Q: I recently started exploring an assisted living facility for my mother. When I told them she would be applying for Medicaid, they informed me that they do not accept Medicaid for room and board but can accept Special Assistance. What is the difference?
A: When it comes to funding care, it is important to understand the two different programs. The state of North Carolina offers a State-County Special Assistance (SA) program that provides a cash supplement to low-income individuals age 65 or over to help pay for room and board in residential facilities. These typically include adult care homes, assisted living facilities, family care homes, and group homes. These residential facilities are different from nursing homes in that medical care is not provided. If your mother qualifies for SA, it would help cover room and board cost, as well as a small personal monthly allowance for items like lotion, soap, or snacks.
Eligibility for SA ensures Medicaid eligibility, which would then cover the medical portion of expenses. The maximum amount of assistance is determined by her income and by the rate of licensed adult care homes charge their residents. This amount is approved by the state. In 2014, the maximum benefit was approximately $1,500 per month. Not all assisted living facilities are licensed to and agree to accept the SA rate, so make sure you ask that question when shopping around.
The first step is contacting your local Department of Social Services or the NC Department of Health and Human Services website to complete an application for eligibility. There are some older adults who have too much income to qualify for SA but do not make enough income to cover room and board. This can be challenging and often means looking at other options for funding sources. Planning ahead is crucial and working with professionals (certified care manager, elder law attorney, and placement specialist) who can help navigate the process is often times necessary.
Medicaid is a program that is applicable to any low-income individual meeting eligibility requirements, not just older adults. If your mom qualified it would cover certain inpatient, comprehensive services such as institutional benefits. This would include things like hospital services, Intermediate care facilities, and nursing facilities. These facilities are typically more of what you consider a traditional nursing home and are licensed by the state. The comprehensive care at this level does include room and board, but an assisted living facility would not be considered under “institutional benefits.” A person must meet criteria for this level of care, as deemed by their physician based on physical and medical needs. So if she is at the assisted living level of care, Medicaid would not be an option for room and board cost.
If your mother qualifies for SA, is receiving this funding at an assisted living facility then five years down the road her level of care increases to nursing home care, she would then be able to apply for Medicaid funding in the nursing facility and SA would no longer be applicable.
These programs have a lot of different parts and are not always easy to navigate. There is quite a bit of information online but it can get overwhelming. The application process also takes time, so start doing your homework now and make sure you are getting accurate information.