Does Medicaid Pay for Assisted Living? Your Questions Answered

If you've started to explore the world of senior living, there's a good chance you've also started to think about how to finance the cost of assisted living or other senior housing. Indeed, finding financial solutions to cover the expenses of assisted living facilities is often the first step on the road to a smooth and stress-free transition into this new chapter of life.

Medicaid is a valuable tool in the financial strategy for senior living, but it can be complicated to understand what Medicaid will - and won't - pay for. Luckily, Seniorly has created your go-to guide for understanding Medicaid and how it can be used for assisted living.

Let's start with the basics. Medicaid is the nation’s public health insurance program for low-income adults. It is a joint federal and state plan program that covers Americans who have costly and complicated care needs. The majority of people who enroll in Medicaid are unable to afford other forms of health insurance.

Medicaid programs must follow federal guidelines. While the federal government pays a portion of the costs, Medicaid is operated individually by each state. Coverage and costs may be different depending on the state in which you live. Each state may also have a different name for their managed care programs, such as Medi-Cal in California or the Medical Assistance Program in Illinois. 

The short answer is yes, Medicaid can play a significant role in covering the costs of an assisted living facility for eligible seniors in most states. But there are a few caveats.

Medicaid offers varying levels of support for assisted living costs depending on the state's program and your personal eligibility. While Medicaid does not cover room and board or daily living costs directly, it can provide financial assistance for services such as personal care assistance, medication management, skilled nursing, and rehabilitative therapies.

However, Medicaid does pay 100% of nursing home (or skilled nursing facility) costs in most cases if you meet eligibility requirements. The Medicaid program will cover certain assisted living services for qualified seniors, such as:

• Nursing Care
• Case management
• Medication management
• Assessments

Medical examsStates often utilize Home and Community-Based Services (HCBS) waivers or other Medicaid programs to help cover the cost of these care services within assisted living communities. As eligibility criteria and program offerings may differ across states, it is will all come down to your state's specific Medicaid policies.

Dementia and Alzheimer’s patients that live in assisted living are referred to as living in “memory care.” Medicaid by law can not pay for room and board but will cover the cost of care for Medicaid recipients. In most memory care facilities, the Medicaid waiver can be used for the cost of room and board.How can I find assisted living community that accepts Medicaid?

If you plan on using Medicaid to cover the cost of assisted living, it can be difficult - but not impossible - to find out whether or not a community accepts Medicaid to defray the cost of an assisted living program. In general, there are a few ways to find out if a licensed senior living community accepts Medicaid.

The task of finding nursing facilities and assisted living programs that accept Medicaid is a lot harder than it should be. States do not keep usable databases that are open to the public, so your best source is going to be an online search. Make sure you have location services turned on in your PC and google “Medicaid nursing homes near me” and “Medicaid assisted living programs near me". From there, placing individual calls to each facility to inquire about their availability and Medicaid policies will be the best way to find a suitable option near you.

There is one well-organized resource. The American Council on Aging maintains a database at www.medicaidplanningassistance.org that is uniquely comprehensive and up to date. You can enter Medicare, Medicaid, or VA as the source of eligibility and search by zip code and distance. Give it a try - you'll be impressed!

A Federal website, www.medicaid.gov, can be used to contact your state Medicaid agency to seek their help in locating a facility. The level of assistance provided varies dramatically from state to state.

Finally, your local Area Agency on Aging (google “Area Agency on Aging Near Me”) may be able to provide assistance.

In all states, Medicaid covers some low-income individuals, low-income families, low-income children, low-income pregnant women, the elderly, and people with disabilities. Qualifications also depend on household size, family size and status, and other factors. Each state has a different set of requirements that must be met to qualify as Medicaid beneficiaries. 

While each state has different condition of eligibility requirements, generally each applicant must meet all of the state program requirements:

• Be a resident of the state you are applying to
• Your financial situation is considered low income
• Be a citizen of the United States

Additionally, federal law requires states to cover individual receiving Supplemental Security Income (SSI)

In some states, the Medicaid program has been expanded to cover all adults below certain income levels. Each state has the option to choose the income level a person must fall into in order to qualify. The expansion of the program allows individuals to qualify based on income alone without any other requirements. The current criteria in most states are based on your income level is 133% below the federal poverty level.

Each state has its own program, enrollment, and eligibility for Medicaid coverage. What is paid for by Medicaid depends on each individual state. Refer to medicaid.gov to check covered care in your state. The following are the basic benefits of Medicaid healthcare coverage for senior living that Medicaid must cover:

• The ability to pick your own Primary Care Provider (PCP)
• Preventative coverage is provided based on gender, age, and health
• Medication for little to no cost
• Extra care and services such as dental, eye, and immunizations
• Inpatient and outpatient hospital services are covered
• Physician services
• Laboratory and x-ray services
• Home care health services
• Nursing Facility services
• Transportation to medical care
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Mental Health personal care services such as addiction or recovery treatment services

Below are optional coverages that vary from state to state:

• Prescription Drugs
• Clinic services
• Physical therapy
• Occupational therapy
• Speech, hearing, and language disorder services
• Respiratory care long-term services
• Other diagnostic, screening, preventive, and rehabilitative services
• Podiatry services
• Optometry services
• Dental Plans
• Dentures
• Prosthetics
• Eyeglasses
• Chiropractic services
• Other practitioner services
• Private duty nursing services
• Personal Care
• Hospice
• Case management
• Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
• Services in an intermediate care facility for Individuals with Intellectual Disability
• TB Related Services
• Health Homes for Enrollees with Chronic Conditions – Section 1945

The Medicaid waiver program is a federal government plan that allows each state to waive rules that usually apply to Medicaid. These waivers allow individuals that would otherwise not be covered by Medicaid, such as the elderly or pregnant women, to receive care. The Medicaid waiver can also allow seniors to receive care at home instead of a long-term care facility.  

After you find out if you are eligible for coverage there are usually no monthly payments, co-pay, or deductibles. If there are charges, they are usually very small. 

The program pays almost the full amount for health and long-term services, provided the medical service supplier is Medicaid-certified.

States can charge premiums and impose cost sharing requirements for Medicaid enrollees. Out of pocket costs may include copayments, coinsurance or deductibles that are set by state law in accordance with certain guidelines; maximum out-of -pocket expenses vary based on the type coverage purchased (elders/disabled), income level etc., but states always exempt vulnerable groups like children & pregnant women from higher charges if they qualify under certain criteria such as low incomes.

Medicare is a federal program that is run by the federal government. It mainly focuses on and provides coverage to individuals who are 65+ or have a disability, no matter what their income. 

Medicaid is an assistance program run by both state and federal governments and provides health coverage if you have a very low income. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Eligibility is largely determined by income level. Medicaid programs offer a wider range of health care medical services compared to Medicare. 

You can qualify to have both Medicare and Medicaid at the same time. If you qualify for Medicare because you are 65 or older and you meet your state’s requirements for Medicaid you are considered “dual eligible.” You may be able to qualify for a dual eligibility plan if:

• You qualify for Medicaid in your state
• You qualify for Medicare Parts A and B (Original Medicare)
• You live in the dual-eligible plan’s coverage area

When you are qualified for both Medicare and Medicaid you are put into a dual health plan. This plan is a special type of Medicare Part C. Dual health plans combine medical, prescription, and hospital coverage while still keeping all of your Medicaid benefits. 

Dual health plans are offered by private insurance companies that allow you to pick the right coverage for you and your health care coverage needs. Medicaid may also pay some of the Medicare premiums, copayments, and deductibles for people who are enrolled in both programs.

Here are some important things to know about applying for Medicaid: 

• CHIP is Medicaid for children. The Children's Health Insurance Program (CHIP) is for children whose parents do not qualify for Medicaid. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
• You may qualify even if you did not before. Since needs and income can change you may qualify now for CHIP or Medicaid when you did not before. You can apply any time of year and if you qualify your coverage can start right away. 
• Fill out an electronic or paper application through the Health Insurance Marketplace. If anyone from your household is “eligible,” the Health Insurance Marketplace will send your personal information to your state agency. Your state agency will then contact you about enrollment. 
• Apply directly to your state Medicaid agency. Once you input your state on the site it will direct you to your Medicaid agency’s contact information.
• Contact the Centers for Medicare & Medicaid Services. The Centers for Medicare & Medicaid Services (CMS) is part of the Department of Health and Human Services (HHS). The organization is there to help people to apply for Medicare, Medicaid/CHIP or enter the Marketplace to build their health care plans around the Affordable Care Act (ACA). The ACA makes it possible for affordable health insurance to become available to more individuals.