MEDICAID and LONG TERM CARE 

Federal Medicaid regulations require participating nursing homes to explain the application procedures for Medicaid benefits to prospective residents. Unfortunately, most nursing homes do a poor job in explaining Medicaid to residents. Medicaid is complicated, and you need to be prepared for the eligibility process. 

The following are some very basic rules. They are a start to understanding eligibility, but you will need further and more detailed information.

What is “Medicaid?”

Medicaid is a federal and state program, which provides health insurance coverage to eligible applicants who need health care services, including nursing home care. Eligibility for Medicaid is determined by looking at your assets and your income. Frequently, people who are not eligible for Medicaid at the beginning of their residence in a nursing home become eligible after they have spent much of their personal assets paying the bills themselves. This process is referred to as “spend-down.”

What if I have an income, but not enough to pay for my nursing home care--Must I sign over this income to the nursing home?

Medicaid will subsidize your nursing home expenses, but you need to follow Medicaid regulations. Medicaid requires that a recipient assign their monthly income to pay nursing home expenses. Medicaid then pays the difference up to the Medicaid rate. The nursing home must accept this as payment in full. You are allowed to keep a personal allowance, currently in the amount of $30.00 a month. In addition, Medicaid allows you to keep enough income to pay any Medigap insurance premium. 

What resources can I keep under Medicaid long term care coverage?

Medicaid only allows the applicant/resident to keep $2,000 in exempt resources. Also, you are allowed to put aside an additional burial allowance. If you have more than $2,000 in a bank account, or in real estate, or in stocks, or other assets, Medicaid will not begin to cover the nursing home bill--even if you owe money to the nursing home or to others. Medicaid only looks at what is in the applicant’s name, not what outstanding debts the applicant has. Normally, applicants for Medicaid coverage “spend down” excess resources to become eligible.

Are there different eligibility rules of Medicaid nursing home coverage for a married applicant as opposed to an unmarried applicant?

Yes, there are major differences in the requirements of eligibility for a married applicant, as opposed to an unmarried applicant. For a married applicant, the spouse who stays at home (called the “Community Spouse”) may be able to keep some of the income of the applicant spouse. This is particularly true if the community spouse’s personal income is low. 

On the other hand, the married couple’s resources (whether held solely by the applicant, solely by the community spouse, or jointly by both spouses) are considered available to pay for long term care. Resources must be spent down to a predetermined level before Medicaid will start paying. 

However, the home for a married couple (the community spouse’s residence) is considered an exempt resource, and need not be sold to meet eligibility criteria for long term care coverage. 

How do I apply for Medicaid assistance?

You apply for Medicaid assistance through your local county or city Department of Human Services or Department of Social Services. You must apply at the office of your last residence before you entered a nursing home. For example, if you are currently in a nursing home in Arlington County, and you were living in Fairfax County before entering the nursing home, you need to apply for Medicaid at the Fairfax County Department of Family Services.

Does the nursing home have any control in whether or not I apply for Medicaid?

No. The nursing home has no authority to tell you if, or when, you can apply for Medicaid. Federal and state law prohibit nursing homes from requiring private pay residents to waive their rights to apply for Medicaid benefits in the future. Nursing homes are also prohibited from requiring you to pay out of your own resources for some period of time before you apply for Medicaid. Your only concern should be meeting the eligibility requirements for Medicaid assistance, should you need to apply.

What is meant by a “Medicaid Certified” Nursing Home Bed?

In order to receive Medicaid in a nursing home the recipient must be in a Medicaid certified bed. Even if you meet the income and resource criteria, you must be in a certified bed before Medicaid pays. Long before you apply for Medicaid you should tell the nursing home that you intend to apply for Medicaid coverage, and they should insure that you are placed in a Medicaid certified bed.

Sometimes nursing homes use this fact as a means of controlling whether they will accept Medicaid coverage when an applicant applies. Remember, if a nursing home requires anyone to pay privately as a condition of eligibility, this is illegal. 

Will I receive substandard care under Medicaid coverage?

No. Federal law makes it illegal for nursing homes to discriminate as to care and services to any resident based on the source of payment, whether by private pay or Medicaid. 

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