How Long Does Medicaid Pay for Assisted Living: A Complete Guide
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Affording assisted living can be challenging, but Medicaid helps cover some expenses for eligible individuals. While it doesn’t pay for room and board, it does cover personal care, medical care, and supportive services in certain states. Medicaid is a public insurance program for low-income individuals in the US, funded jointly by federal and state governments. Coverage includes various long-term healthcare services, like assisted living, although limits apply based on state-specific eligibility criteria and policies.
Key Insights
Medicaid covers assisted living costs as long as you remain eligible for the program.
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Medicaid has general eligibility criteria for asset limit ($2,000), income limit (up to 300% of the Federal Benefit Rate), and individual medical needs.
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The program doesn’t cover room and board costs in assisted living.
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Each state has specific waiver programs with criteria and services that cover assisted living costs.
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78% of dually eligible individuals for Medicaid and Medicare live in 20% of AL communities.
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How Long Does Medicaid Pay for Assisted Living?
Medicaid coverage for assisted living varies from state to state. The length of coverage depends on the individual’s medical and financial eligibility. Medicaid continues to pay for care services as long as the person meets the necessary criteria.
There’s no fixed-time coverage as it depends on several factors, including state regulations, the type of Medicaid waiver program, and financial and medical eligibility.
How Does Medicaid Pay for Assisted Living
78% of dually eligible individuals for Medicaid and Medicare live in 20% of assisted living communities in the U.S. The program offers two types of insurance for the elderly:
Regular State Medicaid
Regular State Medicaid includes basic health care services each state administers and provides to low-income individuals such as pregnant women, children, elderly adults, and people with disabilities.
It covers short-term, acute healthcare needs, such as doctor visits, hospital stays, prescription medications, and preventive care, but it doesn’t offer long-term coverage like assisted living services.
HCBS Medicaid Waivers
Home and Community-Based Services (HCBS) waivers, aka 1915(c) Waivers, cover long-term care needs for elderly individuals or people with disabilities who require assistance with daily living activities (ADLs).
It’s like long-term care insurance that covers costs for seniors living in assisted living facilities, nursing home care, or need in-home services only if they fall under certain eligibility criteria set by the state.
However, not everyone can get HCBS waivers, some states offer limited slots with waitlists.
Medicaid Eligibility
- Applicants must be U.S. citizens and reside in the state where they are applying for benefits.
- Asset limits are commonly $2,000 for individuals applying for HCBS Waivers.
- Individuals should fall under the income limit and can earn up to 300% of the Federal Benefit Rate (FBR).
- Each individual must meet a nursing home level of care for coverage for ADL assistance, but this can vary.
- Some states may only offer HCBS waivers to a target population.
Which Services Does Medicaid Cover?
Medicaid covers the following daily living services for qualifying seniors in assisted living facilities:
- Personal Care Assistance
- Homemaker Services
- Medication Management
- Case Management
- Transportation Services
- Emergency Response Systems
- Skilled Nursing Care (in some states).
However, not all services are necessarily available for all seniors. It depends on what the state has permitted.
How Much Does Medicaid Pay For Assisted Living?
Since Medicaid coverage varies by state, it’s essential to check your state’s official Medicaid website to find out the specific benefits and the amount of monthly assistance available for senior citizens.
Generally, Medicaid pays based on:
- What state does the senior citizen reside in
- What’s their medical history and income limit
- The level of assistance the senior needs
- What program are they rolled in.
Does Medicaid Cover Assisted Living for Dementia?
Medicaid can cover some assisted living services for seniors with dementia, but it varies by state. For example, in California, Medicaid covers memory care services in assisted living facilities for eligible residents, while Florida offers more limited memory care services.
Does Medicaid Cover Assisted Living for Disabled Adults?
Yes, Medicaid covers assisted living costs for disabled adults, but it depends on the state and individual needs.
Coverage Overview
| Aspect | Seniors with Dementia | Disabled Adults |
| Eligibility Criteria | Must meet state-specific income and asset limits; often eligible if receiving SSI. | Must meet similar income and asset limits; eligibility may also depend on disability status. |
| Income Limits | Generally, monthly income must be below $2,349 (varies by state). | Income limits vary by state; often aligned with federal poverty levels or SSI thresholds. |
| Asset Limits | Commonly set at $2,000 for individuals; some states may allow higher limits. | Generally the same asset limits as for dementia care, often around $2,000. |
| Type of Care Covered | Comprehensive coverage in nursing homes, including room and board, healthcare services, and specialized memory care. | Coverage includes personal care and skilled nursing services but may not cover room and board in assisted living settings. |
| Assisted Living Coverage | Limited or no coverage for room and board in assisted living facilities; some services may be covered under HCBS waivers. | Similar limitations on room and board; HCBS waivers may provide some assistance with personal care services. |
| Nursing Home Coverage | 100% coverage for eligible individuals in certified nursing homes, including memory care services. | Also receives 100% coverage in certified nursing homes, but specific services may vary based on individual needs. |
| HCBS | Can receive HCBS through waivers that cover personal care, medication management, and other supportive services; however, these waivers are not guaranteed. | Similar HCBS options available; coverage may include assistance with daily living activities but depends on state-specific waivers. |
Which States Cover Assisted Living?
Medicaid in almost all states covers assisted living costs for activities of daily living, but other services differ in every state.
Here’s a comprehensive graph of the percentage of people who rely on Medicaid for assisted living costs:
How to Apply for Medicaid Assisted Living?
Here’s a step-by-step guide on how you can apply for Medicaid benefits for Assisted Living:
- Step 1: Before you apply for Medicaid coverage in assisted living, make sure to check the eligibility criteria of your state, and what waiver programs they offer. Each state has different income and asset limits, and you may also need to prove a medical need for assistance.
- Step 2: Gather necessary documents like income statements, bank records, and medical reports to demonstrate your enrollment qualifications.
- Step 3: Depending on your state, you can apply online through the Medicaid website or in person at a local Medicaid office. Make sure to add your social security number and other important details.
- Step 4: During the application process, request a Home and Community-Based Services (HCBS) waiver or other long-term care Medicaid programs that may cover assisted living services.
- Step 5: Once your application is submitted, Medicaid will review your financial and medical information. They may do a home visit or interview to assess your care needs. If approved, Medicaid will notify you of the services covered.
If your application is denied, you can resubmit your documents again with the necessary information.
Medicaid also does a recertification process to ensure that you continue to meet the eligibility requirements. Always keep your financial and medical documents updated periodically for long-term coverage.
Bottom Line
Medicaid can help cover assisted living costs, including personal care and supportive services, but eligibility and coverage vary by state. For example, 78% of dually eligible individuals live in just 20% of assisted living communities. Generally, Medicaid won’t cover room and board but may fund essential daily services via HCBS waivers, depending on state-specific guidelines. Income and asset limits apply, typically capped at $2,000 in assets and 300% of the Federal Benefit Rate in monthly income.
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Sources
- Medicaid. AHCA NCAL. Evaluated November 1, 2024.
Link - Hipp, D. Assisted Living Statistics and Facts in 2024. Forbes Health. 11 January, 2024. Evaluated November 1, 2024.
Link - Home & Community-Based Services. Medicaid.gov. Evaluated November 1, 2024.
Link - Home & Community-Based Services 1915(c). Medicaid.gov. Evaluated November 1, 2024.
Link - Cornell, P. Y., Hua, C., Rahman, M., Gadkari, G., Gunderson, R., Smith, L., & Thomas, K. S. (2023). Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid. JAMA Health Forum. Evaluated November 1, 2024.
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