Nursing Home Care and Medicaid Eligibility

Last updated on: June 7, 2024

If you believe that Medicaid planning is just about adhering to stringent income and asset limits for long-term care, there’s more to consider. To qualify for nursing home care coverage, you must also prove that you require the level of care typically provided in a nursing home. This requirement holds whether you’re applying for the coverage directly or seeking a Medicaid waiver program for in-home care services. Each state, including Texas, sets its own criteria for determining whether an individual meets the necessary level of care. Complying with these rules can be challenging, as the criteria for eligibility are not always straightforward.

Determining the level of care necessity usually includes:

  • The need for two or more activities of daily living constitutes bathing, toileting, dressing, eating, and mobility.
  • You require frequent medical care, like IVs or other injections, medications, or other medical treatment.
  • You exhibit behavioral problems such as aggressiveness or wandering away from home.
  • Alzheimer’s disease or another form of dementia impairs your cognitive ability; making decisions on your own is problematic, or you cannot correctly process information.

The state evaluates the assessment of a Medicaid applicant and, in many cases, will require a doctor’s diagnosis. The assessment generally requires the applicant to answer a series of questions about their abilities to perform activities of daily living and any behavioral issues or cognitive problems. There are further questions regarding the applicant’s family and their ability to provide support.

If you or a loved one are trying to secure nursing home care through Medicaid, consulting a seasoned Medicaid planning lawyer can make a significant difference. At The Law Office of Whitney L. Thompson, our Houston Medicaid planning lawyers can clarify if you meet the Texas State Medicaid eligibility requirements and offer guidance in the Medicaid application process. We can help you avoid common pitfalls and maximize the benefits available to you. Contact us today at (281) 214-0173 to schedule a consultation, and let us assist you in this important phase of your life.

Qualified Income Trust or Miller Trusts

Medicaid is designed to assist low-income individuals and those over the age of 65 to pay for nursing home care. People with significant assets may be disqualified from obtaining assistance for long-term care from Medicaid. However, one way to keep Medicaid eligibility for people with assets that exceed the eligibility threshold is to take advantage of Qualified Income Trusts. 

Establishing a Qualified Income Trust (QIT) or Miller Trust is one alternative for Texans who do not meet the income requirement for Medicaid. Assets that go over the threshold of Medicaid eligibility can be transferred into the trust. There is also a five-year “lookback” period for determining Medicaid eligibility. The lookback period is a set period of time before the person’s Medicaid application where the state agency reviews the financial transaction that the applicant has made. Furthermore, a Miller Trust can also be used to hold income instead of assets. 

Speaking to an experienced Medicaid planning lawyer can help you explore your options when it comes to qualifying for Medicaid benefits. Our team of estate planning attorneys at the Law Office of Whitney L. Thompson may be able to assist you with the process. Contact us today to schedule a consultation.

Understanding Medical Services Covered by Medicare

Medicare still covers the medical services you may need beyond nursing care along with institutional Medicaid. If you need to see a specialist or go to a doctor’s office, Medicare pays first, and Medicaid will cover your remaining costs like copayments, coinsurances, and deductibles. When applying for institutional Medicaid, consider the following:

  • The program considers you and your spouse together when counting assets and income. Typically, you can set aside a certain amount of assets and income to protect your spouse’s standard of living. This spousal amount does not count when applying for Medicaid.
  • You will still be able to keep a small amount of income for your allowance even though you qualify. The amount varies by state, and your local Medicaid office can provide more information. The remainder of your income will pay for the nursing home.
  • There is a look-back period of up to five years for institutional Medicaid in most states. When determining your eligibility, your state will count any assets you have transferred in the past five years. If Medicaid determines any transfers violate the Medicaid eligibility rules, you may be penalized. Medicaid may opt to pay only a portion of your nursing home stay or none at all.
  • Owning your own home affects Medicaid eligibility and coverage. An elder law attorney can characterize your specific circumstances and how the equity in your home may count as an asset. When long-term care is no longer necessary, or you are deceased, these assets may repay Medicaid for your care coverage.

Nursing home level of care, also known as nursing facility level of care (NFLOC), Is not an easily definable term as there is no formal federal definition. Each state has the task of defining the term, and rules are not always consistent from one state to the other. Generally, there are four areas of concern, though not every state considers all four; physical functional ability, medical needs/health issues, cognitive impairment, and behavioral problems.

Medicaid Eligibility Considerations Description
Spousal Asset and Income Protection Medicaid considers spouses together, allowing a certain amount of assets and income to be set aside to protect the spouse’s standard of living. This spousal amount is not counted in the Medicaid application.
Income Allowance and Nursing Home Costs Medicaid allows a small income allowance varying by state, with the remainder of income paying for nursing home costs. Information about the allowance can be obtained from the local Medicaid office.
Look-Back Period and Asset Transfers There’s a look-back period of up to five years for institutional Medicaid, counting asset transfers. Violations may lead to penalties, potentially affecting Medicaid coverage for nursing home stays.
Home Ownership and Medicaid Coverage Home ownership impacts Medicaid eligibility; equity in the home may count as an asset, affecting eligibility.

Does Medicaid Cover Nursing Home Care in Texas?

In Texas, Medicaid can be a vital resource for those needing long-term nursing home care, especially if you have limited income or assets. Understanding the conditions under which Medicaid will cover these services is crucial for anyone considering this option.

Firstly, to qualify for Medicaid coverage of nursing home care in Texas, you must demonstrate a clear medical necessity for such care. This means that your medical condition must be severe enough that you require the level of care provided in a nursing home setting. Examples of such care that might be covered include administration of injections, insertion of feeding tubes or catheters, treatment of bed sores, and changing of wound dressings.

Additionally, there are procedural requirements to meet before Medicaid begins to cover nursing home costs. You must reside in the nursing home for at least 30 consecutive days before you can apply for Medicaid services. This initial period is essential for establishing that nursing home care is not just a temporary requirement.

Continuous coverage is also contingent on regular medical evaluations. A doctor must certify every six months that your condition still meets the criteria for medical necessity, ensuring that ongoing care is justified under Medicaid provisions.

If you are exploring nursing home care options and wondering about Medicaid eligibility, it is advisable to consult with a Texas Health and Human Services representative or a seasoned Medicaid planning lawyer. They can provide detailed information and guidance tailored to your specific circumstances, helping you navigate the complex aspects of Medicaid coverage for nursing home care in Texas.

Medicaid nursing home lawyer in Houston

For those families with a loved one who requires more care than they can provide at home but do not require a high enough level of care to qualify for nursing home admittance, there is an in-between care type typically provided in assisted living. However, Medicaid coverage of this type of assisted living is very limited in numbers.

Nursing homes are experiencing very limited capacity, and waitlists can be years. Medicaid is adapting to provide this coverage type in-home to those applicants who may meet NFLOC Medicaid eligibility requirements but not pose a danger to themselves or others in a home environment. Perhaps using this as a springboard as a potential nursing home residence is waitlisted for full-time care.

Before applying to become eligible for Medicaid nursing home coverage, there is much to consider. Applications that are insufficient or incorrectly filed can create delays, and with limited space available, it can be several years on a waiting list before admittance can take place.

The need is more significant than ever before for long-term care in a nursing home. Meeting your state’s eligibility requirements can be a long and complex series of providing documents, answering questionnaires, having assessments and reviews, and filling out and filing forms. The scope of the project can be overwhelming. To get to your best outcome, don’t wait. Proactive planning with an estate planning attorney will help you understand and address all criteria you need to act on to succeed.  Please contact our Houston office at 281-214-0173 or the Bay City office at 979-318-5079 today and schedule an appointment to discuss how we can help you with your legal matters.

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