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The costs of long-term care can be staggering. Even if you have savings, a serious diagnosis or other challenges could mean that eventually you may need assistance paying for help in your home or an appropriate long-term care facility. Planning for this scenario means being informed about what programs are available to you, and how they work.

Many people have a difficult time understanding the difference between Medicare and Medicaid. Both are government-run programs, but they serve different purposes and populations (but some people can get both!). In the simplest terms, Medicare is a federal health insurance program for people age 65 and older, as well as people who qualify based on a disability (a simple rule of thumb is that if you are on Social Security Disability Insurance, you will become eligible for Medicare after 24 months). There is no income qualification for Medicare, almost everyone is eligible. If you did not work about 10 years in your lifetime, you may have some cost-sharing for Medicare Part A, which is usually covered by your payroll taxes. Medicaid is a program that provides health coverage for people with low incomes. Medicaid is more complex, and both the federal and state governments have roles and can make decisions about eligibility and coverage. Therefore, the state you live in can make a big difference in what your Medicaid options are. It is very important to be educated about Medicaid options in your state. For the purposes of this article, I will be sharing examples from Oregon and Washington only.

So, Medicare is for people age 65 or older, or younger and disabled, and Medicaid is for people who don’t have much money. Simple, right? But wait…there’s more! Medicaid also has a long-term care program. This is critical to understand, because Medicare does not cover long-term care. If there is a chance that you will run out of money by paying for help at home or in a long-term care facility, Medicaid is the program that you may eventually need to qualify for. In Oregon and Washington, Medicaid can provide help in your home, depending on your level of need. This can help you stay at home longer if that is your goal. Medicaid can also help pay for a long-term care facility if that is the better fit for you. You will have to spend down to having less than $2,000 and meet the current functional eligibility criteria. A Medicaid caseworker will meet with you and verify that you need help with some combination of bathing, personal hygiene, cognition, grooming (hair and nail care), dressing, eating, elimination, mobility (walking and transferring). Needing help with housekeeping, laundry, shopping, transportation, and medication management are also factored in.

Determining eligibility is a complex process involving rules set by the state. A care manager can be instrumental in helping an individual or family navigate this challenging time. Our first recommendation if you are in the process of “spend-down” (where you still have resources but are concerned you may need Medicaid) is to consult with an attorney who specializes in elder-law and Medicaid planning. Especially if you are married and/or own your home, there are many strategies and options that are available to you but need expert guidance to follow correctly and ensure you do not run afoul of the rules. For example, giving away your money to become eligible for Medicaid can backfire and end up keeping you from becoming eligible in the desired timeframe! Also, be aware that although the client and the spouse can remain in their home for as long as they want and are able to do so, eventually the home will be subject to what is called “estate recovery” where the state will recoup funds spent on the person’s care through the sale of the home after they (the recipient and spouse) pass away.

After consulting with an elder-law attorney and developing a timeline for anticipated financial Medicaid eligibility, a care manager can help you work with a placement coordinator to find the right fit for a long-term care facility, if needed. Medicaid can also help with in-home caregiving to help stay in your home for as long as possible. However, if institutional care is needed, it is essential to work with a placement coordinator to find a facility that has a Medicaid contract and will hopefully be an appropriate setting as needs change. If you can move into a facility while you still have some money to spend as a private-pay client, you will have a wider range of options (location, quality, environment) to choose from. During this process it is especially important to confirm that memory care will be available if needed, to minimize the need for moving someone if possible. Another important but often overlooked detail is to purchase a pre-paid, irrevocable burial or cremation plan to cover all of the client’s final expenses before they spend down to the $2,000, so that family is not burdened by these costs after they pass away.

A care manager can also assist clients in applying for Medicaid. Starting with the application process, we can help fill out the application and gather the necessary documentation such as bank statements and income verification. Recently, I assisted a client living in a rural part of Washington to apply over the internet as she was having difficulty writing on the paper forms. Although online applications are available, it took three attempts to find the correct pipeline for her application, including a lot of duplicate questions! For a person experiencing cognitive or physical health issues, the application process can add stress and having another person helps streamline.

After the application is received and reviewed, a Medicaid caseworker will contact the applicant for an in-person interview and assessment. At that meeting it is important for the caseworker to be fully informed of the client’s functional and cognitive status. I worked with a client who was unable to safely live at home alone because of Alzheimer’s disease, but as part of her cognitive challenges she was unaware of the degree of help she needed and continued to state that she did not need any help. In preparation for the assessment I worked with her physicians, family, friends and caregivers at her facility to document the extent of her disease and cognitive limitations. Although an elder-law attorney had told us it was difficult to be approved for Medicaid based solely on cognitive status, we were successful the first time in getting her the resources she needed to stay safe and healthy. It is also important to remember that if someone is denied initially, there is an appeal process if you believe the state has missed something in the evaluation.

Once a client has been approved for long-term care Medicaid, this will also likely result in some changes to their health insurance coverage. This is because they now have Medicare and Medicaid. This transition period is also a time where a care manager can assist in connecting the client with resources for selecting the best plan (for example, the one that includes as many of the current health care providers preferred by the client as possible) and making sure the client has as seamless a transition as possible. Care managers can also advocate for the client with the health insurance provider, the facility, and the Medicaid caseworker. For example, clients with medical costs such as over-the-counter medications, or medical equipment prescribed by their doctor but not covered by Medicaid, or even dental costs, can have their pay-in to the medical facility reduced by the amount of the medical cost. This is especially important as once someone has long-term care Medicaid, they are required to pay all of their monthly income (except for a small personal allowance) for the cost of their care. However, the client should have little to no out-of-pocket medical costs once they are on Medicaid.

As you can see, a great deal of work can go into assisting a client throughout this process. It is a challenging time in many respects, and an experienced care manager is a valuable part of the team in ensuring that you or your family member gets the assistance and resources they need to be in a safe and supportive environment.

Written by Bethany Wofford, MSSW