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Understanding Medicaid Coverage and Long-Term Care

In another part of this series, we examined the impact of Medicare on long-term care. If the legal and financial issues surrounding Medicare are confusing, Medicaid is no less of a briar patch. If you or a loved one need financial assistance covering long-term care at a facility like Princeton Health Care Center, will you be one of the 564,000 West Virginians the Kaiser Family Foundation estimates take advantage of the program?

Let’s unpack what Medicaid is for, the guidelines for West Virginia, and what you need to know.

What is Medicaid?

In contrast to Medicare, which is designed for hospital care and limited use in skilled nursing facilities, Medicaid is a joint Federal/State partnership that provides healthcare assistance for children, the elderly, and others whose financial situations might otherwise leave them out in the cold. In a separate study, the Kaiser Family Foundation noted that in 2011 — the most recent year for which complete data was available — 76% of all nursing home care in West Virginia was paid via Medicaid disbursements; only 11% was paid via Medicare, with 13% coming from private funds and other sources.

What Does Medicare Cover for Long-Term Care in West Virginia?

Through the Bureau for Medical Services (BMS), the West Virginia Department of Health and Human Resources (DHHR) pays an all-inclusive per diem for all medically appropriate and necessary items and services to maintain optimal care and quality of life for residents of nursing facilities. Among the services covered:

  • Nursing Services
  • Therapy Services
  • Non-Prescription Items
  • Medical Supplies, Accessories and equipment
  • Room and Board
  • Laundry
  • Food and Dietary Services
  • Activities Program
  • Social Services
  • Non-Emergency Transportation Services

A number of other items and services fall under “allowable resident charges,” which are not covered by Medicaid and must be paid by the patient. These include, but are not limited to, items like cosmetics, personal clothing, television, reading materials, and social events that are not part of skilled nursing facility activities. Additionally, the DHHR will determine each individual’s financial obligations in contributing to their own care on a monthly basis; this amount is deducted from the Medicare funds disbursed to the facility.

How is Medicaid Eligibility Determined?

As with Medicare, it’s complicated. There are income and asset requirements to meet, and there are two sets of laws — federal and state — to contend with. West Virginia does, however, provide WV inROADS, a pre-screening process to help you determine your eligibility under state law.

Personal Finances and Medicaid Eligibility

If you’ve been doing your homework, you’ve likely heard plenty of information on how best to qualify for Medicaid. Be careful which advice you take; some of it can cause you more problems than it solves. Your present finances figure heavily into your eligibility. However, there’s also what’s called a “five-year look-back.” That means that your last five years’ worth of finances will come under close scrutiny. Your assets, savings, and retirement accounts will be examined. Just as important, your cash outflow will be gone over with a fine-tooth comb.

If you’ve been gifting large amounts of money to shrink your assets, or if you haven’t received something of fair value in return, you will be penalized by not being eligible for Medicare for a certain period of time.

There are other myths surrounding Medicaid, especially with regard to home values, assets, and a number of legal and financial instruments (like prenuptial agreements). We cannot stress this enough: No amount of internet sleuthing is a substitute for a consultation with a specialist in elder care law or a qualified financial advisor.

Next Steps

Covering your needs and financial responsibilities in a long-term care setting can be complicated. It’s likely to require consultations among you, your family, your long-term care facility, and a legal and/or financial advisor. However, Princeton Health Care Center has decades’ worth of experience helping West Virginia families with long-term care for those they love. We invite you to contact us with your questions, especially those related to bearing the financial responsibilities of long-term care.

Note: The preceding are only guidelines and should not be construed as legal advice; for full details on your rights and responsibilities under Medicare, consult with Princeton Health Care Center or with an expert in elder care.


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