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Dispelling Medicaid Myths – Part 2

Written by: Jeremy Pryor

Posted on: May 24, 2024

Elderly In-Home Health Care Nurse

In our last edition, we began a series on common Medicaid myths by highlighting the myth that Medicaid requires impoverishment. This week, we wish to dispel a second commonly held Medicaid myth: the myth that Medicaid is only for people in nursing homes. At the outset, we should disambiguate a few key terms. Medicaid is a federal program designed to offer benefits to certain populations, which Medicaid refers to as “Covered Groups.” While there are multiple Covered Groups, they may be broadly classified into three major cohorts, known by their acronyms: F & C (Families and Children), ABD (Adult, Blind, Disabled), and MAGI (Modified Adjusted Gross Income). All of these Covered Groups have income limits on their eligibility. Some (but not all) of these Covered Groups have asset limits on their eligibility. For individuals who meet the financial and non-financial eligibility criteria for any particular Covered Group, a plethora of benefits and services become available. And finally, for individuals who are within a Covered Group and institutionalized, one of the benefits available is payment for long-term care costs in a nursing home. So what does it mean to be institutionalized?

Well, historically, it meant that the applicant has been a resident of a medical institution, such as a hospital or nursing home, for thirty consecutive days or more. But decades ago, Virginia decided that it would offer a similar benefit to individuals who were still living in the community through a waiver program. In other words, Virginia can pay for the cost of long-term care costs for individuals who are still living in their homes—i.e., people who are not, strictly speaking, institutionalized. How does it do this? By paying for the hourly cost of in-home care. Now Virginia’s Medicaid benefit does not pay for round-the clock, 24-7, in-home care, but it does pay for up to 56 hours per week of in-home care for individuals who would otherwise be forced by their care needs to reside in a nursing home. In fact, today Medicaid is more commonly used to pay for the costs of in-home care than for the costs of a nursing home. Unsurprisingly, most persons who require long-term care would prefer to receive it in their homes if possible, and it also costs less for the state this way too.

We often find it important to pierce this myth when explaining why Medicaid might be a benefit to our client even when their primary goal is to avoid living in a nursing home. The reality is that the fewer resources one has to pay for long-term care, the more likely it is that the individual will be forced to live in a nursing home. So how can we save funds and stay out of the nursing home? By qualifying for Medicaid’s in-home benefit! This allows the client to stretch the savings, stay in their home longer, and reduce the possibility that a nursing home will ever become necessary.

If you have any clients that need help with Medicaid qualification or questions about how Medicaid might offer a payment solution for someone you know in the meantime, we hope you’ll let us know.

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