What can Medicaid pay for?

Wisconsin Medicaid can pay for long-term care in a nursing home, assisted living facility, or at home. Different programs apply to these different levels of care.

Institutional MA

Institutional Medical Assistance is the program the pays for long-term care in a hospital or skilled nursing facility (in other words, a nursing home). This is the most expensive type of long-term care, averaging $9-10,000 per month.

Of course, most care in a hospital is covered by normal health insurance (including Medicare). Most people don’t need Medicaid for routine visits or emergency care. It’s only when a person stops getting better but still needs nursing-level help with activities of daily living that it becomes long-term care. The person’s recovery or rehabilitation has “plateaued,” as they say, and it looks like they will need the daily assistance of another person long-term.

Usually, a person who needs long-term care only remains in the hospital long enough to find a nursing home to transfer to. So this program is mostly about paying for a nursing home.

It’s also important to know that Medicare often covers the first 1-3 months of long-term care. It covers up to 100 days after a transfer from a hospital, while the person is in rehab. It’s common to see an older person admitted to the hospital because of an emergency or acute illness, then go directly to a nursing home to recover. Medicare coverage can stop short of the 100 days, though, if the recovery stops—if the person “plateaus.” Not everyone is admitted to a nursing home directly from a hospital, either. So Medicare can, and commonly does, pay for the first few weeks or months of long-term care—but not always.

Another important feature of institutional MA is that it can be backdated up to three months. When you submit the application, you can request retroactive coverage for up to the three months before the month of application. So if you submit the application in April, you can potentially get coverage for January, February, and March as well. Of course, you still have to meet all the Medicaid requirements in those months (for example, having less than $2,000 in countable resources if you’re single). But the ability to backdate can be important, and it somewhat lessens the consequences of missing a deadline, of delay, or of having to reapply.

Family Care

Family Care is the primary “community Medicaid” program in Wisconsin. The idea of community Medicaid programs is that if a person needs a nursing-home level of care but can function in a less institutional—and less costly—setting, that’s better for everyone. The State pays less and the person lives in a less restrictive, more independent environment.

A prerequisite for any community Medicaid program is needing a nursing-home level of care. This is determined by something called a functional screen. The functional screen is a detailed interview done by a county worker from the local Aging and Disability Resource Center (ADRC). It is primarily screening for how much help a person needs with activities of daily living (such as bathing and dressing) and instrumental activities of daily living (such as cooking and cleaning). Although “nursing-home level of care” might sound extreme, it is usually not difficult to establish if the person has high enough needs to be paying for professional long-term care to begin with.

Family Care can potentially pay for care in an assisted living facility, memory care facility, group home, or other community-based setting. It can also pay for in-home care to some extent.

Unlike Institutional MA, Family Care cannot be backdated. This makes the timing of the Medicaid application extremely important. Medicaid eligibility is month-to-month; you must get the application officially submitted—in most cases, that means actually received by the county or state during business hours—as soon as possible to start coverage. If you delay, you can easily lose coverage for weeks or months you otherwise would have been eligible for. That can be a multi-thousand dollar error.

The Family Care program delivers care differently from other programs, too. Instead of the facility directly billing the State, you enroll in a managed care organization, or MCO. This is a health care organization that contracts with the State to manage and deliver Medicaid services. You get to choose your MCO, though you might not have many options. Once enrolled, you’ll work with a team from your MCO to plan and arrange the care needed.

IRIS

IRIS is the main alternative to Family Care for community Medicaid. It stands for “Include, Respect, I Self-direct.”

Generally speaking, the idea of IRIS is to give you more control over your care. You get a budget based on your needs, and you can make your own choices on how to spend that budget. An IRIS consultant helps you develop a plan for your support. The tradeoff is that IRIS typically pays for less care overall than Family Care, and working within your allotted budget may be challenging.

As with Family Care, eligibility for IRIS starts with a functional screen. Also the same: eligibility for IRIS cannot be backdated prior to the month the application is submitted.