If your finances are limited and you do not have a long-term care insurance policy, it will be important to find out if your preferred facility has a contract to accept Medicaid Waiver payments.  If the facility does accept this payment source, you will also need to find out how soon after your admission you can start on Medicaid.  But first – what is the difference between Medicare and Medicaid?

Medicare and Medicaid are NOT the same things.  Medicare is a federal program that anyone over a certain eligibility age is guaranteed to get; all those over the eligibility age (usually 65) are entitled to the program.  Those who have worked outside of the home have been contributing to the federal Medicare fund all along in the form of payroll taxes.  Medicare covers major medical costs like hospitalizations, ambulance rides, and emergency care; one can purchase various supplemental plans to cover additional items and services such as prescriptions, office visits, etc.  Medicare also typically pays for a skilled nursing facility (SNF or “Nursing Home”) when you have been determined eligible.  However, one important thing to note: Medicare does not pay for assisted living.

Medicaid, on the other hand, is a federal health care program that is based on need, not an entitlement.  Not everyone will qualify for Medicaid in the way that those over 65 automatically qualify for Medicare.  Medicaid provides coverage for medical and medical-related services on the basis of financial or medical needs.  As we have discussed before, assisted living is not strictly a medical service in the way a nursing home is.  So how can Medicaid cover assisted living costs?  The answer is that assisted living services help to prevent the need for more complex and expensive medical services in the future.  Because of this, many states (including Wisconsin) have received a Waiver from the federal government to create a state program under federal Medicaid that covers services that are not strictly medical in nature.  These programs are called Medicaid Waiver programs; in Wisconsin, our program is named Family Care.  The Family Care program covers assisted living costs and a variety of other services that, in and of themselves are not strictly medical care, but often prevent the need for costly acute care down the road.  An ounce of prevention is worth a pound of cure after all.

At SpringBrook Community of Onalaska, we do accept Family Care as a payment source after private funds have been depleted.  We contract with a Managed Care Organization (MCO) called Inclusa to access Family Care funding.  Our service agreement requires a minimum of two years of payment at the market rate.  If private funds run out after the two-year requirement is met, a tenant or resident can then apply for Family Care funding.  Relocation to a different apartment is often required.  After converting to Family Care, neither the facility nor the tenant will have any control over the rate paid for services.  Typically, the facility receives about a 45% cut in funding when a tenant moves onto Family Care.

Eligibility for Family Care funds is determined by the local Aging and Disability Resource Center (ADRC). We ask for advance notice so that SpringBrook personnel may be present during the Functional Screen that is conducted by the ADRC.  The Functional Screen is a very important document for a variety of reasons, not the least of which is because it determines the rate that the facility will receive to provide all of the care and services that the tenant or resident needs.  If the Functional Screen is not accurate, the rate may not support the level of care needed, leaving both the facility and the resident in a difficult spot.

While no one can 100% guarantee that a rate will be sufficient, at SpringBrook we consider our tenants and residents to be family.  We will do everything in our power, including negotiating with a managed care organization, to ensure that current tenants can stay here even if private funds run out.  Make sure to do your homework when choosing an assisted living facility.  Find out if your chosen facility accepts Medicaid Waiver payments, and if so, what their specific policies and criteria are with regard to that issue.