Medicaid eligibility for Medicare beneficiaries who need long-term care in the home or community

Medicare and Medicaid

All states have at least one Medicaid home and community-based service (HCBS) waiver program that provides general health coverage and coverage for certain services to help you stay at home or in a community-based setting (for example, in an assisted living facility). Remember that Medicare only covers home health care if you meet certain criteria, such as being homebound and needing skilled care. Even if you qualify for Medicare-covered home health care, you may need additional services. Medicaid can be used to supplement the amount and kind of services you get. If you do not meet Medicare’s requirements for home care, you still may be eligible for a Medicaid HCBS waiver program.

Services covered through an HCBS waiver program may include:

  • Personal care
  • Homemaker services
  • Case management
  • Adult day care
  • Skilled nursing care
  • Therapy services
  • Home modifications
  • Respite care
  • Help with chores

The amount and type of services that Medicaid may cover varies by state.

You may qualify for help from a Medicaid HCBS waiver program if you:

  • Meet your state’s functional eligibility requirements for home and community-based services
  • And, have income and assets below certain guidelines (remember, your state may have higher Medicaid income guidelines if you need long-term care, or a spend-down program to help you qualify)

States have different functional eligibility standards for determining whether you are eligible for home and community-based waiver programs. Most states require you need a nursing home level of care to qualify, but you may be able to need less care and still qualify for Medicaid coverage. States will also usually assess your need for help with activities of daily living (such as toileting, bathing, and dressing).

When you qualify for a Medicaid HCBS waiver program, Medicare still covers medical services you may need beyond your home health care. For example, if you need to go to a doctor or specialist’s office, Medicare will pay first for most of these services, and Medicaid will pay second by covering your remaining costs, such as coinsurances, copayments, and deductibles.

There are a few things you should keep in mind before applying for a Medicaid HCBS waiver program:

  • Medicaid HCBS waiver programs may consider you and your spouse together when counting your income and assets, but you may be able to set aside a certain amount of your income and assets for your spouse to keep. If your state allows you to set aside a certain amount for your spouse, this amount will not be counted when you apply for Medicaid.
  • If you own your home, be sure to talk to an elder law attorney about how your Medicaid coverage will be affected. The equity from your home may count as an asset when you are being screened for Medicaid eligibility.
  • Even if you meet the eligibility guidelines for a Medicaid HCBS waiver program, there are generally limits on the number of people who can receive these benefits in your state. Check with your local Medicaid office to see if there is a Medicaid HCBS waiver program waiting list.