I have posted previously about elderly Tennessee residents who fail to qualify for Medicaid (called TennCare here in Tennessee) nursing home services because they receive a pre-admission evaluation (“PAE”) with a score less than 9. A score of 9 is required to qualify medically for nursing home services (in addition to income and asset limits).
Many vulnerable residents who may be totally unable to transfer from bed to wheelchair to toilet, or who are extremely demented, and who score less than a 9 on the grid used by the state, have been left in a quandary. They and their families may be completely perplexed as to how they will survive on the basis of Home and Community Based Services (“HCBS”) alone.
HCBS is also called “CHOICES Group 3” in Tennessee and has the same income and asset limits as nursing home medicaid, but a lower requirement for medical need. HCBS is limited to providing $15,000 for home-based services. Obviously, this will not pay for round-the-clock services (even if both husband and wife are receiving HCBS to the tune of $30,000).
Fortunately, there is a possible method to qualify those who score less than a 9 on the PAE for nursing home care. TennCare regulations provide that an applicant can qualify for nursing home care if “the applicant’s needs cannot be safely and appropriately met in the community with the array of services and supports . . . available through CHOICES Group 3. . ., services available through Medicare private insurance or other funding sources, and unpaid supports provided by family members and other caregivers.”
The complete parameters of this exception have not been worked out by the administrative process and the courts. But medical proof and the statements of lay witnesses would be important in determining that sending the frail and/or elderly applicant out with $15,000 of services a year would not meet that person’s needs safely and appropriately.
This is obviously an area where Medicaid applicants need the assistance of a lawyer specializing in Elder Law.
