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Long-term and senior care services can be costly. While some insurances help pay for these costs, it’s hard to know which ones do and which ones don’t. Medicaid is a complex part of the health care system that can help pay for long-term and senior care services if you and the care you need qualify. Use this guide to better understand how you could qualify for assistance and how Medicaid can pay for long-term care.

Medicaid is the largest source of funding for long-term care services. The Congress Research Service found that Medicaid funded approximately 42.1% of all long-term care, amounting to $475 billion. Put more simply, KFF found that 1 out of every 6 dollars spent on health care can be traced back to Medicaid. If you are unsure if you qualify for Medicaid or qualify and don’t know where to go next, read on to learn more about what Medicaid covers and how you can get started on your application.

What is Medicaid? 

Medicaid was a federal program that started in 1965, along with Medicare, that provided health coverage for low-income people. Each state’s Medicaid program is run differently with a different set of regulations and rules that it operates within. 

For example, California offers a wide variety of Medicaid benefits through Medi-Cal. Some of those include preventative wellness and chronic condition management programs in addition to devices that enhance therapy. Other states’ Medicaid programs don’t offer this wide of a range, however, your state’s Medicaid page can explain more about its particular offerings. 

How do you qualify for Medicaid?

Individuals can qualify for Medicaid based on their income and family size. Each state’s income level is different; however, across the United States, the income threshold is up to 138% of the federal poverty level (FPL). In 2022, for an individual, the FPL was $13,590. To be eligible for Medicaid, the person could not make more than 138% of $13,590, which is $18,754.20. Therefore, the most an individual could make and be eligible for Medicaid is $18,754.20.

Medicaid is based on the financial and medical needs of individuals and families, including

  • People who are pregnant
  • Low-income older adults 
  • People living with disabilities 

There are two ways to apply for Medicaid:

How is Medicaid different from Medicare? 

Medicaid and Medicare are very different programs that serve different purposes. Here are a few of the differences between the two:

  • Medicaid is a need-based federal program administered at the state level, creating variance on a more local level than Medicare. Therefore, Medicaid is designed around income rather than age.
  • Medicare is a federal health insurance program for people aged 65 and above. Therefore, Medicare is designed around age rather than income.
  • Medicaid also has more flexibility in offering more targeted care through the introduction of Medicaid Waivers, the Program of All-Inclusive Care for the Elderly (PACE), and Managed Long-Term Support and Services (LTSS). This wide breadth of programs ensures that if a person is in need of some form of care, there will be a solution that fits their needs. 

How can Medicaid sometimes be used with Medicare? 

In 2019, there were 12.2 million Americans who met dual-eligibility requirements, which means they were eligible for both Medicare and Medicaid. These two programs are not mutually exclusive, meaning that they can sometimes be used to complement each other. Some Medicare Advantage plans are built exclusively with dual eligibility in mind, and they’re called dual-eligible special needs plans (D-SNPs). 

What types of long-term care does Medicaid cover?

Medicaid covers long-term care in various settings, including home and inpatient settings. It will only cover facility settings if the required care involves medical services, like wound dressing or medication administration. 

There are essential services that Medicaid has to cover regardless of the state that you live in, including 

  • Certain hospital visits 
  • Doctor’s visits 
  • Labs and imaging services
  • Skilled care at-home visits 

Custodial services, which are non-medical and can be provided by unlicensed assistive personnel (UAPs), like caregivers, are generally not covered by Medicaid; however, there are Medicaid Waivers that waive those restrictions. 

There are different types of waivers for different populations. For seniors, there are Frail Elderly (FE) waivers that will cover home and community-based services (HCBS). Medicaid will not typically cover assisted living or continuum of care retirement community care unless they have a skilled nursing care wing and require that type of care. 

How to find Medicaid facilities and services near you 

There are many providers out there, and it’s important for you to find services that provide the care you and your family need while considering the payment sources you’re looking to use. 

One place to start is Medicaid Planning Assistance, a website created in affiliation with the American Council on Aging. You can search for skilled care facilities by zip code, and you can check off Medicare, Medicaid, or VA, and select by your Medicaid enrollment status. 

For primary care, specialists, and hospitals, HealthGrades is a resource you can use to find a provider. Under the “Insurance” section you can select Medicaid or your state’s Medicaid program. For example, Californians could indicate “Medi-Cal” as their selection. 

Medicaid is an entirely different program than Medicare, and these resources are here to help guide you along the way from application, provider selection, and beyond.