How do I get Medicaid to understand a medical necessity for long-term care?

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My mom is in a rehab hospital now. She can barely walk as she had a hip replacement go bad. She now has only a temporary hip and cannot get around without a walker and barely at that. She had both knees replaced as well as a shoulder replaced twice. At the current time she can lift neither arm above her shoulders. She has began to behave erratically and say things that are strange and untrue. She had medications all over her house, some bing spilt, etc. She has no idea what medications she had taken or not. She cannot bathe herself and has already knocked the temporary joint out-of-place and going to an emergency room.
I applied for medicaid long-term and was told she qualified easily for income. Then i was told she did NOT qualify as medically necessary. i do not understand this at all. She is at risk to fall at any time and has done so many times int he past year. I worry tremendously about her health. I am at wits-end and do not know what to do. Has anyone been here before?

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Top Answer
Who told you she did not qualify for NH? Have you actually applied, or was this someone guessing how it will be judged?

Has Mom been diagnosed with dementia or mild cognitive impairment? Has the doctor suggested she not be left alone?

If you haven't already, I definitely think you should apply. It will be a matter of getting the right evaluations in front of the people who make the decisions.
We filled out the application. The new center only has the medical records and made the judgment from these. Still trying to find out on the diagnosis mentally. When i get the paperwork finished for Medicaid (which we have) where do I send or submit it?
Tex - I think the issue for you all might be that she is in a rehab facility and that it is not designed for long term care which is probably what your mom needs.She doesn't meet the criteria of care for rehab & you need to look to find another facility (NH) for her to go into. I'd speak with social worker to see what's what.

Perchance was she living at home before this? When this is the case there often isn't enough in their chart to show need. If they are living at home or in IL, and need to move to a NH, you will need to work with their MD to get the criteria in their medical history to show the documented need for skilled nursing care. Just because they are old, or have dementia or incontinent, etc. is not enough. My mom went from her home to IL for a couple of years and then into NH and bypassed going to AL. She was able to do this as she had a critical weight loss (more than 10% in 30 days), critical H & H and some other conditions. Sometimes the MD will need to change their meds – like go from Exelon pill to Exelon patch (more “skill” to apply); or change a med to one that needs to be compounded daily which you can’t do at home; or add a medication for a "chronic" condition which can be a simple as 50 mg of aspirin for cardiac condition. Each state has it’s own criteria for admission under Medicaid. They will be evaluated at the NH and often are denied because they don’t have enough “critical” conditions that need skilled nursing because there is no history when living @ home or in IL unless they have a major issue like a cancer or dialysis. You will have to work with NH and your parents MD’s to get whatever done to establish the need for NH if they are coming from being at home or IL. There is a whole Medicaid medical appeals process in each state for this and separate from the financial appeals. For those still living at home without a huge disease history, becoming a patient of the MD who is the medical director of a NH is good as they will know how to create & write up the health history chart so that it passes Medicaid medical review.

We went through both financial & medical appeals for my mom with TxDHHS. The financial one was done by me (glitch with insurance policy and $ transfer issue). The medical one was done by the NH but I had to fax over my approval for them to do the appeal. For medical, the glitch was that the initial RX's on her chart did not list all her medications just her Remeron and she was not banded for 24/7 fall risk or was using her walker so when she was evaluated she kinda looked fine. Well 1 RX & looking ambulatory just isn't enough to pass review. Good luck.
Wow! Thanks to all of you. Yes, mom was living at home before. She is a fall risk and has fallen many times before. She cannot walk without a walker but can barely lift herself out of a wheelchair. I suppose you are right about her chart and living at home. The situation has changed so much. I am getting with both doctors now to try and get the statement needed that skilled nursing is required. I am glad to hear about the appeals process also--did not know this. Also, only the NH has evaluated her. Do we give the Medicaid application to them, or mail it to someone?? They are only going by partial medical records now. Thanks for all of your good information.
Tex - for my mom the overall Medicaid application was filled out by me and the NH at the NH about 5 days before she moved over from IL. Before that I was given a checklist from the NH of items needed to be attached to & accompany the state application that the NH then submits to their state assigned caseworker along with their bill when they are admitted "medicaid pending". My mom was on a wait list for 2 NH as we were really just waiting for her to get at a 10% weight loss to trigger the critical medical necessity for NH order written by her gerontologist. Each NH had their lists worded differently and different from the NH my DH had to deal with for his mom up in the Panhandle. My point is all were in the same state but all had a differently worded list.

Items were pretty routine stuff like her health insurance cards, the summary statement for her SS and annuity (retirement); insurance policies; birth certificate or whatever to show citizenship; 3 months of all banking and all financials; latest tax assessor statement on her house; funeral & burial policies. I am pretty OCD so I had all this and organized since she went in IL a couple of years before. The only thing that required extra effort was going to her bank and having them do a 3 year review so they could do a letter stating what the disposition was of each account, CD or money market that was closed for the last 3 years.Now I did it so that each account that expired was closed was such that all the $ went into her checking account since 2005, thank goodness. She only uses a single bank so that was easy for a bank officer to do and I already had a relationship with 1 officer in particular but even then it took about 2++ hours.

All in all over 100 pages - mainly due to her old school insurance policies. NH only got duplicates (hello Kinko's!) and I made 3 sets (which was good because the whole set got mislaid by the NH). By applying for Medicaid you sign off for an all access pass to everything mom has owned or can be found via her SS# or their late spouse's SS#, so it's pretty transparent for property ownership items or taxes.

WHATEVER YOU DO.....sign everything in either your mom's name or as "Jane Smith as DPOA for Ann Z. Jones", there will be lots and lots of signatures to do and make sure you do this each and every time you sign anything. Wait to get a copy of everything also and keep it someplace you can easily find it. the signature stuff is really a cya to keep you from getting stuck financially responsible if there is a problem with her being accepted for Medicaid. Not all NH do "medicaid pending"
even though they make take Medicaid, so you need to ask how they work the financials if that is the situation for you. I have friends who have had to put up 2 months of private pay, which was returned once their mom's got on Medicaid.
So ask and be quite clear on the answer.

Oh and do realize that if a NH doesn't work out, it is pretty easy in TX to change from 1 NH to another within the Medicaid system and without penalty from the NH.
Make sure that you are consistent with whatever address & phone number for you or whomever is going to be the point person for all things mom. The application and appeals process has pretty tight timeframes and if you do NOT get whatever to TXDHHS by the date, her application will be denied. We had an issue with her insurance policy from the 1960's which was like 30+ pages and you had to read and reread to figure out it is a term policy...well the caseworker doesn't have time to do that but can check information not provided and I had 48 or 72 hrs to get that cleared up. I got a broker who held a TX insurance license to do a letter stating that the policy was term with no cash value, faxed it over to caseworker at TXHHS and VOILA! problem solved but it can fill you with panic if you don't have stuff organized. Good luck.
my mom recently was in a nursing rehab. her insurance only paid for 20 days of being there,she was the for 2 months because I and the staff felt she was not stable enough to come home even though the insurance did. She has to pay 352.00 a day out of her pocket. Now that she is home a social worker has come and has referred us to aging care locally for financial help she only has her ss and very little in the bank. Will she be reimburst fo these costs if she is accepted for medicaaid?
Update. Finally she is in a NH which says she DOES qualify for Medicaid. We have almost finished all the paperwork. Yes, the amount of documents is mind-boggling but i think we have them all. The place is also a "Medicaid-pending" place which is a relief. All of your answers have been so helpful. Possibly more helpful just to know there are many others going through the exact same thing. Not just me. Thanks, friends.
Tex - keep all documents together and also everything that comes new as you will have to do a multiple page updated reapplication to TxDHHS about a year from now - OK it will likley be about 6 weeks and a year after she & you get the final letter from TXDhhs that she has been accepted. You have like 21 days to get this back to them too but you can do via fax.

They will ask for the current month and last 3 months bank statements too. If she has multiple banks or accounts, I'd suggest that once she is accepted that you close them and get it to 1 bank. If she perchance gets any significant $ you have to account for it - my mom still has her house and she got insurance $ for hail storm repair so that was 4 extra pages of bs to deal with..check from State Farm with deposti slip to her bank and then check to roofing company and contract.
Yep it can be a total pia but thank goodness for Medicaid and Medicare.
Tucker - you really need to speak to the Medicaid office in your state. Most states do Medicaid for NH or long term care only but some states do have waiver programs for other types of help for those still living in the community.

Medicare and Medicaid can be confusing....If an individual covered by MediCARE is discharge from a hospital to a nursing home for continued care (rehabilitation) after an inpatient stay of at least 3 days (in the hospital), MediCARE will cover 100% of the first 20 days only. Then afterwards MediCARE MAY pay up to 100 days, subject to a co-payment by the patient of $141.50 per day for days 21 to 100 (for 2011). Getting MediCARE to pay for day 21 - day 100 is very unusual for elderly patients. MediCARE does not pay for the many months/years that some people need and that reside in a NH for long-term custodial care. In general, Medicare is limited to short-term acute care.

Some have a secondary health insurance policy that will pay part or all of the copay after day 20 if it is medically necessary usually by physicians orders and meets a certain level of care criteria. If not, then the difference is private pay. If you kept mom there because you wanted to or didn't feel she was ready to go home then the insurance (Medicare or any secondary one, like BLue Cross) company won't pay as that was your choice to do so.

You can call or go online to CMS (Center for Medicare and Medicaid) to see what they paid for and for how long and what reason was for stopping payment.
www.cms.gov or 1-800-633-4227. Good luck.
Thanks to all of you. I cannot imagine what you have been through to gain all this knowledge! Still working my way through it. Thanks for sharing.

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