With the average monthly cost of a private room in a nursing home in Washington approaching $10,000 in 2018, those who are likely to need long-term care (LTC) should pay serious attention to ensure they have a way to pay for that care. LTC is usually paid for by private funds, nursing home insurance, or Medicaid. In 2019, Washington's state legislature established a groundbreaking public LTC insurance program, but it will not provide LTC benefits to eligible beneficiaries until 2025. In the meantime, if a patient cannot afford to pay privately and does not have LTC insurance, Washington's Medicaid program might pay for his or her care.
Medicaid is a medical assistance program funded by the federal and state governments to pay for 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.
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 the income and resource qualifications of Washington's Medicaid program.
There are also some limited services for people who still live at home but would otherwise require a nursing home. These are called home-based waiver programs. Similar income and asset rules apply for these programs.
As referenced above, Medicaid is a government health insurance program available to people with limited income and resources. If you are age 65 or older, blind, or disabled and meet income and resource requirements, Washington's Medicaid program, called Apple Health, provides coverage for nursing home residents under certain circumstances.
To obtain Apple Health 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 apply for LTC Medicaid for nursing home coverage, you must submit an application to the Washington Department of Social and Health Services (DSHS), either in paper or online. In general, you must meet financial requirements and require a level of care that cannot be met anywhere but in a nursing home.
Typically, your care nursing facility can assist you with the Medicaid application process or you can apply directly with the DSHS. Before you apply, make sure that to the best of your knowledge you meet the eligibility criteria.
In Washington, a single person can have a monthly income up to only $2,313 in 2019 and qualify for Apple Health-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 $4,626 per month in 2019. These LTC income limits are 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. Additionally, the non-applicant spouse is entitled to a minimum monthly needs allowance, which may range from $2,057.50 to $3,160.50.
If your income is above the limit, you still might be able to qualify for Medicaid if your medical expenses are higher than the amount of extra income you have. In Washington, under the state's "medically needy" program, people who are 65 or older, blind, or disabled can use medical bills that they incur each month to "spend down" their income and qualify for Medicaid.
If you qualify for Medicaid and live in a nursing home, you will be expected to spend almost all income on your care. Washington allows nursing home residents receiving Medicaid to keep only $70 per month as a personal needs allowance.
Medicaid for LTC has different resource rules than those for other Apple Health 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 only up to $2,000 in resources with a few allowable exclusions such as a car and your home (up to a value of $585,000 in 2019). If you are married, your non-applicant spouse at home can keep up to $126,420 worth of joint assets.
Apple Health covers nursing home care for Washington residents who meet applicable financial and functional need criteria, as described above and determined by the Washington DSHS. Washington's Medicaid program structure also recognizes, though, that individuals who qualify for nursing home coverage might prefer to live in their homes or alternate care environments, such as assisted living residences. Living outside of a nursing facility could be less expensive for the state and more convenient and desirable for the individuals, for various reasons.
Therefore, Medicaid "waiver" programs will also pay for some services to individuals who can appropriately be cared for at home or in an adult group care facility. These programs can help individuals maintain their independence, sometimes in their own homes, as an alternative to nursing home placement.
The same financial eligibility rules that apply to Medicaid coverage for nursing homes apply to waiver programs. Thus, in 2019 an individual applicant cannot have monthly income greater than $2,313, and the applicant's assets are limited to $2,000.
Apple Health offers certain Medicaid waiver programs that provide coverage for home and community-based options. For example, the Community First Choice Option (CFCO) program makes available to program participants personal care assistance, personal emergency response systems, respite care, and transitional services from residential living back into the community. Program participants can choose their own care providers, as well. Because CFCO is an entitlement program, there are no waitlists and any eligible applicant may receive services. CFCO primarily provides participants assistance with personal health and care needs, such as activities of daily living and instrumental activities of daily living, like eating, dressing, toileting, bathing, grocery shopping, and meal preparation.
Apple Health also offers a waiver program called the Community Options Program Entry System (COPES), which in recent years has largely replaced Washington's Medicaid Personal Care (MPC) program. Through the COPES home and community-based program, individuals requiring nursing home-level care can obtain care in their home or alternative care environment, along with other supports to enable a successful transition to independent or assisted living. These supports include coverage for adult day care and assisted living, case management, durable medical equipment, home health care, certain home or vehicle modifications, personal emergency response services, and transportation assistance, among others. Because COPES is not an entitlement program, only a limited number of slots are available and there may be waiting lists to receive services.
Under certain circumstances, program participants can receive assistance simultaneously under CFCO and COPES. If you are a Washington resident who needs Medicaid assistance but are unsure whether you meet the relevant income and asset limits, you can read more about eligibility and consult the Washington State Health Care Authority for more guidance.
You can find specific information about CFCO on the Washington DSHS website, and you can learn how to apply through your local Area Agency on Aging. To learn more about and to apply for COPES, visit the COPES program web page.
Washington's Medicaid Alternative Care (MAC) program provides support to individuals at home and their caregivers, helping recipients continue living in their homes or the homes of relatives. The MAC program has eligibility requirements related to age, living arrangement, function, and finances, including requirements that apply to both the participant and his or her caregiver. Those who are eligible to receive services under the MAC program must choose between receiving those benefits or more traditional LTC services, such as those offered through the COPES and CFCO waiver programs.
Through the MAC program, Medicaid-eligible individuals can receive services such as light housecleaning, grocery shopping and delivered meals, respite care, adult day care, personal emergency response systems, and transportation. Visit the DSHS web site for more information about the MAC program, and apply by visiting your local Community Living Connections office.
For seniors age 55 or older who are "at risk" of needing long-term services and supports, and who are not currently eligible for Medicaid, the Tailored Supports for Older Adults (TSOA) program may provide assistance. The TSOA program allows for services similar to those available under the MAC program, another family caregiver support program, but TSOA is designed for non-Medicaid recipients. Therefore, if you need LTC but are financially ineligible for Medicaid, you might want to learn more about TSOA and find out whether you meet program requirements.