Does Medicaid Cover In-Home Care in New Jersey?
Updated 12/14/2022 to include the most-recent income limits for QIT.
The answer here, unlike in my previous article about assisted living care, is not a straightforward "yes."
Programs for Coverage of In-Home Care
There are a number of programs (called "waivers" in technical Medicaid-speak) that cover some version of in-home care for people who need a nursing home level of care (again, help with those three “activities of daily living” or some sort of dementia diagnosis), but the program is neither as robust nor as accommodating as you would hope.
You may have heard of programs such as “Money Follows the Person,” “I Choose Home,” or “PACE” in New Jersey, and they may all be available. However, when people hope to receive round-the-clock in-home care in New Jersey on Medicaid they are invariably disappointed.
Changes in New Jersey
As I mentioned in previous articles, the state recently transitioned its care from a state-managed system to one through so-called Managed Care Organizations (MCOs), which is another way of describing those big health insurance companies that we all know about (and which I will not mention, since they don't pay me to do so).
Income Cap Structure
The State has also moved back to an “income cap” structure, which it hadn't used since the 1990s. What this boils down to is that the financial criteria are the same as for other institutional “adult Medicaid” applications – a single person can keep minimal assets, and a couple can keep more.
If your loved one has income in excess of $2,523 a month (that's the number for 2022) they will need to have something called a “qualified income trust” or “Miller trust” set up. The State has a template available and describes it in some (although not enough) detail. You will also need to make sure your loved one has not made any gifts in the last five years.
Receiving Assistance For In-Home Care
Once you are financially eligible, and you specifically ask for assistance with in-home care, the MCO will send out a nurse to evaluate your loved one, and they will tell you how many hours a week the MCO will authorize for care based on the evaluation tool they use.
Increasing In-Home Care Coverage
The trouble is that the tool is designed to minimize the number of hours, and it is almost inevitable that you will need to lodge an appeal to have those hours increased.
It is simply unreasonable to expect that someone who really could use constant supervision will be fine with only, for example, 25 hours a week of care provided in the home. There are 168 hours in a week, and the expectation would be that the family or some other caregiver would need to be available for the rest of the time.
The reason this happens, most frequently, is that the MCOs make more money when they assign less care in the home, and if they assign too much care it becomes more cost-efficient simply to move the person to a skilled nursing facility.
Finding a Qualified Support System
It should be obvious that applying to this program is not for the faint of heart, and it really helps to have legal representation on your side to make timely appeals and pursue the right advocacy for your loved one in their time of need.
I have been through this process many times, and have been successful in getting additional services for Medicaid applicants. I'm not saying you can't do it yourself, but why not invest the time and resources to get someone on your side?
Please make sure you call an attorney or advisor you trust before you find yourself too far along in the process of applying for in-home care through New Jersey's Medicaid program.
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