Medicaid Eligibility

 Medicare and Medicaid are two separate, government-run programs. They are operated and funded by different parts of the government and primarily serve different groups.

• Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income.
• Medicaid is a state and federal program that provides health coverage if you have low income and assets.
• You can have both. They will work together to provide you with health coverage and lower your costs.

 Medicare and Skilled Nursing Care (rehabilitation)

Here is the difference between Medicare vs Medicaid for long-term care. 

Medicare is a federally funded only health insurance program that provides healthcare services for all Americans aged 65 and older regardless of their income or have meet a disability determined by the Social Security Administration. 

   Most people are under the assumption that Medicare covers nursing home costs. Not true. Medicare does cover (to a limited extent) some coverage for a stay in a skilled nursing facility (SNF) primarily for rehabilitation. To qualify for Medicare coverage in a skilled nursing facility you must:

• Have a hospital stay of three consecutive days.
• Require rehabilitation therapy only available at a skilled nursing facility (SNF).

Medicare coverage for a Skilled Nursing Facility includes:

• 100% coverage for the first 20 days of care.
• Afterwards there is an up to rate of $200.00 copay per-day up to the 100th day (as of 2023).*

*Note: There are some additional coverages available to people with a specific Medigap supplemental insurance that helps with the co-pay between days 21-100. 

Spousal Protected Resource Amount (SPRA) — The portion of a couple's combined countable resources reserved for the community spouse and deducted from the couple's combined countable resources in determining eligibility. 

Spousal Income Protections: There is a rule that allows the Medicaid applicant to transfer income to the community spouse to ensure he or she has sufficient funds with which to live. This is called the Minimum Monthly Maintenance Needs Allowance (MMMNA) and this is the minimum amount of combined monthly income to which the community spouse is entitled to retain.

What this means for you:    When applying for Medicaid as a married couple there are some added protections for the spouse at home to prevent impoverishment (i.e. leaving the spouse at home with little or no income or resources). The spouse at home is called the community spouse. Medicaid allows for the community spouse to keep some of the income and assets from the partner entering the nursing home. Medicaid income eligibility is based on the spouse applying for long-term care Medicaid AND the combined resources of both spouses. This includes marital/community property or separate/pre-marital property OR the spouse’s respective ownership interest in community property.