Medicaid for nursing home and home care in Virginia

Who qualifies

You must meet these tests:

1. Age or disability. You are 65 or older, or blind or disabled.
2. Care needs. A pre-admission screening shows you need nursing-facility-level care. For the CCC Plus Waiver, a doctor must also approve, and the screening must show you can be safe at home.
3. Money rules. Your income and resources are within the limits below.

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Money rules

If your income is over the limit

DMAS says people over the income limit may still qualify if the private cost of their long-term care is more than their income. Ask your DSS eligibility worker how this works for you.

Gifts and transfers

If you gave away money or property for less than it was worth, Medicaid may not pay for your long-term care for a penalty period. During a penalty period, Virginia does not allow patient pay deductions for medical costs. Tell your worker about any gifts when you apply.

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If you are married

Virginia has special rules so the spouse at home does not lose everything.

• Resources: The spouse at home can keep resources between $32,532 and $162,660.
• Income: If the spouse at home has low income, part of your income can go to them, bringing their income up to at least $2,705 a month and as much as $4,066.50. Extra can be allowed for high housing costs above $811.50 a month.

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Patient pay: what you pay each month

Most people on long-term care Medicaid pay part of their income toward care. This is called patient pay. Your eligibility worker figures it at the start and sends you a notice.

You keep:

• In a nursing home: A personal needs allowance of $40 a month.
• On the CCC Plus Waiver or PACE: A personal maintenance allowance of $1,641 a month for rent, food and bills.
• Allowances for a spouse or child living at home.
• Some medical costs Medicaid does not cover. Send the bill within 90 days of the invoice date.

If you get SSI and have no other income, you do not pay patient pay.

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The programs

Nursing facility care

Medicaid pays for medically necessary care in a nursing home after a pre-admission screening approves it.

CCC Plus Waiver (care at home)

The CCC Plus Waiver pays for services that help you stay at home. It has no waiting list. Services include:

• Personal care, from an agency or with workers you hire yourself (consumer-directed), usually up to 56 hours a week, with exceptions.
• Respite care to give a family caregiver a break, up to 480 hours each state fiscal year (July 1 to June 30).
• Adult day health care.
• A personal emergency response system, including medication monitoring.
• Assistive technology and home changes for safety, each up to $5,000 a year.
• Private duty nursing by an RN or LPN, up to 112 hours a week.
• Services facilitation to help you manage workers you hire yourself, and transition services to help you move out of a nursing home.

To qualify, your health and safety must be able to be kept safe at home when an aide or nurse is not there, and you must be at risk of going into a nursing home.

PACE

PACE (Program of All-Inclusive Care for the Elderly) gives all your Medicare and Medicaid care through one team. You must be 55 or older, need nursing-facility-level care, and live in a PACE service area. Each PACE site serves certain ZIP codes; DMAS lists them on its PACE page.

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How to apply, step by step

1. Apply for Medicaid. Online at commonhelp.virginia.gov, by phone with Cover Virginia at 1-855-242-8282 (TTY 1-888-221-1590), or at your local DSS. For nursing home care, apply at the DSS for the city or county where you last lived before going into the nursing home. If you are 65 or older, blind or disabled, include Appendix D with a paper application.
2. Ask for a pre-admission screening. Local and hospital screening teams do these. The screening decides your level of care and whether Medicaid will pay for long-term care. Ask for it when you apply.
3. Send proof of income, resources and any gifts or transfers when DSS asks.
4. Get your notice. It will say if you qualify and your patient pay amount.

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After you are approved

• Renewals. Cardinal Care will ask you to renew. DMAS publishes a long-term care renewal fact sheet on the Cover Virginia LTSS page. Return renewal forms on time.
• Report changes in income, resources or where you live to your local DSS. Patient pay changes are sent to you on a Notice of Patient Pay Responsibility.
• Start care within a year. If your long-term care does not start within 365 days of your Medicaid notice, DSS must look at your case again under the regular rules.
• If you are denied, your notice explains how to appeal and the deadline. Ask quickly.

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Common mistakes

• Skipping the screening. Medicaid will not pay for long-term care without it.
• Assuming your income is too high. If your care costs more than your income, you may still qualify.
• Not reporting medical bills. Uncovered medical costs can lower patient pay, but only if you send them within 90 days.
• Giving away money first. Gifts can cause a penalty period.

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Free help

• Cover Virginia: 1-855-242-8282 (TTY 1-888-221-1590).
• Area Agencies on Aging: Call No Wrong Door Easy Access at 1-888-992-0959 (24/7) to find yours.
• VICAP (free Medicare counseling): 1-800-552-3402.

Read more about paying for a nursing home and see all benefits in Virginia.

Phone numbers: Free help lines for Virginia agencies

Check what you may qualify for