A Beginner’s Guide to Medicaid
Reviewed by: Dr. Brindusa Vanta, MD
Medicaid is a federally controlled, state-administered health insurance program that covers vulnerable Americans at all stages of life. As of November 2020, it insures more than 72 million Americans from birth through age 65 and beyond. Given the scope of its coverage base, it’s not surprising that the system is incredibly complex, and the rules may seem even more confusing if you’re thinking about nursing home placement and trying to navigate important long-term care decisions at the same time.
Although Medicaid has been insuring low-income families since 1965, the program is more important than ever due to the high cost of care. The continual increase in cost of medical care services takes the biggest toll on people who often need it the most like children, pregnant mothers, disabled adults, and seniors. These communities depend on programs such as Medicaid to be able to afford the services and support that they need to thrive.
Medicaid is an excellent resource for seniors as it provides comprehensive coverage and works hand-in-hand with Medicare. But, it can be a challenge to understand how the program works, what it covers and who qualifies, especially since requirements vary by state and differ based on an applicant’s medical needs and financial situation.
In this guide, we’ll explain Medicaid in basic terms to help you understand the program, learn about eligibility requirements and see what’s covered. We’ll talk about specific Medicaid benefits for senior care that’s provided at home, in assisted living communities and in skilled nursing facilities. Our goal is to leave you with a solid understanding of what Medicaid is and how it can help you or a loved one.
What Is Medicaid?
Medicaid is a federal health insurance program available to low-income families and other mandatory coverage groups. In 2013, the Affordable Care Act expanded Medicaid eligibility to adults earning up to 138% of the Federal Poverty Level (FPL). This is true in many states, although income limits can vary. States with the highest Medicaid enrollment include:
- California (10,860,126)
- New York (5,863,440)
- Texas (4,034,937)
- Georgia (3,805,520)
- Pennsylvania (2,980,867)
States with the highest number of enrollees as a percentage of the population include:
- New Mexico (34%)
- Louisiana (28%)
- Vermont (28%)
- Washington, D.C. (28%)
- West Virginia (28%)
One of the most confusing things about this system is that there isn’t just one type of Medicaid. Most states have several Medicaid programs that target specific populations. In addition to regular Medicaid, which serves low-income adults, there’s a poverty-level program for the Aged, Blind or Disabled. Institutional Medicaid is one of the more relevant programs for older adults, and it’s what we’ll focus on in this guide.
Institutional Medicaid is an important source of long-term care funding. This program covers more than 60% of the nation’s nursing home residents. Additionally, Medicaid pays for more than 50% of long-term care claims nationally, which makes this program an important part of the federal budget, as well as the health care industry and the nation’s economy.
Medicaid pays for care provided in nursing homes, which is important because Medicare only pays for 100 days of skilled nursing per coverage period. It also covers in-home care and personal assistance through Home- and Community-Based Services waivers. These add-ons allow states to offer additional benefits, as long as they’re consistent with federal guidelines.
How Does Medicaid Work?
If you want to access Medicaid benefits, including long-term care waivers, the first step is to apply for coverage. You can complete this process through the Healthcare Marketplace or your state’s Medicaid agency. Applications are typically processed by the Department of Human Services or a similar division.
To qualify for Medicaid, you must meet certain financial and medical eligibility requirements. There are income and asset limits, and for some benefits, applicants must require a nursing facility level of care (NFLOC), as determined by a functional needs assessment that rates your health and ability to perform everyday tasks.
Since Medicaid is for individuals who have limited resources and/or extensive medical needs, there are no premiums or deductibles in most cases. However, some states have share-of-cost requirements that are typically based on your income. Once your coverage is in place, you’ll have access to primary and emergency medical care, as well as long-term services and supports. In some states, Medicaid is administered by the government, and other states have managed care organizations that are operated by private insurers. This type of coverage gives you access to Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) networks that will be familiar if you’ve had other types of insurance.
One of the nice things about Medicaid is that if you’re a dual enrollee, it can take care of your Medicare copays or coinsurance, and it will handle any charges that aren’t picked up by your primary insurance. Medicaid may also pay for prescription medications that aren’t covered by your Part D prescription drug coverage or Advantage Plan. According to federal Medicaid regulations, this type of coverage is optional, but all states choose to offer it, and it covers nearly all FDA-approved medications, which the program purchases at cost, thanks to rebates and special agreements with pharmacies.
What Does Medicaid Cover?
Although Medicaid coverage will vary depending on the state, there are certain mandatory medical services that must be covered, similar to those offered by Original Medicare Parts A and B. Medicaid agencies are required by law to provide these mandatory benefits, but there are also optional services states can choose to provide. There are coverage exclusions as well for services and situations that Medicaid will not cover. The table below gives examples of services that are mandatory, optional, or excluded.
Medicaid Always Covers
Medicaid Sometimes Covers
Medicaid Does Not Cover
Unreasonable or medically unnecessary services
Services billed through another allowance
Providers reimbursed through another program
Services and tests that are not covered under the plan
Medical care received outside of the United States unless exception is made
Prescription drug coverage
Durable medical equipment replaced through warranty
Physical and occupational therapy
Health care services provided by another government agency
Free health screenings or devices that are given away
Personal comfort items, such as TVs or beautician services
What Medicaid Does Not Cover
Although Medicaid will pay for some services that aren’t covered by Medicare, the program does have some coverage exclusions. Most items that aren’t covered fall into one of four categories:
- The services are unreasonable or medically unnecessary
- Charges were improperly bundled or billed through another allowance
- Providers were reimbursed through another program
- The particular service or test isn’t covered
Medicaid won’t pay for medical care provided outside of the United States, except in certain travel-related situations or when a foreign hospital is closer than domestic alternatives. Additionally, Medicaid will not pay for:
- Durable medical equipment replaced through a warranty
- Health care services provided by another government agency
- Free health screenings or devices that are given away
- Cosmetic surgery and any resulting complications
- Personal comfort items, such as TVs and beautician services
Who Qualifies for Medicaid?
Medicaid is a federal entitlement program that offers guaranteed coverage to all qualifying residents. Certain individuals, including low-income families, pregnant women and adults who are blind or disabled, are included in mandatory eligibility groups. States may also offer optional coverage to individuals who are categorically needy. This includes seniors who receive home- and community-based services, are on hospice, live in a nursing home or are in poor health. Because each state operates its own Medicaid program within the federal framework, income limits and medical eligibility requirements vary by state.
Financial Eligibility for Medicaid
At least 42 states have adopted the optional Special Income Level standard for Institutional Medicaid. Under the special income rule, individuals who are expected to need nursing home care for at least 30 days can earn up to 300% of the Supplemental Security Income Federal Benefit Rate. For 2021, the limit is $2,382 per month, and it typically doubles for couples applying jointly.
A handful of states, including Tennessee, Washington and Wyoming, set the income limit as low as $794, which is 100% of the FBR. Other states, such as California, Hawaii and Kansas, require seniors to use all or nearly all of their income for institutional long-term care before Medicaid kicks in. Fortunately, there are other ways for individuals who have substantial medical needs to qualify for Medicaid.
Asset Limits and Exemptions
Medicaid has strict asset limits of $2,000 per applicant and $4,000 for couples, although this may vary by state. Since Medicaid is never simple, there are also a number of exemptions. For example, if your spouse needs nursing home care but you plan on staying at home, you may be entitled to keep a significant amount of assets, typically upwards of $100,000 in most states. You may also be entitled to collect at least $2,155 or up to $3,259 of your spouse’s income as a minimum monthly maintenance needs allowance to help you pay your bills and everyday expenses.
The following items are considered countable assets:
- Cash and bank accounts
- Secondary homes or vehicles
- Life insurance policies with a cash value
- Revocable trusts
- Certain annuities
Exempt assets include:
- Retirement accounts
- A primary vehicle
- A primary home up to a fixed value
- Personal property
- Household items
The American Council on Aging provides a state-by-state eligibility guide. You can visit MedicaidPlanningAssistance.org to find the income limit for your state.
Institutional Medicaid only pays for skilled nursing if individuals need this level of care. Most states require seniors to complete a functional needs assessment as part of the application process. This assessment typically takes 45 minutes to an hour to complete. An assessor asks a series of state-approved questions to gauge the applicant’s functional needs, mobility, overall health and need for assistance with activities of daily living. These answers are then scored and used to determine an overall rating.
To qualify for Institutional Medicaid or Long-Term Services and Supports that are covered by Medicaid waivers, applicants typically must require assistance with at least two activities of daily living. States may also consider the applicant’s medical history since some conditions, such as Alzheimer’s disease and Parkinson’s disease, may necessitate the need for institutional long-term care.
If you think you may qualify for Medicaid, you must apply for coverage in your primary state of residence. Benefits are available to U.S. citizens and legal residents. Out-of-state coverage is limited unless you experience a life-threatening emergency or are unable to access necessary services in your home state.
How to Know If You Qualify for Medicaid
The only way to see if you qualify for Medicaid is by completing an application. However, before you do, consider working with a Certified Medicaid Planner (CMP) to ensure the best chances for success. Medicaid is one of the government’s most complex bureaucratic systems so it’s worth hiring a professional, just as you would hire an accountant to file your taxes or consult a lawyer for help with legal questions.
CMPs are certified by the CMP Governing Board. They must meet strict standards for education and work experience before they can sit for this exam. Most certified planners have at least a bachelor’s degree or an associate’s degree, along with two years of full-time work experience in law, financial planning, social work or long-term care within the past six years. CMPs include attorneys, accountants, social workers, financial advisors and geriatric care managers.
Some CMPs charge for their services, while other organizations offer free assistance, thanks to private donations and community block grants. If you have assets that you would like to protect or a spouse and family that you’d like to provide for even if you require long-term care, consulting a professional is the best option for addressing your current and future needs, especially since asset spend-downs and real estate transfers are subject to a five-year look-back period.
You can find a professional in your community by calling 211 or contacting your local senior center, legal aid society or Area Agency on Aging. The American Council on Aging also offers a free service that can check your eligibility and match you with a qualified advisor before you need long-term care.
Medicaid Coverage of Residential Senior Care
Due to the high cost of skilled nursing, which averages around $7,756 per month, Medicaid is an important source of funding for almost two-thirds of the nation’s nursing home residents. Medicaid picks up the slack once Medicare beneficiaries have exhausted their 100 days of skilled nursing facility (SNF) coverage, and it covers individuals who need skilled nursing but don’t qualify for Medicare.
Today, 43% of Medicaid long-term care spending goes toward care provided in skilled nursing and intermediate care facilities. The remaining 57% of funding goes toward waiver programs that allow members to receive long-term services and supports in assisted living facilities, senior living communities or their own homes. There are a few ways that Medicaid can help with the cost of long-term care:
- Nursing Homes: In addition to providing regular medical care, Institutional Medicaid pays for skilled nursing, personal care, room and board and specialized rehabilitative services provided in nursing homes.
- Assisted Living: Since assisted living facilities are less costly and less restrictive, many states will pay for these services through waiver programs. However, residents are still responsible for room and board.
- Community Housing: Nearly all Medicaid waivers will pay for the cost of personal care, home modifications and supportive services provided at home or in a residential setting, such as subsidized senior apartments.
To receive long-term care benefits, you must require a nursing home level of care as determined by a functional needs assessment that gauges your ability to perform activities of daily living, such as cooking, bathing, dressing and toileting. You must also meet your state’s income and asset limits.
Fortunately, many states offer spend-down programs that allow medically needy adults to qualify for Medicaid if they use excess income to pay for qualifying medical bills. States that offer a medically needy qualification pathway must also permit residents to establish a Qualified Income Trust, also called a Miller Trust. With this option, excess money is diverted into an irrevocable trust to help you meet the state’s income threshold. Approximately 36 states provide this qualification option to help residents who need long-term care.
Home- and Community-Based Services (HCBS) waivers are a great resource for seniors. Waivers were first introduced in 1983 through section 1915(c) of the Social Security Act, and many programs still bear this title. Today, there are more than 300 waiver programs available in 47 states. Collectively, they cover more than 1.4 million seniors and disabled adults while giving them the freedom to age in place and avoid institutional care.
Waivers are important because, normally, Medicaid only covers long-term services and supports that are provided in licensed health care institutions, such as nursing homes. Waivers let beneficiaries receive these services at home or in another community-based setting, such as an assisted living facility.
The government’s goal was to reduce long-term care spending by allowing members to receive covered services in the least restrictive and costly setting. However, these programs also benefit seniors who want to age in place and remain in comfortable surroundings, which creates a win-win for the government and the public. There are several types of HCBS waivers:
Traditional HCBS waivers cover medical and nonmedical services, such as respite care and adult day health care, that are designed to prevent or delay the need for institutional services.
Available to targeted groups, State Plan Home- and Community-Based Services cover acute care, as well as long-term supports, such as home modifications and case management.
Some states opt to provide Self-Directed Personal Assistance Services. Participants receive funding to hire, train and pay qualified caregivers, including relatives.
Introduced in 2011, Community First Choice waivers allow states to cover home- and community-based attendant services.
Demonstration waivers are available in nearly 25% of states. These pilot programs give states greater flexibility as long as they can show that government spending won't increase.
How to Use Medicaid to Pay for Assisted Living in Every State
Individuals who need help with assisted living costs are able to use Medicaid waivers if they meet eligibility requirements. Although most states don’t cover the cost of housing for assisted living, some run their own licensed assisted living facilities which are paid for in full or part by Medicaid. There are waivers like the ones mentioned above that provide care services within an individual’s home or in a community residence, like assisted living environments. States are responsible for choosing which waivers they will provide to their Medicaid members, therefore coverage and assistance will vary from state to state:
Alabama does not offer programs that pay for the cost of room and board in an assisted living residence, but they do provide care services in those environments through Medicaid waivers. The Medicaid Waiver for the Elderly and Disabled (E&D) provides a selection of services to eligible Medicaid members over 65 and disabled individuals. These services can be received in the participant’s home or community residence. The Alabama Community Transition (ACT) waiver helps individuals transition out of institutions and into a home or community residence. The Personal Choices Program is similar to the E&D waiver with a focus on self-directed care.
Eligible Alaskan Medicaid members looking for support with assisted living have two waiver options. The state provides assistance with “residential living” through the Alaskans Living Independently (ALI) waiver and the Alaska Adults with Physical and Developmental Disabilities (APDD) waiver.
The Arizona Long Term Care System (ALTCS) is a program offered to eligible Medicaid members through a program contractor who works with a number of providers, including assisted living facilities. The state also allows qualifying members to choose their care providers through the Self Directed Attendant Care (SDAC) option.
The Living Choices assisted living program allows eligible Arkansans to receive 24-hour care services while living in an assisted living facility independently, though room and board is not covered. The state also provides the Choices in Homecare waiver, providing eligible seniors with assistance in their daily life in the environment of their choice.
California’s Assisted Living Waiver (ALW) program pays for care coordination, care development, residential habilitation, and transition care for adults over 65 who live in or are willing to live in an assisted living facility within the 15 approved counties. There is also the Multipurpose Senior Services Program for qualifying seniors to receive services in their home or community residence.
The Elderly, Blind and Disabled (EBD) waiver offered to eligible Colorado Medicaid members provides a wide range of care services including the ability to stay in an “alternative care facility” which is a form of assisted living, but the individual must pay for the cost of room and board and some services. The Consumer Directed Attendant Support Services (CDASS) option under the EBD waiver allows members to select and hire their own attendants.
The Connecticut Home Care Program for Elders (CHCPE) offers an Assisted Living Services option for qualifying individuals living in one of the state’s participating assisted living facilities. While this program pays for care received within a facility, it does not pay for room and board.
Delaware Medicaid members who are covered under the Diamond State Health Plan - Plus (DSHP-Plus) initiative are able to receive assistance with long-term care services within the community, including individuals residing within an assisted living facility.
Florida offers coverage for assisted living services through their Statewide Managed Medicaid Care - Long-Term Care plan. The state no longer offers HCBS waivers but provides assistance under this long-term care plan, including a long list of additional benefits.
The HCBS Community Care Services Program (CCSP) is offered to eligible Medicaid members, providing a variety of services including “alternative living services” which are state-licensed assisted living facilities. The Service Options Using Resources in a Community Environment (SOURCE) waiver program provides care to elderly which include assisted living services.
Hawaii’s QUEST Integration Program serves their aging Medicaid members through Long-Term Services and Supports. This plan includes coverage for assisted living services, allowing eligible individuals who are not institutionalized the ability to receive the same level of care.
The Idaho HCBS Aged and Disabled Waiver allows eligible Medicaid members to receive services based on their individual needs, including care within their assisted living residence. The Idaho Home Choice program aims to help people transition from an institution into a residence like an assisted living facility. These programs do not pay for the cost to reside in an assisted living facility.
Illinois provides their eligible Medicaid members with an HCBS Waiver for Persons Who are Elderly, offering services to individuals in assisted living facilities and homes. The Illinois Support Living Program covers the cost of care for residents of assisted living facilities, but not the cost of room and board.
The Aged and Disabled waiver is an HCBS program for eligible Medicaid members who would otherwise need to be institutionalized. This waiver allows individuals to receive care in their own homes or state-certified assisted living facilities, but does not pay for the cost of room and board.
Iowa offers two waiver programs for aging and disabled adults wanting to remain in their own homes or communities, including assisted living facilities. The first is the HCBS Elderly Waiver designed to prevent institutionalization for adults over 65 years old. The second program is the HCBS Health and Disability waiver for adults under 65 years old. These waivers pay for care received in these environments but do not cover room and board.
Kansas provides an HCBS waiver for their eligible Medicaid members. The Frail and Elderly program was designed for individuals over 65 who would otherwise need to be medically institutionalized but wish to receive care in an environment other than a nursing home. The waiver does not pay for the cost to reside in an assisted living facility.
Eligible Medicaid members over 65 years old are able to use the Kentucky Home and Community Based Waiver to receive coverage for a variety of services in their residence of choice, including assisted living facilities. The program does not pay for room and board.
Louisiana doesn’t offer waivers that pay for the room and board of individuals residing in assisted living facilities, but there is a Community Choices Waiver that provides services for eligible Medicaid members in their home and community, which can include an assisted living facility.
Maine provides the Eldelry and Adults with Disabilities Waiver and the HCBS for Adults with Other Related Conditions option for adults over 65 years old. These state-approved services are available for eligible Medicaid members to receive in the residence of their choice.
Maryland Medicaid covers the cost of assisted living through their HCBS Options waiver program for eligible Medicaid members. The Increased Community Services program also covers the cost of assisted living for eligible members. The Community First Choice option and Community Personal Assistance Services program cover approved services received within the eligible individual’s residence of choice.
Through the Massachusetts MassHealth Medicaid program there are two waivers available. The Frail Elder Waiver (FEW) program provides health care services to seniors in their homes or community residences who would otherwise need to be institutionalized. The state also offers a Personal Care Attendant (PCA) program that provides funding for seniors to hire an attendant to help them with their daily activities in their homes or community residences. These waivers do not cover the cost of room and board. MassHealth may provide subsidies to go toward assisted living expenses, but individuals must apply and qualify for these supplements.
The Michigan Medicaid Choice Waiver and the Health Link HCBS option both provide adults over 65 years of age and adults with disabilities the option to receive nursing home level care services within their homes or community residences. The state does not have programs that pay for room and board costs.
Minnesota’s Elderly Waiver is provided to eligible Medicaid members who need a nursing home level of care but wish to remain in their home or community residence. While this waiver does not cover the cost of room and board, through the Housing Supports program individuals may qualify for housing cost support.
The Mississippi Division of Medicaid does offer the Assisted Living Waiver to eligible members. The waiver does not pay for room and board but does pay state-approved facilities for services Medicaid members receive during residency. Mississippi also provides the Elderly and Disabled Waiver for qualifying individuals to receive care services in their own homes or community residences.
The Missouri Aged and Disabled waiver provides a small list of care services eligible Medicaid members can receive within their homes or community residences. This waiver does not cover housing costs. The MO HealthNet Nursing Home Coverage program offers eligible adults over 65 a monthly cash payment to go toward the cost of living in a nursing home or assisted living facility. The Missouri Care Options program offers assistance to adults in need of long-term care services within the home or community residence of choice.
The Montana Big Sky Waiver offers a long list of services to adults over 65 and adults with disabilities. These services are provided to eligible Medicaid members who would otherwise need to be placed in a medical institution to receive care, allowing them to instead be cared for in their own home or community residence. Adult residential living may be paid for in part or whole, depending on the individual and state approval. The state also provides a Community First Choice/Personal Assistance Program allowing for self-directed care within a qualifying individual’s home or community residence, not to include room and board.
Nebraska’s HCBS Waiver for Aged and Adults and Children with Disabilities waiver provides a variety of services to eligible Medicaid members to be received in their own home or community residence. The list of services includes assisted living service which does not include payment for room and board.
The HCBS Waiver for Persons with Physical Disability is available for eligible aged individuals over 65 and individuals with disabilities, providing care services in the environment of their choice. The state of Nevada also offers a Waiver for the Frail Elderly, which is a similar option for individuals over 65 who need care in their own home or community residence.
New Hampshire’s Choice for Independence Waiver provides care services for aged individuals over 65 and adults with disabilities with the option of receiving care in their own home or community residence. The list of services includes “adult family care” which is similar to assisted living but on a smaller scale.
New Mexico provides assisted living service coverage under their new managed care plan called Centennial Care, though room and board costs are not covered. The state also offers a Medically Fragile Waiver for individuals who qualify as medically frail, enabling members to receive services in their homes and community residences.
Although New Jersey doesn't offer any individual HCBS waivers, the Managed Long Term Services and Supports acts as a home and community-based program. Services are available for eligible members to receive in the residence of their choice. Depending on availability and income caps, the state may cover some or all assisted living room and board costs.
New York provides eligible Medicaid members with the Long Term Home Health Care Program and the Nursing Home Transition Diversion Medicaid Waiver. This waiver allows for care to be received in a community-based setting. The state may allow for subsidies to help pay for room and board, though this is not part of the waiver service. The Assisted Living Program (ALP) will pay for the cost of room, board, and a variety of assisted living services for eligible members.
The CAP/DA Waiver offered by the North Carolina Medicaid agency allows for a long list of care services available to aged individuals over 65 and adults with disabilities who wish to stay in their own home or community residence. The Personal Care Services program provides personal care services to eligible members living in a private home, a state-licensed residential facility, a combination home, or a group home.These options do not pay for room and board.
North Dakota provides a Medicaid Waiver for Home and Community Based Services including homemaker services, adult residential care, adult day care, and more. These services are available to be received within an eligible Medicaid member’s home or community residence. The state also offers a Personal Care Services plan, providing services within the member’s residence of choice.
The Assisted Living waiver provided by the state of Ohio covers the cost of care received in an assisted living residence. The eligible individual is still responsible for paying room and board. The state also offers a few HCBS waivers to provide assistance to eligible individuals wanting to receive care in their own home or community residence. Those waivers include: OH Choices (physically disabled adults 60 and older, OH Integrated Care Delivery System Waiver (to include assisted living services), OH PASSPORT (aged 65 and older and disabled adults), OH Transitions II Aging Carve Out (aged 65 and older and disabled adults).
The OK Advantage Waiver provides care services including assisted living services to eligible individuals over 65 who are living in their own homes or community residences. The OK Sooner Services program provides a variety of personal care services and therapies for adults age 65 and older in the residence of their choice. The State Plan Personal Care (SPPC) program is another option for self-directed care, allowing the eligible member to choose where to receive their services.
The Oregon Aged and Physically Disabled waiver provides case management, transition services, and housing support services for aged adults over 65 and adults with disabilities. The state also offers the K Plan under the Community First Choice option, which provides care services to eligible Medicaid members in the residence of their choice. These programs do not pay for assisted living housing costs.
Pennsylvania’s Community HealthChoices waiver provides a wide variety of care services to eligible Medicaid members over 65 and disabled adults. Qualifying participants are able to receive these services in their own home or community residence, but the state does not cover room and board.
Rhode Island Medicaid offers the Global Consumer Choice Compact Waiver that provides HCBS services to elders through Long Term Services and Supports (LTSS). There is a list of services eligible Medicaid members can choose from within the program that include: Adult Day Service, Assisted Living, Independent Provider, Rite at Home, PACE, and Personal Choice. These services are available to individuals depending on how much assistance they need, what their income level is, and where they would like to receive care. The state also offers SSI Enhanced Assisted Living, providing a monthly stipend to qualifying individuals that can go toward the cost of an assisted living facility.
South Carolina’s Community Choices waiver gives eligible Medicaid members the option to receive a multitude of care services in their own home or community residence. This waiver covers the cost of services but does not pay for room and board within assisted living facilities.
The Assistive Daily Living Services (ADLS) waiver provides eligible Medicaid members with personal care services and more to be received in the home or community residence of their choice. The state also has an HCBS Options and Person Centered Excellence (HOPE) waiver. This waiver is similar to the ADLS waiver but provides further services in coordination with assisted living facilities, though the waiver does not cover cost of room and board or facility maintenance.
Tennessee offers their seniors and adults with disabilities the TennCare CHOICES in Long-Term Services and Supports program. This option provides care services that enable eligible individuals the option to receive care in their home or community residence. Tennessee residents interested in the program will work with a local Area Agency on Aging and Disability (AAAD) to learn more about the program.
The Community Based Alternatives (CBA) waiver program gives eligible Texas Medicaid members who would otherwise need to be institutionalized the ability to receive care services in their own home or community residence. The program covers the cost of services but does not pay for assisted living room and board.
Utah offers a selection of waivers for eligible Medicaid members over 65 and disabled adults who would like to receive care services in their own home or community residence instead of an institution. Those waivers include the Aging Waiver, the New Choices Waiver (individuals must be transitioning from an institution to a community-based setting), and the Physical Disabilities Waiver.
Vermont’s Global Commitment to Health demonstration provides the Choices for Care Program which serves eligible Medicaid members 18 and older who require a nursing home level of care. The program allows individuals to receive care in the home of their choice, an enhanced residential care facility, an adult family care home, or nursing facility. The state also provides a Medicaid benefit called the Assistive Community Care Services program. Eligible members residing in assisted living residences or licensed level III residential care homes are able to receive care services within their residence. The program does not cover the cost of room and board, however. Vermont’s Attendant Services Program allows eligible individuals with severe and permanent disabilities to hire and direct their own attendant care service within their residence of choice.
The Commonwealth Coordinated Care (CCC) Plus Waiver provides care services to eligible Medicaid members who would otherwise need to be placed in a nursing home. The waiver covers things like transition services, adult day health, care and personal care services to individuals in their home or community residence, but does not cover housing costs. The state also offers a Consumer-Directed Model for Medicaid members who qualify. The program allows individuals to direct their own care through companion services, personal assistance/care, and respite care in the residence of their choice.
Washington’s Residential Support Waiver provides services like enhanced residential and community services, day health, and training to eligible Medicaid members needing care within their own home or community residence. The New Freedom program offers fewer but similar services and allows individuals to choose where they receive their care. The Washington Community Options Program Entry System (COPES) is another state program that offers services to eligible individuals who wish to receive care in the residence of their choice. The program does not cover the cost of room and board, but may reimburse for expenses incurred when establishing basic housing like security deposits, utility set-up fees, and moving expenses. The state’s Community First Choice (CFC) and Medicaid Personal Care (MPC) programs are additional options for individuals looking to receive care services in a residential setting.
The Aged and Disabled Waiver (ADW) provided by West Virginia’s Medicaid program provides case management, personal care services, transition services, and more to individuals over 65 and disabled adults in their home or community residence. Personal Care (PC) services are also available to eligible Medicaid members who need help with activities of daily living in their own residence. These programs provide services within assisted living facilities but do not pay room and board expenses.
Wisconsin offers its eligible Medicaid members three waivers for individuals over 65 and disabled adults to receive a wide variety of care services in their own homes or community residences. Those waivers include the Family Care Waiver, the Elderly and Physically Disabled waiver, and the Self Directed Support Waiver. While these services can be provided in an assisted living setting, Medicaid does not cover the cost of housing. The Include, Respect, I Self-Direct (IRIS) program is another option offered by Wisconsin which enables elders and adults with disabilities to determine and direct their own care through a budget provided by the state.
The Community Choices Waiver (CCW) provided by Wyoming Medicaid provides care services, case management, skilled nursing, and more to eligible individuals. Members are able to choose where they receive care, whether it’s in their own home or within an assisted living facility.
Medicaid In Your State
Click on your state below for information about your state’s Medicaid office and program.
Frequently Asked Questions
Is Medicaid free?
Yes, Medicaid is usually free. Although states are permitted to require a share of cost, there are usually no premiums, deductibles or copays with Medicaid since this program is intended for low-income families and individuals with very high medical bills. Cost sharing may be required for some higher-income target groups, and you may incur out-of-pocket expenses when requesting certain name-brand, non-preferred medications. If you qualify for Medicare, Medicaid may even pick up some excess charges.
What’s the difference between Medicare and Medicaid?
Medicare and Medicaid are both federally managed insurance programs, but there are several differences. Medicaid is an income-based program available to certain individuals who meet financial eligibility requirements. Medicare is available to all adults who are aged 65 or older, regardless of income. Younger individuals who have end-stage renal disease, Lou Gehrig’s disease or have received Social Security Disability benefits for at least 24 months also qualify for this program.
Does Medicaid pay for assisted living?
Yes, many Medicaid programs cover assisted living and personal care through waivers or managed care organizations. At least 34 states have Community First Choice Waivers, and 39 states have HCBS waivers or managed care organizations that cover personal care, household assistance, transportation, delivered meals, case management, emergency response systems and related supports. There may be restrictions on where participants can receive these services, and seniors still have to pay for room and board, unless they qualify for an SSI stipend. Waivers are also subject to waiting lists.
Can I get paid by Medicaid to be a caregiver?
It’s possible for informal family caregivers to receive compensation for the services that they provide through Medicaid. Consumer-directed or self-directed waivers may grant seniors a needs-based stipend that they can use to hire their own caregivers. A handful of states, including Arizona, Florida, Kentucky, New Jersey and Wisconsin, even compensate caregiving spouses. The caregiver must register as a provider with the state’s Medicaid program and meet certain other requirements to qualify.
How do you qualify for Medicaid?
Medicaid eligibility is based on your income, assets and medical need. Requirements may vary, depending on your age and whether you have a disability. The state will also consider your health care expenses if you are medically needy and earn too much to qualify through regular eligibility pathways. You can see if you qualify by contacting a Certified Medicaid Planner, completing a Medicaid eligibility test or applying through your state’s Medicaid agency.
“Medicaid Eligibility Income Chart by State.” American Council on Aging, Mar. 2021, https://www.medicaidplanningassistance.org/medicaid-eligibility-income-chart. Accessed 23 May 2021.
“National Health Expenditure Data, Historical.” Centers for Medicare & Medicaid Services, Dec. 2020, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical. Accessed 23 May 2021.
“November 2020 Medicaid & CHIP Enrollment Data Highlights.” Medicaid.gov, Nov. 2020, https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. Accessed 24 May 2021.
“Who Pays for Long-Term Care in the U.S.?” The SCAN Foundation, Jan. 2013, https://www.thescanfoundation.org/sites/default/files/who_pays_for_ltc_us_jan_2013_fs.pdf. Accessed May 23 2021.
“Cost of Care Survey.” Genworth Financial, Feb. 2021, https://www.genworth.com/aging-and-you/finances/cost-of-care.html. Accessed 24 May 2021.
“Medicaid State Fact Sheets.” Kaiser Family Foundation, Oct. 2019, https://www.kff.org/interactive/medicaid-state-fact-sheets. Accessed 23 May 2021.
“Institutional Long Term Care.” Medicaid.gov, https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/index.html. Accessed 23 May 2021.
“Mandatory & Optional Medicaid Benefits.” Medicaid.gov, https://www.medicaid.gov/medicaid/benefits/mandatory-optional-medicaid-benefits/index.html. Accessed 23 May 2021.
“Items & Services Not Covered Under Medicare.” Centers for Medicare & Medicaid Services, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf. Accessed 23 May 2021.
“List of Medicaid Eligibility Groups.” Medicaid.gov, https://www.medicaid.gov/sites/default/files/2019-12/list-of-eligibility-groups.pdf. Accessed 23 May 2021.
“Eligibility.” Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/index.html. Accessed 23 May 2021.
“Spousal Impoverishment.” Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html. Accessed 23 May 2021.
“2021 SSI and Spousal Impoverishment Standards.” Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/downloads/ssi-and-spousal-impoverishment-standards.pdf. Accessed 23 May 2021.
“Medicaid Payment Policy for Out-of-State Hospital Services.” Medicaid and CHIP Payment Access Commission, Jan. 2020, https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid-Payment-Policy-for-Out-of-State-Hospital-Services.pdf. Accessed 23 May 2021.
“10 Things to Know about Medicaid: Setting the Facts Straight.” Kaiser Family Foundation, Mar. 2019, https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight. Accessed 23 May 2021.
“Medicaid Eligibility Through the Medically Needy Pathway.” Kaiser Family Foundation, June 2019, https://www.kff.org/other/state-indicator/medicaid-eligibility-through-the-medically-needy-pathway. Accessed 23 May 2021.
“Spend Down Procedures.” New York State Department of Education, http://www.oms.nysed.gov/medicaid/resources/medicaid_spend_down.pdf. Accessed 23 May 2021.
“Access to Long-Term Services and Supports: A 50-State Survey of Medicaid Financial Eligibility Standards.” AARP Public Policy Institute, Sept. 2010, https://assets.aarp.org/rgcenter/ppi/ltc/i44-access-ltss_revised.pdf. Accessed 23 May 2021.
“Home & Community-Based Services 1915(c).” Medicaid.gov, https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html. Accessed 23 May 2021.
“Home & Community Based Services Authorities.” Medicaid.gov, https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/index.html. Accessed 23 May 2021.
“About Section 1115 Demonstrations.” Medicaid.gov, https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html. Accessed 23 May 2021.
“Cost Sharing.” Medicaid.gov, https://www.medicaid.gov/medicaid/cost-sharing/index.html. Accessed 24 May 2021.
“Differences Between Medicare and Medicaid.” MedicareInteractive.org, Mar. 2018, https://www.medicareinteractive.org/get-answers/medicare-basics/medicare-coverage-overview/differences-between-medicare-and-medicaid. Accessed 24 May 2021.
“Medicare Coverage for People with Disabilities.” Center for Medicare Advocacy, https://medicareadvocacy.org/medicare-info/medicare-coverage-for-people-with-disabilities/. Accessed 24 May 2021.
“How Medicaid Can Help Seniors Cover the Cost of Assisted Living.” American Council on Aging, Jan. 2021, https://www.medicaidplanningassistance.org/assisted-living. Accessed 24 May 2021.
“How to Receive Financial Compensation via Medicaid to Provide Care for a Loved One.” American Council on Aging, Jan. 2021, https://www.medicaidplanningassistance.org/getting-paid-as-caregiver. Accessed 24 May 2021.
“Self-Directed Services.” Medicaid.gov, https://www.medicaid.gov/medicaid/long-term-services-supports/self-directed-services/index.html. Accessed 24 May 2021.”Medicaid Eligibility Test / Pre-Screen for Long Term Care.” American Council on Aging, Mar. 2021, https://www.medicaidplanningassistance.org/medicaid-eligibility-test. Accessed 24 May 2021.
“Medicaid Eligibility Test / Pre-Screen for Long Term Care.” American Council on Aging, Mar. 2021, https://www.medicaidplanningassistance.org/medicaid-eligibility-test. Accessed 24 May 2021.