While numerous facilities for assisted living employ various pricing strategies (e.g., a la carte or all-inclusive) to charge residents for services and amenities, the According to the Genworth Cost of Care Survey, a private one-bedroom apartment in an assisted living facility will cost an average of $4,500 per month nationwide in 2021. The cost of these services may be extremely difficult for seniors who need daily assistance with non-medical custodial care tasks (and their families).
Does Medicaid cover facilities for assisted living? What costs can you expect to be covered? We’ve got the answers you’ve been searching for.
Does Medicaid Pay for Assisted Living?
Yes is the quick response. As of 2022, 47 states and Washington, D.C., offer some level of assistance for individuals in assisted living or other forms of non-nursing home, residential care through their Medicaid programs.
By state, Medicaid assistance for assisted living varies. This is due to the fact that Medicaid is funded in part by the federal government and in part by the states. The federal government establishes rules for how each state must use its Medicaid funding. However, within those restrictions, the states are given a lot of flexibility. This allows states to set their own policies on how they assist persons residing in assisted living residences.
The fact that there are various Medicaid programs that cover assisted living services further complicates matters. HCBS Waivers (1915c Medicaid) for home and community-based services are most frequently used by states. The 1115 Demonstration Waivers and 1915b Managed Care Waivers are two additional waiver types that are used. Finally, regular Medicaid (sometimes called State Plan Medicaid) is also used in some states for assisted living services.
Each of these Medicaid options has advantages and disadvantages from the perspective of the family. Participants may typically have higher income eligibility limits under waivers than under regular or State Plan Medicaid. Most waivers allow monthly income caps of $2,523 in 2022, while Medicaid State Plans may impose a $1,132 monthly income cap. Keep in mind that these are very general numbers that change depending on the state, a person’s marital status, and other factors. Families are advised to read the table below for information specific to their state. The enrollment for waivers is typically limited. They have a limited number of “slots” available, and waiting lists are common. Regular Medicaid and State Plans cannot restrict enrollment because Medicaid is an entitlement. Finally, in most states, Waivers require the participant have “nursing home level of care needs.” The care needs of program participants may be less stringent under regular Medicaid.
Currently, 43 states and the District of Columbia offer some sort of financial support to residents of assisted living facilities. However, the term “assisted living” is not used consistently across these states, nor are their definitions or benefits the same. Other terms that are used include, but are not limited to, residential care, adult foster care, personal care homes, and supported living. Some states pay only for personal care services received in assisted living. Others include nursing services. Coverage for medication administration, chore and homemaker services, and even recreational activities, varies by state. No state is permitted to pay for room and board costs in assisted living. However, states also have other options for limiting these costs. They can:
- Cap the amount the residences can charge.
- Offer supplemental Social Security benefits to people who qualify for Medicaid to pay for assisted living room and board (from general state funds).
- Pay for meal preparation and serving but not the actual cost of the food.
It is crucial to understand that not every family will find Medicaid to be the best source of funding for assisted living. As Medicaid payment rates for assisted living (in Medicaid language it’s called “reimbursement rates”) are not high, not every assisted living community accepts Additionally, many families might benefit from finding affordable assisted living outside of the Medicaid system given the constrained range of services for which Medicaid offers assistance as well as the enrollment restrictions and lengthy waiting lists for Medicaid waivers.
What Medicaid Covers in Assisted Living?
According to the state and the specific program a senior applies for, Medicaid covers different assisted living services. All states offer assistance paying for some degree of personal care services (ADLs), but the ways in which those services are administered differ widely. For example, some state Medicaid programs provide eligible seniors with personal care assistance but not in an assisted living residence.
The fundamental services that most Medicaid programs will pay for in an assisted living facility include:
- Personal care services
- Services like housekeeping (e.g., meal preparation, laundry, light housekeeping)
- Case management
- Transportation
- Personal emergency response systems
If your loved one’s state Medicaid program does not cover the cost of residential assisted living, Medicaid waiver programs might be able to help. These programs might provide comparable personal care options, such as in-home care and adult day care. These exemptions allow senior citizens who are in danger of moving into nursing homes to stay in their current residences and neighborhoods. Unfortunately, many of these waiver programs have enrollment caps and waiting lists that can make it difficult for seniors to get the assistance they need in a timely manner.
How Much Will Medicaid Pay for Assisted Living?
Because Medicaid benefits are defined on a state-by-state basis, it’s difficult to say exactly how much Medicaid will pay for assisted living. The coverage amount will vary, based on:
- The state where a senior resides
- The program a senior is enrolled in
- The level of care a senior needs
However, for residents who meet the eligibility requirements, the majority of state Medicaid programs pay some portion of the cost of assisted living.
Most qualifying seniors will have access to the following Medicaid assisted living services:
- Nursing care
- Management of medications
- Medical exams and medical assessments
- Case Management
But, you might be wondering “does Medicaid pay for room and board in assisted living?
The answer to this question can be tricky as well.
Not exactly.
That’s because state Medicaid programs cannot directly pay for assisted living room and board. However, a number of states offer optional supplements and financial aid programs to assist seniors with that outlay. The Department of Human Services (DHS) or the Social Security Administration (SSA) frequently oversee these supplements and programs.
How to Apply for Medicaid to Pay for Assisted Living?
Seniors must adhere to strict financial and functional requirements, which change from state to state, in order to qualify for assisted living that is covered by Medicaid. The amount of income and assets that are allowed can vary depending on the type of care needed, a senior’s medical condition, where they live, and their marital status. A doctor must also certify that a senior’s need for care in an assisted living facility is “medically necessary.”
To qualify, the majority of seniors must carefully deplete their countable assets and income. They essentially pay out of pocket for the care they require up until they satisfy the financial eligibility standards set forth by their state. Savings, Social Security benefits, pension payments, and retirement funds are frequently used as payment methods for assisted living.
The Centers for Medicare and Medicaid Services (CMS) examines applicants’ financial histories to stop seniors from transferring assets and income to loved ones in order to qualify. The Medicaid look-back period is what we refer to as this. A senior will be penalized with a period of Medicaid ineligibility if they gave away assets or money for less than fair market value in the five years prior to applying.
Summary
The Medicaid program does, in the majority of states, offer some sort of financial assistance for assisted living. However, it is significant to remember that Medicaid does not cover fundamental lodging and food expenses for nursing home residents. the exact services covered by Medicaid in assisted living vary by state and by the specific program for which the senior applies.
