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Specifics on Medicaid Eligibility

“Nursing Home Eligibility”

There are two requirements which determine eligibility for Medicaid nursing home care - financial requirements and medical requirements. The financial requirements are comprised of income limits and asset limits, which were detailed in the prior week’s blog. The level of care requirement entails that the applicant needs care that is usually provided in a nursing home. A formal designation is called “Nursing Home Level of Care” (NHLOC), which requires a medical doctor to make this designation and the rules that define it vary from state-to-state.

Nursing home care/Institutional Medicaid is an entitlement, therefore If an applicant meets the financial and level of care requirements, a state must pay for that individual’s nursing home stay. Home care and assisted living are not considered entitlements. An applicant can meet all the eligibility criteria for home care or assisted living and still be wait-listed to receive assistance.


“Assisted Living Eligibility”

How does Medicaid pay for assisted living/senior living since it is not an entitlement? Those who reside in assisted living residences receive assistance from Medicaid either through HCBS Waivers or through the state’s Aged, Blind and Disabled (ABD) Medicaid.

HCBS Waivers are geared to help individuals who require a nursing home level of care but prefer to receive that care while living at home or living in assisted living. HCBS Waivers will not pay for the room and board costs of assisted living but will only pay for care costs. Waivers are not entitlements. They are federally approved, state-specific programs that have limited enrollments. Many HCBS Waivers have waiting lists. An individual can be financially and functionally eligible for an assisted living waiver and still not be able to enroll due to the waiting list.

The eligibility requirements are the same for both Medicaid assisted living through a Medicaid HCBS Waiver and for nursing home care. Candidates must require “nursing home level of care” and meet all the financial requirements.

Aged, Blind and Disabled (ABD) Medicaid provides help for persons in assisted living differently than Waivers. It provides beneficiaries with a caregiver and the beneficiary can use that caregiver at their place of residence. So, the individual could live at home or in an assisted living community. As long as the beneficiary does not reside in a nursing home, it’s irrelevant where they live.

ABD Medicaid will not pay for assisted living room and board, only for care.  Additionally, it will necessarily pay for all of individual’s care needs. The good news about ABD Medicaid (when compared to waivers) is that ABD Medicaid is an entitlement, so the Medicaid program must provide an applicant with the assistance needed, so long as he or she meets the eligibility criteria. Although ABD Medicaid typically has more restrictive income limits than Medicaid Waivers or nursing home care, it usually does not insist that beneficiaries need a “nursing home level of care.” ABD Medicaid financial eligibility criteria varies according to each state


“In-Home Care Eligibility”

Medicaid beneficiaries can receive assistance in their home through a Home and Community Based Services (HCBS) Waiver or through Aged, Blind and Disabled (ABD) Medicaid. These are two different types of Medicaid programs with different eligibility requirements.

HCBS Waivers offer home care as a benefit throughout each state. Unfortunately, HCBS Waivers are not entitlements. Therefore, being eligible does not necessarily mean one will receive care. It is very likely one will be put on a waiting-list for assistance. Waivers have the same level of care and financial eligibility criteria as nursing home Medicaid.


“Options When Over the Limits”

At times, individuals or couples exceed Medicaid’s income or asset limits, yet they can’t afford to pay for needed care. In these circumstances, Medicaid offers different types of pathways to meet eligibility.


“Medically Needy Pathway”

Medically Needy Medicaid is currently available in 32 states and D.C., is a great option. The Medically Needy Pathway, considers the Medicaid candidate’s income AND their care costs. If Medicaid finds one’s care costs consumes the vast majority of one’s income, then Medicaid will allow the individual to become eligible regardless of how high their income is.

In New Jersey, the program is called the “Medically Needy Program” or the “Special Medicaid Program, Medically Needy Segment.” It’s also commonly referred to as a “spend down” program for excess income. The income amount that is over the Medicaid eligibility limit is used to cover medical bills and health insurance premiums.


“Medicaid Planning”

Medicaid Planning is a strategy for assisting individuals whose income or assets exceed Medicaid’s limits can become Medicaid eligible. They can seek assistance from a Medicaid expert who can re-structure their finances to help them become eligible.


Side Note:

Callahan Financial Services Group takes the guesswork out of applying for Medicaid benefits for long-term care. If you or a loved one are in need of these benefits, please do not hesitate to call us at (973) 325-7500. Our friendly staff is here to help you and answer any of your questions. We can also arrange an appointment to meet with you in person at our office to discuss your eligibility and explain the application process, including the necessary items to apply.


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