Has anyone had experience with such program? Does mom stay in apt and spend almost all money down while beginning the Medicaid eligibility process? Sounds kind of scary, but so is going into AL and that is what we are looking at.
If she stays and pays in her own home and has applied for Medicaid and is accepted, is that the time to request CFC?
What happens if she runs out of money before she meets all requirements for CFC like: Need an institutional level of care.
It is one of the 3 basic criteria:
1. Be eligible for Medicaid.
2. Need help with activities of daily living, such as dressing, bathing and eating.
3. Need an institutional level of care
ACA aka Obamacare, is about feds giving $ for Medicaid expansion. Now most ACA expansion blowback has been over making it available to that huge HuGE group of folks with too much $ for regular low income Medicaid for the poor but not enough $ to pay for a better / or even usual individual health insurance, or have preexisting conditions and uninsurable. If you are in a R Governor state, your state probably did NOT take Medicaid expansion. TX didn’t.
BUT within ACA there also was $ for states that wanted to take a subset of expansion program. States could take a subset but not do full Medicaid expansion.
Community First is that, it’s an offshoot of ACA aka Obamacare and pays to the states 6%-8% additional $ from the Feds to a participating states Medicaid budgets to pay for having individuals to shift from being in institutional care (NH) to providing for care at home or other community setting. It’s different than other older Medicaid waiver programs (like AL waiver) in that there is no enrollment cap. Like TX actually does have AL waiver but it’s limited to type 2 AL (which most AL are not & will not ever have the required staffing to be), so even tho’ it was available, hardly any beds & set to a fixed #.
To get on Community 1st, she has to show “at need” for skilled care in,an institutional. So basically need a NH.
AND
eligible for Texas Star Plus medicaid. She is going to have to ok for the income level for Star Plus
BUT
Community 1st criteria, due to ACA, also now allows for IADLs to be factored in for eligibility. IADLs makes lots more folks eligible. IADLs = Instrumental Acts of Daily Living, like meal preparation, grocery shopping, laundry. Having IADLs counted is a big, big deal cause most elderly aren’t totally needing skilled nursing care; they kinda need help at home and some skilled care. Community 1st does that. Comprende?
Again they need to be on TX Star+Plus Medicaid & that eligibility is on line @TX HHS / DADS. Star+ been around a long time.
HOWEVER
Community requires them in a MCO= managed care organization. There’s I think 5 in TX. Some are newer players in TX, like Molina MCO. Some areas with Superior MCO. Superior is very experienced with Medicaid as they do most CHIP (children’s health Medicaid)coordination statewide since forever. If your in a big big city, there may be an actual choice of MCOs. Like SA or Htown. Most areas have 1 MCO.
Keep in mind MCO = closed network for providers, programs & location.
MCO have set clinics, hospitals, NH and LTSS (long term services and supports). LTSS deals IADL things, like in home services.
Community1st viewed as able to do serious cost containment. No more NH daily room & board paid, no more daily nursing & therapy staff paid, no 2-5 days a week MD medical director care evaluation. No NH with 24/7 oversight. They are gonna be at home, or other less staffed community setting. Last year there was a push to have NH residents move from NH back home & go under Community 1st. I’m sure lots were only too willing to want do this as it sounds just dandy (they all wanna go home or rather go back in time) but without realizing the constraints. I’d bet a case of Prosecco, once they go Community 1st it will be near impossible to get them into a old school NH unless they are hospitalized & discharged as bedfast needing skilled 24/7. The program reads they will need to go into their MCOs affiliated NH.
MCO & it’s participating vendors MUST do all care.
Again its a closed network. If her current docs or clinic aren’t with the MCO & she sees them, Neither Medicaid or Medicare will pay. I’d really suggest that you look at the MCO for your area to see if it can meet your parents likely needs before signing up. Like if they need speciality care, they may need to move to big city to get full range of care.
If my mom was still alive & in NH, I wouldn’t move her to Community 1st. Just sayin’