When Medicaid in New Jersey Will Pay for a Nursing Home

New Jersey Medicaid will pay for nursing home care for low-income folks when it's medically necessary.

In New Jersey, long-term care in a nursing homes is prohibitively expensive for most residents. In 2018, the average daily cost of a private room in a nursing home in New Jersey was $390. Health insurance and Medicare typically don't cover long-term care, and few people purchase long-term care insurance. That leaves Medicaid. Medicaid is a very common source of funding for long-term care in New Jersey, particularly when people have already used up all of their own assets to pay for care. In fact, most long-term nursing home residents use Medicaid to pay for their nursing home care.

There are many different ways to become eligible for Medicaid, and there are specific eligibility rules for long-term care services like nursing homes, assisted living facilities, and home health care services. To apply for Medicaid in New Jersey, contact the Board of Social Services in the county where you live or your local Area Agency on Aging (AAA) Aging & Disability Resource Connection.

Medicaid's Income Limit for Long-Term Care in New Jersey

New Jerseyans who are 65 or older (or disabled or blind) can qualify for Medicaid if they meet certain income and asset limits. If you receive SSI, you already qualify to receive Medicaid in New Jersey. But if you are elderly, blind, or disabled and not receiving SSI, then your monthly income in 2019 must be less than $1,041 per month (for an individual).

There is a higher income limit for seniors (and disabled or blind individuals) who need assisted living or home health services. If you are 65 or older, blind, or disabled, you can qualify for Medicaid long-term care services as long as your monthly income is no more than $2,313 per month for 2019. The limit for a couple is $4,626 per month.

If your income is above the limit, you still might be able to qualify for Medicaid if you have a lot of medical expenses. With New Jersey’s Medically Needy Program, you can use medical bills that you incur each month to “spend down” your income and qualify for Medicaid. The Medically Needy spend-down income limit is $367 per month for an individual in 2019. If you have a household of two people, the income limit is $434 per month. You must show that you have incurred medical expenses each month that would leave you with no more than those amounts. You do not actually have to pay the bills, just receive them. Because nursing homes are so expensive, it can be easy for nursing home residents to qualify for the Medically Needy Program -- their nursing home bills help them spend down their income.

The Medically Needy Program determines eligibility over a period of six months. For example, if you are living alone and have $650 per month in income, then you are $283 per month over the income limit ($650 - $367 = $283). You must show medical expenses of $1,698 within a six-month period ($283 per month x 6 months) to qualify for the Medically Needy Program. You do not have to wait for the end of six months to qualify, though. If you incur a $2,000 medical bill in the first month, for example, then you would qualify for the program.

Resource Limit for Long-Term Care in New Jersey

You must have few resources (assets like money and property) in order to qualify financially for Medicaid. In New Jersey, applicants for long-term care can have assets up to $2,000, or $3,000 for a married couple with both spouses applying. For applicants to regular Medicaid (aged, blind, and disabled), the resource limits are higher, so that an individual can have up to $4,000 in resources and still qualify. A couple with both spouses applying can have up to $6,000 in assets.

People who qualify for the Medically Needy Program are also allowed up to $4,000 in resources, or $6,000 for a couple with both applying. Keep in mind that if you are entering a nursing home and your spouse is not, you will be allowed to keep extra income and resources to support your spouse, according to New Jersey's "community spouse allowance" rules.

Not all property counts toward the resource limit. In New Jersey, your home (up to a value of $878,000 in 2019) is an exempt resource as long as it is your principal residence. But when you live away from your home for six months (for example, in a nursing home), it is presumed to not be your principal residence anymore -- unless your spouse still lives there. Also, one car is exempt regardless of its value, as long as you or a family member uses it for transportation.

When a Nursing Home Is Medically Necessary

In addition to paying only for those with low income and assets, Medicaid will pay for a nursing home only when it is medically necessary. You must show that you need a “nursing home level of care,” meaning that you have a physical or mental condition that requires nursing supervision and assistance with several activities of daily living (ADLs) like bathing, dressing, toilet use, transfer, locomotion, and eating. In other words, you must show that you cannot care for yourself.

Before Medicaid will pay for nursing home care, you must have a "pre-admission screening." In New Jersey, the pre-admission screening is administered by Long-Term Care Field Office counselors for the Office of Community Choice Options. Screenings are usually done by nurses or social workers who visit you wherever you are living when you apply for help. The screener asks you questions to determine whether you need help with your ADLs.

Medicaid uses the information in your screening to decide whether you need a nursing home and, if so, what kind of nursing home is appropriate for you. Medicaid also assesses whether you could stay in your home or in a community-based setting if you were to receive supportive services. In general, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of nursing care that is available only in an institution.

Medicaid Managed Long-Term Care in New Jersey

New Jersey recently changed its Medicaid-based system for providing assisted living and home health care services to Medicaid recipients. The idea is that this change will allow more people to delay going to Medicaid-paid nursing homes and instead to rely on assisted living facilities (which are generally less expensive and less medically intensive than nursing homes) or home health care (which can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning).

In the past, New Jersey served elderly and disabled individuals needing home- and community-based long-term care services through several different Medicaid Waiver programs. More recently, because long-term care is so expensive and accounts for a large part of New Jersey’s Medicaid expenditures, the state transitioned long-term care recipients into a Managed Long-Term Services and Supports (MLTSS) program.

New Jersey's Managed Long-Term Services and Supports Program

With MLTSS, New Jersey no longer pays for each long-term care expense for every Medicaid recipient. Instead, it pays a fixed amount to private companies to manage the long-term care needs of its Medicaid recipients. In MLTSS, Medicaid recipients enroll with one of New Jersey Medicaid's NJ FamilyCare managed care organizations (MCOs) or a Program of All-Inclusive Care for the Elderly (PACE).

If you are 65 or older, disabled, or blind, meet the financial criteria for Medicaid, and need a nursing home level of care, then you qualify for MLTSS. As noted above, New Jersey defines the nursing home level of care as needing help with activities of daily living such as bathing, grooming, using the toilet, and getting around.

MLTSS emphasizes individual care coordination and has increased funding for home and community-based long-term care services like assisted living facilities and home health services. MLTSS offers a full range of long-term care options, from nursing homes to in-home services and supports, depending on the needs of the individual Medicaid recipient. In fact, every MCO must offer personal care services, respite care, care coordination, home and vehicle modifications, home-delivered meals, personal emergency response systems, mental health and addiction services, assisted living, community residential services, and nursing home care.

Not all MCOs are available statewide. You can get more information about choosing an MCO here, and you can get help choosing an MCO by contacting your local Aging and Disability Resource Center.

New Jersey PACE

New Jersey also offers a PACE program. PACE is available only 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 and meet the nursing home level of care but be able to live safely in the community at the time of enrollment. If you are interested in a PACE program, apply directly to the one you are interested in, and they will help determine your eligibility. Medicaid will pay for PACE programs for individuals who qualify.

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