Virginia Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid’s rules, benefits and name can all vary by state. This article focuses on Virginia Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers and ABD Medicaid. This is different than regular Medicaid, which is for financially limited people of all ages.

Virginia Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Virginia Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited Virginia seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:

• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Skilled nursing care
• Physician’s visits
• Prescription medication
• Medication management
• Mental health counseling
• Social activities

Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.

Virginia Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are allowed to keep a “personal needs allowance” (PNA) of $40/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid recipients.

Virginia Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.

Home and Community Based Services (HCBS) Waivers

Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited Virginia seniors who require a Nursing Facility Level of Care, or a hospital level of care, remain living in the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for Virginia seniors living in their home or the home of a loved one. While Virginia’s HCBS Waivers will cover some long-term care services in those settings, it will not cover room and board costs, such as mortgage payments, rent, utilities or food expenses.

Virginia has consolidated its HCBS Waiver options into one program, the Commonwealth Coordinated Care Plus Waiver (CCC+). Long-term care CCC+ benefits include adult day care, private day nursing, home modifications, personal emergency response systems and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Program participants receive all of their CCC+ benefits through a single Medicaid plan delivered by a managed care organization, which has a network of care providers. In addition to using the in-network care providers, CCC+ beneficiaries can self-direct their care by selecting a caregiver of their choice, including family members, for some of these services, like personal care assistance. CCC+ program participants can hire their adult children, adult grandchildren, siblings, nieces and nephews as caregivers, but spouses cannot be hired as CCC+ caregivers.

Aged, Blind, and Disabled Medicaid

Virginia’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited Virginia residents who are aged (65 and older), blind or disabled. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage through ABD Medicaid. Long-term care benefits are provided based on need and availability.

1. ABD Long Term Care Benefits
Eligible Virginia seniors who show a medical need for long-term care goods and services can receive those goods and services through ABD Medicaid. These benefits can include case management, adult day care, meal delivery, home modifications and Personal Emergency Response Systems (PERS). ABD Medicaid recipients qualify for these benefits one at a time. This is different from Nursing Home Medicaid, which makes all of its benefits immediately available for anyone who qualifies. Instead, Virginia seniors will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.

2. Program of All-Inclusive Care for the Elderly (PACE)
Virginia residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Virginia’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Virginia’s PACE programs are located in Alexandria (Cherry Blossom PACE), Big Stone Gap (Mountain Empire PACE), Cedar Bluff (AllCARE for Seniors), Charlottesville (InnovAge Virginia PACE – Blue Ridge), Lynchburg (Centra PACE), Newport News (InnovAge Virginia PACE – Richmond & Peninsula), Norfolk (Sentra PACE) and Salem (InnovAge Virginia PACE – Roanoke Valley). To learn more about PACE, click here.

Eligibility Criteria For Virginia Medicaid Long Term Care Programs

To be eligible for Virginia Medicaid, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.

Virginia Medicaid Nursing Home Medicaid Eligibility Criteria

Virginia residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for Virginia Nursing Home Medicaid for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Virginia Nursing Home Medicaid recipients are required to give most of their income to the state to help cover the cost of care. They are only allowed to keep $40/month of their income as a “personal needs allowance,” plus enough to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy spouses who are not covered by Medicaid.

For married applicants with both spouses applying, the 2024 asset limit for Virginia Nursing Home Medicaid is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant spouse and the income of the non-applicant spouse is not counted.

Functional Requirements
The functional, or medical, criteria for Nursing Home Medicaid in Virginia is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with nursing homes. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals. The assessment will evaluate the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognitive and behavioral issues. Virginia uses its Uniform Assessment Instrument (UAI) to determine if this level of care is needed.

Virginia Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
Virginia residents have to meet an an asset limit and an income limit in order to be financially eligible for their Home and Community Based Services (HCBS) Waivers, which is the Commonwealth Coordinated Care Plus Waiver (CCC+). For a single applicant in 20224, the asset limit for CCC+ is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for CCC+ for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying for CCC+, the 2024 asset limit is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit for the applicant is $2,829/month and the income of the non-applicant spouse is not counted.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Services (HCBS) Waivers in Virginia is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with nursing homes. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals. The assessment will evaluate the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognitive and behavioral issues. Virginia uses its Uniform Assessment Instrument (UAI) to determine if this level of care is needed.

Virginia Aged, Blind, and Disabled Medicaid Eligibility Criteria

Financial Requirements
Virginia residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities.

The 2024 income limit for Virginia ABD Medicaid for a single applicant is $1,004/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2024 asset limit for Virginia ABD Medicaid is a combined $3,000, and the income limit is a combined $1,363/month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.

Functional Requirements
The only functional requirement to receive basic healthcare coverage through Virginia ABD Medicaid is being aged (65 and over), blind or disabled. For ABD Medicaid applicants and beneficiaries who require long-term care services and supports, the state will administer an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and Instrumental Activities of Daily Living (which include shopping, cooking, housekeeping and medication management) to determine the kind of long-term care benefits the state will cover.

How Virginia Medicaid Treats the Home for Eligibility Purposes

One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:

• If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage/debt) is less than $713,000 (as of 2024) then the home is exempt.
• If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives.
• If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $713,000.

These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.

Virginia Medicaid Long Term Care applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Virginia and how you can protect your home from it, click here.

Applying For Virginia Medicaid Long Term Care Programs

The first step in applying for a Virginia Medicaid Long Term Care program is deciding which of the three programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that program. Applying for Virginia Medicaid when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Virginia Medicaid applicant. These documents will be needed for the official Virginia Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Virginia residents can apply for Medicaid online at CommonHelp. They can also call Cover Virginia at 855-242-8282. Another option is printing out the necessary applications from this webpage, filling them out and returning them to the applicant’s local Department of Social Services office. Applicants age 65 and older who need long term care should be aware that in addition to the “Cover Virginia Application for Health Coverage and Help Paying Costs,” they will also need the Appendix D form.

For step-by-step guides to applying for each of the 3 types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.

Choosing a Virginia Medicaid Nursing Home

After being approved for Nursing Home Medicaid through Virginia Medicaid, you or your loved one has to choose which Medicaid-accepting nursing home best meets your needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes accept Medicaid, and those that do may not have available space. Finding the right residence can be a challenge, especially if you’re looking in a specific location.

Virginia has roughly 300 total nursing homes, and about 275 of them accept Medicaid. There are about 40 facilities in the Virginia Beach/Newport News region. Richmond has around 30 nursing homes within 25 miles, and the Virginia suburbs around Washington, D.C., have about 35 nursing homes that take Medicaid. There are roughly 20 facilities within 25 miles of Roanoke, and there are about a dozen around Charlottesville.

Residents in some Virginia communities regularly cross state lines for business and personal reasons, including healthcare. But Medicaid coverage does not cross state lines. So, a Virginia Medicaid beneficiary would not be covered for nursing homes in Maryland or Washington, D.C., even if facilities in those places were convenient and well-suited for the Virginia resident.

When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. You can also contact your local Area Agency on Aging to find out more information about nursing homes in Virginia.

After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.

Data collected by CMS reveals that nursing homes in Virginia may be lacking when it comes to health standards. Virginia nursing homes averaged 34.7 health deficiencies per facility from 2019-2022, while the national average was 25.7. That doesn’t mean that all Virginia nursing homes have health standard issues, but it does mean you should be sure to research this area before making a final decision on nursing homes. Again, the search tool on Nursing Home Compare provides information about health inspections for every nursing home in Virginia and the country.