What is Medicaid Long-Term Care?

The Texas Medicaid program is a federal-and state-funded institution that is governed by the Texas Health and Human Services Commission. It is a program designed to assist the aged, blind, and disabled, as well as impoverished families. It is often confused with Medicare.

For more information or to get started on your case today, call Willingham Law Firm, PC.

What is Medicare?

Medicare is an insurance program that each working American can qualify for after living and working in the United States for at least ten years.

What is Medicaid?

Medicaid is a welfare program based upon medical need, income, and resources.

Medicaid long-term care includes (but is not limited to) institutional programs that assist with long-term care in various controlled settings. These include nursing homes, intermediate care facilities (if your mother has an intellectual disability or related condition), and institutions that accommodate people with mental diseases who are 65 years or older. Medicaid does not usually pay for an assisted living facility unless your mother has an intellectual disability or related condition, in which case this is covered by programs under the umbrella of Medicaid Home and Community Based Services (HCBS).

Despite these caveats, it is enough to understand that Medicaid pays for long-term care when your mother does not have the assets or resources to pay for herself.

However, Medicaid may not be for everyone. Your mother may not want to take part in a Medicaid program if:

  1. She morally disagrees with welfare,
  2. Medicaid-certified homes do not provide her with the opportunity to be in her own room,
  3. She wants to live at an assisted living facility, or
  4. The law changes, completely banning those who gift away their assets from qualifying for Medicaid.

List of Important Medicaid Programs

  1. Institutional Programs: These programs place individuals who are elderly or have disabilities in nursing homes. To be eligible, one must have a medical need for regular, licensed nursing home care. There are usually waiting lists for “Medicaid-certified” beds, since the government may pay as much as 20% less for care than private-pay patients.
  2. Medicaid Non-Waiver Home Care (or Community Care) Programs: These programs are designed to help provide individuals with basic assistance in the home, such as bathing, dressing, toileting, food preparation, and housekeeping:
    1. The most important of these are grouped under the “Primary Home Care Program”, which includes:
      1. Primary Home Care Service: Home care is provided to individuals who have, or are deemed to have SSI.
      2. Community Attendant Services: Home care provided to individuals who are not eligible for any of the mandatory coverage groups, and
        1. Family Care: Home care is funded fully by the state of Texas. This program has higher resource limits, and the beneficiaries are not subject to the Medicaid Estate Recovery Program.
        2. Assisted Living and Residential Care Services: Often referred to as “supervised living,” this service is offered to people who need access to 24-hour care but who do not live in a nursing home.
  1. Medicaid Home and Community-Based Services (HCBS) Waiver Programs: These programs are designed to help individuals who decide to stay home instead of going to institutional care, but they usually have a waiting list. This may be a desirable program for someone who can live at home and have someone come in for assistance.
  2. Medicare Savings Programs: This is a Medicaid program that pays Medicare cost-sharing expenses (similar to premiums).
  3. Home-Delivered Meals: This program provides nutritious meals to individuals who are impaired and have limited assets and income.
  4. Day Activity and Health Services (DAHS): This is an adult daycare program.
  5. Emergency Response Services: This is a service that provides electronic monitoring systems that someone could use in an emergency to call for help.

Yes, there are numerous options for your mother’s care. Do not feel overwhelmed. You don’t need to become an expert on all of the Medicaid-funded programs out there. Once your mother applies for benefits, a Medicaid employee will determine which programs she is able to receive.

Medical Necessity for Institutional Benefits

While your mother might meet the income and resource requirements to be eligible for Medicaid institutional programs, she still might not meet the medical necessity requirement.

"Medical necessity" means that your mother requires assistance beyond the activities of daily living from a registered or licensed vocational nurse on a regular basis for a disease or medical condition. This requirement applies to Medicaid institutional benefits (care in a nursing home) and Medicaid HCBS waiver programs.

The actual rule is found in Tex. Admin. Code § 19.2401:

To verify that medical necessity exists, an individual must meet the conditions described in paragraphs (1) and (2) of this section.

  1. The individual must demonstrate a medical condition that:
    1. is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and
    2. requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.
  2. The individual must require medical or nursing services that:
    1. are ordered by a physician;
    2. are dependent upon the individual's documented medical conditions;
    3. require the skills of a registered or licensed vocational nurse;
    4. are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and
    5. are required on a regular basis.

In order for a nursing home to receive any money from Medicaid, the facility will have to fill out an MDS, or Minimum Data Set, assessment. This assessment gathers the information necessary to determine whether or not your mother needs to be in a nursing home. If you aren’t sure if your mom will qualify, you can go online, download this form and see the questions that will be asked of her.

Community Care programs, on the other hand, do not require that your mother have a "medical necessity,” but they do require your mother to be disabled to the extent that she cannot work. In addition, your mother must have a score of at least 24 on the "Client Needs Assessment" questionnaire (see the next chapter). For your mother to qualify for such programs, there is an upper limit to countable assets.

However, she can qualify immediately by transferring assets, since there are no transfer penalties for these programs. This type of planning can be time-consuming. While there is no penalty for transferring, there is a waiting list to get on some of these programs.

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