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North Carolina Special Assistance

Medicaid in an Assisted Living Facility? Think again!


You’ve been looking at assisted living facilities for Mom, who simply can’t be left home

alone anymore and who cannot afford round the clock in-home care.


Someone may have asked. “Are you going to be applying for Medicaid?” Technically, it

is also the wrong question to ask.


The name of the program is State/County Special Assistance for Adults. Call it “Special

Assistance.” Now burn this into a plaque somewhere: “Special Assistance is NOT

Medicaid.” The rules can be very different in a few critical areas.


First, a bit of background.


Levels of Care

Do not confuse an assisted living facility or adult care home with a skilled nursing

facility. They are two different facilities with different rules and different programs.


A skilled nursing facility (what most of us call a “nursing home”) is a place for folks who

are (usually) nonambulatory and with some chronic medical condition that requires

skilled care on a daily basis. Think of it as a “step down” from a hospital meant for

longer term stays. In the industry we call these “SNFs” (skilled nursing facilities).


Do not confuse these facilities with assisted living facilities. An assisted living facility is a

facility for frail individuals who need assistance with a number of what we call activities

of daily living (ADLs). Think assistance with bathing and toileting, mobility, personal

hygiene, feeding. In the industry we call these ALFs (assisted living facilities).


To add to the confusion, some ALFs have special units usually called “Memory Care” or

some similar variation (the bureaucratic term is “special care unit” or “SCU”). A special

care unit is a separate area of an ALF with locked doors and a higher level of

supervision for residents with various forms of dementia. Care in a SCU is NOT skilled

nursing. It is still part of an ALF.


Paying for It

Generally, SNFs are charging around $10,000 a month. As we’ll discuss in a moment,

Medicaid will pay for most care in most SNFs for eligible individuals. At 10 grand a

month, most folks are keenly interested in whether Mom will qualify for Medicaid. But

Mom is in an assisted living facility, so forget about it.


ALFs run around $3,500 to $4,000 a month for the general areas and perhaps $6,000 to

$8,000 for a SCU or Memory Care Unit (those locks and extra supervision get

expensive). Medicaid does NOT pay for ALF room and board and most incidental

services. They simply aren’t considered “medical.” That’s where Special Assistance

comes in.


If Mom is in an assisted living facility and IF she qualifies for SA, there will be a cap on

how much they can charge for room and board (basically her income plus whatever the

state pays them). Also, if Mom qualifies for SA, she MIGHT qualify to receive some

additional personal care services paid for by Medicaid.


Did I just say MEDICAID!? Yes, but it is not the same as nursing home Medicaid. In this

case it won’t be very much – perhaps a few hundred or a thousand bucks. Plus, unlike

the SNF which has to be happy with the Medicaid payment as complete payment, the

ALF might ask for a little bit extra from the family. But at least they aren’t paying “full

freight.”


Special Assistance Background

Did I already write that Special Assistance is NOT Medicaid? Special Assistance

actually borrows most of the rules that apply to the federal Social Security Supplemental

Security Income (SSI) program. There are some significant differences from Medicaid.

Special Assistance Transfer Rules


SA has transfer rules, as does Medicaid. But Medicaid looks at any transfer made within

5 years of applying, divides the value of the transfer by $6,810, and uses that number to

establish a penalty period in months that Medicaid will not pay for the SNF – beginning

when the person is finally in the SNF and otherwise eligible for Medicaid.

SA looks at any transfer made within 3 years. The value of the transfer is divided by

$2,000, and the result is used to calculate a number of months the individual is ineligible