Can Medicaid say my mom is not sick enough yet to pay for her nursing home bills?

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Mom is in the early middle stage of Alzh. she is still able to walk and dress herself ....feed herself etc......mom is private pay now...when she runs out of all of her money ...in a few months...can Medicaid say my mom is not sick enough yet to pay for her nursing home bills...my fear by then she will be out of money....not sick enough ..then what..need help...Thanks

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A person can qualify for Medicaid and not be “disabled” or blind, if they are at least age 65 AND need daily nursing services of the type provided in a nursing home. To determine that need, the state will typically send a nurse or trained intake worker to the Medicaid applicant’s home, to interview the applicant. The nurse or worker will have a checklist of Activities of Daily Living (ADLs: feeding, dressing, toileting, bathing, transferring (from bed and chair), and (sometimes) continence) and in order to be deemed “sick” enough to qualify for Medicaid, the applicant must “fail” a certain number of these tests.

It sounds like your mother has not "failed" enough of these tests, but you may be able to advocate on her behalf, as some of the other posters have suggested, and get her qualified before she completely runs out of funds!
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Is she is in a skilled nusring level of care now, rather than assisted living? Every state's Medicaid is a little different, but some will cover adult day services at home, some might keep a person in skilled nursing if they were already there. Can you talk about this with a facility social worker of ombudsman, if not going to a life care planner or eldercare attorney who knows your state rules and regs?
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I think you need to talk to the social worker. Medicaid usually pays if there is medical necessity and alzheimers can fall under this depending on how bad it is. Just because she can dress and eat does not mean she can take care of herself. If she cannot remember to take her medicine herself there probably won't be a problem, because then she becomes a danger to herself. I would talk to the nursing home to see if she meets the necessity requirements of your state. They will know.
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The Medicaid program was created in 1965 for the purpose of providing medical assistance to low-income Americans, particularly children, through a shared state-federal commitment. Today, Medicaid is an entitlement program that finances medical care, as well as long-term care, for more than 68 million people. There is no chart saying how sick or well a person has to be in order to qualify. My suggestion would be if you know for a fact that mom will need this assistance, start the process now. This takes several months for approval. Make sure the home where mom will be will accept that form of payment. If she can transition from where she is now into a more skilled area then that makes it all the better. Institutions, i.e. hospitals, nursing homes, have so many beds that are designated Medicaid/Medicare. They love those as opposed to private pay, as they are guaranteed monthly payments. Also, make sure that mom's physician will continue to accept her under Medicaid paid. Too many doctors are moving away from the government programs as the reimbursements are so small and the frustrations and regulations so high. Go to the social worker in the home she is in now if that is where she will be staying, and get the paperwork started. They will help you fill them out. Good Luck!!!
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Medicaid has to satisfy two requirements for each patient: financial need and medical need. Everyone you see commenting has probably gone through what I have gone through. Yes, deal with the home where she is currently residing and work with their social worker and financial wiz. They do want patients and are usually able to go the extra mile with you. Once your mountain of paperwork goes to Medicaid stay in touch with your caseworker. Mine is very helpful. They WANT their applicants to be accepted. Mine kept me up to date and told me what owed good and what did not.
The financial part is easier. The medical qualification could be one person's opinion and they may have never even met your mother! Be an advocate and stay on top of doctors, offices and physical therapists who can help on this.
Remember that Medicaid personnel do not have to meet your mom--only take someone else's word for it!
One more helpful tip. My church had a lady who had worked as a social worker before. She took my application and crossed out several sections that we did not need to fill out. This really helped.
After that, leave no unanswered answers on the application. We were complemented on a nearly perfect application with, what we thought, were complete supporting documents. But you guessed it. We were turned down on our first try. Just keep plugging away and you will Mae it!
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AngelNancy - what you are dealing with is very common and you really have to do things to "massage" the medical review aspect of Medicaid for NH. My mom still could do her ADL's and went from IL to NH which is a big hurdle to manage. Most folks fixate on the financial aspect of Medicaid qualification but the medical qualification is as important and in a way more difficulty as you have to get others (MD's, etc) to work with you in a very timely manner to get the paperwork in and do their part.

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 they need skilled nursing care. Just because they are old, or have dementia or incontinent, etc. is not enough. My mom went from IL to 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 from a pill (that in theory they can easily take) to medication that needs to be compounded daily which you can’t do at home. Each state has it’s own criteria for admission under Medicaid. They will be evaluated at the NH (by a state Medicaid medical evaluation person - usually a MSRN or MSW) and often are denied because they don’t have enough “critical” conditions because there is no history when living@ home (unlike coming from a hospitalization). 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 the NH is good as they will know how to create & write up the health history chart so that it passes Medicaid medical review. For my mom, she went to her gerontologist every 6 weeks and the moment she hit "critical" on her weight loss, he wrote the SNF needed orders so she could get admitted to the NH.

If your mom is still at home and still seeing her old internal medicine doc or family medicine doc, they usually don't know how to do her chart to reflect the history to show the need for skilled nursing care. Understand? That's why a gerontologist or medical director of a NH for her doc can be very important.

Even then there are glitches...I am very OCD on the whole Medicaid process and my mom was initially rejected medically because the idiot aide at the NH did not include every prescription my mom was taking even though it was in her chart. They only put down 1 RX - well that is just not enough. It was an easy fix, but nothing I could do to make sure it was written correctly or even know that it was missing as the medical paperwork is done by the NH. Good luck and keep a sense of humor, you'l need it.
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No, since your mothers assets have to be utilized first. You need to go ahead and get with the nursing home social service director, social worker to fill out the medicaid application so that you may get all necessary info to the Income Support worker prior to when your mothers resources run out. Make sure you get a proof of receipt from ISD office prior to turning over your application, also make sure you always make copies of the application and any paper work you turn in, sometimes state agencies are emphamously known for losing your paperwork and then asking you to resubmit, good luck!
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Wow... I want to thank all of you for all of your support...we live in Ohio...I did contact the facility Social worker.. and the medical director is her doc...she isn't ready yet to apply but I can see it won't be long. Thanks again..:)
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