When most people think about Medicaid, they focus on the financial component — income and asset limits that determine eligibility. For some Medicaid programs, however, the focus needs to be on both financial and clinical eligibility requirements. For example, older adults applying for Medicaid to cover the cost of long-term care need to place equal importance on establishing clinical eligibility. A recent appellate case has brought this issue into sharper focus, underscoring how critical it is for applicants to the Long-Term Services and Supports (“LTSS”) Program meet medical and functional requirements in addition to financial ones.
Understanding Medicaid Clinical Eligibility
To qualify for long-term care Medicaid, an individual must satisfy both financial and clinical eligibility requirements. For clinical eligibility to be established, the applicant must require nursing home level of care. This determination is made through a Pre-Admission Screening (PAS), which evaluates a person’s ability to perform Activities of Daily Living (ADLs) such as bathing, dressing, eating, toileting, and mobility. Clinical eligibility is established when an applicant requires hands-on assistance with at least three (3) of their ADLs.
In other words, applicants who do not require hands-on assistance with three (3) or more ADLs will be considered ineligible for long-term care Medicaid, even if they clearly cannot live safely on their own. This creates a troubling gap for individuals who fall between the cracks: they are not “disabled enough” to qualify for Medicaid-covered long-term care, yet they lack the financial means to pay privately for the care they need.
The Recent Appellate Case: A Cautionary Tale
In the recent appellate case, the court examined an individual who was denied Medicaid benefits based on a finding that they did not meet clinical eligibility despite significant functional limitations. The person could complete some Activities of Daily Living, but required frequent prompting, oversight, and assistance to remain safe.
The appellate court’s analysis highlighted the nuanced nature of the PAS process, emphasizing that clinical evaluations must take into account not just physical capability, but also cognitive function, safety awareness, and the ability to perform tasks consistently without supervision.
What This Means for Families and Applicants
This case serves as an important reminder that Medicaid eligibility for long-term care applicants is not just about income and assets. Families should be prepared to address both financial and medical components when applying for long-term care coverage. Accurate documentation of medical conditions, care needs, and assistance required with Activities of Daily Living can make a significant difference in the outcome of a clinical eligibility review.
If a PAS assessment seems inconsistent with the applicant’s true care needs, it may be worth seeking a reassessment or appealing the decision—especially when safety or cognitive decline are factors.
As this appellate decision illustrates, Medicaid clinical eligibility is a complex and often misunderstood area of law. The Elder Law attorneys at Mandelbaum Barrett PC understand both the financial and medical components of eligibility and can help individuals and families with navigating the system. The right advocacy can ensure that applicants receive the care and benefits they truly need—and that those who can no longer live independently are not left without vital support.