Will Medicaid help pay for assisted living?

What assisted living is

Assisted living is a group home setting where people have their own space and get help with daily life. The government's long-term care site describes it as housing plus help with personal care and other services, such as meals. It says assisted living and board and care homes generally do not provide medical care.

Nursing homes are a different kind of place. The same site calls nursing homes the most service-intensive housing option. They provide skilled nursing care and therapies when a person needs them, along with round-the-clock supervision.

Families often wonder which setting would fit best. The person who needs care should decide with help from the doctor. This page explains only how Medicaid fits in. Our Medicaid nursing home coverage guide covers the other setting in detail.

Why Medicaid does not pay for the room

Medicaid.gov explains how nursing home care is paid. A nursing home takes on the total care of a person, so its payment includes room and board. Room and board means the place to live and the meals. Medicaid.gov also says other Medicaid services are specifically prohibited from including room and board.

That rule is the reason assisted living is hard to cover. Most of the cost of assisted living is the housing and meals, and Medicaid generally does not pay that part. You or your family would pay for the room and the meals from your own money.

Medicare does not step in to fill that gap. Medicare.gov says Medicare does not pay for long-term care, whether it is in a nursing home, at home or in an assisted living facility. The difference between the two programs is laid out in our Medicaid vs Medicare guide.

How a waiver can help with the care

A state can still use Medicaid to pay for care services given in the community. The main tool is the home and community-based services waiver. A waiver is a permission from the federal government that lets a state run a program with its own rules. Medicaid.gov says forty-seven states and Washington, DC run at least one of these waivers.

Medicaid.gov lists the kinds of services a waiver can offer. Examples are case management, homemaker help, home health aide help, personal care, adult day health and respite care. Respite care means short-term care that gives a family caregiver a break. States can also propose other services that help a person stay out of a nursing home.

A federal rule from 2014 sets standards for the places where people get these services. CMS said the rule applies to all settings where waiver services are given and does not single out assisted living. This means an assisted living home can be a place where waiver services are given, if it meets the federal standards and the state includes it. Each state decides which settings and which services its waiver includes.

Waiver programs have rules about who can join. A person must need the level of care that a nursing home or similar facility would give, according to Medicaid.gov. A state can target a waiver to a certain group, such as older adults or people with a certain disability. States can also use the spousal impoverishment rules to decide financial eligibility for waiver services, says Medicaid.gov. Our nursing home guide explains how those rules work.

Waiting lists and caps

States choose the maximum number of people who can be served under a waiver, says Medicaid.gov. When the program is full, new applicants may have to wait. Federal rules now make states report on waiting lists in waiver programs.

A waiting list can be long, so it is worth acting early. Ask your state Medicaid office to add the person to the list as soon as possible. Find out how people are chosen and what help is available in the meantime.

Federal law also looks at gifts and transfers of money before you apply. The 60-month look-back that applies to nursing home care applies to waiver services as well. Talk with a legal aid office before you give away or sell anything. This page is general information and not legal or financial advice.

Questions to ask before you move

Settings must meet federal standards for waiver services, so ask whether a home takes part in your state's program. A few questions can save a lot of trouble, and you should ask them before you sign a contract.

• Does this home accept people who are in a Medicaid waiver program in our state?
• How much is the monthly rent and the meal charge, and what does a person pay for the care services?
• What happens if the person's money runs low, and can they stay if Medicaid begins to pay for the care?
• Does the home keep a place for people with a waiver, or is there a limit on how many it takes?

Ask the home to put the answers in writing. Your state Medicaid office can tell you which homes take part in the waiver. An Area Agency on Aging can help you compare your options.

Where to get free help

You can get help at no cost from several places. Start with your state Medicaid office, which you can find in the directory on Medicaid.gov. Next, call the Eldercare Locator at 1-800-677-1116 to reach your local Area Agency on Aging. The long-term care site says Aging and Disability Resource Centers, where they exist, are single doors into the services system. The same site lists the long-term care ombudsman program, which protects the rights of people who live in care facilities.

A SHIP counselor can explain how Medicare and Medicaid work together. Legal aid groups can answer questions about your rights and about the look-back rule. Our Medicaid for family caregivers guide explains how some states pay relatives to give care at home. For everyday care, a community health center or a cash-pay doctor may fit your budget. If you think you are having an emergency, call 911 or go to the nearest emergency room.