Medicaid Long-Term Care for Seniors: Nursing Home Basics and Next Steps

For many families, Medicaid is the main way to pay for long-term care, especially nursing homes, when savings and Medicare are not enough. Understanding how Medicaid for seniors works can make it easier to plan and to speak clearly with your local benefits office.

This guide from HowToGetAssistance.org explains how Medicaid long-term care and nursing home coverage typically works, who may qualify, what to gather, and how to move forward through official channels. This site does not process applications and is not a government agency, but it can help you prepare for the steps you will take with your state or county.

What Is Medicaid Long-Term Care for Seniors?

Medicaid is a government health coverage program for people with limited income and resources. Unlike Medicare, Medicaid can cover:

• Long-term nursing home care
• Some in-home care services
• Assisted living–type services in certain states (often through special waiver programs)

Key points about Medicaid long-term care for seniors:

• It is run by each state under federal rules, so details vary by state.
• It is usually available only if the person needs a certain level of care (often called “nursing facility level of care”).
• It is means-tested, which means income and assets are carefully reviewed.

To find the exact rules for your area, you will need to contact your state Medicaid agency, local social services office, or check your state’s official benefits portal.

Medicaid vs. Medicare for Nursing Home and Long-Term Care

Many people are surprised that Medicare’s nursing home coverage is limited. Medicaid is usually the main long-term payer.

Here is a simple comparison:

Because of this, many seniors:

1. Start with Medicare coverage for a short rehab stay.
2. Use their own savings for additional care.
3. Then apply for Medicaid when they can no longer afford long-term care costs.

Types of Medicaid Long-Term Care for Seniors

Most states offer multiple ways Medicaid can help seniors with long-term care needs.

1. Nursing Home (Institutional) Medicaid

This is the traditional nursing home benefit. Medicaid may pay for:

• Room and board in a nursing facility
• Skilled nursing care
• Assistance with daily activities (eating, bathing, dressing)
• Medications and therapies covered under the state’s Medicaid rules

To qualify, the senior must usually:

• Need a nursing home level of care, and
• Meet income and asset limits set by the state.

2. Home- and Community-Based Services (HCBS)

Some seniors prefer to stay at home or in assisted living–type settings. Many states offer waiver programs that:

• Provide in-home aides
• Offer adult day health care
• Support assisted living or group homes in certain cases
• Help with home modifications or respite care

These services are usually called Medicaid waivers or HCBS waivers. They often have:

• Their own application process
• Enrollment caps or waiting lists
• The same or similar financial and medical criteria as nursing home Medicaid

To learn what’s available where you live, ask your state Medicaid office or search for “Medicaid waiver” or “home- and community-based services” on your state’s official website.

Who Typically Qualifies for Medicaid Long-Term Care?

Exact rules differ, but most states look at three main areas:

1. Age / Disability
2. Medical need (level of care)
3. Financial situation (income and assets)

Age and Disability

For seniors, Medicaid long-term care usually applies if the person is:

• Age 65 or older, or
• Under 65 but meets criteria for a disability under Medicaid rules

Medical / Functional Need

The senior generally must need a “nursing facility level of care.” States define this differently, but it often means:

• Needing help with multiple activities of daily living (ADLs), such as:
  • Bathing
  • Dressing
  • Eating
  • Toileting
  • Transferring (moving from bed to chair)
• Having ongoing medical or cognitive needs that require supervision or skilled care

A nurse or caseworker may complete an assessment to decide whether the person meets this level of care.

Financial Eligibility: Income and Assets

Most states use income and asset limits. These can change annually.

Common features:

• Income limits: Monthly income must be below a certain amount (which may differ for nursing home Medicaid vs. community Medicaid).
• Asset/resource limits: Savings, investments, and some property are counted.
  • Many states allow only a relatively small amount of countable assets for the person applying.
  • Some assets may be non-countable, such as a primary residence up to a certain equity value, one vehicle, or personal belongings, depending on the state.

Because financial rules are technical and vary by location, families often:

• Speak directly with a Medicaid eligibility worker in their county, and/or
• Consult a qualified elder law attorney or local legal aid program for detailed planning.

Married Couples and “Spousal Impoverishment” Protections

When only one spouse needs nursing home care, states are required to follow special rules to help prevent the spouse at home from becoming destitute.

Typical protections may include:

• Allowing the community spouse (the spouse still living at home) to keep:
  • A portion of the couple’s assets up to a certain limit.
  • A monthly income allowance so they can pay for housing, food, and other basic needs.

These rules are often called “spousal impoverishment protections.” The exact amounts and calculations are different in each state.

If you are married and one spouse needs long-term care, it is usually helpful to:

• Ask for an appointment with a Medicaid caseworker to review spousal rules, and
• Consider speaking with a local elder law attorney or state legal services office for more detailed guidance.

What Medicaid Usually Pays for in a Nursing Home

Once approved for nursing home Medicaid, the program typically covers:

• Room and board at a Medicaid-participating facility
• Nursing and personal care services
• Medications that are on the state’s Medicaid drug list
• Medical supplies and some therapies
• Certain transportation related to medical care

In many states:

• The resident must contribute most of their monthly income to the nursing home as a “patient pay” amount.
• Medicaid then pays the difference between the patient’s contribution and the facility’s approved Medicaid rate.
• The resident may keep a small personal needs allowance each month for clothing, toiletries, and small personal items.

To understand exactly what is covered in your state, contact:

• The nursing home’s billing office, and
• Your state Medicaid agency or county social services.

Documents to Gather Before You Apply

Having key documents ready can make the Medicaid long-term care application process faster and less stressful. Requirements differ, but seniors and families are commonly asked for:

Identity and Citizenship/Immigration

• Government-issued photo ID
• Social Security card
• Birth certificate or other proof of citizenship (or eligible immigration status)

Financial Information

• Bank statements (often last 3–60 months, depending on what your state reviews)
• Records of savings accounts, CDs, retirement accounts, stocks, bonds
• Proof of income:
  • Social Security benefit letters
  • Pension statements
  • Annuity or rental income statements
• Records of life insurance with cash value
• Deeds or tax documents for real estate
• Information on any trusts or recent transfers of assets

Medical / Care Needs

• Names and contact information for doctors and current care providers
• Recent hospital discharge summaries, if applicable
• Any care plans from home health agencies or facilities
• Documentation from doctors about functional limitations (if available)

Marital and Household Information

• Marriage certificate (if married)
• Separation or divorce papers, if applicable
• Social Security numbers for spouse and dependents (if requested)

If you are unsure what to collect, you can call your local Medicaid office or county social services department and ask what documentation they usually require for a nursing home or long-term care application.

How and Where to Apply for Medicaid Long-Term Care

You cannot apply through HowToGetAssistance.org. To start a real application, you will need to use your state’s official channels.

Common ways to apply:

1. Online

   • Many states have an official benefits portal where you can:
     • Create an account
     • Complete a Medicaid application
     • Upload documents
   • Look for your state’s official government website (usually ending in “.gov”) and find the section for Medicaid, Medical Assistance, or Health Coverage.

2. In Person

   • You can often apply at:
     • Your county Department of Social Services
     • Human Services or Health and Human Services office
   • Staff can:
     • Provide paper applications
     • Explain required documents
     • Help complete forms if you need assistance

3. By Mail or Fax

   • Many states allow you to download a paper application, fill it out, and send it by mail or fax to a listed Medicaid office.

4. Through a Hospital, Nursing Home, or Social Worker

   • Some hospitals and nursing homes have Medicaid specialists or social workers who:
     • Help residents and families complete applications
     • Coordinate with the local Medicaid office

If you need help finding the correct agency:

• Call 211 (where available) and ask for help locating your state Medicaid office or long-term care Medicaid office.
• Search for "[Your State] Medicaid" or "[Your County] Department of Social Services" and confirm you are on an official .gov website.

What Happens After You Apply

The process can feel slow, but knowing the typical steps can reduce uncertainty.

1. Application Review

After you submit your application:

• A Medicaid eligibility worker reviews your information and documents.
• The agency may request additional documents if anything is missing or unclear.
• Some states assign a caseworker you can contact with questions.

2. Financial and Medical Determination

Two major questions are usually reviewed:

1. Do you meet financial criteria?

   • Workers verify income, bank accounts, property, and other assets.
   • They may review past financial transactions looking for large gifts or transfers.

2. Do you meet the level-of-care requirement?

   • A nurse or assessor may:
     • Visit the person at home or in the facility, or
     • Review medical records and talk to providers
   • They look at daily care needs and medical conditions.

3. Notice of Decision

After review, you should receive a written notice stating:

• Whether you are approved or denied
• The effective date of coverage (sometimes coverage can be granted for a past period)
• How much you must pay each month (if any) toward nursing home costs

If approved, the Medicaid office will typically:

• Notify the nursing home or service providers
• Explain how to report changes in income, assets, or living situation

If you do not receive any notice, you can call your local Medicaid office and ask about the status of your application.

Common Reasons for Delays or Denials

Many families experience delays or denials that can sometimes be fixed. Common issues include:

• Missing documents
  • Bank statements, proof of income, or property records not provided or incomplete.
• Unclear financial history
  • Large withdrawals, transfers, or gifts in recent years that are not explained.
• Over the income or asset limits
  • Savings or monthly income still above your state’s Medicaid thresholds.
• Medical level of care not met
  • Assessment shows the person does not yet need a “nursing facility level of care” under state criteria.
• Unreported changes
  • Not reporting a move, a new income source, or a change in marital status.

If you receive a denial notice, read it carefully. It should explain why you were denied and usually tells you how to appeal.

How Medicaid Appeals and Fair Hearings Usually Work

If you disagree with a Medicaid decision—whether it is a denial, a termination of benefits, or a change in your patient-pay amount—you generally have the right to appeal.

Typical appeal steps:

1. Read the Notice Carefully

   • Look for:
     • The reason for the denial or change
     • The deadline to file an appeal (often short, such as 30 or 60 days)
     • Instructions for how to request a fair hearing

2. Submit an Appeal or Hearing Request in Writing

   • Follow the instructions in the notice.
   • Send your request to the address or office listed.
   • Keep a copy and any proof of mailing or faxing.

3. Prepare for the Hearing

   • Gather:
     • Updated documents
     • Medical records
     • Any letters or notes that support your case
   • You may be allowed to bring:
     • A family member
     • A legal representative
     • A case manager or other advocate

4. Attend the Hearing

   • A hearing officer or administrative law judge reviews:
     • Your testimony
     • The Medicaid agency’s records
     • Any additional evidence
   • A written decision is issued afterward.

For help with appeals, you can often contact:

• A local legal aid organization
• A disability rights or elder law advocacy group in your state
• The state long-term care ombudsman (for nursing home residents)

Alternatives if You Do Not Qualify for Medicaid Long-Term Care

If you are not eligible right now, there may be other ways to get help with care needs.

1. Medicare and Short-Term Rehab

While Medicare does not cover long-term custodial care, it may help with:

• Short-term stays in a skilled nursing facility after a qualifying hospital stay
• Home health services when medically necessary
• Limited rehabilitation therapies

For more detail, you can contact Medicare directly or speak with your State Health Insurance Assistance Program (SHIP).

2. Veterans’ Programs

If the senior is a veteran or a surviving spouse of a veteran, there may be:

• VA long-term care services
• Aid and Attendance benefits
• State-run veterans’ homes

Information is usually available through:

• The U.S. Department of Veterans Affairs
• Your state’s Department of Veterans Affairs
• Accredited veterans service organizations

3. State or Local Aging Services

Many areas have programs for seniors that are not based solely on Medicaid, such as:

• In-home personal care on a sliding scale
• Meals-on-wheels programs
• Transportation to medical appointments
• Adult day health services

To find these programs, you can:

• Contact your local Area Agency on Aging or Aging and Disability Resource Center.
• Call 211 and ask for senior services in your area.

4. Private Pay, Long-Term Care Insurance, and Family Support

Some families:

• Use long-term care insurance policies if they were purchased earlier in life.
• Pay privately for certain services while planning for future Medicaid eligibility.
• Combine family caregiving with part-time paid help.

Because financial planning for long-term care can be complex, some people consult:

• A financial planner familiar with elder issues, and/or
• An elder law attorney who understands Medicaid rules in their state.

Protecting Yourself: How to Avoid Scams and Find Official Channels

Unfortunately, some businesses and individuals claim they can “guarantee Medicaid approval” or charge high fees for false services. To protect yourself:

Verify You’re Using an Official Source

• Look for “.gov” websites when searching online.
• Call your state Medicaid office, county social services, or Department of Human Services directly using phone numbers listed on government sites or in official directories.
• When in doubt, call 211 and ask to be connected to your state Medicaid agency.

Be Cautious About:

• Anyone who guarantees approval no matter your finances.
• Requests for large upfront fees to “fix” your Medicaid situation.
• People asking for your Social Security number, bank details, or full medical history over email or text, especially if you did not contact them first.

Safer Sources of Help

• State Medicaid offices and local social services agencies
• Area Agencies on Aging and Aging and Disability Resource Centers
• Legal aid organizations and elder law attorneys
• The long-term care ombudsman, especially for residents already in nursing homes

Understanding Medicaid long-term care and nursing home basics can help you ask informed questions and take organized steps. The next move is to contact your state or county Medicaid office, local social services agency, or Area Agency on Aging to confirm the rules where you live and start, or continue, the official application process.