Medicaid-Funded Nursing Home Alternatives for Long-Term Care

Last updated: March 01, 2021

 

Introduction

Seniors who require long term care often prefer to age at home or in their community rather than be admitted to a nursing home facility. Furthermore, many families want to avoid placing a loved one in this care setting if at all possible. While historically Medicaid only paid for long term care in nursing homes, this is no longer the case. Currently, several Medicaid-funded nursing home alternatives exist, all of which offer a larger degree of independence than does nursing home care.

Some of these long-term care options exist for persons who do not require a nursing facility level of care, but others are specifically designed for those who require this level of care. For instance, many home and community based services (HCBS) are offered via Medicaid waivers, and often, these waivers require a nursing home level of care. Based on the state in which one resides, care services may be provided in one’s home, the home of a friend or relative, an assisted living residence (including a memory care unit), or an adult foster care home. Furthermore, benefits to promote independent living (i.e., home modifications and personal emergency response systems) and assist informal family caregivers (i.e., respite care and adult day care) are provided to prevent and delay nursing home placement.

 Each of the programs described here require an individual to be eligible for Medicaid. This website offers multiple ways for candidates to determine their eligibility. A short Medicaid eligibility test is available. Alternatively, detailed state by state eligibility criteria are available here.

In-Home Care / Consumer Direction

One of the alternatives to nursing home care, Medicaid-funded in-home care, is a very popular option. With this type of long-term care, Medicaid beneficiaries receive care services (and benefits) to promote independent living in their own home or the home of a friend or family member. Many families who serve as informal (unpaid) caregivers for loved ones find this an especially good option. This is because the services and benefits provided via Medicaid can supplement the care the informal caregiver is providing, allowing the individual in need of care to continue to live at home.

While every state offers in-home Medicaid long-term care, the specific services and benefits available are state and program specific. A variety of non-medical care services, such as personal care assistance, homemaker services (i.e., cleaning, laundry, preparing meals, shopping for essentials), chore services (i.e., snow removal, lawnmowing), companionship / supervision, medication reminders, non-medical & medical transportation, meal delivery / congregate meals, respite care, and some medical care, such as home health care and skilled nursing, may be provided. Other benefits to promote independent living in one’s home may also be available via Medicaid. Examples include home modifications for safety and accessibility purposes (i.e., wheelchair ramps, grab bars, chair lifts, widening of doorways for wheelchair access), vehicle modifications, personal emergency response systems, assistive technology, and durable medical equipment.

Consumer direction of Medicaid-funded in-home care may be an option, depending on the state in which one resides and the Medicaid program. Program participants may be allotted a cash budget to select the services and supports, including how frequently, and when, care is received. Most commonly, self-directed care allows program participants to hire and manage the caregiver of their choosing to provide personal care, supervision, companionship, and homemaker services. Family members, such as adult children, are often hired as caregivers, and sometimes, even spouses can be hired. This ability to self-direct care can be particularly beneficial for family caregivers who have given up work to care for a loved one, as they can be compensated for providing care.

As with the availability of in-home services and benefits, the avenue of Medicaid payment also differs. In some states, Medicaid pays for in-home care via the state’s regular Medicaid program (or a state plan option, such as community first choice), other states pay for this type of care via home and community based services (HCBS) Medicaid waivers, and some states pay for in-home care through both the state Medicaid plan and HCBS Medicaid waivers. A benefit of receiving in-home care via one’s state Medicaid plan is that it is an entitlement, meaning if eligibility requirements are met, the state will pay for care. For in-home Medicaid waiver services, there may be a waitlist, as this type of program limits the number of participants at any given time. https://www.medicaidplanningassistance.org/medicaid-hcbs-waivers/
To be eligible for in-home care, and hence, Medicaid paying for it, one must meet functional and financial eligibility criteria. Specific requirements vary based on the state and the specific program. To see state specific criteria, click here.

To learn more about Medicaid-funded in-home care, the programs through which it is provided, and eligibility requirements, click here.

 

Assisted Living / Memory Care

Medicaid-funded assisted living is another of the nursing home alternatives for long-term care. Assisted living is a type of housing for the elderly and disabled in which supervision and care is provided. This home-like setting is for persons who do not require extensive care, but who cannot live 100% independently. Generally, assistance with activities of daily living (ADLs), like bathing, dressing, transferring (i.e., from bed to chair), medication management, housekeeping and laundry services, meals, social and recreational activities, and limited skilled nursing is available. In addition to Medicaid covering the cost of assisted living services, Medicaid may also pay for some other benefits, such as personal emergency response systems. The exact benefits available via Medicaid is state and program specific. Medicaid, however, will not pay the room and board portion of assisted living fees.

Some assisted living residences also offer memory care, which is specialized care to meet the needs of persons with Alzheimer’s disease and related dementias. Sometimes called Alzheimer’s care units, residents receive a greater degree of supervision and there is a higher level of security to prevent wandering, which is common in persons with dementia. Not all assisted living facilities offer memory care.

Assisted living services / memory care services may be paid by Medicaid through a state’s regular Medicaid plan, given the state offers personal care assistance through this avenue. Another option through which Medicaid might pay for services in assisted living / memory care is via HCBS Medicaid waivers. However, some states restrict the care setting and will not pay for care assistance for persons residing in assisted living residences, and not all assisted living residences accept Medicaid. Furthermore, there may be a waitlist to receive benefits via a waiver program.

In order for Medicaid to pay for services and benefits in assisted living / Alzheimer’s care units, one must meet the eligibility criteria set forth by the state in which one resides and the specific program for which one is applying. For all programs, an applicant’s functional need and finances are assessed. See eligibility criteria based on state.

For more information about Medicaid-funded assisted living and memory care, including eligibility criteria, click here.

 

Medicare PACE / LIFE Programs

While the Program of All-Inclusive Care for the Elderly (PACE) is not a specific type of long-term care, it provides an avenue through which there are many Medicaid-funded nursing home alternatives. In some areas of the country, this program goes by an alternative name: Living Independence for the Elderly (LIFE) program. PACE / LIFE is a managed care program through which persons 55 years+ who require a nursing home level of care can receive both their Medicare and Medicaid benefits. (Persons eligible for Medicaid and Medicare are called dual eligible).

In addition to medical care, a variety of long-term services and supports are available via PACE / LIFE. While nursing home care is covered via the Medicaid portion of the program, persons more commonly receive other long-term care benefits in place of institutionalization. These might include in-home care (personal care, homemaker services, home health), respite care (allowing family caregivers a break), and adult day care (for persons who require daytime supervision and care). Personal care assistance and homemaker services may be provided in a variety of settings, including one’s home, the home of a relative, an assisted living residence, or a memory care unit for persons with Alzheimer’s disease or another related dementia. To be clear, room and board is not covered for persons receiving care services via PACE / LIFE in an assisted living residence or a memory care unit.

For long-term care via PACE / LIFE, Medicaid reimburses PACE programs for the services provided for program participants.

Unfortunately, PACE / LIFE programs are not an option available nationwide. Rather, they are available in just half of the states.
For more information about PACE / LIFE programs, as well as eligibility requirements (some are specific to Medicaid, some to Medicare, and others to PACE / LIFE), click here.

 

Adult Foster Care

Another of the alternatives to Medicaid-funded nursing home care is adult foster care, also called adult family care or adult family living. This long-term care option allows persons to live in a home setting and receive 24-hour supervision and care. Generally, persons in adult foster care receive assistance with activities of daily living (i.e., bathing, dressing, mobility, eating), companionship, housekeeping, laundry, medication reminders, meal preparation and clean-up, and medical and non-medical transportation. While Medicaid will cover the cost of these care services, Medicaid will not pay for room and board in adult foster care.

In some cases, a relative or friend can provide the “foster home”, with the care recipient moving in with the caregiver or vice versa. (This is not a viable option for an individual to receive compensation for caring for his/her spouse). Adult foster homes may provide care for more than one “adult foster”. The allowable number varies based on the state in which one resides, but the cap is usually set at 5 or 6 adult fosters. However, it is not uncommon for only one adult foster to reside in an adult foster care home.

Depending on the state in which one resides, Medicaid may pay for services and benefits in adult foster care via a state’s regular Medicaid program or via a HCBS Medicaid waiver. Services provided via a waiver are not an entitlement, which means persons who meet the eligibility criteria may have to wait to receive services until a participant slot is available. The option of adult foster care as an alternative to nursing home care is not available in every state; Medicaid will not pay for adult foster care services in all states. Furthermore, the ability to reside in an adult foster care home is dependent on the availability of adult foster care homes.

Specific eligibility requirements vary based on the state and the specific Medicaid program through which adult foster care is offered. To see state-by-state Medicaid eligibility requirements, click here. One will need to inquire with their state Medicaid agency as to the availability of Medicaid-funded adult foster care services.

 If nursing home care is deemed the most appropriate option for Medicaid-funded long-term care for you or a loved one, Eden Alternative nursing homes offer an alternative philosophy to care, setting them apart from traditional nursing homes. In Eden Alternative homes, a person centered approach is featured in which residents are empowered to make decisions regarding their care and day-to-day life. Furthermore, the environment is created to encourage resident interaction with plants, children, and animals. Ultimately, the goal of the Eden Alternative approach is to eliminate loneliness, boredom, and helplessness in Eden Alternative nursing home residents. Unfortunately, not all Eden Alternative homes will accept Medicaid-funded residents.

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