With the average monthly cost of a private room in a nursing home in Washington, D.C. exceeding $12,000 in 2020, seniors who are likely to need long-term care (LTC) should pay serious attention to ensure they have a way to pay for that care. Long-term care is usually paid for by private funds, nursing home insurance, or Medicaid. For those who cannot afford to pay privately and do not have LTC insurance, Washington, D.C.'s Medicaid program (D.C. Medicaid), administered by the District's Department of Health Care Finance (DHCF) agency, might pay for their care.
Medicaid is a medical assistance program funded by the federal and state governments to pay for, among other things, LTC for persons who meet certain requirements. Other types of Medicaid services have different eligibility guidelines than the rules for long-term care.
Patients who live in skilled nursing facilities, intermediate care facilities, or hospitals for 30 days or more and are determined by Medicaid to need this care may qualify for Medicaid benefits, if they meet certain income and resource qualifications. Washington, D.C. also operates a Medicaid waiver plan, known as a Home and Community-Based Services (HCBS) Waiver, including a program that allows elderly individuals in need of assistance to remain living independently, in their homes and communities, instead of in a nursing home.
Medicaid is available to people with limited income and resources. If you are age 65 or older, blind, or disabled and meet income and resource requirements, D.C. Medicaid provides coverage for nursing home residents under certain circumstances.
To obtain coverage for nursing home care, you must be financially eligible, and you must need the kind of care nursing homes provide. Nursing homes provide 24-hour supervised nursing care, personal care, therapy, nutrition management, organized activities, and other services. To qualify, you must need a lot of help with your "activities of daily living." To read more about D.C. Medicaid coverage of LTC services, consult this D.C. Department of Human Services (DHS) brochure.
Before you apply for Medicaid coverage, make sure that to the best of your knowledge you meet the eligibility criteria. Typically, your nursing care facility can assist you with the Medicaid application process. Or, you can call (202) 724-5506 to apply for Medicaid coverage for nursing home services or ask questions about coverage.
In Washington, D.C., a single person can have a monthly income up to only $2,349 in 2020 and qualify for Medicaid-paid nursing home care. (This is 300% of the SSI payment level.) The Medicaid income limit for a married couple, with both spouses applying, is $4,698 per month in 2020. These LTC income limits may be higher than the income limit for those applying for other health care benefits from Medicaid.
For purposes of determining Medicaid eligibility, any income an applicant receives, from any source, is considered. However, when only one spouse of a married couple applies for Medicaid, the income of the non-applicant spouse is not counted, so that he or she has enough funds on which to live. If the non-applicant spouse does not have sufficient funds of their own, he or she is entitled to a minimum monthly needs allowance, which may range from $2,113.75 to $3,216.
If you qualify for Medicaid and live in a nursing home, you will be expected to spend almost all income on your care. The District allows nursing home residents receiving Medicaid to keep only $70 per month as a personal needs allowance.
Note that D.C. also provides a Medically Needy pathway, or "spend-down" program, that allows applicants otherwise over the income limit to qualify for Medicaid services. Individuals with high, recurring medical expenses can "spend down" their income that exceeds the medically needy income limit, effectively reducing their income level to the point that they become eligible for Medicaid to assume coverage. For more on the financial eligibility requirements, see D.C.'s DHCF LTC web page or call (202) 442-5988.
Medicaid for long-term care has different resource rules, which you must satisfy to be eligible for coverage, than those for other D.C. Medicaid programs. Resources are assets like real property, personal property, life insurance with a cash value, vehicles, motorhomes, boats, IRAs, bank accounts and cash. You will have to total up all of these to determine how much you have in resources.
If you are a single person, you can have up to only $4,000 in assets, with a few allowable exclusions, such as a car and your home (up to a value of $893,000 in 2020). If you are married, your non-applicant spouse at home can keep up to $128,640 worth of joint assets.
Washington, D.C. operates a Medicaid Home and Community-Based Services (HCBS) waiver program, which is designed to provide eligible individuals assistance so that they can remain living independently—in their homes and communities—instead of in nursing homes. Assistance offered under one of these program waivers, called the Elderly and Individuals with Physical Disabilities (EPD) Waiver, may include adult day care, personal care assistance, alternative care facilities, in-home support services, and personal emergency response systems, among others.
Generally, the EPD Waiver program offers services that accompany or add to services applicants receive through D.C. Medicaid, other government programs, and family- and community-based supports.
Notably, the EPD Waiver offers a component called "Services My Way" for program participants who live in their homes to retain more choice and control of their Medicaid LTC services. Services My Way, or Participant-Directed Services (PDS), allows EPD Waiver enrollees the option to choose and oversee their service-providers.
To qualify for the EPD Waiver, applicants must meet certain financial and program criteria, and they must be willing to receive services in the home or community. For more information about the EPD Waiver, visit the DHCF web page or contact the EPD Waiver program at (202) 724-5626.
Washington, D.C. offers, in addition to those services available through the EPD Waiver program, Personal Care Aide (PCA) Services and Adult Day Health Program (ADHP) services through D.C. Medicaid and the DHCF. Eligible enrollees can receive assistance with activities of daily living in their homes through PCA Services, and they can receive similar services at adult day health facilities through the ADHP.
PCA Services are rendered by home health agencies, and ADHP services are provided at daytime facilities. These benefits and services may be available to individuals enrolled in D.C. Medicaid, provided they meet financial and functional eligibility criteria.
For more information about PCA Services, refer to the DHCF PCA quick-reference sheet, contact the Aging and Disability Resource Center (ADRC) at (202) 724-5626 or [email protected], or call DHCF LTC Administration at (202) 442-5988. For more about ADHP options or to enroll, contact the ADRC or DHCF LTC, or refer to the DHCF ADHP quick-reference sheet.