- Medicare limits the amount of at-home care you can receive, as well as long-term care in a facility.
- Medicaid waiver programs (HCBS waivers) may allow you to get medical care and other services at home or in a facility in your community.
- Each state includes different conditions in its HCBS waiver programs, so check your state’s Medicaid guidelines to see if you’re eligible.
If you or a loved one has a complex health condition requiring a high level of care, you may be concerned about coverage. Medicare has strict limits on the long-term benefits you can receive at home or at a long-term care facility.
The good news is that a Medicaid waiver program may help get you the high-level care and services you need, either at home or in a community-based facility near you.
Medicare is a federal program that provides healthcare coverage for people with certain disabilities and those 65 years old and over. You must be a U.S. citizen or permanent legal resident to qualify for Medicare.
Medicare doesn’t base your eligibility on your income level, and the program is primarily funded through payroll taxes.
Medicare has four parts. Here is a quick overview of what each part covers:
- Medicare Part A. Medicare Part A is hospital insurance. It covers you during short-term, inpatient stays in hospitals and for services like hospice. It also provides limited coverage for skilled nursing facility care and select in-home services.
- Medicare Part B. Medicare Part B is medical insurance that covers everyday care needs like doctor’s appointments, therapist visits, medical equipment, and urgent care visits.
- Medicare Part C. Medicare Part C is also called Medicare Advantage. These plans combine the coverage of parts A and B into a single plan. Medicare Advantage plans are offered by private insurance companies and are overseen by Medicare.
- Medicare Part D. Medicare Part D is prescription drug coverage. Part D plans are stand-alone plans that cover only prescriptions. These plans are also provided through private insurance companies.
Because Medicare and Medicaid have similar sounding names, it’s easy to get them confused. Here’s how Medicaid is different.
Medicaid is a program that’s jointly run by federal and state governments to provide healthcare coverage to people with low incomes and limited resources. People of various ages are enrolled in Medicaid.
It is possible to be enrolled in both Medicare and Medicaid at the same time.
The Medicaid waiver program is one of many ways that Medicare and Medicaid work together to meet the healthcare needs of beneficiaries.
Section 1915(c) of the Social Security Act describes a waiver program that authorizes home and community-based services (HCBS) to provide health and other basic necessities to people who would otherwise be cared for in a long-term care facility.
A community-based program, in this case, isn’t a nursing home. It refers to care you might receive in a family member or caregiver’s home, assisted living facility, senior care home, or similar residential setting.
With this program, you may be eligible to have a home health aide, personal care aide, or homemaker assist you with activities of daily living.
Healthcare professionals may also provide services like rehabilitation with a physical therapist or speech and language pathologist. Transportation, meal delivery, and adult day care services may also be included.
Because Medicaid is run by state governments, each state’s waiver program operates differently. States cannot target specific populations to receive these benefits, but they are allowed to target different health conditions in the waiver program.
Some of the commonly covered conditions in HCBS programs include:
It’s possible to be enrolled in both Medicare and Medicaid, since their eligibility requirements are different. If you qualify for both programs, you are what’s called dual eligible, and most of your healthcare needs are likely to be covered by one program or the other.
Eligibility rules differ from state to state, but there are a few guidelines that are true in most states. One is that you must need a level of care similar to what you’d receive in a nursing facility.
For most people, that means round-the-clock access to medical services, plus personal care services like help with dressing, bathing, and going to the bathroom.
What counts as a nursing home-level of care is different in every state. Contact your state’s Medicaid office to see if you or someone in your care is eligible.
Because HCBS waivers are not an entitlement, states are allowed to limit the number of people who can receive care through the program. That means you may be placed on a waiting list if your state has reached its cap on eligible participants.
To apply for services through an HCBS waiver, you’ll need to contact your state’s Medicaid office to find out about the eligibility requirements.
You can look up contact information for your state Medicaid office by using the search tool on the right sight of this page.
Medicare and Medicaid work together to make healthcare services available to people with complex health conditions in need of long-term care.
The Section 1915(c) HCBS waiver program allows people to receive medical and personal care services at home or in a community-based facility such as a caregiver’s home or an assisted living facility.
The HCBS waiver programs are operated through state Medicaid offices. Each state’s eligibility requirements differ, so contact the Medicaid office in your state to find out if you qualify and if there’s a waiting list for participants with your health condition.
If you are eligible and your state has openings in the program, you may be able to receive services like meal delivery, transportation, and assistance with daily activities in addition to medical services.