Medicaid is a valuable resource for families with loved ones needing in-home care (see, What is home care?). Medicaid will cover in-home care for older adults under specific income and care need circumstances.
Understanding the criteria to qualify for Medicaid, what it covers, and how you can maximize the benefit will ensure you get the care you or a loved one needs and deserves.
Most older adults state they prefer to age at home and receive services where they live, and Medicaid can assist with that goal. Let’s review Medicaid, how it differs from Medicare, and how they can work together to provide wrap-around services for your loved one.
Understanding Medicaid and Its Coverage
Medicaid is complicated because it is a joint program between the federal government and the states. Although the federal government dictates rules, states have the flexibility to stipulate eligibility and benefits so programs can vary.
What is Medicaid?
Medicaid is a federal program that helps cover medical expenses for low-income individuals 18 and over. In contrast, Medicare provides health insurance for people 65 and older and for some people with disabilities or specific conditions. Medicare is not income-based but doesn’t provide many of the services that Medicaid does.
Medicaid Eligibility for Older Adults
Let’s examine Medicaid eligibility for older adults more closely, given that state-specific variations in criteria and coverage will occur.
Qualifying for Medicaid
Medicaid eligibility is determined by a complicated methodology called Modified Adjusted Gross Income (MAGI). For adults and children under the age of 65, MAGI uses taxable income.
For adults 65 and over, eligibility will depend on where you live, but in general, these factors determine eligibility:
- Citizenship Status: You must be a US citizen or eligible to become a citizen
- State You Reside In: You must live in the state where you are applying
- Income: An income below 138% of the federal poverty level. For example, in 2024, the federal poverty level for an individual is $15,060.
- Age: Eligibility may vary depending on whether you're under or over 65. For individuals 65 and older, additional factors like long-term care needs or certain state-specific programs may apply.
- Household Size: Medicaid takes into account the number of people in your household when calculating income eligibility. The more individuals in the household, the higher the allowable income limit for eligibility.
- Disability Status: Individuals with disabilities may qualify for Medicaid regardless of age. Eligibility is typically determined based on medical evidence of a disability that limits the ability to work or perform daily activities, as defined by Social Security Administration standards.
State Variations
Beyond the federal government requirements for people who meet the automatic enrollment guidelines, each state can extend coverage to other optional groups.
Mandatory Medicaid Coverage
If you receive Supplemental Security Income (SSI), you automatically qualify for Medicaid. Also, if you have qualified for the Medicare Savings Program (MSP), you may qualify for some Medicaid benefits.
Optional Medicaid Coverage
Each state can choose coverage for optional groups that may include:
- Low-income individuals
- Individuals eligible under the “medically needy category”— a classification for people who may exceed the income level for Medically but have medical expenditures that can help them meet the criteria to qualify for Medicaid. This process is called a “Medicaid spend-down.”
- Individuals with certain disabilities—people with certain disabilities may meet a broadened income definition to qualify for Medicaid. Each state determines the level of care needed to be eligible for benefits.
Section 1115 Waiver
Section 1115 Waiver is a provision that allows some states to implement pilot programs that extend Medicaid benefits to individuals who may not otherwise qualify. Section 1115 pilot programs are essentially demonstration projects approved for five years and extended beyond that if they continue to meet federal criteria.
Dual eligibility
"Dual-eligible” refers to people who qualify for both Medicare and Medicaid. There are several ways Medicaid can work with Medicare:
- Medicaid can act as secondary insurance. Medicare is considered your primary insurance, and Medicaid pays last, covering coinsurance and copays.
- Medicaid can cover premiums. The Medicare Savings Program (MSP) pays your Medicare Part B premium and may offer additional help as well.
- Qualified Medicare Beneficiary (QMB). QMB requires that you meet income-specific income criteria. If you do, QMB helps pay for Medicare Part A and B premiums, coinsurance, copayments, and deductibles.
- Prescription drug coverage. Dual-eligible individuals are automatically enrolled in the Extra Help Program to assist with the cost of prescription drugs.
To determine which of these benefits apply to you, you'll need to know your income level and whether you qualify for programs like the Qualified Medicare Beneficiary (QMB) or Medicare Savings Program (MSP). Your state’s Medicaid program and Medicare interact differently depending on these factors.
It’s important to check with your state's Medicaid office or Medicare directly to get specific details about your eligibility and how the programs will work together for you. Additionally, your Medicare plan’s annual notice of changes may include information about your dual eligibility benefits.
Medicaid Coverage for In-Home Care
Medicaid covers some form of in-home care in all 50 states. It generally has more flexible options for in-home care than Medicare.
Types of In-Home Care Covered by Medicaid
When we talk about in-home care, it is important to define Medicaid-covered in-home care in broad terms that include both medical and non-medical care.
Let’s examine the services someone on Medicaid might be eligible for in their home:
- Activities of Daily Living (ADLs): Help with dressing, bathing, mobility, cooking, cleaning, and toileting.
- Home Health Care: Home health care includes medical services such as skilled nursing, physical, and occupational therapy.
- Durable Medical Equipment (DME): Provision of wheelchairs, walkers, oxygen, hospital beds, etc.
- Respite Care: Intended for family caregivers, respite care provides caregivers and family a break from caregiving duties.
- Transportation: Medical and non-medical.
- Meal Delivery Services
- Home Modifications: Examples include installing grab bars, wheelchair ramps, etc.
However, it’s important to note that Medicaid coverage can vary by state. While many states offer these services, not all Medicaid beneficiaries are automatically eligible for each service. Eligibility may depend on the specific Medicaid program you’re enrolled in, your medical condition, and your state’s rules. You can learn more about the different responsibilities a home caregiver might perform here.
Some services may be available through Home and Community-Based Services (HCBS) waivers, which have additional requirements or limitations.
To get a clear understanding of the services available to you, it’s important to check with your state’s Medicaid office or a Medicaid caseworker.
Medicaid Waivers and Programs
Medicaid Home and Community Based (HCBS) Waiver programs are state programs that offer in-home support and services in place of institutional care. States have wide latitude regarding the types and number of programs they choose to provide.
Traditional Medicaid requirements are “waived” to support more people in need, and in some cases, family caregivers are paid to provide care to a loved one.
Here are the requirements of HCBS Waiver programs:
- They must demonstrate that the cost of a waiver program doesn’t exceed the cost of institutional care.
- The program must have provider standards to meet the population's needs.
- Ensure an individualized plan of care.
- Ensure that the client's health is protected.
State Variations
States can design programs that meet the unique needs of their state population by doing the following:
- States can target the areas of greatest need.
- States can offer waiver programs to clients most vulnerable for placement in institutional care.
- States can waive specific income requirements to keep people out of institutional care.
Steps to Apply for Medicaid In-Home Care
Applying for Medicaid can seem daunting, but taking your time and having all the information you need before applying will help the process go more smoothly. Once you are approved for Medicaid you can apply for in-home care programs.
Preparing Your Application
You must apply for Medicaid in the state where you reside.
In general, you will need the following documentation for your application:
- Proof of date of birth and US citizenship, such as a passport, birth certificate, driver’s license, green card, or employment authorization card.
- Proof of income such as pay stubs, social security income, and retirement benefits.
- Proof of assets such as stocks, property, and bank statements.
- Insurance cards such as Medicare or other health insurance
Overcoming Common Challenges
If you have trouble applying for Medicaid, call your local Area Agency on Aging, who can direct you to local resources that can help.
If you are turned down for Medicaid, you have the right to appeal the decision but ensure that the reason you were denied wasn’t due to missing documentation. Once on Medicaid, you must re-certify each year to demonstrate that you are still eligible.
Applying for In-Home Care
One thing to remember is that not every home care agency is contracted with Medicaid to provide services. Since each state has various Medicaid programs, if you have access to the internet, reviewing programs you might be eligible for is a good first step.
Your state Medicaid office will have in-home care programs you can apply for if you think you qualify. If you need additional assistance, contact your local Area Agency on Aging to help you through the process.
What to Do If Medicaid Doesn't Cover Your Needs
If Medicaid doesn’t cover your needs, you will want to consider some creative alternatives to get the care you need.
Alternative Financial Assistance Options
Here are some possible financial assistance options to pay for care, but you may want to consult with your family or a financial advisor before making significant financial decisions.
- Clara Home Care: Clara Home Care helps families save money by contracting directly with the best caregivers. Our tailored care services ensure that you get the support you need at an affordable price, without compromising on quality.
- Veterans Benefits: If you or your spouse is a veteran, you may qualify for homemaker or home care services through the U.S.Department of Veterans Affairs. Also, check the Aid and Attendance program through the VA.
- Home Equity: If you own your home you may be able to leverage your home as a financial resource through a home equity line of credit or reverse mortgage.
- Life Insurance Policy: You may be able to convert your policy into cash to pay for in-home services. Check with your insurance agent to review your options.
- Nonprofit Organizations: Nonprofit organizations such as Catholic Community Services and Jewish Family Services often have programs to assist families with caregiving.
- Benefits Check Up: Benefits CheckUp is a site where you can find government and local programs for financial assistance.
Paying Out-of-Pocket
Paying out of pocket for in-home care can get expensive. However, Clara Home Care offers the best value and top-tier care, ensuring your loved one receives the highest quality support at a price that works for your budget.
Medicaid and In-Home Care
Medicaid is a terrific resource that can assist families in paying for in-home care. Depending on where you live, you may have access to a range of programs to keep you safe and cared for at home.
This article was reviewed and fact-checked by Megan Jones, MSW, LSWAIC.
Sources
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