Medicaid Level of Care Eligibility for Nursing Homes
After meeting financial eligibility criteria, an individual must go through an devaluation with a state Medicaid assessment specialist in order to determine a need for care. If the individual fails to meet the minimum level of care needed to qualify for that State's Medicaid coverage, then no Medicaid help is forthcoming.
A need for skilled nursing care will automatically qualify a person in any state. It's also likely that a candidate already in a nursing home but not needing skilled care will still qualify. Skilled care must be needed on a frequent basis. Examples of skilled care might include the need for: frequent monitoring of vital signs, wound dressing changes, maintenance of mechanical ventilation equipment, maintenance of a catheter, help with elimination problems, maintenance of IV administrations, careful monitoring of medication usage, managing colostomy problems, careful supervision of severe diabetes, frequent injections, maintaining a feeding tube and many more problems requiring the skill of a nurse or doctor.
People who are otherwise able to manage their own health problems or who are healthy but mentally impaired must meet the minimum level of care defined by the State Medicaid regulations. These regulations define whether a person qualifies for a minimum level of care provided by a nursing home. Even if Medicaid intends on providing a qualifying candidate with home care through a community waiver, a candidate must still meet the minimum level of care for a nursing home.
The minimum level is tied to a person's ability to perform a certain number of activities of daily living (ADLs) without assistance. Consideration is also given to people with mental impairment such as dementia, Alzheimer's or disabling mental illness, who may be able to perform ADLs but nevertheless require supervision. The mentally ill disabled may be provided services in special Medicaid intermediate care facilities licensed for this type of care. The most commonly used ADLs are transferring, dressing, bathing, toileting and eating. Some states define more ADLs such as wandering or medicating. Some states give consideration to instrumental activities of daily living (IADLs) such as: meal preparation, medication management, shopping, housework, doing laundry, using the telephone and handling finances.
Assistance or supervision required to manage a care recipient with ADLs and IADLs is defined differently by the States. Some states allow only a presence or verbal coaching for some ADLs. Some states require hands-on assistance for some ADLs. A person needing care in one state may not qualify under that state's rules but might qualify under the rules of a neighboring state. Of particular concern are candidates suffering from dementia or Alzheimer's. It's difficult to quantify their need for care and in some states, those people who are cognitively impaired might not get help with Medicaid even though their needs might be greater than the needs of those who are physically disabled.
Some states use a scoring system based on verbal tests and questions. Meeting a minimum score qualifies. Most states determine the minimum number of eligibility rules met in order to qualify a person.
A person might meet the ADL and supervision criteria from one state but not those of another state. Families should consider moving loved ones who have been declined in one state, to live with a member of the family in another state and possibly qualifying in that state.
Medicaid Reimbursement of Nursing Homes
About 62% of all nursing home costs are paid by Medicare or Medicaid so it's not surprising that most facilities would want to be certified by either or both of these government programs. Out of approximately 1,850,000 nursing home beds in this country, 3.4% are certified for Medicare only, 45.6% are certified for Medicaid only, 44.9% are certified for both and 6% are not certified. Non-certified facilities either do not meet government standards or they have deliberately chosen to avoid government red tape and only service private-pay residents. Medicaid is administered by each state and because of a desire to shift long-term care services away from nursing homes, some states choose to restrict the number of Medicaid beds. However, Federal mandates will not allow States to restrict supply of beds such that access to Medicaid is impeded. In areas of high demand the State may not bring new beds on-line fast enough and potential Medicaid residents in high-demand areas may have to go on a waiting list for a Medicaid bed or find a vacant bed hundreds of miles away from family or friends.
It's estimated that in 2002, Medicaid will pay about 44% of all nursing home costs. Medicaid is also paying part or all of the costs of about 70% of all elderly and functionally disabled nursing home residents. Decisions and reimbursement policies of State Medicaid Departments have a profound impact on the operations of U.S. nursing homes.
Medicaid reimbursement is carried out at a state level. Generally the States employ some rather convoluted and arcane rules to reimburse nursing homes. Most states reimburse with a prospective payment system like Medicare but a few states reimburse actual costs up to certain predetermined statewide maximum amounts. Some states pay directly, others pay through privately-contracted managed care administrators. Medicaid reimbursement to nursing homes is not uniform from state to state. In many states, nursing homes are not given enough money to cover their actual costs. One state nursing home association claims that 85% of its member nursing homes are not meeting costs with Medicaid. In other states nursing homes may be faring better.
Medicaid reimbursement has a direct impact on the daily bed rates of private-pay residents. These are residents who are paying out-of-pocket for their own care. They may be spending money from their own income and assets or their family may be pitching in as well. Many of these people are going through Medicaid spend down--depleting assets until they qualify for Medicaid. If the nursing home is losing money on government Medicaid reimbursement it may be charging private-pay residents higher daily rates to make up the difference. But one should not assume this is always the case. At least 2 states, Minnesota and North Dakota, prohibit nursing homes from charging more than the Medicaid reimbursement rate. In addition, not all homes lose money on government reimbursement. These facilities may be charging the same for all residents. Finally, although most states prohibit nursing homes from charging private-pay less than the Medicaid reimbursement rate, in those states that allow it, private-pay residents may be paying less than with Medicaid.
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