by Joyce Good Henderson

Created on: May 28, 2010   Last Updated: June 01, 2010

An overview of Medicaid eligibility for nursing home care and payment should actually begin with understanding the difference between Medicare and Medicaid.  Medicare is the Federal health insurance program for Americans age 65 and older and for some disabled persons.

Medicare pays for many, but not all, of your health care expenses. Nursing home and long-term home care are not covered by Medicare. Medicaid pays for long-term nursing home care, filling the gap left by Medicare.

Medicaid is also an entitlement program, like Medicare, however, Medicaid is not funded solely by the federal government. States, and in some states, counties pay part of the cost.

Medicaid is operated by each individual state, which decides who is eligible and what health services are available. Medicaid provides health care coverage for some low-income people who cannot otherwise afford it, and for persons with certain disabilities.  

In 39 states, people who receive Social Security because of disability, or because they are over 65 years of age, are automatically eligible for Medicaid.

Some Medically Needy Individuals may be eligible for Medicaid coverage even when they have income or resources above the required limits set by their state because they have paid sufficient medical expenses to allow them to meet a "spend down" test.

Medicaid is also a form of social welfare, with eligibility based on income. For persons with limited income or financial resources, Medicaid covers a broader spectrum of services than Medicare does.

Medicaid benefits are paid directly to the provider of services. Medicaid is a needs-based program. To determine eligibility, the individual’s medical and financial needs are considered. 

There is a three-part test to determine eligibility for Medicare. Each one part must be passed to qualify. If any one is missing you will not be eligible for the program and will have to pay for nursing home care out of your own pocket.

First Test - "Medical" Need: The care needed by the individual can be either medical or custodial in nature.  The person must have some form of impairment limiting the activities of daily living to the point where nursing home care is needed. 

That care is defined as 24-hour nursing care in a "skilled care facility," which provides professional nursing services, access to physicians, respiratory care, audiologists, physical and occupational therapists.

The individual's needs might also be medically complex requiring

• 1
• 2
• Next Page >>