All states have a Nursing Facility Medicaid program that provides general health coverage plus coverage for nursing home services. These services include room and board, nursing care, personal care and therapy services. Nursing Facility Medicaid may pay for a stay in a nursing home if you:
- need a nursing-home level of care or meet nursing home functional eligibility criteria; and
- have income and assets below certain guidelines.
Different states have different standards for determining whether you need a nursing home level-of-care, but generally look at your ability to function. For example, your state might assess whether you need help with activities of daily living (i.e., basic everyday activities such as getting in and out of bed, dressing, bathing, eating and using the bathroom).
While Medicare covers some skilled nursing facility care, it will only cover this care for a limited amount of time (up to 100 days in a benefit period) if you meet certain criteria. If you do not meet Medicare’s requirements for the skilled nursing facility benefit or you have reached Medicare’s limit of covered skilled care, Medicaid may pay for this care.
When you have Nursing Facility Medicaid, you still have Medicare coverage for the medical services you need aside from your nursing care. For example, if you need to go to the hospital or need to go to a doctor or specialist’s office, Medicare will pay first for most of these medical services and Medicaid will pay second by covering your remaining costs, such as the Medicare coinsurances, copayments and deductibles. Medicaid may also pay for some medical services that are not covered by Medicare, such as routine dental care.
In order to qualify for Nursing Facility Medicaid, you will need to meet financial guidelines in addition to meeting functional eligibility guidelines. You can have income higher than you could have if you did not need nursing home care and still qualify for Medicaid. Your state may have:
- higher Medicaid income guidelines for people who need nursing home care than for those who do not; and/or
- a “spend-down” or “medically needy” program. Spend-down programs are meant for people who have income higher than would normally qualify them for Medicaid coverage, but who have medical expenses that significantly reduce their usable income.
Some things to be aware of if you are thinking of applying for Nursing Facility Medicaid:
- Nursing Facility Medicaid programs will consider you and your spouse together when looking at your income and assets, but you will be able to set aside a certain amount of your income and assets for your spouse to keep. This amount will not be counted when you apply for Medicaid.
- If you qualify for Nursing Facility Medicaid, you will be able to keep a small amount of your income for a personal allowance. The amount that you can keep for yourself varies by state. Contact your local Medicaid office for the exact amount in your state. You will have to pay the remainder of your income to the nursing home.
- Medicaid has a “look-back period” of up to five years. This means that Medicaid will look at any assets you have transferred in the past few years when determining eligibility and when Medicaid coverage will begin. If Medicaid determines that you have transferred assets in violation of the Medicaid rules, it can penalize you by not paying for part or all of your nursing home stay.
- If you own your home, be sure to talk to an elder law attorney about how it will affect your Medicaid eligibility and coverage. Depending on your circumstances, the equity from your home may count as an asset. When you no longer need long-term care, or when you are deceased, your assets may be used to repay Medicaid for the care that it covered for you.