Elder Law, Estate Planning Blog

Medicare with Medicaid – Do You Know The Difference?

Medicare is a public health insurance program eligible for all seniors who have paid into the Medicare system during their working years. In addition to the similarity in names, another reason for the confusion is that Medicare, under certain circumstances, will cover for certain nursing care costs (care is limited to no more than 100 days at rehabilitation and limited physical and occupational therapy at home).

Example: A client of mine broke her hip while getting onto a bus. After her hospital stay, she was placed into an assisted living facility for rehabilitation and was covered by Medicare until her rehabilitation reached a “plateau”, approximately 75 days later. When she returned home, Medicare assisted with her rehabilitation 3 days a week.

Medicaid is a jointly funded program at the federal and state level. The federal government sets guidelines and the states interpret those guidelines. As a result, Medicaid rules and regulations vary state to state. In Florida, when most people think of Medicaid for the elderly, they are referring to the Medicaid benefits available through the Institutionalized Care Program (ICP) which pays for nursing home care. The general criteria for eligibility are as follows:

1. Medically necessity;
2. Federal citizen or resident and state residency;
3. Income of $2,022 per month;
4. “Countable” assets of or below $2,000 ($3,000 if both spouses apply);
5. The spouse not requiring care (community spouse) cannot have “countable” assets above $109,560.

Example: The children of a mother living with Alzheimer’s came into my office wanting their mother on Medicaid. The facility their mother was living in was ideal for her needs and over time, Medicaid could subsidize some of the care. Unfortunately, the children’s perception was that Medicaid should pay for all the care once assets are “maneuvered”. Even if the mother was Medicaid eligible, the care that they wanted was not nursing home care and thus, not available to pay for the care they expected.

In the example above, the client would not be covered under ICP (in Florida) because the mother was not in a nursing home. This does not eliminate her from potential Medicaid benefits. However, the assisting living care may be covered by alternative Florida Medicaid programs; it is critical to understand that benefits in these alternative programs may be much less than the amount Medicaid will spend for nursing home care.

Planning Strategy: The two alternative programs are Assisted Living Facility Medicaid Waiver and Medicaid Long Term Diversion Program. The majority of patients receiving benefits through Medicaid alternatives receive benefits under the Long Term Diversion Program, which is similar to an HMO program that may typically provide up to approximately $1,200 off of the patient’s assisted living bill or a limited amount of hours of home care per week. Note, ICP Medicaid does not run out dollars whereas the Medicaid Long Term Diversion Program often runs out of funding requiring the applicant to go on a waiting list.

About Evan W. Turk Esq.

My name is Evan W. Turk Esq. and I am a Managing Member here at Principle Counsel, PL. Our Elder Law practice is based out of Delray Beach, Florida. Our firm specializes in Asset Protection, Veterans Benefits, Medicaid Benefits, and Elder Law Care among other things.