When Will Medicaid Pay for Nursing Home Costs or Assisted Living?

When Will Medicaid Pay for Nursing Home Costs or Assisted Living?

For some individuals, Medicaid will cover nursing home costs or expenses for an assisted living facility – both considered types of long-term care. You must meet financial and medical eligibility requirements. Generally speaking, financial eligibility imposes a limit on both assets and income.

Types of Long-Term Services Covered by Medicaid

Nursing Home Costs

For individuals who are eligible for Medicaid and qualify for nursing home care, the federal law requires the states to provide for nursing home costs and/or home care costs.

Long-Term Care Costs

For Medicaid recipients who do not qualify for nursing home care, states can use Medicaid funding to provide other long-term care services including assisted living facilities and adult foster homes.

In summary, funding for eligible Medicaid recipients may be available for:

  • Nursing home care
  • Home care services
  • Assisted living facilities
  • Adult foster homes
  • Other long-term care services

Not all nursing homes or assisted living facilities will accept Medicaid payments. If you are hoping to have your costs covered under the program, you should ask each facility you are considering if they accept Medicaid.

Eligibility for Medicaid

To be eligible for Medicaid, you must meet both medical and financial eligibility requirements. Each state will have its own income guidelines for Medicaid eligibility for long-term care.

Medical Eligibility

A common misconception is that you need to be elderly to qualify for long-term care coverage under Medicaid. While the majority of people who receive Medicaid for long-term care are elderly, a physician can determine if it is “medically necessary” for you to have long-term care at any age.

For the Commonwealth of Massachusetts to determine you need nursing home care, they look at whether you can adequately take care of yourself. This is referred to as “activities of daily living,” or ADLs. The patient must need help in at least two ADL areas as well as have either a medical need or a mental dysfunction. Ultimately, your physician(s) will be able to advise you as to whether you meet the functional criteria to qualify for MassHealth (Medicaid) long-term care.

Financial Eligibility

Financial eligibility requirements include the following:

  • Income: The income of an individual and their spouse will be considered in determining Medicaid benefits. Medicaid also recognizes the need to cover monthly expenses while an individual is receiving long-term care. A monthly minimum maintenance needs allowance (MMMNA) is used to determine whether a Medicaid applicant should receive benefits, and the amount of benefits. The MMMNA is based on a complex formula that varies from state to state, but which takes into account housing costs.
  • Available resources: Ownership of a certain value of assets may disqualify you from Medicaid.

    In Massachusetts, an individual cannot have countable assets that are worth more than $2,000 and cannot have a home with equity of more than $893,000 in 2020 (adjusted annually). For married couples, the family cannot collectively have assets worth more than $128,640 (2020) and a home. With proper planning, some assets can be protected in order to make an individual eligible.

    If your assets put you over the resource limit, you will not be able to be eligible until you “spend down” those resources below the limit. There are several spend down strategies that can be used to reduce one’s assets below the resource limit.

  • Medically needy: This term refers to people who do not fit the income or resource guidelines but still have a great enough medical need that they can qualify for Medicaid. In such a case, you likely have assets or income over the eligibility levels, but also very high medical expenses to such a point that they reduce those income or assets to proper eligibility. For any type of long-term care, we recommend individuals plan ahead as early as possible.

Additional Medicaid Eligibility Information

Baker Law Group advises seniors and their families on eligibility for Medicare or MassHealth. Our attorneys have extensive experience helping individuals prepare for long-term care and completing MassHealth / Medicaid applications. Our web page Nursing Home Medicaid MassHealth Eligibility provides more in-depth information for Massachusetts.

For more information and to learn how to account for Medicaid in your estate planning, contact an experienced attorney at Baker Law Group, P.C.

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