Paying for Long Term Care

Four Ways to Pay for Long-Term Care
There are four ways to pay for long-term care. The first is with your money. Sometimes paying your own way is desirable because you have more choices. Sometimes it is unavoidable because other benefits programs don’t pay for the level of care you need or want. The second way to pay is with long-term care insurance. Insurance gives you choices and would pay for any level of care, whether at home, in assisted living or in a nursing home. Unfortunately, it is subject to medical underwriting so if you already have a chronic condition, then it’s unlikely you would qualify. The third way to pay is with Medicare. However, Medicare payments are severely limited and are linked to a “skilled” need. When it comes to nursing home care, Medicare is also limited to a maximum of 100 days; after 100 days Medicare would not pay for any nursing home care. The final option, which ninety percent of all nursing home residents eventually turn to, is the Medicaid program.


The Medicaid Program and Eligibility

Medicaid is sometimes viewed as health insurance of last resort. Medicaid pays after all other available resources are exhausted. In theory, you spend your own money and become impoverished before you qualify for Medicaid. After you qualify, Medicaid pays the cost of covered health care. Since we are focusing on nursing home care, suffice it to say, Medicaid will pay nursing home bills for persons with low income who are 65 and older, blind, disabled.

If you are trying to achieve Medicaid eligibility, speeding up the impoverishment process while, at the same time, preserving a pool of resources available to improve the quality of life for the nursing home resident and her (or his) still-at-home spouse is the heart of Medicaid Planning.

Generally, you don’t get Medicaid until you meet the eligibility criteria and, after you are eligible you can lose Medicaid if you cease to meet those criteria. In that regard, there are three categories of criteria that Medicaid considers when you apply: categorical, medical, financial.

Categorical Criteria
Many applicants satisfy the Categorical criteria, but you must still prove eligibility. You must: (i) be a U.S. citizen, or a lawfully admitted permanent resident alien, (ii) be 65 or older, blind or disabled, and (iii) reside in (or intend to stay in) the State and county where you apply for Medicaid. Enumeration and Length of Stay requirements also apply to long-term care classes of assistance. If you can check off these boxes, then you probably meet the categorical criteria for nursing home assistance in Georgia.

Medical Criteria
If your doctor certifies that you need nursing home care, and if you have been, or will be, in a nursing home for thirty (30) days or more, then you probably meet the medical eligibility criteria.

Financial Criteria
Medicaid assumes you will exhaust your resources and income first. Then, Medicaid steps in to pick up any additional costs for nursing home care. As part of the application process, Medicaid will review both what you make (your income) and what you have (your resources) to determine whether you are “poor enough” to qualify. With this in mind, it is very important that you keep good records and document your spending as we move through the planning process.

As alluded to above, even persons with substantial assets may be poor enough to qualify Medicaid. In many cases, eligibility requires planning. The rules can be confusing. To make matters even more confusing, the rules change if there is a Community Spouse (as opposed to situations where an applicant is currently unmarried, or where both spouses are institutionalized).

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