Top Ten FAQs about Medicaid, Medicare, and Long Term Care

Medicare vs. Medicaid

1. What does Medicaid pay for long term care?

If you are eligible, Medicaid pays for long-term care services at the nursing home level of care. Medicaid can also pay for with care services given at home by visiting nurses, therapists, or caregivers. Not to be confused with Medicare, Medicaid pays for care in nursing homes and custodial care at home.

2. Can I have Medicare and still qualify for Medicaid?

Some services overlap when it comes to Medicare and Medicaid coverage. Overlapping services can include hospital care, doctor’s visits, some home care, and skilled nursing care. When this happens, Medicare will pay first and then Medicaid covers any remaining costs such as Medicare copayments and coinsurances. When people are eligible for both programs, they are called “dual eligible.” For those people who meet the eligibility requirements for both Medicaid and Medicare, most, if not all, of their health care costs will be covered.

3. Can seniors get Medicaid?

Unlike Medicare, simply being 65 years old does not guarantee you access to Medicaid. Each state has different eligibility requirements which include income, assets, and medical neediness. Some people may be financially eligible, but do not meet the strict medical requirements. Your state will send out an agent to perform a medical test. Applicants are expected to submit up to five years of their financial history with their applications.

4. What do you need to be eligible for Medicaid?

Medicaid is a joint effort between federal and state governments and in order for states to participate in Medicaid; federal law requires them to cover specific groups of individuals. These groups include low-income families, eligible pregnant women, low-income children, Supplemental Security Income (SSI) recipients, and low-income seniors in need of nursing home level of care. All states cover the same groups of people, but each state has unique eligibility requirements. Click here for more information about your state’s specific requirements.

5. Is long term care covered by Medicare?

Medicare is not meant to cover long term care costs. They will help pay for a short stay in a skilled nursing facility if the person in need has already spent time in a hospital. For people in need of long term care, we recommend looking into your state’s long term care Medicaid program.

6. Is assisted living covered by Medicare?

Generally, Medicare does not cover costs associated with assisted living or any other type of long term care facility. Although Medicare will not cover the cost of living in a facility, they will cover qualified healthcare costs while living at a long term care facility. As mentioned above, Medicare is more commonly used for skilled nursing or certain facets of home health.

7. How do I apply for Medicaid Long term care?

You must be a U.S. resident, meet the medical requirements, and meet the financial guidelines. Each state has unique rules so be sure to visit your state’s long term care website. Generally, applications are taken through the Department of Human Services (DHS) or the Department of Aging (DoA). Elder law attorneys can help make sure your application is correct. They should also help you understand if it is worth it to apply in the first place.

8. How long does Medicare pay for nursing home care (skilled nursing)?

If the person in need of care has already spent at least three days in a hospital receiving medically necessary care, Medicare will pay for up to 100 days of nursing home care immediately after hospital discharge. The patient must go to a nursing home that is Medicare-certified.

9. What is Medicaid Spend-Down?

Because Medicaid has income and asset limitations, people sometimes need to spend down excess income in order to qualify. The catch? The extra income must be spent on medical bills or long term care costs. The medical expenses must be more than the spend-down amount, which again, is the amount of money by which a person’s monthly income exceeds the Medicaid income allowance for living expenses.

10. What is the PACE program?

PACE stands for Program of All-Inclusive Care for the Elderly. PACE provides certain medical and social services to elderly people who choose to remain in the community rather than seeking care through a nursing home. The person seeking care must need a nursing home level of care. PACE provides services covered by Medicare and Medicaid, as organized by a healthcare team. These services include: prescription drugs, doctor’s visits, transportation, home care, hospital visits, nursing home stays if necessary, adult day care, social work counseling, physical/occupation therapy, meals, and more.

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