Don’t Forget About Medicaid’s Medical Test
When families call our office to inquire about Medicaid, the conversation tends to focus mostly on my explanation of the financial requirements. People generally understand that Medicaid is a needs based benefit with an income test and an asset test. The State’s scrutiny of an applicant’s finances over a 5 year period leading up to the application is detailed. It tends to overwhelm families if they are not prepared for it.
At some point during the conversation, however, I always remind families that there is a medical requirement that we cannot overlook. Even if you spend down your assets and provide each and every document that is requested, if you are “too healthy” to qualify it doesn’t matter that you have satisfied the financial test. Only when you need “nursing home level” care do you satisfy the medical requirement.
The medical test is defined in terms of the activities of daily living (ADLs). Those activities are ambulating, bathing, dressing, toileting, feeding oneself, and incontinence. One must show the need for assistance with at least 3 of ADLs to meet the test of needing nursing home level care. This is established by Medicaid who sends a nurse to conduct an evaluation and issue a report. If the test is met, a medical PAS form (pre-admission screening) is issued. This form establishes what is called clinical eligibility. Neither the applicant nor the facility make this decision. It is solely for the State to evaluate.
In the 30 years I have been filing Medicaid applications, I have never had an applicant who lives in a nursing home fail the test of needing nursing home level care. No one moves to a nursing home unless they absolutely need to be there. Assisted living facilities (ALFs), on the other hand, raise a different issue. An ALF by definition is not a nursing home (not even the memory care or renaissance unit of an ALF) and is not licensed as a nursing home. So, not all ALF residents need nursing home level care.
Because of this fact, we need to be especially mindful of the possibility that an applicant can be rejected if they do not meet the medical test. While that had not happened in our office for as long as I can remember, a few months ago that was exactly the scenario. I’ll tell you more about that next week.