Medicaid (con’d)


Medicaid Benefits


For those who qualify for Medicaid, the benefits provided are extensive. Benefit provisions vary from one state program to another, but federal guidelines require all states to provide a minimal benefit package, including hospital inpatient and outpatient care, physician care, and many other services. In the area of long-term care, all states are required to pay for nursing home care, and they must also pay for home healthcare for those who are “nursing home eligible” (those who would need nursing home care if they did not receive home care). And although federal guidelines do not require it, an increasing number of states also pay benefits for home and community-based services. These services may include personal care, home health aide services, rehabilitation, therapies, respite care, adult day center care, homemaker services, and other services. In addition, a few states pay for long-term care services received in an assisted living residence.


Unlike Medicare, with its highly restrictive conditions for payment of nursing home or home care benefits, Medicaid generally meets the need for long-term care (for those who qualify). Medicaid pays benefits for personal and supervisory care even if skilled care is not also needed, and the program covers ongoing care needed to cope with a chronic impairment, not just care required for a short time to facilitate recovery from an acute illness or injury. However, there are some important limitations to Medicaid long-term care benefits:


· Medicaid coverage of home and community-based services, while expanding, is still limited. Not all states extend this coverage beyond the federally required home care for recipients who are nursing home eligible. In states that do provide such coverage, eligibility may be restricted and funding is often limited.

· While a few states offer benefits for care in an assisted living residence, they generally pay only for long-term care services (such as assistance with ADLs), not for room and board.

· Medicaid covers nursing home care only if it is provided in a Medicaid-certified facility. (Most nursing homes are Medicaid-certified, but not all.)


The Disadvantages of Relying on Medicaid


For the poor, Medicaid is usually the only way to meet long-term care needs. Those who are not poor but are considering spending down in order to obtain Medicaid benefits should be aware of several disadvantages to this approach.


Spending down generally leaves a person with extremely limited assets and income and results in the loss of financial independence. An elderly person who has worked hard and been self-supporting her whole life becomes indigent and must depend on the government for her needs. Spending down also means that hard-earned assets cannot be used for such purposes as helping grandchildren go to college, and they cannot be left to heirs.


In addition, the types of long-term care available to a Medicaid recipient are often limited. Benefits for home and community-based services are not offered everywhere, eligibility for them may be restricted, and funding is generally limited. And only a few state programs pay benefits for care in assisted living residences. Consequently, some Medicaid recipients who could be cared for at home are forced to enter a nursing home.


Finally, a Medicaid recipient may have a more limited choice of long-term care facilities, and the facilities generally considered the most desirable may not be available to her. High-quality nursing homes can easily fill their beds with higher paying non-Medicaid patients, so they do not accept Medicaid recipients. Nursing homes that do admit Medicaid patients often assign only a limited number of beds to them, and the most popular of these facilities often have long waiting lists for Medicaid recipients. Consequently, Medicaid recipients often end up in facilities that, although certified by Medicaid and perfectly adequate, are found by others to be less desirable for various reasons. Another consideration is that, if fewer facilities are open to a Medicaid recipient, she may have to go wherever a bed is available, which might be distant from her family and friends.  


In summary, those who rely on Medicaid to meet their long-term care needs lose their assets and their financial independence and often have limited choices of types of care and facilities.


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