(provided by Dick & Karen Sayre, Sayre & Sayre, p.s.)
Medicaid’s long term care program is a based upon need, both physical and financial. There are two gatekeepers you must satisfy to obtain benefits under the long term care program and each of the gatekeepers has two parts. In this Part 1, we’ll look at what comes first and foremost. The first gatekeeper requires that you show the physical need for care. This need may be satisfied when you can show that the person requesting benefits meets certain criteria established by the Department of Social and Health Services (DSHS). When a request for benefits is received, it triggers a visit from a DSHS evaluator. The purpose of the evaluation is to determine whether the applicant needs sufficient physical care services to meet the DSHS base requirements.
The first part of this gatekeeper breaks basic needs down into what are considered to be the seven activities of daily living. These are the types of things we all need to be able to do to get through the average day. They include the ability to bathe yourself; dress yourself; groom yourself; take care of your own toileting needs; feed yourself; be able to transfer safely from a seated to a standing position and walk; and to demonstrate that you have sufficient cognitive ability to live alone safely. When you need significant hands on assistance with two of these activities you may qualify for some level of assistance.
The second part of the gatekeeper requires that the applicant be in a facility which contracts with DSHS to deliver benefits under the program, or that you are applying for the COPES program at home and that you have a worker in place providing care. If you are in a care facility, it may be a skilled nursing facility, a congregate care facility, an adult family home or an assisted living facility. In many facilities you must be in a shared room or studio apartment. Not all facilities accept Medicaid however. Before you move in you should find out whether your facility will accept Medicaid when your runs out. If it won’t you’ll be forced to leave.
It is important to note that the need for physical assistance is the first step in qualification and must be demonstrated prior to any examination as to the need for financial help in providing care. This can be frustrating when you are dealing with a family member who is in the early stages of dementia. They may have some need for guidance or reminding but they do not yet demonstrate a need for hands on assistance.
Often after a hospitalization and rehabilitation a person who was ill and disabled may be able to return home and function independently again. In the event they are not able to get all the way back to their prior level of functioning, it will be important to determine at exactly what level they can function. Older family members can be very convincing. They may be good at appearing to be fine and say that they can function on an independent level. The need to be viewed as capable and able is strong and important to their self esteem, but may really be only a cover for what is happening to them. It may take time and repeated exposure to what they are able to do on a day by day basis to truly know if they have a continuing need for oversight and care.
It is important to have a good Durable Power of Attorney which includes health care provisions or a Durable Power of Attorney for Health Care Power of Attorney. If the Durable Power of Attorney authorizes the agent to act as the personal representative of the principal under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the agent will have the same rights to inspect and obtain copies of any medical or other health information as the principal or ill person would have. This should allow the agent to speak directly with the person’s treating physician and determine exactly what care needs the physician believes are appropriate.
It will not however, allow the agent to make any placement of the family member which is specifically against their wishes. If the agent believes that the principal is so disabled as to be a danger to themselves or others or gravely disabled a request should be made for an evaluation by Adult Protective Services. If the person is found to be so disabled, placement may be made by a County Designated Mental Health Professional and services provided in an attempt to overcome the existing disability.
(Sayre and Sayre is a Spokane-based law firm specializing in Elder Law issues)
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