Introduction

 

 

Many people know virtually nothing about Medicaid policy for nursing home care until the need arises. This guide is a good starting point to become knowledgeable about Medicaid policy and program requirements. It should be used in conjunction with visits to nursing homes and, where necessary, consultations with a qualified attorney.

 

This guide is based on Federal law and the laws of the State of Delaware. Relevant law may change from year to year, so be sure you have the most recent edition of this guide. You should always consult local Medicaid offices to supplement and verify the information contained in the following pages.

As life's circumstances change, an individual may not be able to maintain his or her home and function independently. He or she may need Long Term care services which can be expensive. At some point, an individual may not have enough income or savings to pay privately for this care. When this occurs, a person may need to seek some type of assistance for payment of the needed long-term care services. Two government plans which may help pay for long-term care are Medicaid and, to a lesser extent, Medicare. Private insurance may also be a payor for long-term care services.

What are some differences between Medicare and Medicaid?

 

Medicare

 

• Is a health insurance program that individuals receive when they get regular Social Security.
• Will only make payments for someone who requires and is placed in a nursing facility with a skilled level of care after a 3 day hospital stay.
• Has never covered long-term nursing facility care.Will only pay for a limited number of days.

Medicaid

• Is a program that individuals may receive based on medical and financial need.
• Will make payments for nursing home residents who require and are placed in a Medicaid accepting facility, for skilled or intermediate level of care.
• Medicaid will pay for this nursing home care as long as the resident remains medically and financially eligible.

What services are available in Delaware for long-term care coverage?

If an individual who is a resident of Delaware meets the medical and financial eligibility requirements, the Delaware Division of Social Services can pay for long-term care through three Medicaid programs:

1. Nursing Facility program
2. Long Term Acute Care program
3. HCBS Waiver
   • Elderly and Disabled Waiver
   • AIDS Waiver
   • Intellectual Disabilities Waiver
   • Assisted Living Waiver

• STEP 1 Medical eligibility
• STEP 2 Financial eligibility

How do I begin the process for Medicaid payment for long-term care services?

First, a referral must be made (usually by phone).  For

• Nursing home care call the Pre-Admission Screening (PAS) unit .

Upon referral, arrangements will be made for a medical team, consisting of a nurse and a social worker case managers from the PAS unit, to visit the applicant and evaluate him/her medically to determine if he/she requires a skilled or intermediate level of care (LOC) as defined by Delaware Medicaid criteria.

If the applicant is found medically to have a skilled or intermediate level of care, the PAS unit will refer the applicant to the Financial Eligibility unit which will determine his/her financial eligibility for Long-term Care services.

If the PAS team does not leave an application packet, the financial unit will send the packet to the applicant or family contact. The person receiving the packet is instructed to call the office for an appointment with a financial eligibility social worker case managers.

The applicant or family contact should complete the application prior to the interview but not sign the application. All information relating to the application should be brought to the interview so that an accurate and timely determination of eligibility can be made. If the social worker case managers needs further documentation, a letter will be given to the applicant or family member stating what items are still needed.

Once all of the information has been received, and if the applicant is determined to be eligible financially, Medicaid may begin payments for long-term care services at the time of institutionalization. Institutionalization would be placement in a nursing facility or receiving community based services in the home.

APPLICANTS MUST BE MEDICALLY IN NEED OF A SKILLED OR INTERMEDIATE LEVEL OF CARE AS DEFINED BY DELAWARE MEDICAID CRITERIA AND FINANCIALLY ELIGIBLE TO QUALIFY FOR EITHER THE NURSING HOME OR COMMUNITY BASED LONG-TERM CARE SERVICES.

Next Page - Financial Eligibility