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Medicaid - Community vs. Nursing Home


Who pays for in-home care when an elder has no long term care insurance and insufficient assets to pay out of pocket? Medicare only covers skilled care and is not the answer. While some benefits exist under the VA Aid and Attendance program, the program is helpful to a point, but certainly not the cavalry to the rescue.


So we must look to Community Medicaid which also goes by the name MassHealth.

A baffling array of programs exists within Community Medicaid including the Home Based Community Waiver and the Personal Care Attendant programs which are generally based on clinical status, income, assets and whether assets have been transferred. Be forewarned: the rules and Medicaid practice can sometimes change with the weather.


What can you do when an elder’s home care needs are so crushing as to bring the family and/or care providers to the point of collapse? That may be the time for admission to an Assisted Living Facility (ALFs) though there is minimal government funding for ALFs.

What if an ALF is financially out of reach or an elder’s needs exceed that which an ALF can provide? Some veterans apply to the Holyoke Soldiers Home. But available spaces are rare since placement there is so inexpensive.


Skilled Nursing Facilities (SNF’s) are far more expensive than ALFs but admission to one does not have to spell financial doom. There may be asset protections strategies that can be employed, particularly when the SNF resident has a spouse. This is because SNFs accept Medicaid whereas ALFs generally do not.


Strategies might involve so called Medicaid annuities, Pooled Supplemental Needs Trusts, restructuring of finances and/ or estate plans, transfers of the house to a caretaker child and Caregiver Agreements with family members.


Our elderly population is exploding with the arrival of the baby boomers. What is the least expensive yet safe and humane way to care for them and who pays for it? That is the $64,000 question which stymies our legislators and elder advocates. Often expensive home care ends up being cheaper than a relatively inexpensive ALF. And under certain circumstances a SNF might actually be cheaper than in-home care. Because there is no easy answer, be sure to consult with a professional who is able to see the entire picture of finances, law, health care and family dynamics.

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