Medicaid for Virginians Needing Assisted Living or Home Health Care

Virginia has limited coverage for assisted living facilities and home health care through its Medicaid program.

Virginia has several Medicaid and non-Medicaid programs that offer payment for home health care services. Home health care can include skilled nursing or therapy services, home aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning. Virginia also offers limited waiver programs that provide coverage for assisted living facilities, which are generally less expensive and less medically intensive than nursing homes.

For Medicaid to pay for assisted living or home health care services, you must be eligible for Medicaid under Virginia's rules. Virginia's Medicaid eligibility rules are more lenient for long-term care services than for doctor visits or hospital stays. For more information, see Nolo's article that discusses Medicaid eligibility for long-term care in Virginia.

Medicaid Coverage of Home Health Services

If you receive Medicaid, the program will pay for some limited home health care services. The services must be prescribed by your doctor as part of a plan of care for a particular problem, and the services must be directed at curing or rehabilitating you.

If you need ongoing home services to help you do activities of daily living or manage your medications, Medicaid will not cover that type of help. Instead, you should consider whether you qualify for any of Virginia’s several Medicaid Home and Community Based Care Waiver (CBC) programs or its Program for the All-Inclusive Care of the Elderly (PACE) that provide home and community-based care services to low-income residents. To qualify for most of Virginia’s Waiver programs for home care, you must meet the nursing home level of care, as discussed in Nolo's article on when Virginia's Medicaid program pays for nursing homes.

Virginia’s Medicaid Waiver Programs

There are three waiver programs in Virginia that help seniors and disabled individuals receive long-term care services in the community.

Virginia’s Alzheimer’s Assisted Living Waiver offers Medicaid coverage of assisted living facility costs if you are 55 or older, have a diagnosis of Alzheimer’s or a related dementia, and meet the nursing home level of care. If you qualify, the state will pay for most services offered in an assisted living facility, as long as the facility is one that is licensed by the state as being a “safe and secure” environment.

Virginia's Elderly and Disabled with Consumer Direction (EDCD) program offers services like adult day health care, respite care, personal care, medication monitoring, and emergency response systems for those who live at home. Adult day health care is the provision of medical and rehabilitative services in a group setting during the day. To qualify for EDCD, you must be 65 or older or have a disability. You must also meet the nursing home level of care. Depending on your income, you may have to pay a portion of the cost of your services under this waiver program. In this program, you can choose to either have an agency hire and supervise your personal care attendants, or you can choose to hire and supervise your own. If you choose the “consumer-directed” model, the state will assign a services facilitator to help you coordinate your own care.

Virginia's Technology Assisted (Tech) Waiver offers services like respite care, private duty nursing, environmental modifications, emergency response systems, and case management for those who live at home. To qualify, you can be any age, but you must be able to show that you need significant skilled nursing care. If you are over 21, you are only eligible for this waiver program if you need a ventilator or have had a tracheostomy. Depending on your income, you may have to pay a portion of the cost of your services under this waiver program.

Other Waiver Programs are available for Virginians with intellectual or developmental disabilities. For more information about those, contact your local Community Services Board.

Virginia’s PACE Program

Virginia offers a Program for All-Inclusive Care for the Elderly (PACE). PACE is only available in certain locations in the state. PACE participants receive their services from an interdisciplinary team of professionals like physicians, nurses, and social workers, whose role is to coordinate individualized care and services to keep seniors in their own homes and communities. PACE participants must be at least 55 years old, have income below 300% FPL, and meet the nursing home level of care. If you are interested in a PACE program, apply directly to the one you are interested in, and the program staff will help determine your eligibility.

Additional Help Available If You Are Moving Out of a Nursing Home

If you enroll in one of the above Waiver or PACE programs after you have been in a nursing home for more than 90 days, then you may be entitled to additional services aimed at transitioning you back to your home. You can get assistance making modifications to your house and with temporary rental payments while home modifications are being completed. These services are provided under Virginia’s Money Follows the Person (MFP) program, which is funded through 2016. You can get these services if you are moving into your own home or apartment, your family’s home or apartment, or a small community-based group home containing no more than four unrelated people.

Supportive Services for Virginians Who Do Not Qualify for Medicaid

If you do not qualify for Medicaid and do not meet the nursing home level of care, you may still qualify for some personal assistance services if you are physically disabled and need help with activities of daily living like eating, dressing, or bathing. Virginia’s Departments of Aging and Rehabilitative Services offers personal assistance services through the Personal Assistance Services (PAS) Program. Note that you cannot participate in the PAS program if you qualify for any of Virginia’s Medicaid Waiver programs. To apply, contact Virginia’s PAS program.

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