When Medicaid in Wisconsin Will Pay for a Nursing Home, Assisted Living, or Home Health Care

With the average monthly cost of a private room in a nursing home in Wisconsin surpassing $10,000 in 2024, seniors who are likely to need long-term care should plan ahead to ensure they have a way to pay for that care. Long-term care is usually paid for with savings funds, nursing home insurance, or Medicaid.

If a patient can't afford to pay privately and doesn't have long-term care insurance, Wisconsin's medical assistance program (Wisconsin Medicaid) might cover the cost of care. The state's Department of Health Services Division of Medicaid Services (DMS) administers Wisconsin Medicaid.

Medicaid is funded jointly by the federal government and the state government. It pays for, among other things, long-term care (LTC) for state residents 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.

Wisconsin Medicaid Long-Term Care Programs

Wisconsin Medicaid will pay for skilled nursing facilities or intermediate care facilities for individuals who are determined by Medicaid to need this functional level of care for 30 days or more. To qualify, you must meet specified income and resource requirements.

Wisconsin also operates certain Medicaid waiver plans, known as Home and Community-Based Services (HCBS) waivers. HCBS waiver programs are designed to allow seniors in need of assistance to remain living independently, in their homes and communities, instead of in a nursing home.

Medicaid Coverage for Nursing Homes in Wisconsin

If you're 65 or older, blind, or disabled and meet income and resource requirements, Wisconsin Medicaid will cover nursing home costs under certain circumstances. To get coverage for nursing home care, you must be financially eligible and need the kind of care that nursing homes provide, such as:

• 24-hour supervised nursing care
• therapy
• personal care, and
• nutrition management.

Federal law requires pre-admission screening for nursing home Medicaid. (42 U.S.C. § 483.112.) Wisconsin uses a tool called the "Long-Term Care Functional Screen" (LTC FS) to determine how much help you need with "activities of daily living," such as:

• bathing
• dressing
• eating
• moving around your home
• preparing meals
• administering medicines, and
• managing money.

LTC FS is used to determine your specific long-term care needs and if you need enough help to qualify for a Medicaid-paid long-term care facility or participation in an HCBS waiver program.

Medicaid Income Rules in Wisconsin

In Wisconsin, a single person can have a monthly income up to only $2,901 in 2025 and qualify for Medicaid-paid nursing home care. (This is 300% of the SSI payment level.) The Medicaid LTC income limit for a married couple, with both spouses applying for benefits, is twice as much—$5,802 per month in 2025. Wisconsin's long-term care coverage has higher income limits than the income limit for some other health care benefits from Medicaid.

The state will count any income you receive from any source when determining Medicaid LTC eligibility. But when only one spouse of a married couple applies for Medicaid, the income of the non-applicant spouse doesn't count, so that the non-applicant spouse has enough funds to live on.

A non-applicant spouse with a low income can keep a minimum monthly needs allowance from the applicant spouse's income. (Wis. Admin. Code DHS § DHS 103.075.) This rule allows you to give your non-applicant spouse some of your income—enough to raise your spouse's monthly income to the maximum allowed of $3,406.66 (or up to $3,948.00 for spouses with high housing and utility costs).

If you qualify for Medicaid and live in a nursing home, you'll be expected to spend almost all your income on your care (minus the minimum monthly needs allowance your spouse receives, if any). Wisconsin Medicaid allows nursing home residents receiving Medicaid to keep only $55 per month for their own use as a personal needs allowance.

Long-Term Care Medicaid Asset Rules in Wisconsin

Medicaid for long-term care has different resource rules—which you must satisfy to be eligible for coverage—than those for other Wisconsin Medicaid programs. Resources are assets you own, like:

• real estate
• life insurance with a cash value
• vehicles
• motorhomes
• boats
• other personal property
• bank accounts, and
• cash.

You'll need to add together the values of all your non-exempt, countable assets to determine how much you have in resources.

If you're single, you can have only up to $2,000 in assets with a few allowable exclusions such as a car and your home (with up to $750,000 in equity in 2025). If you're married, your non-applicant spouse at home can keep 50% of your joint assets, up to $157,920.

Applying for Medicaid for Nursing Home Care in Wisconsin

You can apply for Medicaid assistance online through the state's ACCESS website. For more information, visit Wisconsin's Department of Health Services Medicaid Programs for Seniors page or call DHS at (608) 266-1685.

Before you apply for Medicaid coverage, you'll want to make sure you meet the eligibility criteria. Typically, a nursing care facility can help you determine this and assist you with the Medicaid application process.

Wisconsin's HCBS Waiver Programs, Assisted Living, and Home Care Options

Wisconsin Medicaid also covers some long-term care services 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 get the services they need. These Medicaid LTC services are designed to allow recipients to remain living independently—in their homes and communities—instead of in nursing homes.

Some of Wisconsin's home care services are provided by regular Medicaid—meaning any eligible Medicaid recipient can get those services. There are no waiting lists for regular Medicaid-covered LTC services.

Wisconsin Medicaid also offers Home and Community-Based Services (HCBS) waiver programs that provide a limited number of individuals with LTC services. Because of program limits, you might find yourself on a waiting list for HCBS waiver services.

Wisconsin's Medical Personal Care Assistance (MAPC) Program

Through the state's Medical Assistance Personal Care (MAPC) program, Medicaid-eligible individuals can receive assistance with daily activities. (Wis. Admin. Code § DHS 107.112.) This program provides recipients living at home, in foster care homes, or in assisted living facilities the opportunity to get help with activities such as dressing, toileting, meal preparation, and food shopping.

MAPC program services are part of the state's Medicaid entitlement program, so every eligible recipient can get these services.

Wisconsin's Family Care and Family Care Partnership Waivers

Family Care and Family Care Partnership are Medicaid LTC waiver programs that offer managed care services and allow individuals to direct their own care. Participants can designate family members as caregivers (including spouses).

Both programs cover a full range of LTC home and community-based services, such as:

• adult day care
• personal care assistance
• assisted living services
• adult foster care services
• durable medical equipment
• personal emergency response systems, and
• many more LTC services.

The difference between these two programs is that Family Care Partnership covers medical and prescription drug services and Family Care covers only non-medical care.

Self-Directed Care Through Wisconsin's IRIS Waiver Program

Another waiver program, IRIS ("Include, Respect, I Self-direct"), is a consumer-directed program through which participants, with help from a case manager, create and budget for their own LTC plans. Medicaid-eligible "frail elders" and adults with disabilities can qualify for IRIS. Program benefits can include services such as:

• adult day care
• adult family home
• nursing services (beyond Medicaid card coverage)
• transportation
• home modifications
• home-delivered meals, and
• other services.

The IRIS waiver program also allows participants to hire family members to provide personal care services and covers training for your workers.

Learn More About HCBS Waivers in Wisconsin

For more information about Wisconsin Family Care, Family Care Partnership, or IRIS waiver services or to apply, contact your local Aging and Disability Resource Center.

If you have questions about the IRIS program, you can contact the IRIS Call Center at 888-515-4747 or send email to [email protected].

Learn more about all Medicaid LTC programs in Wisconsin by calling Medicaid Member Services at 800-362-3002 or sending an email to [email protected].