How do I determine if my Mother qualifies for Medicaid paid NH care based on "medically necessary" in Michigan?
For now, I would like to exclude the financial eligibility requirement. Also, I'm asking for "long term ... remainder of life", not just because of some recent temporary issue.
dnk - the medical necessity will require that a MD writes orders for " skilled nursing care" needed. Your right that just bring old, or forgetful or needing a walker is enough. Mom will need documentation in her medical history to show a long term need for skilled care.
Most NH admits - from 60 % to 80% - are for post hospitalization rehab into a LTC / NH that does rehab. Usual story is they fall & break hip go to hospital, get surgery then discharged to rehab done in a NH. These come in with a fat medical file from the hospitalization; the rehab is bring paid 100% the first 3 weeks by Medicare (not Medicaid). Then they stay in rehab if " progressing" but with Medicare paying 80% up to 100 days. If need be, they stay at NH for the rest of their life and then either private pay, get Medicaid, LTC insurance, etc but they have this even bigger medical file to show "need" by this point. So the elder easily pass the medical necessity review & the NH has little work to do in the paperwork needed for medical necessity as they come in with a fat file.
BUT For those at home, in IL or AL, that fat file is not there. It will need to be created. I'd start with the medical director of the AL first. If they will sign orders for skilled and do whatever lab work, etc to support that, then mom should be ok. But my experience is that AL -since in most states is private pay- will press upon family to continue at AL. My mom moved from her home in her early 90's to IL for 3 years. This IL was lovely & part of a tiered system ( IL, AL, NH & hospice wing), I thought (& was told), that all was ideal as mom could age & impoverish out on the tiered system. Well mom started having issues the latter part of year 3, & the medical director would not sign off on skilled needed & admissions really pressed on me a variation of "you don't want your mom over there on the great unwashed medicaid NH side". Not going to budge on this. So much for my plan!
Now mom -since still in IL - was a patient in a gerontogy group practice of which all the docs also were medical directors at other facilities. I met with moms MD and he started doing lab work to support skilled care needed. Mom had been with this practice 6 years. But not enough problems to show skilled needed. What he did was about 6 mos of visits every 3 - 5 weeks. The visit mom had a 10%+ weight loss & a bad H&H lab work, he wrote the orders for skilled needed. I moved mom within 5 weeks to NH. Mom was already ok for the financial asset part of medicaid by this point. There are some things RX that can be done too, like changing a medication from a tablet to one that needs to be compounded or augmented (this is why you see medication being mixed with applesauce or yogurt) as both of those requires some degree of "skilled" to happen. Most AL do not do on- site drug compounding ever btw. Another often done is changing the RX (like Exelon) from pill to patch as the patch requires skilled to apply correctly. An MD who is medical director of a NH will know what meets the skilled criteria for state review. Comprende?
They will need to have some co-mobidities too - probably the most common one used is an RX for 81 mg of aspirin for coronary disease. At 90, your mom will have something that works to show the need for skilled.
The medical director of a NH will have a private practice that mom can become a patient of IF the AL turns a deaf ear on doing this for you all. The medical directors NH may not be your favorite one BUT If need be you can move mom to another NH once she clears Medicaid. I did this with my mom within the first year.
When my mom moved into her first NH, state sent out a nursing team to review her & her chart to approve within the first week. Even though mom supposedly had all in order, she got denied initially as the NH CNA did not enter her medications that mom brought with her into the chart . It was a pretty simple fix, but I did have to file an appeal within 30 days to continue her stay as Medicaid Pending. I got a call from the Asst DON of the NH that medical denied and happened all the time. No biggie. The medical appeal was interesting in that once i filed an appeal, it was 6 mos before the hearing date & the state sent letters on appeal date every couple of weeks both to me & the NH. Now for medical denial, the DPOA / MPOA has to file the appeal but the facility has to submit the information needed. The missing RXs got faxed over as addl pages of admission application to state by NH. I got a letter from state that mom was approved within 2 mos. But still got letters of scheduled hearing date....that took over 5 mos to coordinate the information to cancel hearing.
Speak clearly with staff on doing this approach. AL are profit centers and seem to be loath to have well-paying residents leave in my experience. Good luck!
She's 90. Cannot walk without the assistance of a walker, hearing and eyesight are not great but functional. Her brain function and memory are poor but she does remember to take her meds, get dressed and go to cafeteria twice a day. She has no friends from her live outside AL and has made none in the 5 years since she's been there. She does no activities other than eating and some occasional TV watching but can't really follow much other than the news. Her only family is her daughter and son-in-law who handle groceries, bills, litter changing for her cat along with anything else required to survive other than eating. I realize all info not pertinent but maybe some is ?
The short version of the story is that she wants to go to a nursing home (NH) and we've explained to her that she cannot afford to private pay and likely does not qualify for Medicaid paying for it based on "medically necessary". Medically necessary is a new term I just learned, but cannot locate any specific definition for it in Michigan.
Let me know what other information you need. Thanks.
Btw I was able to get my mom moved from private pay IL to a NH on medicaid and totally bypassed the AL phase or having mom go to the NH post hospitalization. Can be done but what her capabilities & health concerns can make a difference in high to approach. Thats why her backstory is important to know.
It says that in addition to the financial requirements, you may qualify for long term care if you are 65 or older, have End stage renal disease, have Lou Gherig's disease or have received Social Security Disability payments for at least two years previous. There could be other ways to qualify that aren't listed, but there are plenty of people to contact listed on the document.
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Most NH admits - from 60 % to 80% - are for post hospitalization rehab into a LTC / NH that does rehab. Usual story is they fall & break hip go to hospital, get surgery then discharged to rehab done in a NH. These come in with a fat medical file from the hospitalization; the rehab is bring paid 100% the first 3 weeks by Medicare (not Medicaid). Then they stay in rehab if " progressing" but with Medicare paying 80% up to 100 days. If need be, they stay at NH for the rest of their life and then either private pay, get Medicaid, LTC insurance, etc but they have this even bigger medical file to show "need" by this point. So the elder easily pass the medical necessity review & the NH has little work to do in the paperwork needed for medical necessity as they come in with a fat file.
BUT For those at home, in IL or AL, that fat file is not there. It will need to be created. I'd start with the medical director of the AL first. If they will sign orders for skilled and do whatever lab work, etc to support that, then mom should be ok. But my experience is that AL -since in most states is private pay- will press upon family to continue at AL. My mom moved from her home in her early 90's to IL for 3 years. This IL was lovely & part of a tiered system ( IL, AL, NH & hospice wing), I thought (& was told), that all was ideal as mom could age & impoverish out on the tiered system. Well mom started having issues the latter part of year 3, & the medical director would not sign off on skilled needed & admissions really pressed on me a variation of "you don't want your mom over there on the great unwashed medicaid NH side". Not going to budge on this. So much for my plan!
Now mom -since still in IL - was a patient in a gerontogy group practice of which all the docs also were medical directors at other facilities. I met with moms MD and he started doing lab work to support skilled care needed. Mom had been with this practice 6 years. But not enough problems to show skilled needed. What he did was about 6 mos of visits every 3 - 5 weeks. The visit mom had a 10%+ weight loss & a bad H&H lab work, he wrote the orders for skilled needed. I moved mom within 5 weeks to NH. Mom was already ok for the financial asset part of medicaid by this point. There are some things RX that can be done too, like changing a medication from a tablet to one that needs to be compounded or augmented (this is why you see medication being mixed with applesauce or yogurt) as both of those requires some degree of "skilled" to happen. Most AL do not do on- site drug compounding ever btw. Another often done is changing the RX (like Exelon) from pill to patch as the patch requires skilled to apply correctly. An MD who is medical director of a NH will know what meets the skilled criteria for state review. Comprende?
They will need to have some co-mobidities too - probably the most common one used is an RX for 81 mg of aspirin for coronary disease. At 90, your mom will have something that works to show the need for skilled.
The medical director of a NH will have a private practice that mom can become a patient of IF the AL turns a deaf ear on doing this for you all. The medical directors NH may not be your favorite one BUT If need be you can move mom to another NH once she clears Medicaid. I did this with my mom within the first year.
When my mom moved into her first NH, state sent out a nursing team to review her & her chart to approve within the first week. Even though mom supposedly had all in order, she got denied initially as the NH CNA did not enter her medications that mom brought with her into the chart . It was a pretty simple fix, but I did have to file an appeal within 30 days to continue her stay as Medicaid Pending. I got a call from the Asst DON of the NH that medical denied and happened all the time. No biggie. The medical appeal was interesting in that once i filed an appeal, it was 6 mos before the hearing date & the state sent letters on appeal date every couple of weeks both to me & the NH. Now for medical denial, the DPOA / MPOA has to file the appeal but the facility has to submit the information needed. The missing RXs got faxed over as addl pages of admission application to state by NH. I got a letter from state that mom was approved within 2 mos. But still got letters of scheduled hearing date....that took over 5 mos to coordinate the information to cancel hearing.
Speak clearly with staff on doing this approach. AL are profit centers and seem to be loath to have well-paying residents leave in my experience. Good luck!
Let me know what other information you need.
Thanks.
Could you give a bit more backstory on mom & her abilities?
It says that in addition to the financial requirements, you may qualify for long term care if you are 65 or older, have End stage renal disease, have Lou Gherig's disease or have received Social Security Disability payments for at least two years previous. There could be other ways to qualify that aren't listed, but there are plenty of people to contact listed on the document.
https://www.michigan.gov/documents/miseniors/MedicaidLTC_274718_7.pdf