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Texas Elder Law Series - Episode 3 - What is Medicaid Long Term Care?

Texas Medicaid program is a federal/state funded institution that is governed by Texas Health and Human Services Commission. It is a program designed to assist the aged, blind, disabled, and impoverished families. It is often confused with Medicare. Medicare is a insurance program which each working American earns after obtaining a certain number of credits. Medicaid is a welfare program which is based upon medical need, income and resources. Medicaid long-term care or Medicaid-Institutional and Community Care programs assist with paying for long term care needs in a nursing home, intermediate care facility if your mother has an intellectual disability or related condition, and institutions which cover 65 years and older mental diseases. Medicaid does not usually pay for an assisted living facility (however, Assisted Living and Residential Care Services is covered under a Community Care program) unless it meets one of the requirements above. I promised that I would try to keep this as simple as possible so what you need to understand is that Medicaid is what pay for long term care when your mother does not have the assets or resources to pay for herself.

Medicaid is not for everyone. Here are some reasons why you may not what do be a part of Medicaid: (1) you morally disagree with welfare, (2) Medicaid-certified homes may not provide the opportunity to be in your own room, (3) you might want to live at an Assisted Living Facility, or the law could change making a plan to gift away your assets baring you from Medicaid.

Some important programs to be aware of are as follows:

  1. Medicaid Waiver Programs -- These programs are designed for your mother if she decides to stay home instead of going to institutional care. These programs usually have a waiting list. Often this is more desirable program because your mother could live at home and have someone coming into the home to assist her.
  2. Medicare Savings Programs -- This is a Medicaid program that pays Medicare cost-sharing expenses.
  3. Primary Home Care -- It provides for personal assistance services to a person of any age who has a functional impairment in the ability to perform activities of daily living.
  4. Family Care -- It provides for personal assistance services to individuals who are not eligible for Medicaid-Funded primary home care services. These services can be meal prep, cleaning, shopping, laundry, and transportation.
  5. Home-Delivered Meals -- This program provides nutritious meals to individuals with limited assets and income who are impaired.
  6. 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.
  7. Day Activity and Health Services (DAHS) -- this is an adult day care program.
  8. Emergency Response Services -- A service which provides electronic monitoring systems.

While reading through this list you might become overwhelmed with the option which are available for your mother. You should not worry. You do not need to know which programs your mom needs. After you have applied for Medicaid and become eligible, a Medicaid employee will determine which programs your mother will receive.

MEDICAL NECESSITY

While your mother might meet the income and resource requirements to be eligible for Medicaid. She might not meet the Medicaid Necessity requirement. "Medical necessity" means, in general, that your mother requires assistance from a registered or licensed vocational nurse on a regular basis for a disease or a medical condition which is more than assistance with activities of daily living. This requirement applies to Medicaid institutional benefits (care in a nursing home). A Community Care program does not require that your mother have a "medical necessity,” but does require that your mother is disabled to the extent she cannot work. In addition, your mother must have a score of at least 24 on the "Client Needs Assessment" questionnaire. For your mother to qualify for such programs her countable assets must be below $2,000 (or $5,000, depending the program which is involved). However, your mother can qualify immediately by transferring assets (here are no transfer penalty which applies to these programs). This planning can be difficult. While there might not be a penalty for transferring, there is a waiting list to get on some of these programs.

Your mother might qualify for Medicaid benefits, but she also has to find a facility which has a “Medicaid bed” available. It is no secret that the government pays less. Usually as much as 20% less for your mother to stay at a nursing home. It is often difficult to find a good Medicaid nursing home which does not have a waiting list.

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