What are the requirements to qualify for Medicaid?

Medicaid is a needs-based program for people 65 years of age or older, or who are permanently blind or disabled. They must also meet certain income requirements and asset limits for their state. If someone receives Supplemental Security Income (SSI), then they are automatically eligible for Medicaid benefits and do not need to go through the application process. 

Additional requirements:

  • A U.S. citizen or show proof of eligible immigration status, 
  • Live in the state in which they are applying for benefits, and 
  • Have a social security number (or show proof of having applied for one). 

Medicaid’s resource limit is $2,000 for an individual or $3,000 for a couple when both people are receiving benefits, but there are many assets that do not count against this number. For example, the applicant can still own their home while they are in a nursing home and receiving Medicaid benefits. 

Medicaid also has an income requirement for an applicant, but the number is based on the applicant’s cost of care and can vary from applicant to applicant. 

What does Medicaid Cover?

Woman in wheelchair reviewing a note

Medicaid provides a broad level of health insurance coverage including doctor visits, hospital expenses, and nursing home care. Prescription drugs are not required to be covered by Medicaid. In very limited circumstances, Medicaid might cover some limited in-home care or community-based services, but generally, it’s used to pay for long-term care once a person has “run out of money.” 

Since Medicaid is a public assistance program, recipients must qualify to receive benefits. The Medicaid program was created by federal law but is administered by each state. Each state then has its own rules and interpretations when it comes to administering the Medicaid program. In North Carolina, individual county departments of social services administer the program at the local level. When an applicant applies for Medicaid benefits, their application is processed by their local department of social services office. 

Medicaid currently pays about 50% of nursing home expenses in the US. Many people think that Medicare also pays for long-term care, but Medicare only pays for about 7% of nursing home expenses in the US. Medicare is designed to be a health insurance program for those 65 and older and pays for mostly routine health care and short-term hospital or rehabilitation stays as opposed to long-term care. 

Because Medicare does not usually pay for long-term care, it is important to effectively plan for needing Medicaid benefits later in life. As our life expectancy has increased, the likelihood of needing long-term care services during our lifetime has also increased. About 70% of people reaching age 65 are expected to require long-term care at some point in their lifetime, and about 20% of those people reaching age 65 are expected to require long-term care for 5 years or longer. At an average cost of $7,000 per month for a nursing home, that would be over $400,000. 

Filing a Medicaid Application

Working with an experienced elder law attorney can be critical to the success of a Medicaid application. Because of the needs-based nature of the program, there are very specific requirements regarding income and assets, and it is very easy to apply at the “wrong time.” If a Medicaid application is submitted too early, the applicant may wait months for the application to be processed only to find out they were not eligible at the time they submitted the application. Then, the applicant may owe thousands of dollars to the nursing home for the care they received while the application was pending with no choice but to privately pay for that care. 

If you would like to find out what your options may be for yourself or a loved one to plan or apply for Medicaid benefits, please call our office at 919-443-3035 or visit our website to schedule a free needs assessment call.