While Medicaid coverage can vary from state to state and each state can offer some optional benefits, there are certain Medicaid benefits that are mandatory under federal law. Nursing home coverage is among those mandatory Medicaid benefits.
Medicaid nursing home coverage is also sometimes referred to as Institutional Medicaid.
Nursing home care is the highest level of long-term care. Residents of nursing homes receive 24-hour assistance with activities of daily living in addition to medical care and physical, occupational and speech therapy.
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A nursing home is designed for individuals who can no longer live independently in their own homes and require around-the-clock care.
Medicaid’s long-term care benefits depend on the type of care being received.
For nursing home care, Medicaid provides coverage of four fundamental expenses:
The above coverage must be provided in any Medicaid-certified nursing home facility that accepts Medicaid to any resident who meets the eligibility criteria. Not every nursing home accepts Medicaid.
In order to qualify for Medicaid nursing home coverage, individuals must be:
In addition to the above criteria, all applicants must meet both financial and functional limits in order to qualify for Medicaid’s nursing home coverage. The exact specifications of each criteria may differ by state.
You must have income and countable assets that are below certain guidelines. While the exact numbers may vary by state, general guidelines are a maximum monthly income of $2,523 and no more than $2,000 worth of countable assets in 2022.
Countable assets do not include your primary home, one vehicle or other furniture and personal belongings such as family heirlooms or jewelry.
You can further explore the state-specific Medicaid income and asset limits.
In addition to meeting the income and assets limits of your state’s Medicaid program, a “nursing home level of care” is required to qualify for Institutional Medicaid. There is no federal definition of this level of care, so each state Medicaid program will define it differently.
The ability to complete daily activities, medical needs, cognitive issues and behavioral problems are often included, and an evaluation of the applicant is typically conducted to assess their functional eligibility.
Many residents of nursing homes still bring in some money in the form of inheritances, stimulus checks or other means. Residents are entitled to a modest personal needs allowance that can vary by state.
Neither the Medicaid program nor the nursing home may seize any money or assets accumulated by a resident. Medicaid may simply stop providing coverage for the nursing home, or the beneficiary may spend down their assets on approved purchases in order to remain under the financial limits for continued eligibility.
Medicare does not provide coverage of nursing home care or certain other forms of long-term care if the only type of care that is needed is assistance with activities of daily living. There are instances in which Medicare Part A will cover skilled nursing care administered in a nursing home when ordered to be medically necessary.
Skilled nursing care is covered by Medicare when administered in a skilled nursing facility.
Because each state may have slightly different guidelines for eligibility and enrollment, it’s best to contact your state Medicaid program for information about you can apply for nursing home coverage.
Individuals who qualify for both Medicare and Medicaid are considered “dual eligible” and may qualify for a certain type of Medicare Advantage plan called a Special Needs Plan.
One particular type of Special Needs Plan is a Dual Eligible Special Needs Plan (D-SNP), which are designed to meet the specific needs of those with limited income and resources.
You can compare plans online to find out if D-SNPs are available where you live, or you can call to speak with a licensed insurance agent for information about eligibility and enrollment.
Speak with a licensed insurance agent
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.
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