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Medicare Medicaid Assisted Living Facilities

What Medicaid Covers In Assisted Living

Here’s how you can support Treasure Valley nursing home, assisted living facility residents for the

The exact services that Medicaid covers will vary by state and the specific program a senior applies for. All states offer some degree of personal care services , but the ways in which they are administered differ widely. For example, some state Medicaid programs provide eligible seniors with personal care assistance but not in an assisted living residence.

Generally, though, the fundamental services that most Medicaid programs will pay for in an assisted living facility include:

  • Personal care services
  • Personal emergency response systems

Skilled Nursing Facility Care

Part A of Medicare provides coverage for care received in a skilled nursing facility as long as:

  • You have Part A and days left for use in your benefit period
  • You have a qualifying hospital stay
  • The services are deemed necessary by your doctor
  • You receive these services in a Medicare-certified skilled nursing facility
  • Your medical condition is either a hospital-related condition treated during your qualifying 3-day inpatient hospital stay, or it is a condition that began while you were in receipt of care in the skilled nursing facility for a hospital-related condition.

The benefits for skilled nursing facility care can include :

  • Semi-private room
  • Ambulance transportation

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Assisted Living Costs Covered By Medicare

Medicare usually wont cover custodial care, but under certain conditions, it may cover skilled nursing care. This is care usually provided or supervised by a certified nursing professional or doctor. It includes services like physical therapy or changing sterile dressings. In assisted living environments, this care may be covered by Medicare Part A.4

However, you wont usually get skilled nursing care at an assisted living facility. Assisted living normally provides custodial care and supervision, but not the type of medical treatment typically found in a nursing home. But there are a few things in an assisted living facility that Medicare may help cover, such as transportation to doctors appointments or some preventive health services.5

In A Residential Facility

How To Pay For Assisted Living With Medicare

Sometimes its not possible to live by yourself or with your family. In those cases, assisted living or a nursing home might be right for you. These facilities are professionally staffed businesses that provide different levels of care, depending on what you need.

Assisted Living Facility

If you choose to live in assisted living facility, you will usually have your own room or apartment. You can bring your things with you to make it feel like home. You will usually eat with others. Services might include:

  • Help bathing or getting dressed.
  • Someone to make sure you get your medicine.
  • Employees checking on you to make sure you are doing OK.

Learn More

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Income Retained By A Nursing Home Resident

Once a long-term care facility resident qualifies for Medicaid and begins to receive benefits, that resident must contribute nearly all of their income to the facility. Medicaid will pay the balance of the bill for the costs of care. However, the resident can retain a small amount of income in the following forms:

  • a monthly personal needs allowance to spend on personal items such as books and magazines, clothing, vending machine snacks, and toiletriesusually ranging from $30 to $100 a month, though a few states allow more
  • out-of-pocket medical expenses not covered by Medicare or Medicaid, including income the resident spends directly on Medicare premiums, deductibles, and copayments,
  • a monthly home maintenance allowance during short-term stays in a facility , in which a resident can keep a certain amount each month for home maintenance expensessuch as repairs, mortgage payments, and property tax payments on the resident’s private homefor up to six months this allowance requires a doctor to determine that the resident will likely be able to return home within six months after entering the facility, and
  • a spousal allowance, if you’re married and your spouse would otherwise become impoverished .

How Much Income And Assets A Spouse Can Keep

If you have a spouse who is going to continue to live independently, then Michigan will allow you to keep more income and assets to support that spouse. This is called spousal maintenance.

Your spouse will be allowed to keep some income each month. The amount will depend on how many dependents and expenses he or she has. In 2019, the minimum amount your spouse can keep is $2,057.50, and the maximum is $3,090. If your spouse needs more than the Department of Health & Human Services decides to allow, then you can go to court and ask a judge to order more.

You will also be allowed to keep more than $2,000 in resources if you have a spouse who will remain in the community. The Department of Human Services does a complicated calculation to determine how many assets your spouse can keep.

When you are admitted to a nursing home, you will complete a form called an âAssets Declaration,â and the staff will do ask you about all of your assets in an âInitial Asset Assessmentâ . Michigan assumes that half of your IAA should belong to your spouse, subject to a limit that changes annually. In 2019, the minimum âProtected Spouse Amountâ is $25,284, and the maximum is $126,420. When you apply for Medicaid, your PSA is subtracted from your countable assets at the time of your application.


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Think About Healthcare Needs

Even though Medicare doesntcover assisted living itself, youll still need medical care and services. Besure to reviewyour plan options under Medicare before selectinga plan.

Remember that Part C plans may offer additional coverage, such as vision, dental, and hearing. They can also include further benefits, like gym memberships and transport to doctors appointments.

If you know that youll need prescription drug coverage, choose a Part D plan. In many cases, Part D is included with Part C plans.

Since the specific costs and coverage in parts C and D can be different from plan to plan, its important to compare multiple plans before selecting one. This can be done on Medicares site.

Determine how to pay for assisted living

Medicare doesnt cover assisted living, so youll need to determine how youll pay for it. There are several possible options:

  • Out of pocket. When you choose to pay out of pocket, youll pay the entire cost of assisted living care yourself.
  • Medicaid. This is a joint federal and state program that provides free or low cost healthcare to eligible individuals. Programs and eligibility requirements can differ by state. Learn more by visiting the Medicaid website.
  • Long-term care insurance. This is a type of insurance policy that specifically covers long-term care, including custodial care.

Comprehensive Personal Care Home

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A Comprehensive Personal Care Home is a facility thats approved by the Department of Health to provide:

  • Assisted Living Services
  • Arrange for resident transportation to and from health care services

In a CPCH:

  • The stove in the kitchen can be removed if it is a safety hazard
  • There is a front door that can be locked from inside
  • You can get to your own apartment kitchen at any time to get food and drinks
  • You may share a unit with another person

You cannot receive this service at the same time as:

  • Adult Day Health services

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  • Respite care and other in-home long term care
  • Personal care services

Medicaid also may help cover costs if you cant pay the Medicare co-pay for days 21-100 during a hospitalization, or if you cant pay for long-term care in the skilled nursing facility after rehabilitation is complete.

Assisted Living Admissions & Ssi

Assisted living communities will accept seniors who utilize SSI, SSD, & OSS. However, the rate of acceptance is lower than those who use private insurance and self-payment options. There is no law that requires RCFEs to accept admissions from seniors who are on SSI, but usually, seniors with lower care requirements will be readily admitted.

The disparity in acceptance of seniors on SSI, SSD, & OSS is mainly caused by the lower payment amounts as opposed to their care needs. Most assisted living facilities are for-profit, so it makes sense for them to admit residents who offer them a higher profit margin. While this may seem unfair, there are many assisted living homes that will accept residents who will use SSI payments to cover costs of care.

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How To Know If Youre Eligible For Medicaid In Connecticut

To qualify for HUSKY C, seniors must meet financial eligibility criteria. Income limits differ by geographic area. In Region A, which encompasses towns in Southwestern Connecticut, single applicants can have up to $643 in countable income and married applicants can have up to $817. In Regions B and C, which includes Northern, Eastern and Western Connecticut, single applicants can have a net income of up to $532, and married applicants can make up to $708.

These income limits dont include unearned income, such as Social Security benefits, pensions and interest from investments. In addition to these income limits, single applicants may have up to $409 in unearned income and married applicants may have up to $818. Seniors must also meet asset limits to qualify for Medicaid. Single applicants may have up to $1,600 in countable assets, and married couples may have up to $2,400.

2022 Medicaid Income Limits for Seniors in Connecticut


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Alternative State Payments For Assisted Living Expenses

Does Medicare Cover Assisted Living Costs?

States offer a broad range of alternative coverage for seniors that are not part of the typical Medicaid program. These payments are provided through alternative programs that allow for the waiver of some federal rules such as income eligibility. Most seniors who apply for these waivers must exhibit care needs equivalent to a senior who lives in a nursing home in order to qualify.

Alternative payment programs also have a limited number of spots available, often significantly fewer than Medicaid. Because the waiting list is quite common and lengthy, many seniors will apply well in advance of their actual needs. Support programs differ from region to region and not all programs may be available to seniors statewide. Make sure to ask your enrollment officer about alternative programs available for their location when researching assisted living communities to join.

There are also other non-traditional assistance programs that are available for specific groups of seniors. For example, veterans or the surviving spouse of a veteran have special programs available to help defray the cost of assisted living. Many religious groups and organizations also offer funding for long-term care or have assisted living facilities for seniors that operate on a not for profit model.

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When A Nursing Home Is Medically Necessary

Medicaid will pay for a nursing home only when it is medically necessary. You must show that you require a ânursing home level of care,â meaning that you have a physical or mental condition that requires nursing supervision and assistance with activities of daily living .

Within the first two weeks after you are admitted to a nursing facility, Medicaid requires that you have a âLevel of Careâ determination. In Michigan, nursing facility staff do the LOC determination using an online state system.

To determine the level of care you need, nursing facility staff will ask you questions to determine how much assistance you need with your ADLs. The ADLs that Michigan uses to determine whether you meet the nursing home level of care are: bed mobility, transfers, eating, toileting, short-term memory, cognitive skills for decision-making, and making yourself understood. For each, the assessor will decide how much assistance you need and assign you a functional level. The levels are: Independent, Supervision, Limited Assistance, Extensive Assistance, Total Dependence or Activity Did Not Occur. For example, if you usually cannot get up from a chair without someone helping you, then the assessor may say that you need limited assistance with transfers.

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How Can I Pay For Nursing Home Care

Medicare generally doesn’t cover

stays in a nursing home. Even if Medicare doesnt cover your nursing home care, youll still need Medicare for hospital care, doctor services, and medical supplies while youre in the nursing home. Find out what nursing home care Medicare does cover, and how Medicare prescription drug coverage works if you live in a nursing home or other institution.

Most people who enter nursing homes start by paying for their care out-of-pocket.

There are several other ways you can pay for nursing home care:

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Can I Get Financial Assistance For Assisted Living Facilities

You may qualify for help from your state if you need long-term assisted living assistance contact your states Medicaid office or State Health Insurance Assistance Program for information.

If you purchased a long-term care insurance policy, you may also qualify for benefits to cover assisted living facilities check your policy documents for more information.

How Do You Qualify For Medicaid To Pay For Assisted Living

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Medicaid eligibility varies depending on the state, but federal law requires each state to cover certain populations. For instance, while the eligibility process differs, people with disabilities and low-income families are mandated to be eligible for Medicaid in each state.

To qualify for Medicaid to pay for assisted living, you must meet the following requirements:

  • You must either have U.S. citizenship or be a permanent resident of the United States
  • You must be a resident of the state where you wish to receive benefits
  • Your income must fall below your states Medicaid income and countable assets limit

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Qualifying For Medicaid To Pay For Assisted Living

Long-term care Medicaid is a joint federal and state program that helps seniors with low income and limited assets get the care they need. Specific income and asset limits vary depending on factors like the kind of care required, a seniors medical diagnosis, where they live and their marital status. A doctor must also certify that a seniors need for care in an assisted living facility is medically necessary.

If a senior meets all financial and functional eligibility requirements, they must then find an assisted living facility that accepts Medicaid as payment. This final step can be difficult since there are typically few Medicaid-certified assisted living facilities due to low reimbursement rates. If a facility does accept this form of payment, they may only have a limited number of beds available for Medicaid patients. The best way to find a Medicaid facility is to contact the nearest Area Agency on Aging .

Keep in mind that assisted living can be referred to by many different names, including adult foster care, board and care homes, residential care, group homes, personal care homes and memory care facilities. Understanding how your state refers to this type of care will make it much easier to navigate eligibility requirements, file an application and find a care facility.

Does Medicare Pay For Assisted Living Costs

Medicare Part A, Part B, and Part C do not provide any cover for assisted living or retirement home costs. Instead, they only pay for the expenses associated with medical care for seniors, which may include a short-term stay in a skilled nursing home or a rehabilitation facility. Medicare can also be used to cover the costs of in-home care if the senior is recovering from an illness or injury and needs specialized healthcare supervision from a home health nurse or therapist. However, Medicare does not pay for any kind of long-term care, be it in an assisted living community or a nursing care center.

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What We Like About Long

  • Helps lower your out-of-pocket cost for care
  • More choices for care
  • Premiums often increase over time
  • Harder to qualify for a policy as you get older
  • Some plans won’t kick in until you pay out-of-pocket for a set amount of time

Before deciding to purchase a LTC insurance policy, do your research. Check what services are covered. For example, many policies only cover assisted living care if you live in a facility they don’t cover in-home assisted living services. If navigating insurance isn’t your thing, ask your trusted loved ones for help.

When The Elder Runs Out Of Money In Assisted Living What Happens

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We often see that when families are shopping for assisted living facilities, the family will ask the assisted living facility representative “what happens if mom run out of money? Will we have to move him/her?” Here, the assisted living facility representative may tell them that mom/dad can stay in the facility on Medicaid. But we know this advice is not quite right because:

  • Even if mom/dad spend all of their money on assisted living care, this does not mean that Medicaid will be there due to the wait list that makes no guarantees on when the elder’s name comes to the top and
  • Medicaid generally provides only the $1,200-$1,500/month subsidy, so an expensive ALF may require more money than mom/dad’s income.

Trying to pay for an elder’s assisted living facility is even more difficult than trying to get care in a nursing home. Why is that? The long wait list for ALF Medicaid that will likely not correspond when/if the elder runs out of money. Here is an example, however, of what to do when the elder is in assisted living and is about to run out of money:

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