A Medicaid applicant must prove "medical need" to gain eligiblity. The two major concepts are Level of Care ("LOC") and Length of stay ("LOS"). Essentially, how sick are you and how long will your condition continue?
LOC, addressed in Section 2240 of the Georgia Medicaid Manual, applies to each Class of Assistance. Medical verification comes through your health care providers. In a nursing home, for example, Form DMA-59, Authorization of Nursing Facility Reimbursement, is signed by the nursing home administrator. In addition, Form DMA-6 is completed by the physician and the Director of Nursing at the nursing home and remains on file at the nursing home. By completing these forms, your health care providers are certifying to the State that you need a specific level of care. (Note: In Tennessee, this form is called a Preadmission Evaluation or PAE).
LOS is a basic concept discussed in section 2235 of the Georgia Medicaid Manual. The need for assistance must continue over a period of time not less than 30 days. Medicaid coverage is retroactive to the date of admission after the 30 day LOS is met. In Georgia, but not Tennessee, Medicaid coverage may be retroactive for up to three months.
Recently the case of Maryland Department of Health and Mental Hygience v. Brown (November 27, 2007), addressed the medical standard applicable for home and community based services in Maryland. Ms. Brown suffered from multiple medical conditions including Alzheimer's, osteoarthritis, osteoporisis, elevated cholesterol, hypertension, bilateral cataracts and a benign brain tumor. On April 13, 2005, she applied for home and community-based services under Maryland's Older Adults Waiver Program. Her application was denied because, allegedly, she did not meed the standard for medical eligibility; it was undisputed that she satisfied the financial criteria.
At the hearing evidence was admitted describing Ms. Brown's condition, including her need for supervision, that she was at-risk for wandering and that she wouldn't take medications correctly or eat right. Her medical records were admitted without objection.
The Department offered the testimony of a nurse who described the application process. Applications are first reviewed by a nurse and, if denied, are sent to a physician for review. Next, the department offered the testimony of a physician who described the medical standard as if the applicant: (1) has a 'skilled nursing need,' which requires, on a daily basis, the hands-on activity of a nurse or a physician; (2) requires physical therapy or rehabilitative therapy, ordered by a physician and performed by a licensed therapist, five days per week; or (3) requires 'health-related services above the level of room and board that could only be provided in an institutional setting under licensed
health care professionals.' In its closing at the fair hearing, the Department argued that the eligibility standard is whether or not a person needs licensed health care professionals on a daily basis. The Administrative law judge ruled with the Department, finding that although Ms. Brown could benfit from assistance, she was not medically eligible because she did not need twenty-four hour supervision by licensed health-care professionals. On appeal, the Board affirmed the ALJ's findings.
On appeal to the Circuit Court, Brown argued that the Department had set the standard too high by requiring a showing that she needed daily monitoring by a licensed health-care professional. She argued that the standard for intermediate care was the proper eligibility standard. The circuit court agreed with Brown and reversed the decision below. The Department then appealed to the Court of Appeals.
Applying federal law, the court found that Congress set the applicable standard as the need, on a regular basis, for health-related care and services above the level of room and board (citing 42 USC § 1396r(a)(1)(C); and 42 C.F.R. § 440.155). The Court rejected the Department's argument that the standard for home and community based services is identical to the federal standard for the nursing home level of care. Instead, the Court held that 42 C.F.R. § 440.155, which is the federal regulation concerning nursing facility services at the intermediate level of care, and 42 U.S.C. § 1396r(a)(1)(C), which defines nursing facility care at the intermediate level of care, do not require direct involvement of, or even supervision by, licensed health care professionals. The Court found nothing in federal law requiring that intermediate level care, which is what Ms. Brown needed, be "under the supervision of licensed health care professionals." Ultimately, the court found that the applicant need only require health related care and services; above the level of room and board; that are provided on a regular basis at least 5 days in a 7-day period; and [c]an be made available to the individuals through institutional facilities.