RALPH S. ROBBINS, CFP©
A CERTIFIED FINANCIAL PLANNING PRACTITIONER
elder care and special needs planning
criteria for Medicaid eligibility
There are four criteria, or "tests" that must be met to become eligible for the Medicaid Nursing Home Program in Florida (Medicaid ICP).
These same requirements must be met when applying for Medicaid Long-Term Care Diversion or Assistive Services programs (sometimes referred to as "waiver" programs or more generally, "home and community based services" or "HCBS") even though care may actually be received in a venue other than a nursing home (such as at home or in an assisted living facility).
The first test is residency; the applicant must be a U.S. citizen or qualified resident alien and a Florida resident. The next three, a) medical need, b) age, disability, or blindness, and c) financial need, are discussed below.
The second test is medical need. The definition of medical need with respect to Medicaid is a bit more fluid than with respect to Medicare.
The care provided to the individual need not be strictly medically necessary, but may be custodial in nature. The person must have some form of impairment that limits their activities of daily living to a point where nursing home level of care is needed. The standards to determine whether or not the need is present are:
In Florida, medical need is ascertained by the Comprehensive Assessment and Review of Long-Term Care Services (CARES) unit of the Department of Elder affairs. This unit performs the federally mandated function of conducting nursing home pre-admission screening and assessment for Medicaid long term care programs.
Persons who are applying for Medicaid nursing home care are assessed by either a CARES nurse or social worker with medical review by a physician prior to approval. There is no charge for the assessment which also must be performed for those applying for home and community based services.
Age, Disability, or Blindness
The third test requires that the applicant either have some form of disability, be over 65, or blind. A 60 year old with Alzheimer's would meet this test as the effects of Alzheimer's (being unable to function safely alone) qualifies as a disability. A seventy year-old, on the other hand, need not have a disability as long as he or she needs nursing home care as a result of the medical need test described above. This test can present an eligibility issue particularly for those applying for home and community based services or any case that may appear to be borderline (e.g., required ADL loss or cognitive function).
Generally speaking, there are two "sub-tests" under the banner of financial eligibility: The "Asset Test" (what the applicant owns) and the "Income Test" (how much earned and unearned income the applicant receives).
What is considered an asset and what is not? What is considered income and what is not? What about the house? Not surprisingly, the answers are not as simple as we would like.
For details on financial eligibility click below: