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ALF Medicaid vs. SNF Medicaid

Assisted living facilities are a housing option for people who can still live independently, but who need some assistance with their daily activities. Costs can vary greatly depending on location and services offered. Medicare won’t pay for this type of care, but Medicaid will, subject to the assisted living resident meeting certain requirements.

Unlike Medicaid-accepting nursing homes, there is no requirement that Medicaid pay for assisted living residents, and no state Medicaid program can pay directly for a Medicaid recipient’s room and board in an assisted living facility. In fact, residents receiving Medicaid in an assisted living facility are receiving a Medicaid waiver program meant for those living in the community, and not institutional Medicaid.

To qualify for the Medicaid waiver in an assisted living facility, applicants must meet the same financial and clinical eligibility requirements of nursing home residents. In addition, Medicaid-accepting assisted living facilities in New Jersey are only required to fill ten percent (10%) of their beds with Medicaid recipients. Some facilities interpret the regulation as creating a “ceiling” whereby they cap the amount of Medicaid beds at ten percent (10%), while other facilities view the regulation as a baseline, filling Medicaid beds in excess of the ten percent (10%).

Another significant difference is the private pay requirement imposed by most assisted living facilities. Unlike nursing homes, assisted living facilities may condition the acceptance of a resident into their facility on the applicant’s ability to pay for assisted living facility services for a set period prior to qualifying for Medicaid. Most facilities in New Jersey will ask for a two-year private pay commitment, while others only ask for one year.

But what happens when an assisted living resident qualifies for Medicaid by virtue of meeting clinical eligibility requirements and being spent down to less than $2,000 in available assets, but the assisted living facility has no available Medicaid beds? This is where a lot of people run into trouble. Unlike nursing homes, assisted living facilities may ask for a third-party guarantor for payment in the event this situation arises. The third-party guarantor often unknowingly signs the assisted living facility’s admissions paperwork as a guarantor, not realizing the legal implications. Under this (very real) hypothetical, the resident will be put on an internal waiting list until a Medicaid bed becomes available, all the while the third-party guarantor is contractually liable for paying the costs associated with the resident’s stay. This example highlights the importance of seeking out knowledgeable elder law attorneys prior to signing any admissions forms for loved ones entering assisted living facilities (or nursing homes). The elder law team at Mandelbaum Barrett is happy to assist you and your family with these issues and many more.