When it’s time to place a loved one in a good home, you, as his worried family member, find yourself in a confusing world of terms, programs, and acronyms. Many have heard of Medicare and Medicaid, but figuring out what each can and can’t do can be a lot to take in. Knowing which residential care options are covered is the most important question you can ask, especially since the answer depends entirely on what type of care is needed and which program is covered.
Here is what we will go through step by step, which will empower you to make informed decisions and leave with peace of mind.
Looking at Medicare and Medicaid: What’s Their Difference?
Before looking at the details of residential care options, it is vital to understand that Medicare and Medicaid are separate programs with distinct purposes.
First, Medicare is a federal program that provides insurance for individuals age 65 and older and for younger people with disabilities, as determined by the Social Security Administration. The program primarily covers what is deemed medical necessity, including (but not limited to) inpatient hospital stays, doctor’s visits, and skilled nursing care. It does not, however, include long-term care in a home-type setting, as that is not the program’s intent to begin with.
On the other hand, Medicaid is a joint effort between the Federal government and State programs to put together health care services for low-income and limited-asset individuals, making it the largest player in long-term care. While Medicare is focused on health care, Medicaid does a great job of covering ongoing support, transforming it into the top choice for residential care options for people who meet the financial requirements.
Which Residential Care Options Does Medicare Pay For?
We have to be honest here: Very few long-term residential care options are covered by Medicaid. This is the most common (and costly) problem families must handle when it comes to healthcare for an individual with IDD.
Skilled Care Facilities and Rehabilitative Services
The main issue here is that Medicare does not cover custodial care in assisted living facilities or nursing homes for daily activities such as bathing, dressing, or meal preparation. That said, Medicare Part A may pay for a stay in a Skilled Nursing Facility (SNF), but this is very much a case-by-case issue with certain conditions that must be met:
- The stay is short-term, which is within the first few weeks of a qualifying hospital stay of at least 3 days.
- Daily skilled nursing or therapy services are constantly required.
- Care must be provided by a Medicare-certified facility.
This does not include long-term residential care. This is a residential care option designed for recovery (post-stroke, surgery, injury) and to get the individual back home.
Home Health Care as an Option
While Medicare Part A is not a residential facility, it does cover skilled nursing, physical therapy, and home health, but only if the individual is homebound and needs skilled care. This, in turn, can allow time at home to be extended, thereby postponing, in some situations, the need for residential placement.
What is Not Covered by Medicare?
Medicare does not cover:
- Room and board in assisted living facilities.
- Custodial care, including help with daily activities in a residential setting.
- 24-hour supervision or long-term care.
For families considering residential care options, Medicare is usually not the solution for ongoing daily support needs.
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Medicaid as the Main Payer for Long-Term Residential Care Options
In most cases where Medicare leaves a gap, Medicaid steps in and fills it, though the coverage process is a bit more complex than it seems. It serves as the country’s largest provider of long-term health care, including many residential options.
Coverage in Long Term Care Facilities
While federal Medicaid law does not allow states to use Medicaid funds for room and board in assisted living homes, Medicaid may pay for the services provided within those homes. According to KFF, 41 states provide home health care services to eligible residents in assisted living facilities, provided they meet certain conditions.
This means Medicaid may pay for:
- Personal care assistance (bathing, dressing, eating).
- Medication management and administration.
- Nursing services.
- Case management.
- 24-hour on-call support.
The resident is still responsible for room and board provided by the residential care options, in which case they may pay from Social Security income or other resources. In some cases, states may also provide supplemental payments to help with these costs.
Home and Community-Based Services (HCBS) Waivers
Most states, including D.C., offer HCBS waiver programs that allow Medicaid funds to be used for community-based residential care options as an alternative to nursing homes. Services covered may include:
- Personal care and homemaker services.
- Respite care for family caregivers.
- Home modifications.
- Adult daycare.
Eligibility usually requires proof of nursing home-level care, as well as income and asset limits. Additionally, the individual must be a member of a target group (persons with IDDs, for example).
Long-Term Care in Nursing Homes
Medicaid does cover long-term care in nursing facilities for people who meet financial and functional eligibility criteria. For some, this is the only residential care option Medicaid will pay for directly, which is why home and community-based options are a national trend nowadays.
How to Begin the Journey
If you are looking into residential care options and wish to use Medicaid, there are a few steps you should consider:
- Reach out to your local Area Agency on Aging. They can go over your state’s specific programs, waivers, and eligibility requirements.
- Gather up financial documents. Medicaid has strict income and asset limits, as well as a five-year look-back period for asset transfers.
- Schedule a care evaluation. A nurse or social worker will determine what level of care is required.
- Consult an elder law attorney. Medicaid planning can be complex, which is why professional input is key to protecting assets while achieving eligibility.
Understanding which residential care options are covered by Medicare and Medicaid requires patience and research. Medicare provides short-term skilled care, but does not cover long-term custodial care. Medicaid, through its state-designed waivers and programs, is an alternative for those who qualify, including covered services in assisted living and other community-based settings. The key is to get started early, ask lots of questions, and seek out expert help.
At Harriet Residential Care in Washington, D.C., we work with families to resolve these complex issues, which means we are dedicated to ensuring that each woman who comes to us receives the respectful, person-centered support she deserves.
