You make reach a point in your life when it becomes clear that Medicaid is the only option for help with your long-term care expenses. If you have never participated in the Medicaid program, however, you may have a number of questions and concerns about everything from the program eligibility requirements to what Medicaid covers. Because there are so many factors that can impact the benefits you receive as a Medicaid recipient it is always best to consult with a Medicaid attorney if you have specific questions. It may help, however, to gain a basic understanding of what Medicaid covers if you need Medicaid to help with your nursing home expenses.
Medicaid is a healthcare program that is predominantly funded by the federal government; however, some states also contribute funding to the program and the program is administered by the individual states. Medicaid is what is referred to as a “needs based” program, meaning participants must demonstrate a need for the benefits in order to be eligible to participate. In practical terms, this means that you must have income that is at or below the income limit and you cannot have assets, or “countable resources,” valued above the program limit.
The Medicaid program has a number of different categories under which an applicant might qualify for benefits, including:
- Children under age 18
- Parents of minor children if they qualify as low income
- Pregnant women
- Aged (over 65)
- Emergency Medicaid
Medicaid Coverage – Basic Benefits
Medicaid is much like your average private, or employer sponsored, health insurance program with regard to what it covers. Most Medicaid programs cover things such as:
- Doctor visits
- Hospital stays
- Emergency care
- Preventative care
What Medicaid Covers for Seniors
One of the Medicaid eligibility categories is the aged, aimed at providing healthcare to Texans who are age 65 or older and who meet the income and asset requirements. If you are in this category and have recently realized you may need to qualify for Medicaid it is probably related to the need for long-term care (LTC) and the high cost that goes with that care. Because neither Medicare nor most private health insurance policies will cover LTC expenses, many seniors turn to Medicaid for help. The good news is that Medicaid does cover nursing home and other long-term care expenses.
Medicaid will cover nursing home care if that care is considered “medically necessary.” In essence, this means that your condition is such that you need the type of care that is only available in a LTC facility. For Medicaid to cover your nursing home costs your physician will need to document your need for nursing home care and will need to re-certify you for nursing home care at least every six months.
For those who qualify, Medicaid may also cover costs associated with home and/or community based care. Texas offers two Medicaid programs that cover these costs — Community Based Alternative (CBA) Medicaid and STAR PLUS Medicaid Waiver. Both of these programs will pay for home and community based care and/or care is an assisted living facility, all of which can help you avoid, or at least prolong, the need for nursing home care. In addition, if your doctor says that you have a medical condition that causes you to need assistance with one or more “activities of daily living,” then you may qualify for Primary Home Care (PHC), a Texas program providing long-term care services at home. Common examples of things that qualify as an “activity of daily living” include: bathing, getting dressed, doing routine hair and skin care, preparing meals and eating, getting exercise, using the toilet, walking, and getting in or out of a bed, chair, or wheelchair.
As you can see, the Texas Medicaid program offers a number of benefits for seniors who participate in the program. Because eligibility for Medicaid depends on the value of your assets, among other things, you want to be sure to plan ahead to avoid putting your assets at risk when you suddenly need to qualify for Medicaid benefits.
If you have questions or concerns relating to what Medicaid covers in Texas, contact the experienced Texas Medicaid planning attorneys at The Mendel Law Firm, L.P. by calling 281-759-3213 to schedule your appointment today.