Written by attorney Taylor Phillip Willingham

Texas Elder Law Series - Episode 4 - 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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