Nursing Homes Denying Medicaid Beneficaries

There are two ways to look at this question. Can Medicaid deny coverage for a specific nursing home or assisted living residence? And can a nursing home or assisted living residence deny entry for a Medicaid beneficiary?

First of all, not every nursing home nor assisted living residence accepts Medicaid. It is estimated that approximately 90% of nursing homes and 50% of assisted living residences are Medicaid-certified. This means that they accept Medicaid as payment. If a facility is not Medicaid-certified, Medicaid will never pay for long-term care in that facility. Furthermore, even if a facility accepts Medicaid, the number of Medicaid “beds” may be limited, and once the facility has reached its maximum number of Medicaid residents, no more are accepted. Therefore, Medicaid coverage in that facility is denied (unless a Medicaid bed becomes available). Therefore, when considering a nursing home facility or assisted living residence, it is vital that one inquire if Medicaid is accepted, and if so, if there is a Medicaid bed available. Find Medicaid-certified nursing homes. Learn more about finding Medicaid-certified assisted living residences.

While Medicaid will pay for long-term care, as well as room and board in Medicaid-certified nursing homes, Medicaid will never pay for room and board in a Medicaid-certified assisted living residence. Instead, Medicaid will only pay for long-term services and supports in assisted living. Therefore, the Medicaid recipient must pay this cost. States try to make room and board costs more affordable for Medicaid recipients, but if one cannot afford it, they cannot reside in the assisted living facility, and Medicaid will not pay for long-term care. Additionally, Medicaid does not pay for assisted living services in all states, and therefore, Medicaid coverage for assisted living services is denied.

Another piece of the puzzle as to if Medicaid will deny coverage, is the ability of a specific facility to meet one’s care needs. For instance, in some cases, one’s medical needs might be greater than a facility is equipped to handle. If this is the case, admittance to the nursing home or assisted living residence is denied, and Medicaid will not provide payment.

Note: Medicaid payments to a nursing home or assisted living residence are generally less than private pay, and therefore, facilities often prefer residents who pay privately. However, if a facility is Medicaid-certified, they cannot discriminate against Medicaid recipients and deny entry solely on the basis that one is on Medicaid. Additionally, a private pay client that becomes a Medicaid recipient cannot be evicted for this reason (unless the facility does not accept Medicaid or has no available Medicaid beds). Learn about evictions and denied admittance to assisted living for Medicaid applicants and beneficiaries.