With the average monthly cost of a private room in a nursing home in Wisconsin surpassing $9,000 in 2020, 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 by private funds, nursing home insurance, or Medicaid. If a patient cannot afford to pay privately and does not have long-term care insurance, Wisconsin's Medicaid program (Wisconsin Medicaid), administered by the state's Department of Health Services Division of Medicaid Services (DMS), might cover the cost of care.
Medicaid is a medical assistance program funded by the federal and state governments to pay for, among other things, long-term care (LTC) 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.
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, if they meet specified income and resource qualifications.
Wisconsin also operates certain Medicaid waiver plans, known as Home and Community-Based Services (HCBS) waivers, including programs that allow elderly individuals in need of assistance to remain living independently, in their homes and communities, instead of in a nursing home.
If you are age 65 or older, blind, or disabled and meet income and resource requirements, Wisconsin 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 that nursing homes provide. Nursing homes provide 24-hour supervised nursing care, therapy, personal care, nutrition management, organized activities, and other services.
Wisconsin uses a tool called the "Long-Term Care Functional Screen" (LTCFS) to determine whether a patient needs assistance with enough "activities of daily living," such as bathing, dressing, transferring, and administering medicines, to qualify for a Medicaid-paid facility.
In Wisconsin, 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 the non-applicant spouse has enough funds on which to live. If the non-applicant spouse doesn't have any income, he or she is entitled to keep a minimum monthly needs allowance, which may range from $2,818.34 to $3,216, from the applicant spouse's income.
If you qualify for Medicaid and live in a nursing home, you will be expected to spend almost all income on your care. Wisconsin Medicaid allows nursing home residents receiving Medicaid to keep only $45 per month as a personal needs allowance.
Note that Wisconsin also provides a Medically Needy pathway, or "spend-down" program—the Medicaid Deductible 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.
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 like real property, 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 $893,000 in 2020). If you are married, your non-applicant spouse at home can keep up to $128,640 worth of joint assets.
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.
Before you apply for Medicaid coverage, make sure that to the best of your knowledge you meet the eligibility criteria. Typically, a nursing care facility can answer questions and assist you with the Medicaid application process. For other questions about Wisconsin Medicaid and nursing home coverage, call the Department of Health Services at (608) 266-1685.
Wisconsin 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 Medical Assistance Personal Care program, Medicaid-eligible individuals can receive assistance with daily activities. This program provides recipients living at home, in foster care homes, or in assisted living facilities the opportunity to obtain help with activities such as dressing, grooming, toileting, meal preparation, and food shopping.
Wisconsin Medicaid also offers Home and Community-Based Services (HCBS) waiver programs that provide individuals with LTC services assistance so that they can remain living independently—in their homes and communities—instead of in nursing homes.
Family Care and Family Care Partnership are Medicaid LTC programs that offer managed care services featuring self-directed supports, so that individuals can direct their own care. Participants can also designate family members as caregivers and, through these programs, available support services may include adult day care, personal care assistance, durable medical equipment, and personal emergency response systems. A primary difference between these two programs is that Family Care covers non-medical services, and Family Care Partnership covers medical and prescription drug services.
Another waiver program, IRIS ("Include, Respect, I Self-direct"), is a consumer-directed program through which participants, with case manager assistance, create and budget for their own LTC plans. IRIS, designed for Wisconsin's Medicaid-eligible frail elders and adults with disabilities, also allows participants to hire family members to provide personal care services. IRIS benefits may include services such as adult day care, adult family home, day services, nursing services, transportation, and home modifications, among others.
For more information about Wisconsin Family Care, Family Care Partnership, or IRIS programs, or to apply, contact your local Aging and Disability Resource Center. You can also call the Family Care program office at (608) 267-7286.