Level of care requirements can change drastically for seniors with Alzheimer’s disease and other dementias as their condition progresses. Medicaid can account for these changing needs through its three programs relevant to the elderly – Home and Community Based Services (HCBS) Waivers, Nursing Home Medicaid and Aged, Blind and Disabled (ABD) Medicaid. These programs can provide important benefits to seniors in the early, mid or late stages of dementia, and they can provide them in a variety of settings, including the home, assisted living facilities and nursing homes.

Medicaid’s Functional/Medical Eligibility Requirements

Needing a Nursing Facility Level of Care (NFLOC) is an eligibility requirement for Nursing Home Medicaid and most HCBS Waivers. In general terms, NFLOC means the type of care and supervision normally associated with a nursing home. But how NFLOC is defined and measured can vary depending on the state. Some states may consider a NFLOC as needing help with two of the five Activities of Daily Living (mobility, bathing, dressing, eating, toileting), others may consider it as needing help with three of the five.

Most importantly for this discussion, having Alzheimer’s disease or another dementia does not necessarily mean a person requires a NFLOC.

Most states do take cognitive issues into consideration when assessing level of care needs, but how much weight they give those issues and how they evaluate them can vary. For people with late-stage Alzheimer’s or severe dementia, chances are good their health has deteriorated to the point where they will require a NFLOC and will most likely need nursing home care. But seniors with dementia who require a NFLOC and want to stay living in the community can receive long-term care services and supports that will help them do just that through a HCBS Waiver.

Every state has a HCBS Waiver that will provide long-term care in a beneficiary’s home or the home of a family member. There are also some HCBS Waivers that will provide benefits in adult foster homes, adult day centers and assisted living facilities, including memory care units for people with Alzheimer’s and other dementias.

Seniors in the early or middle stages of Alzheimer’s disease or another dementia may not meet the qualifications of needing a NFLOC. In these cases, ABD Medicaid might provide them with some useful benefits. ABD Medicaid has no medical requirements for general healthcare, but ABD Medicaid recipients in some states who show a need for long-term care benefits might be able to qualify for these benefits on a piecemeal basis through ABD Medicaid without needing a full NFLOC. For example, someone with early-stage dementia may be physically strong and not require a NFLOC, but since they keep forgetting their medication they could qualify for the long-term care benefit of medication management.

The financial requirements for ABD Medicaid tend to be stricter than those for Nursing Home Medicaid and HCBS Waivers. But these financial requirements can change depending on the state, the exact program and the applicant’s marital status.

To find out which HCBS Waivers and ABD Medicaid programs are available in your area, how they might help dementia patients and their families, what their requirements are and how your state might define and measure NFLOC, connect with our team of professionals.

Waitlists for Benefits vs. Entitlements

Most HCBS Waivers have a limited number of enrollment spots. Once those spots are full, additional applicants will be placed on a waitlist. How these waitlists are populated and prioritized depends on the state and the Waiver. Some use a first-come, first-served method to take individuals off the list, while others prioritize based on need. Some will pre-screen and only place eligible applicants on waitlists, while others will place all additional applicants on their lists. This is an important distinction for people with a deteriorating dementia condition since they could get on a waitlist knowing they didn’t meet the qualification of needing a NFLOC yet, but they will in the near future.

ABD Medicaid, on the other hand, is an entitlement. This means all eligible applicants are guaranteed benefits without wait. For ABD Medicaid, however, eligible applicants are only guaranteed general healthcare coverage. There may be a wait for long-term care benefits via ABD Medicaid depending on the situation. The organizations that provide long-term care in the community for ABD Medicaid often have limited funding and staff, and either of those could create a waitlist for services. In some places it may be the same organization providing long-term care for both the HCBS Waiver and ABD Medicaid beneficiaries in the area, so they could all be subject to the same waitlist.

Nursing Home Medicaid is also an entitlement, so there is no waitlist for coverage for qualified applicants. However, Nursing Home Medicaid beneficiaries may run into waitlists at individual residences that have limited Medicaid beds. So, for families with loved ones who are in the early or mid-stages of Alzheimer’s disease or another dementia and don’t need a nursing home yet, it might be worthwhile to do some research, see if the local nursing homes have Medicaid beds or waitlists, and get on a waitlist, or find another nursing home, if necessary. During this process they should also be wary of Medicaid-based discrimination.

Medicaid Benefits for Seniors with Alzheimer’s Disease and Other Dementias

The in-home, long-term care benefits covered by HCBS Waivers and ABD Medicaid can be invaluable for people with dementia and their families. As mentioned above, these benefits can be provided in the home, the home of a family member, adult foster homes, adult day centers and assisted living facilities, including memory care units for people with Alzheimer’s disease and other dementias. However, if a benefit is already being provided by the facility, Medicaid will not cover a duplicate benefit, but it may be used to enhance the benefit. For example, if an assisted living facility provides all meals, Medicaid will not cover meal delivery. But if a facility covers 10 hours/week of personal care, Medicaid may add to that coverage and up it to 15/hours per week, if it is deemed medically necessary to maintain or improve the health condition of the individual.

In general, HCBS Waivers offer a wider range of services and supports than ABD Medicaid programs, but the benefits can vary depending on the state program, the Waiver and the beneficiary’s needs. However, many programs and Waivers include the following services and supports that would be especially helpful to those with Alzheimer’s disease and other dementias:

• Case Management
• Adult day health care
• Assistance with the Instrumental Activities of Daily Living (cleaning, shopping, cooking, medication management)
• Transportation to medical appointments
• Meal delivery
• Medical alert/reminder devices
• Personal Emergency Response Systems
• Financial management services
• Home modifications for safety and accessibility
• Respite care for family caregivers
• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)

If an Alzheimer’s patient can no longer live in the community, Medicaid will help cover all costs associated with living in a nursing home, including room and board, medical care, medications and 24/7 supervision. However, Nursing Home Medicaid beneficiaries are required to give almost all of their income to the state to help pay for coverage.

Program of All-Inclusive Care for the Elderly

The Program of All-Inclusive Care for the Elderly (PACE) will coordinate healthcare, long-term care and social service benefits for individuals over the age of 55 who require a NFLOC but want to live in the community and have a PACE organization in their area that will help them do so. This streamlined approach can be especially helpful to those with Alzheimer’s or dementia, since the PACE plan organizes coverage and benefits, including Medicaid and Medicare benefits for those who are dual eligible, schedules appointments and provides transportation. In fact, the National PACE Association estimates that just about half of PACE program participants have been diagnosed with dementia. PACE also covers hearing, vision, dental and foot care, and PACE adult day health centers count provide medical oversight, nursing services, meals, social activities and exercise programs among their benefits.

PACE is fully covered for Medicaid beneficiaries. Once enrolled in PACE, program participants don’t have to pay deductibles or co-pays for any care, medication or service provided by the PACE interdisciplinary team.