I’m new to this forum and I see a lot of questions about Medicaid qualifications as far as asset limits, look back period and spend down but what about medical need? How does Medicaid determine medical need for nursing home care? My mom with dementia also has afib with a pacemaker, macular degeneration, type 2 diabetes and high blood pressure which are all being controlled for the most part. However, she can’t really do any ADLs by herself. I have to bathe her, cook for her because she doesn’t eat otherwise and make sure she takes her medication. She can still go to the bathroom by herself but she does have a lot of accidents.
Medical and Functional Criteria for Medicaid Long-Term Care
To receive institutional long-term care services paid for by Medicaid, an applicant must need a “nursing home level of care.” A medical specialist in the state conducts a needs assessment of the applicant and determines if they require care in a nursing home, care in an assisted living facility or if they are a candidate for home- and community-based services (HCBS) like in-home care services and adult day care. HCBS are a slightly different type of Medicaid program aimed at delaying or preventing applicants’ placement in institutional facilities like nursing homes. These services are typically provided through Medicaid waivers, which allow applicants to receive appropriate services in their own homes and communities.
Each state defines its own nursing facility level of care criteria, and the explanations are often very complex or vague. However, the requirements for meeting a nursing home level of care typically include a combination of medical, functional and cognitive components.
Medically, an applicant may need to be certified as requiring skilled nursing care from a licensed nurse (e.g. assistance with injections, IVs, catheter care or other medical devices and treatments). An applicant’s functional level is commonly determined by assessing their ability to perform activities of daily living (ADLs). An evaluation is completed to identify how much assistance is needed with the following daily activities: eating, bathing, dressing, continence, toileting and transferring/mobility.
My Mom private paid for 2 months before Medicaid kicked in. So not sure if someone from the State came to the NH to evaluate her. The NH had already declared her 24/7 care or she would not have been excepted. I applied for Medicaid in April, Mom paid May and June. I confirmed in June all criteria had been met (spend down, info needed provided, Mom placed) and Medicaid started July 1st.