Don’t Forget About Medicaid’s Medical Test – Part 2

In my blog post last week, I began a discussion about Medicaid’s medical test.  While the financial requirements to qualify for Medicaid are extensive and involve “looking back” through 5 years of financial transaction, we cannot forget that there is also a medical requirement of needing nursing home level care.

As I explained last week, this is never a problem when the applicant is living in a nursing home and applying for Medicaid.  No one resides in a nursing home who doesn’t need to be there.  Assisted living facilities (ALFs) however, are trickier.  That’s because they are not licensed as nursing homes and therefore, not all residents need nursing home level care.  

In fact, the majority of assisted living residents do not need nursing home level care when they first enter a facility.  Over time, as their health declines, they need increased care.  The concern, however, is that a resident may run out of money before he or she meets the medical test for Medicaid.  

When families are looking for a facility in which to place a loved one and then engage with the facility regarding the financial terms, a discussion about Medicaid typically happens.  Most ALFs have a 2 year or 3 year private pay requirement before they will make a Medicaid slot available to a resident.  This discussion about Medicaid during the admissions process often leads to a misunderstanding.  

Families take this to mean that as long as they meet the private pay requirement they will be eligible for Medicaid.  That is an incorrect assumption, however, because the State approves Medicaid, not the facility. It is irrelevant what the ALF and resident have agreed to.  So, what happens if a Medicaid application fails medically?  The resident has no more money to pay the facility and Medicaid is not yet an option.

Next week I’ll tell you what happened in one such case.