What does a person do who qualifies for Medicaid financially but not in terms of medical necessity?

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Our mother is 95, has her mental facilities, owns no property, has less than $2000 in her account and receives around $920/month Social Security. She may not qualify as a 'medical necessity' Medicaid recipient for the nursing home. She can not live with either me or my sister due to her safety concerns. In cases such as this, where do people go to live? What happens to them?

Answers 1 to 10 of 15
Hope some expert posters can step up here. Would there be local resources to help in the home, or is it a question that living at home is not workable, even with help coming in? Would the local area council on aging have some suggestions? Group home? Does Medicaid in your state offer any assisted living option?
Top Answer
You really have to start with her local Area Agency on Aging. They should be able to tell you what mom's needs are (needs assessment) and what she's eligible for.
For those living at home or in IL getting them to show "at need" to qualify for medicaids medical part will be a challenge but do-able. Mom will need to have a health chart updated & probably the simplest way is to find a NH that you/mom likes and then have mom become a patient of the gerontologist or internist MD who is the medical director of the NH. Most will have a full time private practice and a part time as medical directors of a NH or perhaps a couple of NH. They will know what needs to be there for medicaid eligibility. There are some things that are simple changes like orders are written for RXs to be compounded. Or perhaps Rxs changed to one that requires more skill to do... Like switch from Exelon pill to Exelon patch. Mom could actually have co-morbities that aren't currently in her health history but need to be there.

The majority of NH admits come from a post hospitalization discharge to rehab at a NH. So they have a fat
Medical chart to show need. Your mom - short of her taking a bad fall & getting admitted to the hospital - will need to update hers to show need.
You can apply for Medicaid before medical necessity takes place. Also, if your mom is on Medicare you can get a Medicare savings benefit from your State's DHS. The latter is not Medicaid!
Does your county have subsidized senior housing? Some areas include levels of social services at those locations. In addition, the apartments are designed for safety.
Ricky - the OP Sashby wants to get her mom into a NH and have Medicaid pay for mom. Its not about being eligible for low income general population Medicaid (like what CHIP is). For NH Medicaid they have to show to be "at need" both financially AND medically. Financially basically impoverished, which Sashbys mom seems to be ok for. But medically her mom needs to show existing "need" for skilled nursing care. Just being old & needing help is not enough to deem needing skilled nursing care in a NH unless they are totally going private pay (6k -15k a mo). Usually those still ok on ADLs go into AL which most states Medicaid programs do not cover at all or cover via a medicaid waiver (limited # of spots & with deep waiting lists).

At 95, her mom is likely to have all sorts of co-mobidities (heart condition, cataracts, vertigo) that can go into an update chart to show "need". My mom did the jump to hyperspace from IL to a NH and bypassed the AL phase totally. Took about 5 months of gerontogist visits to build chart. The visit my mom had a bad H&H plus 10% weight loss her doc wrote orders for skilled nursing care needed. Got her moved from IL to NH within a couple of weeks. The state did send out a 2person Medicaid team to the new NH to do an onsite review moms status too. For her state for those not coming in via post hospitalization/rehab scenario, state review is done routinely (which I wasn't aware of so it was good that she had a throughly updated health history).
Medicaid varies state to state. Google your local DCF office. Here, it's accessflorida.com. Medicaid is based on income and my dad gets same amount and he is on Medicaid. His internist is also a gerontologist which was great advice that your mother get one or an internist who specializes in gerontology. Great advice to consult with MD heading a facility. That will help me as well.
I would apply anyway. I am sure her doctor will sign off on her needing in-home care to prevent disaster of falling at her age. It is all about tasks that she can no longer do without assistance, like cooking, cleaning, toileting, etc. So, even if she can walk OK now, people her age can go downhill very fast and if no preemptive care is given, well...fill in the blanks _______________________________.
I live in MD, so it depends on what your state offers, but my mom, who is 87, and despite several health issues, does not qualify for Medicaid nursing. However, she could not afford private pay AL. The county she lives in offers in-home visits from 1-7 days a week. An aide will come in and help with light house keeping, meal prep and showering. That worked for awhile, but her dementia got worse. Fortunately, the county also has subsidized adult group homes. They are not high quality, but she gets her meds, her meals, a private room, and someone to watch over her. This keeps the indigent elderly from being homeless. Please check with your area Council on Aging and Disabilty. Best of luck.
Rick, in NY state Medicare does not cover nursing homes. It only covers "skilled nursing care". According to the Medicare website, it only covers nursing homes if "custodial care" is the only care needed.

Slashby, I would check with your state's DHS to see what can be done. I will be thinking of you.

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