Are You Eligible For Nursing Home Care?
Will Medicaid Really Cover Nursing Home Care for the Long Haul?
Yes. In every state and the District of Columbia, Medicaid can pay for nursing home care when a person meets both the financial rules and the medical “level of care” test. Coverage includes room, meals, and necessary medical services and can continue as long as eligibility is maintained—often for the remainder of life.
Why Isn’t Medicare Enough for Long-Term Care?
Medicare is short-term and rehab-focused—it may cover up to 100 days of skilled nursing under limited circumstances. Medicaid, by contrast, is designed to fund long-term nursing home care for those who qualify.
What Names Might States Use for Medicaid?
Program names vary. Examples include California (Medi-Cal), Tennessee (TennCare), Massachusetts (MassHealth), and Connecticut (HUSKY Health).
Who Actually Qualifies—What Are the Two Tests?
States evaluate:
Financial Eligibility: Income and asset limits that differ for singles, married couples applying together, and married couples with only one applicant.
- Nursing Home Level of Care (NHLOC): A state-specific standard showing the person needs substantial assistance and/or skilled oversight.
What Counts as a “Nursing Home Level of Care”?
Definitions differ by state, but consider whether the person would be unsafe if left alone for hours due to factors like complex medical needs (e.g., IV therapy), advanced cognitive impairment (e.g., Alzheimer’s/dementia), behavioral issues, or inability to perform multiple Activities of Daily Living (bathing, dressing, eating, transferring, toileting).
Does a Dementia Diagnosis Automatically Qualify?
Not in the early stages. As dementia progresses and supervision and hands-on help become necessary, most individuals meet NHLOC criteria.
What Will Medicaid Pay—and What Will You Owe Monthly?
Medicaid generally covers 100% of nursing home costs, but residents must contribute nearly all of their monthly income toward the cost. This required payment is called Patient Liability.
Can Residents Keep Any Spending Money?
Yes, a small Personal Needs Allowance (PNA) is reserved for personal items, and the amount varies by state. Example: in Florida (2025), the PNA is $160/month. Uncovered medical costs, including Medicare premiums, may also be deducted before calculating the monthly contribution.
What About Married Couples—Will One Spouse Lose All Income?
No. Spousal Protection rules prevent impoverishment of the spouse at home. In 2025, the applicant can transfer up to $3,948/month of income to the non-applicant spouse (Minimum Monthly Maintenance Needs Allowance). A portion of joint assets is also protected via the Community Spouse Resource Allowance—up to $157,920 in 2025 (state rules vary).
Over the Limits? How People Still Qualify (Legally)
Income Path 1: Medically Needy “Spend-Down”
In some states, those with income above the limit can qualify by “spending down” their excess on medical expenses until they reach the state’s medically needy income level for a set period.
Income Path 2: Qualified Income Trust (Miller Trust)
In certain states, income over the cap is deposited into an irrevocable trust managed by a trustee. Funds can be used only for approved purposes (e.g., nursing home costs), and income in the trust is not counted for eligibility.
Asset Strategies—and the 60-Month Look-Back
Applicants may “spend down” countable assets on permissible items (e.g., medical devices, home repairs, debt repayment, an irrevocable funeral trust). However, transfers for less than fair market value during the 60-month look-back can trigger a penalty period of ineligibility.
Is There a Veteran-Specific Option?
Yes. VA nursing homes have their own eligibility rules and may be an alternative for qualifying veterans and spouses.
Do All Nursing Homes Accept Medicaid?
Most facilities do, but many limit the number of “Medicaid beds.” Facilities often prefer private-pay residents because private rates are typically higher than Medicaid reimbursement.
How Big Is the Price Gap?
As a rough national average for 2025, private pay may be around $285/day while Medicaid reimburses about $199/day—one reason availability of Medicaid beds can be tight.
How Do You Apply Without Tripping Over the Details?
Apply only when you’re confident you meet both the financial and level-of-care criteria. Expect to provide extensive documentation and complete a medical assessment.
What Paperwork Should You Gather?
- Proof of identity and residency
- Income records (Social Security, pensions, annuities)
- Bank statements and investment account statements
- Deeds, vehicle titles, life insurance details (cash value)
- Health insurance/Medicare cards and premium statements
- Medical bills and receipts for uncovered expenses
- Trusts, powers of attorney, and other legal documents
What About the Medical Assessment?
The state (or its contractor) evaluates whether the applicant meets NHLOC through clinical review and/or functional assessments.
2025 Medicaid Nursing Home Eligibility at a Glance (Approximate; States Vary)
| Household Status | Income Limit | Asset Limit |
|---|---|---|
| Single Applicant | $2,901 / month | $2,000 (countable assets) |
| Married, Both Applying | $5,802 / month ($2,901 per spouse) | $3,000 (countable assets) |
| Married, One Applicant | $2,901 / month (applicant) | $2,000 (applicant) & up to $157,920 (non-applicant spouse) |
Note: Limits are typical 2025 figures and vary by state and program category. States also adjust annually.
Quick Example: How Patient Liability Works
If a Florida resident (2025) has $2,000/month income and a $160 PNA, their monthly contribution is roughly $1,840. If income is $1,000/month, the contribution is about $840. Uncovered medical costs and Medicare premiums may further reduce the contribution.
