Medicaid and Long Term Care

To qualify for Medicaid long-term care services you have to have limited income and resources. You must also meet other requirements such as:

  • age;
  • if you are pregnant;
  • if you are disabled;
  • if you are blind; or
  • if you are a U.S. citizen or a lawfully admitted immigrant.

In addition, to quality for Medicaid long-term care services you must require a certain amount of assistance with personal care like bathing and dressing called Activities of Daily Living. These rules vary from state-to-state. To see if Medicaid may pay for your long-term care services, you need to find out if you are eligible for the program. You can start by reviewing the Medicaid Eligibility Requirements for long-term care.

How Do You Apply for Medicaid Long-Term Care Services?

To apply for Medicaid for long-term care services, you will have to:

  1. Fill out an application form
  2. Provide documentation to verify general and financial requirements
  3. Go through a functional eligibility assessment.

You may apply for Medicaid coverage or you may designate another person, such as a family member, your attorney, or a friend, to apply for you. If someone else apples for you, that person should be familiar with your situation, be able to answer all eligibility questions, and have access to your financial records. The state may also require a face-to-face interview.

If you own a home, the state may ask you to document the current fair market value of the home and any loans for the home, such as mortgages or equity loans. The state may ask for these documents:

  • A current tax bill
  • A real estate appraisal
  • Copies of your mortgage

If your savings went down a lot within the past five years, the state may ask you to show evidence of what you did with the money. If you are married and in a nursing home, you will also be asked to document your assets when you first entered the nursing home—this establishes how much your spouse is able to keep.

Where Do You Apply for Medicaid?

All states have local Medicaid eligibility offices where you can file applications. Many states also provide applications at different locations in your community, including Aging and Disability Resource Centers. In some states, you can also apply online.

Visit your State Medical Assistance Office to find out where you can apply for Medicaid benefits.

When Should You Apply for Medicaid?

The best time to apply for Medicaid depends on your medical situation, your marital status, and the complexity of your finances. If your finances are straightforward, the state may be able to process your application faster.

The Medicaid agency usually has 45 days to process your application. If the application requires a disability determination, the agency can take 90 days.

What is Medicaid?

Medicaid is a joint federal and state government insurance program that helps people of low income pay for some or all of their health care bills. It covers both medical care, like doctor visits and hospital costs, and long-term care services at home, such as assistance with personal care, and nursing home services.

Overall program rules and coverage are based on federal requirements, but states have options in developing programs including which services they provide and the eligibility requirement they use. As a result, rules and services vary from state to state.

General eligibility requirements and how to apply can be found on the Centers for Medicare and Medicaid Services website. Check the Resources section of this website for how to find the eligibility standards for your state.

If you have Medicaid and need long-term care services, you may be asked to meet additional eligibility requirements. These can be complicated. Requirements include how much assistance you need with personal care like bathing and dressing—called Activities of Daily Living.

Most states use a specific number of personal care and other service needs to qualify for nursing home care or home and community based services. There may be different eligibility requirements for different types of home and community based services. Each state has its own rules for who qualifies for Medicaid long-term care services.

Your State Medical Assistance office is the best source for information about how to qualify for Medicaid in your state, and if you qualify for long-term care services, is.

Applying for Medicaid

It may take longer to apply for Medicaid if you do not provide the required documents on time. If Medicaid thinks that you are not cooperating, it may deny your application for “administrative reasons.” If this happens, you will have to start your application over again once you have your documents in hand.

If the Medicaid agency determines that you are eligible, you will receive a letter with your date of eligibility and the amount you must pay toward the cost of your care. Medicaid will review your eligibility status every year. During the yearly review, you will be need to document your income and assets again. The review process is usually simpler than the original application process.

If the Medicaid agency determines that you are not eligible, you will receive a letter that explains the reason for denial. The notice will also explain how you can appeal the decision.

Medicaid Eligibility Requirements

You must meet three types of requirements to qualify for Medicaid long term care services:

  • General medicaid eligibility requirements
  • Functional requirements
  • Financial requirements

What are General Medicaid Eligibility Requirements?

To meet the general Medicaid requirements for long term care services you must:

  • Be age 65 or older
  • Have a permanent disability
  • Be blind
  • Be a U.S. citizenship or meet certain immigration rules
  • Be a resident of the state where you apply

What are Functional Eligibility Requirements?

In order for Medicaid to cover your long-term care services, a medical specialist in your state must evaluate your needs and decide if you need long-term care services. Usually, the specialist will make their decision based on whether you need assistance performing certain Activities of Daily Living (ADLs), such as:

  • Bathing
  • Dressing
  • Using the toilet
  • Transferring to or from a bed or chair
  • Caring for incontinence
  • Eating

If you do not meet Medicaid’s functional eligibility criteria, Medicaid will not cover long-term care services, regardless of financial eligibility.

If you do need long-term care services, the specialist will usually determine if you need nursing home care or home and community-based services.

The functional eligibility evaluation is not the same as your financial eligibility evaluation.

What are Medicaid’s Financial Eligibility Requirements?

To see if you meet the financial eligibility requirements for Medicaid, the state will look at your available income and assets.

To get Medicaid, you must have limited income and savings. The amount of income varies by state, but is generally set at the poverty level which in 2010 is $22,050 per year for a family of four. When the state determines your financial eligibility for Medicaid, the state will count some of your income, but not all. Your income includes these sources:

  • Regular payments such as Social Security
  • Veterans’ benefits
  • Pensions
  • Salaries
  • Wages
  • Interest from bank accounts

Medicaid will count payments to which you are entitled even if you don’t receive them. For example, if you get $500 a month from a trust that could pay you $1,000, Medicaid counts $1,000 as your income. If you and your spouse receive joint payments, such as rental income, the state allocates half to you and half to your spouse.

When the state determines your financial eligibility for Medicaid, some of your assets are considered, while others are excluded. During the Medicaid application process, you will have to document your assets. While Medicaid’s assessment of your income is relatively straightforward, the assessment of your assets is fairly complex.

Assets that do not get counted for eligibility include the following:

  • Your primary residence
  • Your personal belongings
  • One motor vehicle
  • Property that is essential to self-support
  • Life insurance with a face value under $1,500
  • Certain burial arrangements
  • Assets held in specific kinds of trusts.

Unless specifically excluded, any other real or personal property that you and your spouse own is counted in the Medicaid eligibility determination.

If you own assets jointly with others, the assets are generally divided equally among all owners when the state determines your Medicaid eligibility.

The amount of assets you can have and still qualify for Medicaid varies from state to state. In most states, you can retain about $2,000 in countable assets and married couples who are still living in the same household can retain about $3,000 in countable assets.

If one spouse lives in an institution and the other lives in the community, the community spouse is allowed to keep more assets without disqualifying the spouse in the institution from Medicaid coverage. In most states, the community spouse is allowed to keep half of the married couples’ combined assets, subject to both a minimum and a maximum amount. In 2010, the minimum was $21,912 and the maximum was $109,560.

Medicaid LTC Services

Medicaid covers nursing home services for all eligible people age 21 and older. Medicaid also covers home and community-based services for people who would need to be in a nursing home if they did not receive the home care services.

In most states, Medicaid will also cover services that will help you remain in your home, such as personal care services, case management, and help with laundry and cleaning. Medicaid will not pay for your rent, mortgage, utilities, or food. Check to see whether your state Medicaid program offers alternatives to nursing home care services.

It is important to understand that Medicaid programs and eligibility for services vary from state to state. Services that may be available to you in one state may not be available in another. For example, some states cover assisted living services under their home and community-based services waivers, while others do not. Contact your state Medicaid office to learn more about your state’s programs and eligibility requirements.

Medicaid Estate Recovery

If you receive Medicaid coverage for long-term care services, federal law requires states to recover the amount Medicaid spent on your behalf from your estate after you die. An estate is all of the personal property you own when you die, such as your home.

Estate recovery happens after the death of a Medicaid recipient who was either permanently institutionalized or age 55 and older. Some estates are exempt from estate recovery. For example, if your spouse is still alive, your estate is exempt from recovery. In these cases, states may recover from the spouse’s estate after his or her death. Your heirs can also seek a hardship waiver from estate recovery.


Administration on Aging

U.S. Department of Health & Human Services