Does Medicaid Cover Assisted Living?

Does Medicaid Cover Assisted Living? – Overview

Medicaid may cover some services provided in assisted living, such as personal care and medical services, but it does not typically cover room and board in assisted living facilities.

To be precise, Medicaid covers extended care services such as personal care and specialized home care services for persons who meet the qualification requirements.

Medicaid may also cover skilled nursing and emergency response costs.

However, Medicaid will not cover the cost of the accommodation and board. Since Medicaid is a state program, the qualification requirements and benefits vary from state to state.

This is because the federal government has given each state a certain amount of flexibility on how it would like to run its Medicaid program.

Also, within each state, there are various Medicaid programs with different eligibility requirements. So the issue of whether Medicaid will cover assisted living isn’t as straightforward as you may presume.

For further clarification, it’s vital to understand that most states in the U.S have two Medicaid programs, namely the regular state Medicaid program and HCBS (Home and Community Based Services) Medicaid waivers.

All states are mandated to offer personal care aid via Medicaid; some states offer it through their regular state programs, while others offer it through HCBS waivers.

A few states offer it via both Medicaid programs. However, although all states cover personal care aid via Medicaid, not all of them cover to aid in assisted living centers.

What Is Regular State Medicaid?

The regular state Medicaid is an entitlement program that provides many health care benefits that the Federal Government requires.

States are required to cover nursing facility services for eligible Medicaid recipients under federal law, but home nursing services are covered at the state’s discretion. The federal government also includes optional benefits, which are implemented at the discretion of each state. One such benefit is assisted personal care.

What Are HCBS Medicaid Waivers?

Many states offer 1915(c) waivers, also known as HCBS Medicaid waivers, though not all states may have them. These waivers enable residents to continue living at home or within the community rather than being placed in assisted living centers.

Waivers accomplish this by providing care and other benefits that facilitate independent living, such as personal care aid, personal emergency response, home health aides, adult daycare, housekeeping, and meal delivery.

How Can You Qualify Assisted Living Coverage Under Medicaid?

Financial Need

State Medicaid programs limit recipient earnings to certain percentages of the Federal Poverty Level or Federal Benefit Rate.

Functional Need

Recipients must need a nursing level of care or hospitalization. The requirements vary from state to state. For instance, some states could call for beneficiaries to require aid with two daily living routines such:

  1. Chopping up their food and eating.
  2. Dressing and undressing.
  3. Going to the washroom and cleaning up.
  4. Moving from a bed to a couch.

Some programs require a physician’s certification of a need for a nursing home level of care, which may include conditions like Alzheimer’s but does not automatically qualify one for assisted living benefits.

Which Assisted Living Service Does Medicaid Cover?

The assisted living benefits covered by Medicaid will vary based on the recipient’s state of residence and the specific Medicaid program in which they are enrolled. However, the following are the usual assisted living services available under Medicaid:

  1. Personal care aids include eating, dressing, cleaning, and toileting.
  2. Specialized home care services include food preparation, shopping for basics such as foodstuffs, laundry, and housecleaning.
  3. Case management.
  4. Personal emergency response.

Medicaid will not pay for the accommodation and board concerning assisted living. However, many states have an OSS (Optional State Supplement). This is a cash aid program to help cover the cost of housing and board.

This benefit, also known as SSB (State Supplementary Benefits), supplements recipients’ federal SSI earnings.

The agency that issues these federal payments varies from state to state, but mostly the SSA (Social Security Administration) or DHS (Department of Human Services).

All local DHS outlets can be found on the Medicaid portal.

What Is the Extent of Coverage for Assisted Living Under Medicaid?

The extent of coverage for assisted living under Medicaid will depend on:

  1. A recipient’s state of residence.
  2. The state Medicaid program (Regular Medicaid or HCBS Medicaid).
  3. The amount of care a recipient requires.

A needs assessment is needed to compute the number of hours Medicaid will cover. For instance, recipients highly dependent on assisted living will be allocated more caregiver hours each month.

Which Assisted Living Centers Accept Medicaid?

Not all assisted living centers consent to Medicaid coverage as payment. When picking a residence, ensure you ask if it’s Medicaid-approved. In some instances, even if the care center doesn’t accept Medicaid, it might allow 3rd party caregivers to come in and give aid.

In such an instance, Medicaid will reimburse the third-party caregiver because they don’t work for the assisted living facility. If you’re considering this alternative, ensure you ask the care center if they accept third-party caregivers.

Unfortunately, there isn’t a countrywide database for assisted living facilities that accept Medicaid. Contact your local AAA (Area Agency on Aging) outlet to find these residences.

Most AAA offices keep a directory of assisted living centers that accept Medicaid. They will point you to a statewide searchable database if they don’t have a directory of these centers.

Note that assisted living centers that accept Medicaid cap the number of beds allocated to Medicaid-sponsored residents. This means that the number of beds available for Medicaid recipients is limited.

The best approach to finding care centers that accept Medicaid is to make a list of care centers near you and call most of them. If they don’t allow Medicaid-sponsored residents, ensure you ask them about third-party caregivers.

Final Thought

Some states cover assisted living through their Medicaid programs, others via their HSBS waivers, and others through both state plans and waivers.

Ensure you discuss the feasibility of using Medicaid as payment for assisted living with a Medicaid planning expert. This is because some people receive assisted living care while others encounter challenges.

See Also

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Does Medicaid Cover Dental Implants

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