The Bench & Bar magazine is published to provide members of the KBA with information that will increase their knowledge of the law, improve the practice of law, and assist in improving the quality of legal services for the citizenry.
Issue link: https://kentuckybenchandbar.epubxp.com/i/132126
Dealing with the Kentucky Medicaid program is not science and the same facts presented to different offices may generate different results. In dealing with local offices, it is important to know the rules, be respectful but persistent, and understand how to utilize the appeals process. MEDICAID PROGRAMS FOR THE AGED, BLIND AND DISABLED A brief overview of Medicaid eligibility is available at: http:// chfs.ky.gov/dms/mnfs.htm. There are basically two types of benefits: 1) in-home and 2) nursing home benefits. HOME AND COMMUNITYBASED SERVICES The Kentucky Medicaid program for the elderly has a Home and Community Based Services program (HCBS) and an Institutionalized Care program (IC). The HCBS has financial requirements similar to the IC and is designed to provide modest help to keep people on the cusp of nursing home care in the home a little longer. Statewide, however, only limited services for the HCBS exist. Effort is being made at the cabinet level to expand this portion of the Medicaid program, with a goal of maintaining quality of care while shifting some elderly care nursing home costs, the highest-priced option, to home care, a potentially lowerpriced option.6 Medicaid's Home and Community Based Waiver (HCB) services include personal care assistance, program coordination, homemaker services, respite care and case management. While HCBS services allow more elderly to remain at in-home care, a determination still needs to be made whether expansion of this program would net any cost savings to the state. 70 percent of nursing home residents on any given day are Medicaid-eligible. Medicaid pays for some portion (though rarely the entire cost) of such residents, amounting to approximately 60 percent of the state's overall daily nursing home revenue. The balance of nursing home revenue comes from residents who pay 30 percent using their assets and income, 8 percent from Medicare and 2 percent from long term care insurance and other sources. HCBS benefit applications are made at the Medicaid office in the county where the applicant lives. The applicant must provide a physician's letter stating that nursing home level of care is needed and that without immediate home-based services, nursing home admittance would be required. In other words, there is currently no homebased support service availability until the wolf is actually at the door. Who is Eligible for Nursing Facility Services? NURSING HOME CARE The application process to Medicaid for a nursing home resident is similar but not identical to HCBS's HCB application process. Approximately MEDICAID ELIGIBILITY A person may be eligible for Nursing Facility services if he or she: • is a U. S. Citizen, Qualified Alien who has been legally admitted and a permanent resident for at least five years or a Nonqualified Alien7 • is age 65 or over, blind (20/200), or disabled8 • resides in a facility that participates in the Kentucky Medicaid Program and is placed in a Medicaid certified bed; • requires and meets the Nursing Facility Level of Care (LoC) criteria giving consider- THE LEVEL OF CARE REQUIREMENT Most nursing home residents meet the LoC requirement. Otherwise, they would not be in a nursing home. Essentially, they must need assistance with at least two of the following six Activities of Daily Living (ADLs): 1. Eating 2. Walking 3. Bathing 4. Dressing 5. Toileting 6. Transferring (i.e., bed to chair) Nursing homes initially assess the LoC required. Be advised that the state contracts with a separate entity, referred to as the Peer Review Organization (PRO), to certify the individual meets LoC criteria. The final decision regarding LoC is the PRO's decision, not that of the nursing home or the individual's physician.10 THE INCOME REQUIREMENT As a practical matter, for nursing home Medicaid eligibility, if the resident's monthly income is less than the cost of monthly nursing home care, the resident is income-eligible. As Medicaid is the payor of last resort, any other result would leave some nursing home residents who receive small pensions but have no assets, with no means of paying for care despite having followed B&B; • 05.13 9 & LONG TERM CARE ation to the medical diagnosis, age-related dependencies, care needs, services and health personnel required to meet these needs and the feasibility of meeting the needs through alternative institutional or noninstitutional services; and • is income and resourceeligible.9 Individuals who are not "65 or over, blind, or disabled" do not directly qualify for Medicaid regardless of how poor or sick they are. They may, however, qualify for other programs, e.g., SSI, which may then automatically qualify them for Medicaid.