I can get my mom in a nursing home without Medicaid but can't get Medicaid without her being in a nursing home first. Is this always the case?

Yeah, kinda. Here’s the rub…. For LTC Medicaid you have to be “at need” medically. Medically means at need for skilled nursing care in a facility for most States LTC program. (Some also do “waiver” programs for MC or AL so states “waive” a % of dedicated LTC $ to MC AL, those have different criteria). And State will review a residents chart & care plan at the NH to evaluate medical need and also may send out LTC needs assessment team. NH will have chart done to reflect codes that Medicaid is gonna wanna see; NH will have a medication management plan written up, may have a detailed dietary plan done, etc. Those plans & Codes (as in ICD-10 #’s) are things which neither you or I have the ability to do or be recognized by a NH or health care provider or Medicaid to be valid.

Majority of NH admits are from a post hospitalization discharge to rehab done in a NH. They enter as a MediCARE paid rehab patient & have a fat chart from the hospital. Then plateau in rehab and cannot go back home. So segueway from Medicare patient to LTC Medicaid resident. That now even fatter chart is there to show lots of “at need”.

I moved my backside of 90s mom from IL to a NH bypassing AL phase and bypassed mom going the hospital2rehab2NH stages. At the time I did not realize how beyond unusual this was. Moms gerontologist was also medical director of a NH as was all other MDs in the practice. So they know what’s needed. What happened was that for a few months prior to NH move, mom went to gerontologist abt every 3-4-5 weeks and got blood work, testing, labs done. She got her chart built up as before this it was every 6 mos visits. Chart showed increasing pattern of need; the visit she had more than 10% weight loss & bad labs, he wrote skilled care needed orders & she moved into NH within weeks. A chart that has only annual MD visit or bi annual will flat not have enough detail to show need in my experience. MD writing a script stating skilled nursing care needed is in & of itself not enough.

Fwiw, 4 more FUN! for us, was that intake staff left off most of moms RXs (aka medication management) & last labs so State found her ineligible medically. (Her financials not really an issue, couple of items but nothing serious, she entered as Medicaid Pending). So the DON (Director of Nursing who is goddes& ruler at a NH) got involved, we met and I filed a medically at need appeal to the State but DON took care of having her staff get items to the State to show medical need & in depth. Appeal hearing like 6 mo. out but NH sent up via fax in detail all sorts of info quickly & mom got approved medically maybe 6 weeks after ineligibility notice. All info was there either in moms preNH docs charts, labs & tests, RXs, and whatever else NH medical director elaborated on. Things I could not ever do. Appeal hearing cancelled.

I bring all this up cause if your mom is at home, IL or AL, there may not be extensive enough health issues in her chart to show need. Ime she’s going to have to have this. Unfortunately how NH are set up for care does not really enable a resident to easily go see a nephrologist, endocrinologist, internal medicine doc, get speciality lab work or tests done, etc. She has to come in showing “at need for skilled”.

I’d suggest that she gets a needs assessment done asap to see how far off she is from needing skilled. Then talk with her MDs to see if in fact she has issues that can be legitimately placed into her chart. If your mom is youngish & obviously puro custodial care, she will not be eligible for skilled care that LTC NH Medicaid will cover. This is a big reason why vast majority of admissions come via post hospitalized discharge to a NH for rehab……. they have obvious need for skilled nursing care in their health history & in detail. Good luck.

Medicaid is managed by each state independently and often the rules vary accordingly. Your state's Medicaid probably only covers LTC and some in-home services, so I would have a talk with her doctor to see if she can be assessed as needing it. Or, consult with a Medicaid Planner to figure out when and how she can qualify, if ever.

She can be admitted to a nursing home as "Medicaid pending".