In Home Care - Medicare Coverage

Services such as personal care assistance and limited supportive care are available to every home-based Medicaid recipient as long as he presents a medical need, and in some states Medicaid acts as a secondary insurance to Medicare.

In order to qualify for Medicaid, the senior must either qualify for SSI or be eligible for a Nursing Home Waiver program. Supplemental Security Income (SSI) is a federal program that helps to increase the income of a senior who lives below the poverty line to just over $670.00 per month (2011 amounts). Some states pay an additional contribution over and above the federal amounts, which allows a senior to qualify for Medicaid even though his income is above the federal poverty limit. Like nursing home Medicaid, the senior may have a home (it must be occupied by the senior and there can’t be any extra income to the senior from renting out rooms), a car, a burial plan, and less than $2,000 in assets. Call Social Security at (800) 772-1213 to see if a person qualifies for SSI, or visit each state’s website for additional information about Medicaid.

Medicare beneficiaries who also have Medicaid are considered to have Dual Eligibility. In addition to paying the out-of-pocket costs such as co-payments and deductibles, Medicaid also pays the Part B premium of $96.40 (2011 amounts) per month that is usually deducted from the beneficiary’s Social Security Retirement income before it’s received. In other words, it’s possible that the income for dual eligibles will increase $96.40 per month. Like other supplemental policies, Medicaid pays the part of the senior’s portion of the charges that Medicare approves but doesn’t pay. Medicaid programs usually pay a contracted rate that is less than the private rates paid by a Medigap policy; because of the lower reimbursement rate some providers won’t accept patients with Medicaid at all – even if the senior’s primary insurance is Medicare.

Depending upon the state in which the beneficiary lives, there might also be coverage for dental care, hearing aids and prescription glasses. There are usually limits on the types of services and amounts that Medicaid will pay. Medicare beneficiaries who receive Medicaid also might also receive additional such as incontinence supplies, home bathing assistance, additional equipment and services such as blood draws that Medicare doesn’t pay for. For additional information about these extra services, it’s best to contact Medicaid, a local Senior Center or an Area Agency on Aging. It is also possible that a medical equipment provider or home health agency may have information as to how to access these services.

Seniors with Dual Eligibility have the option of choosing a Medicare Advantage plan (Health Maintenance Organization) that covers dental, hearing and prescription glasses even if the state doesn’t provide them under Medicaid. Like all HMO’s, there are limits to these programs. However, they do offer supplies and services that the senior might not otherwise be able to afford.

Qualified Medicare Beneficiaries

Qualified Medicare Beneficiaries (QMB) is another program offered by Medicaid that acts as a supplemental policy to Medicare. Like Medicaid, there is no charge to the client for the program, which is designed to assist beneficiaries who can’t afford to pay for a supplemental policy. QMB pays the Part B premium of $96.40 each month, effectively raising the senior’s income by that amount. Under the QMB program, the senior receives a Medicaid card in the mail each month that must be presented to the provider at the time of service.

QMB doesn’t pay for the extra services that full Medicaid pays for, such as the incontinence supplies, home bathing assistance, additional equipment or services such as blood draws. QMB also doesn’t pay for prescription eyeglasses, hearing aids or dental care. To qualify for QMB clients must have less than $6,680 in assets, and no more than a burial plan, a car & a home; there are also income limits that vary by state. It’s worth applying if a client believes that he might be eligible for the program – there is no penalty for applying and being denied. For further information on QMB, contact your local Medicaid office.

Specified Low Income Beneficiaries

Specified Low Income beneficiaries (SLMB) is a program for seniors who are over the income limit for QMB, but are still considered to be lower-income. SLMB pays the monthly Medicare Part B premium for the senior – while not actually a supplement to Medicare, it does save the client about a hundred dollars per month. SLMB does not cover any other services for the client. The income limit for SLMB varies by state; for further information on SLMB, contact your local Medicaid office.

Aging Waiver Programs

Medicaid Aging Waiver programs are designed to provide assistance in senior’s homes, or wherever the senior resides including the homes of family members or in Assisted Living Facilities. The goal of waiver programs is to assist seniors who meet the criteria for nursing home level of care, but are able to maintain elsewhere with the help of agencies and/or family members. In order to qualify for waiver programs, seniors must qualify for Institutional Medicaid (also known as Nursing Home Medicaid), but the requirement that the senior must be in a nursing home is waived.

Waiver programs are often difficult to understand – in order for the senior to qualify for the program they must meet the nursing home level of care. If the senior is too independent, he won’t qualify but if his level of care is too high, he also won’t qualify. The waiver program is designed for those seniors that need assistance, but not 24-hour care. The program will send in staff from a home-care agency to bathe the senior, provide them with a homemaker, shopping assistance, senior companions to sit with the senior, pay for specialty equipment and food supplements, and also might provide up to a couple of weeks of respite care in a facility so that the senior’s caregiver can take a break. It is a wonderful program, but there are often long waiting lists resulting in lengthy waits before the senior is assessed for the program.

Each state also offers a waiver program under the Olmstead Act, which was enacted in 1999 to allow people to leave nursing homes and return to independent living. Depending upon the state in which the senior lives, the program might help pay for a group home or assisted living to provide care – the senior pays a portion of the charges in rent and the program pays the rest. Like most waiver programs, these programs vary from state to state and may have long waiting lists. The financial eligibility criteria for these programs mirror that of nursing home Medicaid. The client is allowed to keep some or all of his income to maintain the household; if the senior is over income it’s possible that he will be able to “spend down” every month (pay the amount of overage to the Medicaid program) to qualify. There are usually concessions made for medical-related expenses.

Because eligibility guidelines vary from state to state, it’s best to contact the Area Agency on Aging in the senior’s community to find out if the program exists, and if the senior is eligible.