With the average monthly cost of a private room in a nursing home in Oregon surpassing $10,000 in 2020, seniors who are likely to need long-term care (LTC) should plan ahead 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. If a patient cannot afford to pay privately and does not have long-term care (LTC) insurance, Oregon's Medicaid program (Oregon Health Plan, or OHP), administered by the Oregon Health Authority Health Systems Division (HSD), might cover his or her care.
Medicaid is a medical assistance program funded by the federal and state governments to pay for, among other things, long-term care for persons who meet certain requirements, such as being over 65, disabled, or blind. Other types of Medicaid services have different eligibility guidelines than the rules for LTC. Oregon Health Plan provides LTC assistance under certain circumstances.
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 specified income and resource qualifications. Oregon Health Plan also operates certain programs that allow elderly individuals in need of assistance to remain living independently, in their homes and communities, instead of in a nursing home. These include Medicaid waiver plans, known as Home and Community-Based Services (HCBS) waivers, and other specific Oregon programs.
If you are age 65 or older, blind, or disabled and meet income and resource requirements, Oregon Health Plan 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 that nursing homes provide. Nursing homes provide 24-hour supervised nursing care, personal care, therapy, nutrition management, organized activities, and other services. OHP will look at the limitations you have on your "activities of daily living" to determine your eligibility for a Medicaid-paid nursing home.
Typically, your nursing care facility can assist you with the Medicaid application process. For other questions about the Oregon Health Plan and nursing home coverage, call OHP Customer Service at (800) 699-9075.
In Oregon, 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 LTC 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. Additionally, the non-applicant spouse is entitled to a minimum monthly needs allowance, which may range from $2,155 to $3,216.
If you qualify for Medicaid and live in a nursing home, you will be expected to spend almost all of your income on your care. Oregon Health Plan allows nursing home residents receiving Medicaid to keep about $64 per month as a personal needs allowance.
Medicaid for LTC has different resource rules, which you must satisfy to be eligible for coverage, than those for other Oregon Health Plan programs. Resources are assets like real estate, personal property, life insurance with a cash value, vehicles, motorhomes, boats, bank accounts, and cash. You will have to total up all of your non-exempt, countable assets to determine how much you have in resources.
If you are a single person, you can have only up to $2,000 in assets with a few allowable exclusions such as a car and your home (up to a value of $595,000 in 2020). If you are married, your non-applicant spouse at home can keep up to $128,640 worth of joint assets.
Oregon residents may be eligible for Medicaid LTC services that are delivered outside of the nursing home facility setting. The state has programs with different eligibility requirements that offer certain other benefits, so that seniors at home or in the community can obtain needed services.
For example, through the Aged and Physically Disabled (APD) waiver, Oregon provides waiver case management and transition services for eligible elderly and physically disabled individuals. This program is designed to assist individuals qualified to live in an institutional setting, like a nursing home, and receive nursing home care but who prefer to return to live in the community. The APD waiver offers recipients services such as transitional services (moving costs, housing application fee assistance, security and initial deposits, purchases of household items and essentials, and similar other items), case management, and wellness education.
Under Oregon’s K Plan, also known as the Community First Choice (CFC) Option, the state offers another alternative to institution-based nursing care and provides certain long-term home and community supports to eligible individuals. This plan offers supportive services for individuals who require nursing home-level care and need benefits such as adult day care, meal delivery and preparation, activities of daily living, or even home modifications, among others.
For more information about the K Plan, you can contact the Oregon Department of Human Services.
Oregon offers other related programs that can provide Medicaid recipients further flexibility and options for receiving and managing care outside of the nursing facility setting. The Client-Employed Provider Program (CEP) and Independent Choices Program (ICP) allow eligible individuals to act as employers of and manage their care providers, who assist with certain daily living activities. Oregon’s Spousal Pay program pays non-applicant spouses to provide care to their in-need spouses, also including assistance with activities of daily living.
For more information about Oregon’s CEP, ICP, and Spousal Pay programs, you can contact your local Area Agencies on Aging (AAA) or Aging and People with Disabilities (APD) office. You can also call the Aging and Disability and Resource Connection of Oregon at (855) 673-2372, or the Oregon Department of Human Services at (503) 945-5600.