Alternatives to Nursing Home Medicaid
Authored By: Legal Hotline For Texans - TLSC
If you are not eligible for Nursing Home Medicaid, you may still be able to get care, including:
o Home health care, hospice care, and other services paid for by Medicare,
o Alternative Medicaid programs, and
o Other options that you can pay for yourself.
Medicare may pay for home health care services.
Medicare pays for home health care if you are sick or injured, and:
o You need part-time or periodic (not full-time) care,
Your doctor has set up a home care plan because you can only leave your home for brief periods of time,
o Medicare covers the services you receive, and
o Medicare has approved the agency that provides your home health care services.
What kinds of services will Medicare cover?
Medicare will pay for services that your doctor recommends, such as:
o Skilled nursing care
o Physical, occupational, and speech therapy
o Care by home health aides (if you are also getting skilled nursing care or other therapy)
o Medical social services to help you with social and emotional concerns you have related to your illness
o Certain medical supplies, like wound dressing (but not drugs or prescriptions)
o Durable medical equipment (80% of approved amount)
o Visits by a home health nurse to provide injections to women suffering from bone fractures due to osteoporosis. Your doctor must certify that you cannot give the injections to yourself. Medicare covers the visits, but you pay a 20% copay for the drug.
Which services are not covered by Medicare?
Medicare does not pay for these home health care services:
o 24-hour home nursing care
o Most prescription drugs
o Meals delivered to your home
o Homemaker services, such as shopping, cleaning, and laundry
o Personal care given by home health aides, like bathing, using the toilet, or help getting dressed
(if this is the only care you need)
Can I choose any home health care agency I want?
No. If you are enrolled with a Medicare managed care plan, you must use a home health care agency on the plan’s list. Your Medicare managed care plan must give you a list of the approved agencies, covered home health care services, copays, and information about your appeal rights.
Will the home health care agency send me a bill?
No. The home health care agency sends the bills to Medicare. Before your care starts, the home health agency must explain which items and services are and are not covered by Medicare. The agency must explain this to you in writing and in person or over the phone.
How much of the bill will I have to pay?
If you receive only covered services (listed above), Medicare will pay for the complete cost.
Exception: Medicare will only pay 80% of the cost of durable medical equipment. That means you have to pay 20%.
What if I do not agree with the amount I am asked to pay?
If you disagree about the amount Medicare will pay and the amount you pay, you have the right to appeal. To learn about appeal procedures, go to: www.medicare.gov/basics/appeals.asp.
For more information about Medicare coverage of home health services, contact:
Texas Regional Home Health Intermediary: (800) 583-2236, or
Centers for Medicare & Medicaid Services website: www.medicare.gov
Will Medicare pay for hospice care?
If you qualify for Medicare, and you are eligible for hospice services, Medicare will pay for your:
o Nursing care
o Doctors’ services
o Drugs for pain relief and symptom management
o Physical, occupational, and speech therapy
o Home health aide and homemaker services
o Medical social services
o Medical supplies and equipment
o Short-term inpatient care, including respite care
o Counseling, including dietary and spiritual counseling
Medicare will also pay for covered services for problems that are not related to your terminal illness.
How do I know if I am eligible?
You are eligible if:
o You choose a Medicare-approved hospice program,
o Your doctor and hospice director certify you are terminally ill and will probably die within
6 months, and
o You sign a statement choosing hospice care instead of routine Medicare benefits for your
Important! The Medicare hospice benefit does not pay for:
o Treatment that is not for symptom management and pain control,
o Care that was not arranged for by the patient’s hospice, or
o Care from a provider that duplicates care the hospice is required to provide.
How long is hospice care available?
Medicare will pay for:
o Up to two 90-day periods, and then
o Any number of 60-day periods.
At the start of each period of care, your doctor must certify that you are terminally ill so you can continue getting hospice care.
Medicare will also pay for hospice patients to stay in a hospital or nursing home for up to 5 days to give temporary relief, called respite care, to the caregiver at home. They can do this as often as needed.
Can I stop my hospice care?
Yes. You can end your hospice care at any time, for any reason. Then, you can get health care using your Medicare health plan.
Can my doctor end my hospice care?
Yes. If your health improves or the illness goes into remission, the doctor may determine that you do not need hospice care.
How much does hospice care cost?
Medicare pays for all of your hospice care, except:
o 5% copay or $5 for each prescribed medicine (whichever is less), and
o 5% copay for inpatient respite care, based on the Medicare-allowed rate.
Can I (or my insurance) pay for the care I need?
Yes. If Medicare or Medicaid does not cover the care you need, you can also arrange for care that you (or your insurance) would pay for, including assisted living facilities and continuing care facilities.
Assisted living facilities provide food, shelter, and personal care services, such as help with dressing, moving, bathing, medications, and general care of your physical and mental well being. In most situations, Medicare and Medicaid do not pay for assisted living facilities. You must pay for an assisted living facility with your own money.
Exception: Community Based Alternative Medicaid Programs may pay for home and community based services for people who would otherwise be institutionalized. Enrollment is limited. For more information, contact your local TDHS Community Care for Aged and Disabled Office.
Continuing care facilities (CCF) are for patients who need long-term care, but do not need specialized nursing care. CCFs give patients a place to live where they can get personal care services, nursing services, medical, and other health-related services. CCFs are not covered by Medicare and Medicaid. In most cases, you have to sign a contract, pay an entry fee, and pay a monthly fee. The contracts are usually for a 12-month period or for the rest of your life.
The fees for CCFs vary. It’s best to compare because there can be big differences in the fees and the quality of services. Also consider if the CCF seems stable and is likely to stay in business for the time period you need it.
All CCFs have to give you written information about how to end your contract. You will get this when you sign up. If you need another copy of the information ask the CCF administrator. Or contact the Texas Department of Insurance.
If you are not eligible for Medicaid Nursing Home services, you may still be eligible for a Medicaid Community Care Program. These programs provide services in the community to elderly people with physical or developmental disabilities.
o Primary Home Care programs provide personal care services that help with daily living and personal care, if medically necessary.
o Program of All-inclusive Care for the Elderly (PACE) in El Paso helps people who are over 55, live in certain areas of El Paso, and have been certified eligible for nursing facility care. For more information, contact Bienvivir Senior Health Services at: (915) 599-8812.
o Community Based Alternative Programs provide home and community based services to people who would otherwise be institutionalized. Enrollment is limited. For more information, contact your local TDHS Community Care for Aged and Disabled Office.
o Adult Foster Care programs place adults in foster homes if they can no longer live independently because of physical, mental, or emotional limitations. The foster caregivers offer help 24/7 with personal care, daily living activities, and providing or arranging for transportation. The caregivers and residents live in the same home and share a common living area. There can be no more than 3 adults, unless the home is licensed by DADS. The client pays the caregiver for room and board.
o Family Home Care program provides personal care, home management, and escort services for eligible adults.
For more information on these programs, contact your local Area Agency on Aging. Ask a benefits counselor if you are eligible. To find your Area Agency on Aging, call: (800) 252-9240.
How can I pay for my own nursing home care if Medicaid or Medicare does not cover it?
If you need long-term nursing home care, you can pay with your own money. Or you can use your long-term care insurance (if you have any). If you plan on paying for long-term care yourself, we suggest you talk to a financial planner. A planner can help you calculate the value of your assets and the likely cost of your care over time. A planner can also tell you about “Medicaid qualifying trusts,” which allow you to keep some of your assets and still be eligible for Medicaid.
For a trust to qualify, you must set it up at least 5 years before you go into a nursing home. Once you are in the home, Medicaid may require you to use the money available to the trustee to pay for the care. If your trust says that the trustee can only use the interest income, you will be able to preserve the principal value of your assets.
The rules for trusts are complicated, and there are risks. For example, you are allowing someone else full control of your assets in exchange for sheltering them. Talk to a lawyer before you set up a trust.
Many insurance companies sell long-term care insurance. Generally, the older you are, the more they cost. Please read the Texas Department of Insurance publication, What Texans Should Know about Long Term Care Insurance.
You can read it online at: www.tdi.state.tx.us/consumer/ltcrgintro.html
Or order it from:
Texas Department of Insurance
P. O. Box 149104
Austin, TX 78714-9104.
For help finding a lawyer, call the State Bar of Texas Lawyer Referral Service: (800) 252-9690
Or contact your local Legal Aid office.
For more information…
Contact the Texas Department of Aging and Disability Services. Ask to speak to a Benefits Counselor at your local Area Agency on Aging. Call: (800) 252-9240
Texas Law Help has useful information on many areas of the law. Go to www.texaslawhelp.org.
Legal Hotline for Texans: (800) 622-2520 or (512) 477-3950
Call our attorney-staffed legal hotline. Advice is free for Texans 60 and over or for anyone eligible for Medicare.