When Medicaid in Virginia Will Pay for a Nursing Home

Virginia's Medicaid program pays for nursing home stays for those without a lot of income who need help with activities of daily living. Nursing homes are expensive; in 2018, the average daily cost of a private room in a nursing home in Virginia was $280. Assisted living facilities and home health care services are a bit more affordable, but still costly. (For details, see Nolo's article on when Virginia Medicaid will cover assisted living facilities and home health care.) Long-term care isn't covered by private health insurance policies or Medicare, and few people purchase private LTC insurance policies.

In Virginia, Medicaid is a very common source of funding for long-term care, particularly when people have already used up all of their own assets to pay for care. Approximately 70% of nursing home residents nationwide use Medicaid to pay for their nursing home care.

There are many different ways to become eligible for Virginia's Medicaid program, and there are specific eligibility rules for long-term care services like nursing homes, assisted living facilities, and home health care.

Income Limits for Long-Term Care in Virginia

Virginians who are 65 or older, disabled, or blind can qualify for Medicaid if they also meet income and asset limits. Most people who receive SSI already qualify to receive Medicaid in Virginia. To qualify for basic Medicaid in Virginia (not long-term care), if you are elderly, blind, or disabled and not receiving SSI, then your monthly income must be less than 80% of the federal poverty level (FPL). (In 2019, 80% of the FPL is $833 per month for an individual. With Medicaid expansion effective in 2019, Medicaid is now also available to certain non-elderly Virginia residents earning up to 138% of the FPL, or $17,237 per year for an individual in 2019.)

Fortunately, there is a higher income limit for seniors (and some others) who need long-term care services. If you are 65 or older, blind, disabled, pregnant, under age 19, or a parent living with a child under 18, then you can qualify for Medicaid for long-term care as long as your monthly income is no more than 300% of the SSI amount for an individual, or $2,313 per month for 2019.

If your income is above the limit, you still might be able to qualify for Medicaid for long-term care if you have a lot of medical expenses. Going through Virginia's Medically Needy Program, you can use medical bills that you incur each month to "spend down" your income and qualify for Medicaid.

The Medically Needy spend-down income limit varies depending on the county in which you live. As a general guideline, however, the spend-down limit is 47% of the FPL—in 2019, $489 per month for a single person and $662 per month for a married couple—meaning that you must show that you have incurred medical expenses each month that would leave you with no more than those amounts. Once you show that you have those expenses, you qualify for Medicaid coverage for the rest of that month. You do not actually have to pay the bills with your income, just incur them.

Resource Limit for Long-Term Care in Virginia

To qualify for Medicaid in Virginia, you must have no more than $2,000 in resources. Resources are assets like money and property. Some property does not count toward the resource limit; for instance, in Virginia, one car is exempt, and household goods are exempt.

The state follows complicated rules to decide whether your house is exempt or not. If you are living in your home, it is exempt. If you have land surrounding your home that is worth more than $5,000, that land is counted as a resource if you qualified for Medicaid by meeting the 300% FPL limit. If your qualifying income is less than 80% of the FPL, then your home and all surrounding land is exempt.

If you need Medicaid for long-term care, then you cannot have more than $585,000 in equity in your home in 2019. In addition, your home is only an exempt resource for the first six months that you are in an institution. If your spouse, dependent child, disabled adult child, or disabled parent continues to live there, then your home is exempt indefinitely. If your income is below 80% of the FPL, your home can also remain exempt after six months if you intend to return to it or if selling it would cause undue hardship to a co-owner.

These rules are confusing; you should talk to an elder care lawyer if you need help determining if the equity in your home counts as a resource.

When a Nursing Home Is Medically Necessary

Medicaid will pay for a nursing home only when it is medically necessary. You must show that you require a "nursing home level of care," meaning that you have a physical or mental condition that requires nursing supervision and assistance with activities of daily living (ADLs). You must show that you cannot care for yourself.

Before Medicaid will pay for nursing home care, you must have a "pre-admission screening." These screenings are usually done by a nurse or social worker who visits you wherever you are living when you apply for help. The screener uses a form, called the Virginia Uniform Assessment Instrument, to help evaluate whether you need help with certain activities, including bathing, eating, taking medication, using the bathroom, moving around, and dressing. The screener will decide how much assistance you typically need to get those activities done. Whether you meet the nursing home level of care depends on the combination of the number of things you need help with and the level of help you need.

Medicaid uses the information in your screening to decide whether you need a nursing home and, if so, what kind of nursing home is appropriate for you. In general, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of nursing care that is only available in an institution.

Personal Needs Allowance for Nursing Home Residents

If you receive Medicaid and live in a nursing home, you will be expected to spend most of your income on your care. Virginia allows nursing home residents receiving Medicaid to keep only $40 per month as a personal needs allowance. If you receive Medicaid and get home- and community-based Medicaid Waiver services (discussed on the next page), then you are allowed to keep $1,272 per month as your personal needs allowance.

Read on to find out when Virginia Medicaid will cover assisted living facilities and home health care.

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