A recently decided case gives some insight into the nitty-gritty workings of the Medicaid program and offers hope for the most vulnerable among us. Medicaid is a health payment program for needy individuals. If an individual meets the criteria for eligibility, Medicaid will pay for appropriate and necessary medical care and treatment.
The criteria for Medicaid eligibility are based upon need. An individual must be both financially eligible for Medicaid and eligible from a health perspective.
In order to be financially eligible for Medicaid, the individual’s income must be less than the cost of his care. For instance, if an individual lives in a nursing home and the cost of that nursing home to a resident who is paying privately is $11,000 per month, then the Medicaid applicant’s income must be below $11,000 a month. This makes sense because if the applicant’s income exceeded the cost of his care, then he is not a needy individual; his income would be sufficient to meet the cost of his care.
An individual must also have very limited assets in order to qualify for Medicaid. Typically, the applicant must have less than $2,000 in countable resources. A countable resource is all assets except those assets that are specifically designated as non-countable resources. Non-countable resources are the house, a car, and personal goods and household items; however, the house is only non-countable if the applicant is residing in the house. I always say that a home is non-countable, a house is not. The house must serve the applicant’s home.
If an individual is residing in a nursing home or an assisted living residence and is not expected to return to his house, then his house is no longer his home. In these cases, the house must be sold, and once sold, the proceeds of sale are a countable resource.
Finally, in order to qualify for Medicaid, an individual must needy help with physical or cognitive issues. In a nutshell, the applicant must either require hands-on assistance with three of the activities of daily living or require queuing with three of the basic activities of daily living.
The “activities of daily living or ADLs” are clothing, bathing, toileting, transferring (from a bed to a chair or from a chair to a standing position), eating, and mobility (walking). The activities of daily living do not include such things as meal preparation, shopping, and medication administration. These latter items are called the “instrumental activities of daily living or IADLs” and needing assistance with the IADLs alone will not permit an individual to qualify for Medicaid benefits. Requiring assistance with the IADLs can augment an application for Medicaid, but the applicant must require assistance with three of the ADLs.
Once an individual qualifies for Medicaid, Medicaid will pay for the cost of his care in a nursing home. When a nursing home participates in the Medicaid program—and most every nursing homes in the state of New Jersey do participate in the Medicaid program—the nursing home must treat Medicaid beneficiaries in the same manner in which it treats residents who are private paying and the nursing home must meet the needs of the resident.
In a recent case, the question was whether or not the Medicaid program would pay for a power wheelchair for a resident. The nursing home had manual wheelchairs, but no power wheelchairs. Testimony was presented that the resident’s use of a manual wheelchair resulted in further deterioration of the arm she used to manually propel the wheelchair.
The state’s Medicaid office claimed that a power wheelchair was not medically necessary and that the Medicaid program only pays for medically necessary items. The State also argued that the nursing home should supply staff to push the resident around in her manual wheelchair and that the payment of the staff’s salary was included in the amount the Medicaid program paid the nursing home.
The Court held that a power wheelchair was a form a treatment that could be paid by the Medicaid program. The Court remanded the case for further findings as to whether or not a power wheelchair was the most cost-effective means to meet the resident’s needs or whether other means (such as paying staff to push her around) would be more cost-effective.