Eligibility for Nursing Home Medicaid Coverage

Discussing the Medicaid Application Process for Nursing Home Coverage
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Medicaid is a federal government program but each state administers it a little differently than the next. Medicaid that covers nursing homes often consists of a different application and eligibility requirements than Medicaid for those who live in the community.

In order for Medicaid to cover nursing home services, individuals must qualify both financially and medically.

Financial Eligibility

Medicaid is designed to cover the cost of medical care for those who can’t afford it.

When an individual applies for Medicaid, a state worker will review the individual’s assets and look at how they spent their money in the last five years prior to nursing home placement.

Some assets are not countable (i.e., they don't prevent a person from receiving Medicaid in a nursing home), such as a house (some states have an equity limit), vehicle, and personal belongings. Additionally, if the person in a nursing home has a spouse that lives in a house or condominium in the community, the objective is not to render that person financially desolate but rather to allow a reasonable amount of assets to support that person in the community while using the rest to pay for the other person’s care.

Medical Eligibility

States often use a process called a level of care assessment or determination to evaluate this area. They are seeking to assess whether the individual really needs care in a facility or if the person could be living in her own home with a few services coming in to the home.

Often, these level of care assessments are conducted by a nurse or a social worker. Some states conduct those assessments prior to placements in a facility and others require the evaluation to be completed after admission to the facility.

Each state has its own process of determining if someone requires enough care to warrant nursing home coverage, but most look at the following areas:

  • Physical/medical needs of the person:

This may include how much assistance an individual requires in their activities of daily living (ADLs), how medically fragile they are or an assessment of their diagnoses and needs.

For example, if a person is dependent on oxygen, has frequent medication changes or has a condition such as a decubitus ulcer that requires frequent treatments, he might qualify for Medicaid coverage in a nursing home. Other states base their decisions almost solely on activities of daily living, such as if someone needs a significant amount of assistance with things like bed mobility, toileting, eating and moving from bed to chair.

  • The cognitive ability of the person:

This often includes the individual’s ability to make sound decisions throughout the day, how well his memory functions, as well as his ability to communicate with others.

In some states, cognitive functioning might be assessed by a simple question asking if the person needs assistance throughout the day to make appropriate decisions or maintain an awareness of mealtimes and other scheduling needs.

Other states use a cognitive test such as an MMSE or Alzheimer's Disease Assessment Scale- Cognitive Subscale (ADAS-Cog) to assess the thought processes and abilities of a person.

Applying for Medicaid

To receive Medicaid coverage for nursing home care, you must fill in an application for Medicaid. You can receive more information about Medicaid from your local government; the office that administers it is often called the department of human services or social services.

The application will ask several questions including your income and assets, and the department will verify that information. You typically will be assigned a caseworker who will process the application and make a decision about your eligibility.

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Disclaimer: This article should not be misconstrued as offering legal advice. See an attorney who specializes in this area for legal advice.


Michigan Department of Community Health. Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines. November1, 2004. http://www.michigan.gov/documents/AttachC_Process_Guidelines_pc-WEB_107342_7.pdf

Rutgers Center for State Health Policy. Determining Medicaid Nursing Home Eligibility: A Survey of State Level of Care Assessment. Accessed April 22, 2012. http://www.cshp.rutgers.edu/Downloads/7720.pdf

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