How to Keep Your Parent Out of a Nursing Home.

Most of my clients want to stay home as long as possible. The government also understandably wants your mother to be able to stay home if possible. Why? Because it costs the government a lot less if your mother is not in a facility. There are two different types of programs that offer care to the elderly at home. One is financed through Medicaid, the other is financed through Title 20 (block-grant) funds.

Title 20 (Block-Grant) Fund Programs

If your mother desires to stay home, the three major programs which could assist her are: Family Care, Primary Home Care, and Community Attendant Services. There are a number of services they could provide for your mother. However, it is fairly difficult to pre-plan what services will be offered to her. First, she will have to undergo an assessment interview; this, in turn, will determine how many hours of services she receives. The hours will be between 6 and 41. If she needs more than 41 hours, Medicaid will require that your mother be placed into a nursing facility or assisted living facility. Remember, in order for her to qualify for this program she will have to score at least a 24 on the “Client Needs Assessment” questionnaire.

Client Needs Assessment Questionnaire

Here are some of the questions they will ask her:

  1. Do you have any problems taking a bath or shower?
  2. Can you dress?
  3. Can you feed yourself?
  4. Can you shave, brush your teeth, shampoo, and comb your hair?
  5. Do you have any problems getting to the bathroom and using the toilet?
  6. Do you have trouble cleaning yourself after using the bathroom?
  7. Can you get in and out of your bed or chair?
  8. Are you able to walk without help?
  9. Can you clean your house?
  10. Can you do your own laundry?
  11. Can you fix your own meals?
  12. Can you do your own shopping?
  13. Can you take your own medicine?
  14. Can you trim your nails?
  15. Do you have any problem keeping your balance?
  16. Can you open jars, cans, bottles?
  17. Can you use the telephone?
  18. During the last month have you often been bothered by little interest or pleasure in doing things? Have you felt down, depressed or hopeless?
  19. During the last two weeks, on how many days have you had trouble concentrating or making decisions?
  20. Does the individual have the ability to make decisions independently?
  21. Does the individual appear to have short-term memory impairment?

Each one of these questions carries a score between 0 and 3. 0 indicates that there is no impairment, 1 is mild impairment, 2 is severe impairment, and 3 is total impairment. The next part of the test is used to determine who is going to help with services and how much time will be paid for by Medicaid. If the time exceeds the 8-hour per day limit, then your mother will not be allowed to get assistance at home; instead, Medicaid will encourage her to go to a facility. If you are insistent that your mother stay home, you will be responsible for taking on more responsibility. You want to be very careful signing up for this type of commitment as failure to provide services that you tell the government you will in fact offer as far as your mother’s care goes, can be seen as a form of elderly neglect. This consequently, is considered a crime in the state of Texas. Your attorney has a legal obligation to report any abuse, exploitation, or neglect of an elderly person, even if it violates attorney-client privilege.

These programs may be able to assist her in cleaning and other housekeeping tasks. Also, they could provide personal care services. In order for your mother to qualify, her income cannot exceed $2,205.00 per month. Another significant limitation to this program is that your mother cannot become eligible by using a "Qualified Income Trust” to reduce her income. The asset requirements are different under the Community Attendant Services and Family Care.

Community Attendant Services is the same as Medicaid ($3,00 for a couple and $2,000 for an individual). However, the Family Care program allows you to have up to $5,000 and $6,000 if you are married. If your mother wants to get on this particular program, we can execute the gifting strategy without the “transfer penalty.” With this program, you do get to keep your income, but you have to spend her money every month or she will be disqualified from the program.


Medicaid Funded Waiver Programs

These programs are referred to as “waiver” programs because they waive the requirement of residing in a nursing home or ICF-IID facility. Home and Community-Based Services (“HCBS”) beneficiaries will receive the same benefits as those on Medicaid Long-term care living in a nursing home. If your mother is eligible for both Medicaid and Medicare, she is considered “dual-eligible.”

"Star+Plus Waiver" is probably the most likely program which your mother will use if she opts to stay at home. Since this program is funded by Medicaid, the eligibility requirements are the same as for nursing home care. A key difference between this program and the one above is that the transfer rule applies, but you can use a “Qualified Income Trust” if your mother’s income is too high.

If your mother uses a Qualified Income Trust, any money above the income limit (as of 2018 it was $2,205) will have to serve as a copayment for the home care services. Unlike using the Client Needs Assessment test above, eligibility for this program is determined based upon whether or not your mother’s needs can be met for not more than twice the cost of nursing home care.

Your mother can use this program to fund assisted living costs if she does not want to stay home, but also doesn’t want to go into a nursing home. Bear in mind, however, that this program does have an extensive waiting list (“interest list”). If the program is used to help with assisted living costs, your mother will need to give her income to the assisted living facility. She will be able to keep $85 ($25 more than a nursing home) for her personal care. If you believe your mother will be going to an assisted living facility in the future, it is important that you call Texas Health & Human Services Commission (512-424-6500) and get her placed on a waiting list today.

How to Bypass the Interest List

If your mother wants to stay home but needs immediate assistance, one strategy you can do is to have mom move into a facility. Once she has been approved for the Star+Plus Waiver services, she can then return home and still receive benefits.[1] This is known as the “Money Follows the Person” rule. It does not apply though if your mother fails to get approved for these services. Therefore, you have to make sure she is approved first, prior to moving her. It also stands to note here that future funding for this particular program is not guaranteed. Please reference the Star+Plus Handbook 3511-3526 to see the procedure for this rule.


The Housing Choice Voucher Program (Section 8)

If your mother is renting a residence that is not owned by a family member, Public Housing Authority (PHA) could be an option for getting the services needed to apply for assistance with rent payments. Some PHA’s allow participants to use section 8 vouchers on their own mortgage payments. You would have to contact your local PHA to see if they offer this program. There is going to be a waiting list, but if your mother is homeless (living with you or another family member), in substandard housing, or paying more than 50% of her income towards rent, then she could be moved forward on this list. The program does not pay the full rent but does remit partial payment by way of a voucher. In limited situations, a family member can be a landlord, but your mother would have to be disabled and only the family member can provide the accommodations necessary. Here are the following points you should be aware of:

1. The PHA will approve an application; they do not locate a residence. It will be your responsibility to find your mother a residence for which she will pay a reasonable rate. This residence will be inspected by the PHA. The landlord will also have to enter into an agreement with PHA.

2. There are three eligibility requirements for your mother: (1) she must meet the definition of a family, (2) fall within the household income limits established by HUD (not the Medicaid income limit), and (3) be a U.S. citizen or eligible alien.

3. The family definition is used to determine the household income requirement. The PHA in your area will have its own guidelines.

4. If you would like to know the income limit for your area, you can go to The direct link, as of the writing of this book, is However, the link has been subject to change, so you might need to search on

5. Your mother’s social security check will be considered income, as will any income she receives from her retirement accounts. If your mother is married and her spouse is in a nursing home, your mother’s spouse’s income is not counted as her income.

6. If your mother has more than $5,000 in countable assets, a calculation will be done to determine how much those assets would contribute to her income if invested in a savings account, or of course if there is actual income generated by the assets. They will use the higher of the two to determine income.

7. The last issue which you should be aware of is the transfer rule. Assets that were transferred within the past two years will be considered an asset as far as the calculation of income. Your mother may choose to do a self-settled special needs trust and transfer her money into that trust with no penalty. However, the State of Texas would be the primary beneficiary of that trust.

Assisted Living Facilities

Assisted living facilities are not covered by Medicaid long-term care but can be covered by the Waiver program under Medicaid if they are certified to provide services under the Community Based Alternative Program (“Star+Plus Waiver”). The State of Texas maintains a site of all the assisted living facilities which are under the five waiver programs:

There are three types of assisted living facilities:

1. Type A are facilities whose residents do not require assistance during nighttime sleeping hours and are able to follow directions in emergency situations.

2. Type B are facilities whose residents would need assistance in an emergency situation and who need some nighttime care.

3. Type C are facilities that are four-bed facilities and meet the requirements for adult foster care.

4. Unlicensed facilities are facilities that have four or fewer residences; these are generally created for those with less than $2,000 a month and who don’t meet the medical necessity requirement to be in a nursing home.


Board and Care Homes (Personal Care Homes)

These are homes with fewer than four residents who live together to cut down on costs. They are not per se illegal or bad. In fact, in some situations, they could be a great option for your mother. In general, these types of places tend not to have a diversity of functions. However, in some situations, these facilities can be better than a licensed assisted living facility. Usually, the cost will reflect the type of care you receive. These facilities are also known as adult care facilities, adult foster care homes, and residential care facilities. It is important to note that these are not licensed assisted living facilities, and some are being run illegally within the state. You need to investigate such accommodations very thoroughly prior to moving your mom into one.

Continuing Care Retirement Community

Your mother might want to spend her money on a larger facility that could take care of her for some time. These communities are designed for individuals who have the money to pay; these are not for those using government-based assistance programs. There have been problems seen with these types of places, as they can be quite expensive and also can go bankrupt down the road. Choosing such a facility is a rather difficult decision to make; most people cannot afford to stay in them for the remainder of their life and thus other arrangements would have to be made.


[1] Star+Plus Handbook 3510