Medicaid for nursing home and home care in Wisconsin

Who qualifies

You must be 65 or older, blind, or disabled, live in Wisconsin, and need long-term care. For care at home, the Long-Term Care Functional Screen (done by the ADRC) checks that you need enough help. Family Care also requires a long-term care condition expected to last more than 90 days.

If your income is over the limit

• At home (waivers): You can still qualify in what the state calls Group B Plus if your income is not more than the cost of nursing home care plus the medically needy limit. You pay a monthly cost share toward your services. In Family Care, Family Care Partnership and PACE, that cost share is capped at $4,015.55 a month.
• In a nursing home: Ask your county or tribal income maintenance agency about the medically needy rules, which count your care costs against your income.

What counts and what does not

Countable assets include cash, checking and savings accounts, certificates of deposit, stocks, bonds and other investments, life insurance policies, and real estate other than your home.

Not counted:

• Your home, while you, your spouse or a dependent relative lives there (subject to the home equity limit).
• One vehicle.
• Some burial assets, such as burial insurance, some irrevocable burial trust amounts, and burial plots.
• Household items, clothing and personal items.

Income: For you to qualify, only your own income counts, not your spouse's. Your spouse cannot be made to pay for your care unless a court orders it.

What you pay each month

In a nursing home, most of your income goes toward your care. You keep $55 a month for personal needs, plus amounts set aside for a spouse at home.

In a home care waiver, you keep a basic needs allowance of $1,192 a month for rent, food and other costs. It can go up to $2,982 if you have earned income or housing costs over $350 a month. Health insurance premiums, including Medicare and Part D, are also taken off before your cost share is figured.

Protections for a spouse at home

These rules apply when one spouse is in a nursing home for 30 days or more, or enrolled in Family Care, Family Care Partnership, IRIS or PACE.

The person needing care also keeps $2,000 in their own name. After approval, they have one year to move extra assets to the spouse at home. You can ask your agency for an asset assessment before you apply. Both spouses must sign the application, or it will be denied. If the spouse at home cannot sign, use form F-02733.

The extra shelter amount applies only when the spouses do not live together. It is the spouse's housing costs (rent or mortgage, taxes, insurance, upkeep fees and a utility allowance) above $1,082.

Care at home: the programs

• Family Care: A managed care organization arranges your long-term care, from help with bathing, dressing and meals to mental health care. Available in every county.
• IRIS (Include, Respect, I Self-Direct): You get a budget and choose and hire your own workers.
• Family Care Partnership: Combines health care and long-term care, including for people with both Medicare and Medicaid. Offered in some counties.
• PACE: All-in-one care for people 55 and over in Kenosha, Milwaukee, Racine and Waukesha counties.

Giving away money or property

Wisconsin looks back 60 months (five years) before you apply. Gifts or sales for less than fair market value can lead to a penalty period when Medicaid will not pay for long-term care. Some transfers are allowed, such as transfers to a spouse and transfers made for a reason other than qualifying for Medicaid. The rules apply to nursing home and waiver care.

How to apply, step by step

1. Call your ADRC at 844-947-2372. The ADRC explains your choices and does the functional screen for home care.
2. Apply for Medicaid online at access.wi.gov, by mail with form F-10101, or at your county or tribal income maintenance agency.
3. Send proof of income, bank and investment balances, life insurance, property, and any gifts or sales in the past five years. If married, include your spouse's assets.
4. Wait for a decision. The agency must decide within 30 days. You get at least 20 days to send papers it asks for.
5. Choose and enroll in Family Care, IRIS, Partnership or PACE with help from the ADRC.

After you are approved

• Report changes in income, assets or address to your agency.
• Renew when your agency asks; renewals are required to keep coverage.
• If you are denied or cut off: The Division of Hearings and Appeals must receive your request within 45 days of the date the action takes effect. Use form DHS-28 or a letter. Mail it to P.O. Box 7875, Madison, WI 53707-7875, fax (608) 264-9885, or email [email protected]. Ask before the action date if you want your benefits to continue during the appeal.
• Estate recovery: If you are 55 or older and get long-term care, the state may seek repayment from your estate after death. It waits while a spouse, a child under 21, or a blind or disabled child is alive. Questions: Estate Recovery Program, 608-264-6755.

Free help

• ADRC: 844-947-2372.
• ForwardHealth Member Services: 800-362-3002 (TTY 711).
• More on costs: paying for a nursing home. See all benefits in Wisconsin and Medicare.

Phone numbers: Free help lines for Wisconsin agencies

Check what you may qualify for