Assisted living facilities offer a practical middle ground between independent living and nursing homes. One of the most common questions about assisted living is whether or not Medicaid covers the expenses, especially in states like Colorado.
We’re here to answer that! Let’s understand the nuances of Medicaid coverage to make it easy for families and individuals planning to move into assisted living.
Medicaid vs. Medicare: Knowing the Difference
It’s important to distinguish between Medicare and Medicaid. Medicare is a federal health insurance program for seniors and disabled individuals that primarily covers skilled nursing care. This includes short-term healthcare services like home visits by physical, speech, or occupational therapists following a hospital stay. Medicare does not typically cover custodial care that encompasses assistance with activities of daily living (ADLs) for seniors.
Medicaid Coverage for Assisted Living in Colorado
In Colorado, traditional Medicaid does not directly pay for assisted living services. However, the state offers the Elderly, Blind, and Disabled (EBD) Waiver within the Home and Community Based Services (HCBS) program. This waiver supports eligible individuals to live independently in their home or in a qualified assisted community.
The EBD waiver can cover a range of services in assisted living settings, including:
- Personal care assistance with activities of daily living
- Medication management
- Meal preparation and housekeeping
- Transportation
- Socialization activities
It’s important to note that Colorado also offers the Program of All-Inclusive Care for the Elderly (PACE) program through Medicaid. PACE provides comprehensive health and social services to frail elders who want to live in the community. While PACE may not directly translate to traditional assisted living residences, it offers a valuable alternative for some eligible individuals seeking Medicaid-funded community-based care.
Eligibility Criteria
Individuals must meet specific eligibility criteria to receive Medicaid coverage for assisted living services through the EBD waiver or participate in PACE. This includes a functional needs assessment proving they require a level of care typically provided in a nursing home but can safely reside in a less restrictive setting with additional support.
The program also has income and asset limitations, similar to other Medicaid programs.
Limited Availability of Medicaid-Certified Assisted Living Facilities
Here’s a crucial point to consider: not all assisted living facilities in Colorado participate in the EBD waiver program. These facilities, known as Alternative Care Facilities (ACFs), have undergone a rigorous certification process with the state’s Medicaid program (Health First Colorado). This certification ensures ACFs meet specific quality standards and agree to accept Medicaid reimbursement rates.
The certification process is usually complex and expensive for assisted living facilities. As a result, the number of ACFs in Colorado accepting Medicaid is limited compared to the overall number of assisted living options. This limited availability can pose a challenge for individuals seeking Medicaid-funded care.
Cost Considerations for Medicaid-Certified Assisted Living
Even when an individual qualifies for the EBD waiver and finds a Medicaid-certified assisted living facility, additional costs might exist. Medicaid reimbursement rates for ACFs are often lower than the actual cost of care provided. This can create a situation where ACFs may request a “supplemental payment” from the resident in addition to Medicaid coverage to cover the gap in expenses.
If Medicaid coverage isn’t a viable option, you can consider alternative strategies like long-term care insurance, veteran benefits, or private funds to cover the costs. Make sure to assess your financial options carefully before making a decision.