Medicaid Planning Series 2026: Part 2 -Understanding Types of Long-Term Care Programs

Attorney RJ Connelly III Certified Elder Law Attorney Professional Fiduciary

Welcome to part two of our series on Medicaid planning. In today’s discussion, we will delve into a range of Medicaid programs that support long-term care for seniors, individuals with disabilities, and the caregivers who assist them. Our objective is to illuminate the often-complex world of Nursing Home Medicaid, Home and Community-Based Services (HCBS) Medicaid Waivers, 1115 Demonstration Waivers, and Regular State Medicaid.

"Throughout this blog, we will clarify the types of environments in which long-term care can be provided, outline the breadth of services covered by Medicaid, and detail the financial and functional criteria required to qualify for these vital programs," said professional fiduciary and certified elder law Attorney RJ Connelly III. "Join us for an insightful discussion as we explore these essential resources in order to help you gain an understanding of long-term care programs. Together, we will examine how these resources can empower various communities and assist our clients and their families in making the choices that can be of benefit to them in times of need."

Where Long-Term Care Is Provided

Long-term care is a comprehensive spectrum of services that can be provided across various settings, tailored to meet the unique needs and preferences of individuals. Key options include skilled nursing facilities—commonly known as nursing homes—where residents receive around-the-clock medical care and assistance with daily activities, as well as assisted living communities that offer a blend of independent living and supportive services, ideal for those who require help but wish to maintain a degree of autonomy.

Additionally, adult day care centers serve as a vital resource, providing supervised care and social activities during the day, allowing caregivers some respite while ensuring participants engage in a structured environment. Home-based care is increasingly favored, where services can be delivered in the comfort of an individual’s own residence, encompassing personal care, medical assistance, and home modifications to enhance accessibility and safety.

Medicaid programs play a crucial role in financing long-term care across these settings, with a significant and growing focus on home- and community-based services. This shift aims to promote greater independence and improve the overall quality of life for individuals, enabling them to remain connected to their communities and loved ones while receiving the support they need.

Nursing Home Medicaid: Coverage and Eligibility

Nursing Home Medicaid is a government assistance program designed to support individuals who require extensive medical care typically available in a skilled nursing facility. To qualify for this essential program, applicants must meet stringent financial criteria that vary by state but generally include specific limits on monthly income and total assets. These limits are regularly updated and depend on factors such as marital status and living arrangements.

In addition to financial qualifications, applicants must also demonstrate a medical necessity for nursing home-level care. This often means providing documentation from healthcare professionals indicating that the individual requires substantial assistance with activities of daily living (ADLs). ADLs include critical tasks such as bathing, dressing, eating, toileting, and mobility, which may be impossible for the applicant to perform independently due to physical or cognitive limitations.

Once an individual is approved for Nursing Home Medicaid, the program covers a broad spectrum of services essential for their well-being. This includes room and board within the facility, skilled nursing services provided by licensed healthcare professionals, personal care assistance for daily activities, various therapeutic services such as physical, occupational, or speech therapy, and necessary medical supplies required during their stay. Overall, the program aims to ensure that eligible individuals receive the comprehensive care they need in a supportive and safe environment.

HCBS Medicaid Waivers: Care at Home and in the Community

Home and Community-Based Services (HCBS) Medicaid Waivers are specialized programs that enable eligible individuals to receive long-term care in the comfort of their own homes or within community-based settings, rather than in institutional facilities such as nursing homes. The primary goal of these waivers is to promote individual independence, facilitate community integration, and provide necessary support services.

To qualify for HCBS Waivers, applicants must meet specific financial criteria that generally align with the income and asset limits for Nursing Home Medicaid. Additionally, they must meet functional criteria demonstrating their need for a level of care typically provided in nursing homes, while expressing a preference to remain in a home environment. This combination ensures that assistance is prioritized for those who require substantial support while maintaining their autonomy.

HCBS Waivers can encompass a diverse range of services tailored to each individual's unique needs. These services often include personal care assistance (such as help with bathing, dressing, and grooming), homemaker services (which can involve meal preparation, light housekeeping, and laundry), adult day health programs (providing social and health-related services during the day), respite care (offering temporary relief for primary caregivers), and home modifications (to enhance accessibility and safety within the living space). By offering these varied supports, HCBS Waivers play a crucial role in enabling individuals to live dignified lives within their communities.

1115 Demonstration Waivers

Section 1115 Demonstration Waivers represent specialized programs that enable states to explore innovative strategies for Medicaid coverage and service delivery. These waivers frequently expand eligibility criteria, enhance service options, or adjust delivery methods, occasionally incorporating elements from both Nursing Home Medicaid and Home and Community-Based Services (HCBS) Waivers.

Each state’s 1115 waiver program is distinct, and the range of coverage may encompass augmented community-based services, integrated care models, or customized supports for specific demographic groups. It is essential to examine state-specific details concerning eligibility requirements and available services when evaluating these programs.

For instance, in 2022, the Centers for Medicare & Medicaid Services (CMS) approved Massachusetts' extension of the MassHealth Section 1115 Demonstration Waiver (MassHealth 1115 Demonstration) through December 2027. The 2022-2027 1115 MassHealth Demonstration will continue to enhance health outcomes and address health disparities among its members, in alignment with other MassHealth initiatives.

Please check this site to see if your state has any approved or pending 1115 demonstration waivers.

Regular State Medicaid: General Coverage and Differences

Regular State Medicaid offers essential health coverage to eligible individuals and families, contingent upon meeting specific income and asset thresholds. This program covers a wide array of medical services, including routine doctor visits, hospital stays, prescription medications, and preventative care. However, when it comes to long-term care benefits, Regular Medicaid tends to be more limited than specialized programs such as Nursing Home Medicaid or Home and Community-Based Services (HCBS) Waivers.

While Regular Medicaid may cover certain aspects of home health care, including skilled nursing services and some personal care assistance, its support for comprehensive long-term care needs is generally insufficient. For individuals requiring extensive long-term support, whether in a nursing facility or in the community, accessing these services typically involves navigating waiver programs or institutional Medicaid coverage designed to provide the necessary benefits for long-term care. These specialized programs often offer more extensive benefits, ensuring that participants receive the holistic care and support they need to maintain their health and well-being.

What Medicaid Covers for Long-Term Care

Medicaid coverage for long-term care encompasses a wide range of essential services designed to support individuals with varying levels of need. This coverage may include:

Nursing Care: Skilled nursing services provided by licensed nurses to assist with medical needs, medication management, and daily health monitoring.

Personal Care: Assistance with activities of daily living (ADLs) such as bathing, dressing, grooming, and mobility to help individuals maintain their hygiene and comfort.

Therapy Services: Physical, occupational, and speech therapy to help individuals recover from illness, enhance mobility, improve daily functioning, or address communication challenges.

Room and Board in Facilities: Coverage for costs associated with living in nursing homes or assisted living facilities, including meals, living accommodations, and basic utilities.

Medical Equipment and Supplies: Provision of necessary medical devices, such as wheelchairs, walkers, and hospital beds, as well as consumable supplies, such as incontinence products and oxygen equipment, to support individuals in their care.

Transportation Services: Organized transportation to and from medical appointments, therapy sessions, and other essential services to ensure access to necessary care.

Case Management: Personalized planning and coordination of care services to navigate the complexities of the healthcare system and ensure that individuals receive appropriate support tailored to their needs.

Supportive Services: Availability of additional assistance, including meal delivery programs, home modifications to enhance safety and accessibility, and respite care for family caregivers.

It's important to note that the specific benefits and services covered can vary significantly depending on the state's Medicaid program and individual eligibility criteria. Families should consult their local Medicaid office to understand the comprehensive options available to them.

Financial Criteria for Medicaid Programs

To qualify for Medicaid long-term care programs, applicants must meet specific income and asset limits that vary by state. For programs such as Nursing Home Medicaid and Home and Community-Based Services (HCBS) Waivers, these limits are typically stringent. Income thresholds for these programs are often aligned with the federal poverty level, which can change annually, making it essential for applicants to stay informed about the current guidelines.

Additionally, the asset limits for Medicaid long-term care programs may exclude certain essential resources from consideration, allowing individuals to retain their primary residence and one vehicle without impacting eligibility. However, there is usually a cap on the total value of other non-exempt assets, and these caps can differ significantly from state to state.

Regular State Medicaid programs also impose income and asset requirements; however, these standards may be less strict compared to those required for specialized long-term care programs. This variability underscores the importance of understanding each state's specific Medicaid eligibility rules and regulations to ensure individuals receive the support they need for long-term care. Comprehensive planning and consultation with a knowledgeable advisor can help navigate the complexities of these requirements effectively.

Functional Criteria for Medicaid Long-Term Care

In addition to meeting financial eligibility requirements, individuals seeking long-term care must also satisfy specific functional criteria that demonstrate their need for such services. This process generally includes comprehensive assessments to evaluate medical necessity and the extent of required care. For instance, applicants may be assessed on their ability to perform essential daily activities, also known as Activities of Daily Living (ADLs), such as bathing, dressing, eating, toileting, and mobility.

To facilitate this evaluation, many states use standardized assessment tools or structured evaluations to determine the appropriateness of nursing home-level care versus home- and community-based services. These assessments often take into account not only the individual's physical limitations but also their cognitive function and social support systems. The goal is to create a clear picture of the applicant's overall health status, needs, and the level of assistance required to ensure their safety and well-being in a long-term care setting.

A Final Word

"Navigating Medicaid long-term care programs can be challenging, but understanding the types of coverage available, where care can be provided, and the eligibility criteria is the first step in effective planning," said Attorney Connelly. "Whether you’re considering Nursing Home Medicaid, HCBS Waivers, 1115 Demonstration Waivers, or Regular State Medicaid, it’s important to review your state’s specific rules and seek professional guidance from Connelly Law, your Medicaid Planning experts in southern New England, when needed. By staying informed and proactive, you can help ensure access to the services and support necessary for long-term care."

The information presented within this blog is intended exclusively for general informational purposes and should not be construed as legal, financial, or healthcare advice. The content, materials, and insights provided may not reflect the most recent developments in these fields and, therefore, should not be relied upon for personal or professional decisions. Further, this blog may contain links to third-party websites, which are included solely for the convenience of our readers. It is essential to note that Connelly Law Offices, Ltd. does not automatically endorse or recommend the contents of these external sites. Given the complexities and nuances of legal, financial, or healthcare matters, we strongly encourage individuals to consult a qualified attorney, a professional fiduciary advisor, or a healthcare provider regarding any specific issues or concerns. Your well-being and informed decision-making are of paramount importance to us.