Article 26-Estate Planning Series: Qualifying for Medicaid Assistance – Part 1 – Medical Necessity

Written by Wright Law on . Posted in Estate Planning, Long Term Care

In recent weeks, I have addressed the difference between Medicare and Medicaid as it relates to seniors receiving long term care.  In the last article, I also discussed how Medicaid may be your most expensive option to pay for long term care.  Nevertheless, Medicaid is an important resource for those without options. 

To receive Medicaid assistance for long term care, seniors must meet certain conditions.  Those conditions address both the applicant’s health and financial condition.  This column addresses how an applicant’s health is assessed.

When an applicant seeks Medicaid assistance for long term care, a qualified nurse will conduct an assessment to determine the appropriate level of care needed.  This assessment is done using what is called a Uniform Assessment Instrument (UAI).  The nurse will conduct a face to face interview, but may also consult medical records, the primary care physician and/or family members as needed.

The first thing the nurse will review is the applicant’s ability to perform activities of daily living (ADLs).  ADLs include actions such as bathing, dressing, toileting and mobility.

The nurse will also assess conditions for which the applicant is being treated or may need a health referral. Finally, the nurse will assess the applicant’s psychological, social and cognitive condition for specific abilities and limitations that will assist in identifying appropriate resources.  From the UAI, a personalized support plan is created to assist the applicant.  

Most applicants prefer to receive assistance in their own home, an approach that is encouraged by Health and Welfare.  However, if warranted by the applicant’s health condition, the applicant can choose a different level of appropriate care.  If care in a skilled nursing facility is needed, a doctor will make this determination.

The UAI allows for a uniform, fair approach to determine the health needs of an applicant, and to ensure the appropriate level of care is provided.  However, even if the applicant’s medical necessity is established, there are certain financial requirements that must be met.  I will begin addressing those in the next article.

© 2015 Steven J Wright  

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