The 3 Types of Medicaid Long Term Care

Summary
While most everyone knows what Medicaid is, what most families don’t know is that there are 3 different types of Medicaid programs that provide long-term care; Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers and Aged, Blind and Disabled (ABD) Medicaid. As the name implies, Nursing Home Medicaid covers all costs associated with living in a nursing home, including room and board. HCBS Waivers and ABD Medicaid cover long-term care benefits in the community, such as the recipient’s home, the home of a loved one or an assisted living facility.

All three programs require seniors to meet financial and functional criteria in order to qualify but these criteria are different for each program. The financial requirements, an asset limit and an income limit, are updated annually and vary depending on the recipient’s state of residence and marital status. The functional, or medical, requirements also vary depending on the program and state.

1) Nursing Home Medicaid

Medicaid is best known, and most used, for its nursing home coverage. Since Medicare will not cover long-term stays in nursing homes, the burden of government-funded coverage falls on the Medicaid program. Receiving Nursing Home Medicaid is an entitlement, meaning all qualified applicants are guaranteed to receive benefits without wait. However, as you know, not all nursing homes accept Medicaid, and those that do have limited spaces. So, qualified applicants may be guaranteed coverage, but they are not guaranteed a spot in any nursing home they choose.

Coverage and Eligibility Criteria
Nursing Home Medicaid covers all expenses normally associated with nursing homes. This includes physician’s visits, prescription medication, social activities and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as room and board costs. Items not covered by Nursing Home Medicaid include a private room, personalized food, and any care services not considered medically necessary.

In most states in 2024, the individual asset limit for Nursing Home Medicaid is $2,000 and the income limit is $2,829/month. Most assets and income are counted, with the exception of the home, which can be exempt under multiple circumstances. These financial limits can vary depending on the state and the recipient’s marital status. It’s also important to note that Nursing Home Medicaid beneficiaries must give most of their income to the state to help cover the cost of care.

The functional, or medical, criteria for Nursing Home Medicaid in all 50 states and Washington, D.C., is needing a Nursing Facility Level of Care (NFLOC). In general, a NFLOC is defined as needing the type of constant care and skilled supervision typically associated with a nursing home. However, the exact medical definition of NFLOC and how an individual’s care needs are evaluated can change depending on the state. Some states may define NFLOC as needing help with three of the Activities of Daily Living, others may say its needing help with four. Some states may place a greater emphasis on cognitive or behavioral issues in their evaluation, while others may weigh the need for skilled nursing services above all else.

2) Home and Community Based Services Waivers

Medicaid uses Home and Community Based Services (HCBS) Waivers to cover long-term care benefits for qualified seniors who live in the community. This often means living in their own home, but it can also refer to living in the home of a loved one, an assisted living facility, an adult foster home or other places outside of a nursing home. Exactly where HCBS Waivers will provide coverage depends on the waiver, the state and the individual.

Unlike Nursing Home Medicaid, HCBS Waivers are not an entitlement. Instead, they have a limited number of enrollment spots and once those spots are full additional applicants are placed on a waitlist. How those waitlists are prioritized and how long they might also last depends on the waiver, the state and the individual. That’s a lot of variables, but our team of professionals can help you find the exact coverage locations and waitlist details for the HCBS Waiver(s) relevant to your clients.

Benefits and Eligibility Criteria
HCBS Waivers provide a wide range of long-term care services and supports, although the exact benefits will depend on the program. These benefits can include:

• Personal care assistance with the Activities of Daily Living
• In-home nursing care
• Medical alert services
• Medication management
• Home modifications for safety and accessibility
• Homemaker and chore services
• Meal delivery
• Transportation
• Adult day care
• Respite care for unpaid caregivers

Every state has an HCBS Waiver that will cover long-term care benefits in the Medicaid recipient’s home or the home of a family member. As mentioned above, certain waivers in some states will also cover long-term care benefits in other places in the community. What HCBS Waivers won’t cover in any of these various locations is room and board expenses, such as mortgage payments, rent, utility bills and food expenses.

In most states in 2024, the financial requirements for HCBS Waivers are the same as the requirements for Nursing Home Medicaid – an individual asset limit of $2,000 and an income limit of $2,829/month. Again, most assets and income are counted, with the exception of the home, which can be exempt under multiple scenarios. And these financial limits can change depending on the state and the recipient’s marital status. Unlike Nursing Home Medicaid beneficiaries, HCBS Waivers beneficiaries are allowed to keep their income (with only a few exceptions).

The functional, or medical, criteria for most HCBS Waivers is needing a Nursing Facility Level of Care (NFLOC), which is the same requirement for all Nursing Home Medicaid recipients. As mentioned above, the precise medical definition of NFLOC and how care needs are evaluated can vary depending on the state. Some HCBS Waivers only require recipients to be “at risk” of needing a NFLOC.

3) Aged, Blind and Disabled Medicaid

Aged, Blind and Disabled (ABD) Medicaid can also be referred to as state plan or regular Medicaid for seniors, but it should not be confused with the state plan or regular Medicaid that is available to financially limited individuals of all ages. ABD Medicaid may also have different names in different states such as Texas where it is called Medicaid for the Elderly and People with Disabilities and Florida, Medicaid for Aged and Disabled.

ABD Medicaid is an entitlement, so all qualified applicants are guaranteed to receive coverage. However, there may be a wait for long-term care benefits depending on the availability of programs, funds and caregivers in the recipient’s area.

Benefits and Eligibility Criteria
ABD Medicaid will cover long-term care services and supports for beneficiaries who live in their own home or the home of a family member. Depending on the state and circumstances, ABD Medicaid may also cover long-term care benefits in other places in the community, such as the home of a friend, an assisted living residence, adult foster care or adult day care.

The long-term care services and supports covered by ABD Medicaid generally aren’t as robust as the benefits covered by HCBS Waivers, but they are similar. In most states, ABD Medicaid will cover personal care assistance with the Activities of Daily Living, in-home nursing, medical alert services, medication management and minor home modifications for safety and accessibility.

The functional criteria to receive these long-term care benefits through ABD Medicaid is very different than the HCBS Waivers criteria. ABD Medicaid recipients qualify for their long-term care benefits one at a time by showing a medical or functional need for that benefit, whereas HCBS Waivers recipients must show a Nursing Facility Level of Care to qualify, and then they are entitled to all of the benefits of that Waiver. The same is true for Nursing Home Medicaid, which makes all benefits and coverage available to all applicants as soon as they qualify.

The financial criteria for ABD Medicaid is also different than the financial criteria for HCBS Waivers and Nursing Home Medicaid, which is similar to each other. In most states in 2024, the individual asset limit for ABD Medicaid is $2,000 and the income limit ranges between $943 and $1,751/month. These limits can change depending on the recipient’s marital status.

Understanding the nuanced rules and differences between these programs, and how a senior can best use them and maximize their resources, is no easy task. But that’s exactly what our Certified Medicaid Planners do. To consult with them, click here.