not cover room and board costs. An in-person screening using the interRAI Home Care Assessment System Tool will determine if EPD Waiver applicants meet the functional requirement of needing a Nursing Facility Level of Care.

EPD Waiver benefits include adult day care, home modifications, housekeeping services and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Benefits are made available depending on the needs and circumstances of each individual.

EPD Waiver benefits can be provided by licensed care workers, but EPD Waiver program participants also have the option of self-directing their care using the Services My Way Program. This allows the DC Medicaid beneficiary to hire caregivers of their choice. That includes some family members, although spouses and legal guardians are not allowed to be hired as EPD Waiver caregivers.

Unlike Nursing Home Medicaid, the EPD Waiver is not an entitlement. Instead, it has a limited number of enrollment spots (6,160 per year as of 2023). Once those spots are full, additional applicants are placed on a waitlist.

Aged, Blind, and Disabled Medicaid

Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited Washington, D.C. residents who are aged (65 and over), blind or disabled. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially limited people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.

DC Medicaid ABD beneficiaries who show a medical need for long-term care benefits can receive them through the Adult Day Health Program, Personal Care Aide Services or the Program of All-Inclusive Care for the Elderly (PACE).

1. Adult Day Health Program
The District of Columbia’s Adult Day Health Program (ADHP) provides adult day care for District of Columbia residents who are age 55+ and have chronic medical conditions. To determine if ADHP applicants meet this medical criteria, a functional assessment will be completed that takes into consideration their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognitive and behavioral issues. ADHP participants can live in their own home or the home of a loved one. They can not live in assisted living residences or adult foster homes.

ADHP participants can attend adult day health care centers up to eight hours per day and five days a week. ADHP centers provide supervision, meals, nursing consultation, medication assistance, social activities and exercise.

Like District of Columbia ABD Medicaid itself, the Adult Day Health Program is an entitlement. This means that all eligible applicants are guaranteed by law to receive benefits.

2. Personal Care Aide Services
The District of Columbia’s Personal Care Aide (PCA) Services program provides long-term care benefits to District of Columbia seniors who require help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). PCA Services program participants can live in their own home or the home of a loved one.

PCA Services include personal care assistance with the Activities of Daily Living, as well as assistance with grocery shopping, meal preparation, medication management, telephone use and vital sign monitoring (heart rate, temperature, respiration rate, etc.). These benefits will be made available depending on the needs and circumstances of each individual. The Department of Health Care Finance will assign a licensed care worker to provide PCA Services.

Like District of Columbia ABD Medicaid itself, the Personal Care Aide Services program is an entitlement. This means that all eligible applicants are guaranteed by law to receive benefits.

3. Program of All-Inclusive Care for the Elderly (PACE)
Washington, D.C. residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Washington, D.C.’s PACE program can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs, and regular health checkups and services to program participants. There is one PACE center in Washington, D.C. – Edenbridge PACE at Skyland. To learn more about PACE, click here.

 

Eligibility Criteria For DC Medicaid Long Term Care Programs

To be eligible for District of Columbia Medicaid, a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.

 Just For You: The easiest way to find the most current District of Columbia Medicaid eligibility criteria for your specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

District of Columbia Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Washington D.C. residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through DC Medicaid. For a single applicant in 2024, the asset limit is $4,000, which means they must have $4,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, DC Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $103.20/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.

For married applicants with both spouses applying, the 2024 asset limit for nursing home coverage through DC Medicaid is a combined $6,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $4,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

  Plan Ahead: There are alternative pathways to eligibility for DC Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Washington, D.C. has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for nursing home coverage through District of Columbia Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. The state will conduct a functional assessment of DC Medicaid applicants to determine if they need this level of care. The assessment will take into account the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognition and behavior.

District of Columbia Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
Washington, D.C. residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2024, the asset limit for HCBS Waivers in Washington, D.C. is $4,000, which means they must have $4,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Counts the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for HCBS Waivers in Washington, D.C. for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2024 asset limit for HCBS Waivers in Washington, D.C. is a combined $6,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $4,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

  Plan Ahead: There are alternative pathways to eligibility for DC Medicaid HCBS Waivers applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Washington, D.C. has a Look-Back Period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Services (HCBS) Waivers through DC Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is usually associated with a nursing home. An in-person screening using the interRAI Home Care Assessment System Tool will determine if DC Medicaid HCBS Waiver applicants meet the functional requirement of needing a Nursing Facility Level of Care. The screening will take into account the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognition and behavior.

 

District of Columbia Aged, Blind, and Disabled Medicaid Eligibility Criteria

Financial Requirements
Washington, D.C. residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid. For a single applicant in 2024, the asset limit is $4,000, which means they must have $4,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for a single applicant is $1,255/month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.

For married applicants, the 2024 asset limit for District of Columbia ABD Medicaid is a combined $6,000, and the income limit is a combined $1,703/month. This applies to married couples with both spouses applying or with just one spouse applying.

  Plan Ahead: There are alternative pathways to eligibility for District of Columbia ABD Medicaid applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While DC Medicaid has a Look-Back Period of five years for Nursing Home Medicaid and HCBS Waivers applicants to make sure they don’t give away their assets to get under the limit, the Look-Back Period does not apply to ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid or HCBS Waivers, and those programs will deny or penalize the applicant for giving away assets.

Functional Requirements
The only functional requirement for receiving basic healthcare coverage through ABD Medicaid in Washington, D.C. is being age 65 or over, blind or disabled. For ABD Medicaid beneficiaries who need long-term care services and supports, DC Medicaid will administer a functional assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to determine the kind of long-term care benefits the state will cover.

 

How DC Medicaid Treats the Home for Eligibility Purposes

One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:

  • If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage/debt) is less than $1,071,000 (as of 2024) then the home is exempt.
  • If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives.
  • If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $1,071,000.

These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.

DC Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States (and the District of Columbia) are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by location, but all states have a MERP. To learn more about the MERP in Washington, D.C. and how you can protect your home from it, click here.

 

Applying For DC Medicaid Long Term Care Programs

The first step in applying for District of Columbia Medicaid Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for DC Medicaid when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the District of Columbia Medicaid applicant. These documents will be needed for the official Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Washington, D.C. residents can apply for District of Columbia Medicaid online at District Direct. They can apply over the phone by calling the Department of Human Services Economic Security Administration at 202-727-5355. They can also download and complete a DHS Integrated Application and mail it to Department of Human Services, Economic Security Administration, Case Record Management Unit, P.O. Box 91560, Washington, DC 20090, or fax it to 202-671-4400.

For step-by-step guides to applying for each of the three types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.

  Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.

 

Choosing a DC Medicaid Nursing Home

After being approved for nursing home coverage through District of Columbia Medicaid, seniors have to choose which Medicaid-accepting nursing home best meets their needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes accept Medicaid, and those that do may not have available spaces.

Finding the right nursing home can be a challenge, especially if you’re looking in a specific location. There are only 12 nursing homes in the District that accept Medicaid.

Washington, D.C., residents regularly cross city and state lines for business and personal reasons, but Medicaid coverage does not cross state lines. So, someone with District of Columbia Medicaid would not be covered for nursing homes in Virginia or Maryland, even if facilities in those places are convenient or well-suited for D.C. resident.

 TOOLS: District of Columbia residents can find and compare nursing homes using Nursing Home Compare, which is a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information on more than 15,000 nursing homes across the country.

When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. The District of Columbia Department of Aging and Community You can also contact your local Area Agency on Aging and Community Living can also provide information about area nursing homes as well as other resources for seniors living in D.C.

After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.

CMS data reveals the District of Columbia nursing homes fared poorly when it comes to health standards. Nursing homes in D.C. averaged 50.2 health deficiencies per facility from 2019-2022, which was much higher than the national average of 25.7. On the other hand, D.C. nursing homes averaged 9.5 fire safety deficiencies during that same time period, which was better than the national average of 13.7.