Housing, prescription drugs, adaptive equipment — there’s so much to consider when it comes to helping older adults lead productive and comfortable lives.
While many seniors have federal Medicaid waivers, the distinction between what is and isn’t covered can easily become a blur.
That’s why the experienced team at Legacy Navigation compiled all the information you need to help you understand what Medicaid doesn’t cover for seniors. From non-medical housing to caregiver services, we explore the common gaps in coverage so you’ll know exactly how to plan for the future.
Table of Contents
- What Does Medicaid Not Cover for Seniors?
- 7 Services Typically Not Covered By Medicaid Waivers
- Additional Considerations About Medicaid Coverage for Seniors
- Bring Clarity to Medicaid Coverage for Seniors With Legacy Navigation
What Does Medicaid Not Cover for Seniors?
Federal Medicaid waivers are available to anyone 65 or older or those who suffer from a disability. Before we delve into what Medicaid doesn’t cover for seniors, here’s what they do take care of:
- Personal assistance
- Adult day care
- Respite care
- Home-delivered meals
- Non-medical transportation
- Home modifications
- Assistive technology
- Specialized medical equipment and supplies
- Therapy services
- Case management
- Supported employment/prevocational services
On the other hand, while the waivers provide comprehensive health benefits for seniors, they do not cover:
- Non-medical housing costs
- Room and board in assisted living
- 24/7 care in a skilled nursing facility
- Medicaid services already covered under standard Medicaid
- Unapproved experimental or luxury services
- Services beyond waiver caps or limits
- Services for non-Medicaid eligible family members
If you or a senior you love is attempting to navigate the confusing world of Medicaid, Legacy Navigation is here to make the job easier. We provide comprehensive Medicaid planning assistance for seniors, including walking you through the application process. Contact us today for a free consultation.
7 Services Typically Not Covered By Medicaid Waivers
#1: Non-Medical Housing Costs
Typically, the most misunderstood federal Medicaid waiver exclusion is housing costs. Federal law explicitly prohibits waivers (and all other forms of Medicaid) from paying for “room and board,” outside of rare situations such as short-term respite stays.
#2: Room and Board in Assisted Living
While Medicaid waivers may cover personal care services delivered in adult foster care or assisted living facilities, the following are usually the responsibility of the resident or their family:
- Rent or housing costs
- Utilities
- Amenities
- Meals
#3: 24/7 Skilled Nursing Facility Care
Federal Medicaid waivers are designed to help seniors stay at home or in the community and can be used to pay for personal attendants or home health aides for a specified number of hours each week. It is rare, however, for them to provide live-in or round-the-clock care (although Medicaid outside the waiver program may cover these options).
In some situations, a state may approve 30 or 40 hours of care per week. However, for seniors in need of constant supervision, such as those with dementia or advanced illness, families must either hire private assistance or provide the care themselves.
#4: Medical Services Already Covered Under Standard Medicaid
Federal Medicaid waivers focus on supportive, long-term services and aren’t designed to duplicate or replace medical coverage.
Waivers do not cover:
- Doctor visits
- Surgery
- Hospital care
- Prescription drugs
#5: Unapproved Experimental or Luxury Services
While federal Medicaid waivers may foot the bill for improvements like widened doorways, a wheelchair lift, or grab bars, they do not cover:
- Bathroom or kitchen remodels unrelated to mobility needs
- Spa services
- Vehicle purchases or upgrades
- Recreational services
- Alternative therapies
- Investigational devices and procedures
- Clinical trial costs
- Non-FDA-approved procedures, such as certain wireless cardiac stimulators or transdermal glomerular filtration rate measurements
The key consideration is “medical necessity.” If a doctor can provide evidence of a medical need for an item or service, it may be possible to get approval through an appeal process.
#6: Services Beyond Waiver Caps or Limits
Many federal Medicaid waivers cap the number of service hours that can be delivered to an individual. Once those limits are reached, the senior or family must pay the remaining amount out of pocket.
For example:
- An individual’s state may allow 40 hours per week of attendant care.
- If the senior requires 50, the family must pay for the additional 10 hours.
Under federal law, Medicaid waivers must remain cost-neutral — meaning the average cost of services under the waiver cannot exceed what Medicaid would have spent on institutional care.
If the senior has excessive care needs, the state may choose to deny waiver enrollment or transition them to nursing facility care.
#7: Services for Non-Medicaid Eligible Family Members
Medicaid waivers apply only to the senior who qualifies, not to their entire household. Examples of services not covered by waivers in this situation include:
- Transportation, personal care, or meals for spouses who are not enrolled in Medicaid
- Ongoing assistance for a caregiver (even though caregiver training and respite may be covered)
Additional Considerations About Medicaid Coverage for Seniors
The benefits and coverage for federal Medicaid waivers can vary significantly from state to state, so it is best to contact your state’s Medicaid office or visit HealthCare.gov to find specific information about the benefits and services your state covers.
Some states may be able to receive federal waivers to offer home and community-based services, which may include funding for support services for assisted living or home modifications.
Commonly Asked Questions About What Medicaid Does Not Cover for Seniors
Are Prescription Drugs Covered By Medicaid Waivers?
No. Federal Medicaid waivers focus on long-term support and care rather than general medical services like prescription drugs.
What Are the Disadvantages of Having Medicaid?
Some of the disadvantages of Medicaid include:
- Limited access to providers
- Variations in coverage and eligibility
- Limitations on care and treatment
Does Medicaid Cover Services for Family Caregivers?
While Medicaid sometimes may pay for caregiver training or respite care, it does not cover direct medical care for non-eligible family members in caretaker roles.
Bring Clarity to Medicaid Coverage for Seniors With Legacy Navigation
Legacy Navigation is a team of Medicaid specialists certified in Medicaid planning. We’re here to help organize your finances and protect your assets. We’ll also complete the Medicaid application process on your behalf in a fraction of the time — removing the burden and confusion of long-term care planning.
Our team of professionals can help with:
- Medicaid application assistance
- Medicaid financial planning
- Medicaid asset protection
- Durable power of attorney
- Clinical case management
- Non-emergent medical transportation
Contact us today to schedule a free consultation.
