You retired several years ago and have been relatively healthy, but lately, your health is starting to slip, requiring you to attend more appointments outside of your yearly physical.
It’s getting harder for you to get around, and you don’t drive as much. Your children are grown and can’t always get time off work to help.
The cost of your healthcare is starting to become more than your retirement income can comfortably cover. You start considering applying for assistance to make your life easier.
But, what does Medicaid cover for seniors? How is it different from Medicare, and is it right for you?
This article brings clarity to Medicaid coverage for older adults, some eligibility guidelines, and the difference between Medicaid and Medicare.
Table of Contents
What Does Medicaid Cover for Older Adults?
Medicaid is a federal-state partnership that ensures funding for essential medical and long-term care for older and low-income adults.
The goal of Medicaid is to offer medical care and support services considered medically necessary and to keep older adults healthy and independent. These services may include doctor visits, medications, hospital visits, and supplemental services not covered by Medicare.
Medicaid provides vital care for approximately 7 million seniors, including:
- Doctor visits: Medicaid covers routine doctor visits, such as yearly check-ups, but also covers visits to specialists and emergency care visits.
- Hospital stays: Should a senior require a medically necessary hospital stay, Medicaid typically covers both inpatient and outpatient services that are not elective or experimental. Specific coverage for inpatient services varies by state.
- Prescription medications: Older adults with Medicaid typically have prescription medications covered. For seniors eligible for both Medicare and Medicaid, Medicaid will usually cover prescriptions that are not covered by Medicare.
- Medicare cost-sharing: Low-income seniors eligible for Medicare can use Medicaid to help with health care premiums, deductibles, and copayments for doctor visits.
- Supplemental services: Medicaid covers services such as dental care, vision care, and transportation to medical appointments. This coverage is usually available for seniors without a car, with mobility issues, or without a driver’s license. The out-of-pocket cost for transportation services is typically covered, but there may be limitations based on distance or the number of appointments in a given period.
- Nursing home care: For older adults who need the level of care provided in a nursing home, Medicaid can cover the full cost for eligible individuals.
- Home and community-based services: For older individuals who can stay in their homes, but require daily help, Medicaid usually covers assistance with daily living activities such as mobility, meal preparation, and household tasks as well as assistance with personal care such as bathing, toileting, dressing, walking, and eating or feeding.
Am I Eligible for Medicaid?
Ultimately, you must apply to determine your eligibility. You can do so online, in person at your local Medicaid office, or by mail.
Eligibility will be determined by either one or a combination of criteria based on your age, income level, the number of people in your family, and whether you have a disability. Eligibility requirements will vary depending on your state of residence.
To qualify, your income must be below a certain threshold based on the federal poverty level. It is typically less than $2,901 per month for a single senior, but the exact income requirement will depend on where you live. If you receive Supplemental Security Income, you may be automatically eligible.
If one of the following factors applies to you, consider applying:
- You have been diagnosed with breast or cervical cancer
- You are blind
- You have a disability or disabilities
- You need nursing home care
- You are over the age of 65
- You have very low or no income
Even if you aren’t sure you qualify, you should apply for Medicaid if you or someone in your family needs health care.
At Legacy Navigation, a Certified Medicaid Planner™ can assist you with the application process. Our team understands the financial challenges of long-term care for older adults and can help you with financial planning strategies to see if you are eligible for Medicaid programs.
How To Apply
Once you’ve determined that you might be eligible, you must apply to receive benefits. There are two ways to apply:
- Directly with your state
- Through the health insurance marketplace (healthcare.gov)
Understand What Medicaid Covers for Seniors
Medicaid is a partnership between the federal and state governments to offer a program that assists low-income populations, including older adults, with medical care costs.
As adults age and require long-term care solutions, Medicaid can help cover those costs. Both in-home services and care facilities such as assisted living or nursing homes are within the scope of Medicaid.
Doctor’s visits, specialist appointments, eye appointments, and dental care are within the parameters of Medicaid coverage.
Required Services
While services offered through Medicaid vary by state of residence, there are certain health care-related services that all states are required to provide. These services include:
- Doctor visits: Medicaid covers office visits for sickness or preventative care and excludes visits for elective or experimental purposes.
- Hospital services: Medicaid coverage encompasses both inpatient and outpatient hospital visits that are considered medically necessary.
- Mental health services: Therapy, medication management, and crisis services are covered.
- Substance use treatment: Inpatient and outpatient treatment, medication-assisted treatment, and recovery support services are often covered.
- Preventive care: Medicaid coverage includes routine physical exams, medical screenings, and eye and dental check-ups as well as immunizations.
- Long-term care (in nursing homes and at home): Medicaid typically covers the cost of room, board, and care for individuals requiring nursing homes. It also covers personal care assistance for individuals who wish to remain in their homes. In some states, Medicaid may also cover the costs of assisted living facilities.
Although it is not required, many states also choose to cover additional services, which may include:
- Physical and occupational therapy
- Home and community-based services
- Prescription drugs
- Dental and vision care
- Prosthetic devices
- Assistive technology or devices
To determine the exact services offered in your state, check with your local Medicaid office.
Services That Vary by State
Although Medicaid is funded partly by the federal government, it is a partnership with individual state governments, meaning the services offered and covered in one state may not be identical in other states.
Additionally, eligibility for these services is determined by each individual’s circumstances.
Some services that are often available but are not required by federal mandate may include:
- Assistance with chores
- Adult daycare services
- Respite care
- Home modifications for easier accessibility
- Transportation assistance
- Case management
- Dental and vision care
- Hearing aid cost assistance
- Personal Emergency Response Systems
Check your state’s Medicaid program to determine what services are available for you or your loved one.
What Does Medicaid Not Cover for Seniors?
While each state’s Medicaid coverage is different, some items are usually not covered, including:
- Elective cosmetic procedures: Surgeries and procedures that are done to improve one’s appearance are not typically covered. These include procedures such as cosmetic dentistry or orthodontia, facelifts, tummy tucks, liposuction, or microdermabrasion.
- Non-emergency transportation: Not all states provide transportation for regular medical appointments. On the contrary, emergency transportation is typically covered.
- Compensation for caregiving services by a household member: Medicaid is not mandated to provide coverage for private nursing done by household members. If it is covered, it may require proof of medical necessity and prior authorization.
- Medical supplies: Items such as bandages, adult diapers, or other disposable medical items are not typically covered by Medicaid.
Our Certified Medicaid Planners™ at Legacy Navigation can help clarify which services are covered in your area.
How Are Medicaid and Medicare Different?
Medicare and Medicaid are both federally funded programs, however, they do have some differences in who and what they cover.
People who are 65 or older, people with disabilities, and people with some chronic conditions such as end-stage kidney disease or ALS are typically covered by Medicare. Medicare begins the month you turn 65. Medicare requires monthly premiums and cost share amounts.
Medicaid assists people who are considered low-income based on state-by-state qualifications. Medicaid is not just for seniors, it also includes children, pregnant women, families with low income, and people who receive Supplemental Security Income (SSI). Once your application is approved, Medicaid coverage goes back to the month you applied. Medicaid pays most healthcare costs, but the costs that are not covered cannot exceed 5% of your income.
Some individuals qualify for both programs.
Can I Receive Medicaid and Medicare Benefits at the Same Time?
If you meet the eligibility requirements for both Medicaid and Medicare, then you can be dual eligible. This is often true for low-income seniors or people with disabilities.
If you are over 65 and meet the income threshold, you would qualify for both Medicare and Medicaid.
In this case, Medicare would be used primarily for your healthcare needs, while Medicaid would be used for additional healthcare needs or long-term care services that Medicare doesn’t cover.
Medicare would be considered the primary payer, and Medicaid would be the secondary payer, covering the majority of your health care costs.
Determine the Extent of Your Medicaid Coverage With Help From the Professionals at Legacy Navigation
Not sure where to start with applying for Medicaid coverage? Let our professionals at Legacy Navigation help you.
With our combined 40+ years of experience, we can help you manage the application process, organize your finances, and protect your assets.
Our clinical care team consists of a Registered Nurse and a Master Social Worker to provide a holistic approach to senior care planning.
If you aren’t sure what resources are available to you or who to turn to, we are here to help.
