Eligibility overview

You know that Medicaid can pay for long-term care and that it’s the long-term care insurance policy for the middle class. But can it pay for your care? Are you eligible?

Medicaid eligibility is complex. Your eligibility depends on the sub-program you need, your age, where you reside, the level of care you need, your assets, your income, and a host of other things. Remember that Medicaid is not a single program, but many, and the rules differ program-to-program.

This post is an overview of eligibility for the Medicaid programs that apply to most of my clients—the programs that pay for long-term care in a nursing home, assisted living facility, or at home for the elderly, blind, or disabled. When it comes to these programs, I like to break eligibility down into two categories: nonfinancial eligibility and financial eligibility.

Nonfinancial eligibility

These are the most basic requirements. They are about who you are, rather than what you have.

  1. You must be a citizen of the United States (or, in some cases, a resident).
  2. You must be a Wisconsin resident.
  3. You must be elderly (65 or older), blind, or disabled.

Other Medicaid programs cover residents who need help but are not elderly, blind, or disabled.

You must also have a medical need for long-term care. Exactly what counts as needing long-term care can get complicated, but this usually gets assessed before entering a nursing home or other medical institution.

Financial eligibility

Medicaid is a means-tested benefit, which means it is only available to people with income and assets below a certain level.

In general:

  • Your monthly income must be less than the average monthly cost of a nursing home in Wisconsin (currently about $9-10,000).
  • If you are single, you must have $2,000 or less in countable resources (in other words, assets).
  • If you are married, you and your spouse together must have less than $52,000 to about $139,400 in countable resources (the exact number depends on your specific situation, and the upper limit is adjusted each year for cost-of-living increases).

There are many exceptions and nuances to these rules, though. For instance, you usually don’t have to count the value of your house, your car, or your spouse’s retirement account. And you might have to count the value of things you normally wouldn’t think of, like an ATV, the cash value of life insurance, or that loan or land contract you had set up with a family member.

Financial circumstances are the largest obstacle to eligibility for long-term care Medicaid. Many people are told they’ll have to spend everything, or nearly everything, before qualifying. Many people think they’ll have to sell their home before qualifying, which is almost always wrong. And so, many people simply pay the bill each month, waiting until there’s nothing left.

But there are better ways to use those resources, and often ways to keep more than you’ve been told. Elder law attorneys help clients make the best use of their limited resources, plan ahead, and become eligible for Medicaid sooner without getting tripped up by hidden rules and regulations. Financial eligibility for Medicaid is something you can, and should, be proactive about.

But: It depends

It’s helpful to know the general rules, to know what’s possible. But, in the end, everything depends on your specific situation. Especially with Medicaid, for every general rule there is a multitude of exceptions, alternatives, and conditions to keep in mind. That’s why most people need an expert.