Critter Corner: Will Medicaid Pay for Assisted Living?

Dear Baxter,

My father is in the early stages of dementia, and is considering assisted living. If my father is eligible, does Medicaid cover assisted living, or only nursing home care?

Thanks for your help!

Anita Sistance

Dear Anita,

Assisted living has become an increasingly popular alternative to nursing care when our aging loved ones need attention and care outside the scope of our capabilities. For those who do not require around-the-clock care, there is a greater degree of autonomy in assisted living than in nursing homes. However, for those relying on Medicaid for long-term care assistance, assisted living is not always an option.

An assisted living facility (ALF) is different from a nursing home or skilled nursing facility because in assisted living, there are typically nurse aides rather than actual nurses, and ALFs are designed for people who need a lesser degree of assistance with activities of daily living. In all states, Medicaid covers nursing home care for someone who is financially eligible, but in some states, such as Virginia, Medicaid does not provide any coverage for assisted living.

At this time, forty-four states do offer some level of financial assistance to individuals in assisted living. Keep in mind that the term “assisted living” is not used consistently across each state, nor are their definitions or benefits the same.  Terms used include: residential care, adult foster care, personal care homes, supported living and several other variations.  Some states pay only for personal care services received in assisted living, while others include nursing services, and/or room and board costs.

The Centers for Medicare and Medicaid Services (CMS) sets certain guidelines on how each state must spend its Medicaid dollars, but each state is permitted considerable latitude within those guidelines. Most states that help with the cost of assisted living do so through their Medicaid waivers instead of with general Medicaid dollars.

In Virginia, there is one Medicaid waiver program that is theoretically available to individuals with Alzheimer’s disease or dementia who require the services of ALFs. However, there are an extremely limited number of positions available and a very long waiting list, making the waiver essentially illusory. Virginia also has a separate program, called the Auxiliary Grant (AG), which is not part of Medicaid but can help certain people with very low income pay for an AG bed in and ALF.  Unfortunately, not all ALFs participate in the AG program, and those that do typically have very few AG beds, and they become available less frequently than nursing home beds.  Although the AG program is administered by the local Medicaid agencies in each County and City, AG is not a type of Medicaid.

When is assisted living not enough for a loved one? According to Dr. Catherine Hawes, a professor of health policy and management at the Texas A&M Health Science Center, “Anyone with moderate to severe cognitive impairment and problem behaviors like resisting care or becoming alarmed if someone tries to help them shower generally belongs in either a dementia unit with well-trained staff or in a nursing home. In standard assisted living, “there’s not enough staff to help.”

Assisted living is also not enough for seniors with complicated medical conditions that require regular monitoring. Assisted living doesn’t provide much health care, so residents risk going in and out of hospitals for conditions that could perhaps be treated in a nursing home.

Medication management (a program to provide the right dose at the right time) can take place in either type of facility, but in most states assisted living staff cannot legally administer medication, and may only hand it to a resident. Therefore, someone whose dementia means that moments later he or she won’t remember to swallow their pills, may easily fall off his or her drug regimen.

Assisted living can pose a problem for seniors with incontinence, too. Housekeeping staff in assisted living typically change linens weekly. This would not work well for someone who needs help getting changed several times a day and needs the sheets changed more frequently.

Further, federal regulation provides greater protection for nursing home residents. State regulations govern assisted living, and they vary widely. Assisted living facilities can evict people at any time and basically for any reason. Nursing homes can only discharge people for a small handful of reasons, and must always make a “safe discharge.”

Nevertheless, assisted living can work well for people with mild cognitive impairment who desire privacy (private apartments being more common) and who are sociable and alert.

Do you have a loved one who is suffering from dementia? Are you considering long-term care options, including assisted living or nursing home care? Persons with dementia and their families face special legal and financial needs. At the Virginia and DC Medicaid Planning Law Firm of Evan H. Farr, P.C., we are dedicated to easing the financial and emotional burden on those suffering from dementia and their loved ones.  If you have a loved one who is suffering from dementia, we can help you prepare for your future financial and long-term care needs.  We help protect the family’s hard-earned assets while maintaining your loved one’s comfort, dignity, and quality of life by ensuring eligibility for critical government benefits. Call 1-800-399-FARR to make an appointment for a no-cost consultation in any of our offices: Fairfax, Virginia; Fredericksburg, Virginia; or Washington, DC.

Arf Arf,

Baxter

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