While Medicaid covers many services, there are a number of items that are not provided by this program. Medicaid does not cover the following services:

  • Private room, unless it is medically necessary
  • Specially prepared food, beyond that which is generally prepared by the facility
  • Telephone, television, and radio
  • Personal comfort items, including tobacco products and confections
  • Cosmetic and grooming items and services that are in excess of those included in the basic service
  • Personal clothing
  • Personal reading materials
  • Gifts purchased on behalf of a resident
  • Flowers and plants
  • Social events and activities that are beyond the included activity program
  • Special care services that are not already included in the facility’s Medicaid payment

It is important to note that some exceptions may apply. However, exceptions must typically be medically necessary and ordered by a physician before the exception can be applied.

Unlike Medicare, there are some fairly strict financial rules with which one must fall into in order to qualify for Medicaid’s nursing home benefits. Yet, for those in need of this coverage, there are numerous strategies and combinations of strategies that can be used to qualify.

By using these strategies properly, with the guidance of a professional, proper care for a loved one can be obtained while preserving assets and income for a healthy spouse and / or other family member(s).

If an applicant is living in their home (i.e., not in a nursing home), the Medicaid program refers to them as living “in the community.” In this case, Medicaid will still pay for certain services if the person qualifies. The basic test is whether the individual would otherwise require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded. In other words, an applicant for home care must meet the level of care for some type of institutionalized care.

Many states – including Florida – have a program called “HCBS.” This stands for Home and Community Based Services. Until recently, a state wishing to provide Medicaid assistance to elderly people outside the nursing home had to apply to the federal government for a specific waiver of the usual Medicaid rules.  However, as a part of the Deficit Reduction Act, and beginning in 2007, all states are eligible to offer this program now without first having to obtain a federal waiver by submitting a state plan amendment setting forth the scope of the new HSBS program they wish to implement. Therefore, both the old waiver program and the new SPA option will exist concurrently. There is no federal requirement limiting the number of HCBS programs that a state may operate at any given time, and currently there are just fewer than 300 HCBS waiver programs in operation throughout the U.S.

In general, HCBS will pay for the following in-home services:

  • Case management
  • Personal care services
  • Respite care services (i.e., care for the patient in a nursing home for a few days in order to give the home care giver a needed break)
  • Adult day care services
  • Homemaker / home health aide services
  • Habilitation (i.e., assistance for people in furthering their skills in areas such as mobility, social behaviors, self-care, basic safety, housekeeping, personal hygiene, health care, and financial management)

It is important to note that room and board of the HCBS recipient are not covered and that home care is very limited even when full qualification is obtained.