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How Do You Qualify Medically for Long-Term Care Coverage Under Medicaid?

January 23, 2023

If you or a loved one needs long-term care coverage, Medicaid is one possible way to pay for that care. However, there are two parts to qualifying for Medicaid coverage. First, you must meet certain financial requirements that establish how much income and assets you can have. Second, you must satisfy the medical qualifications by demonstrating that you lack the functional ability to take care of yourself or you need assistance in caring for yourself.

How Does Medicaid Determine Whether You Are Eligible Medically?

If you don’t need skilled nursing care, then eligibility for Medicaid long-term care coverage typically rests on showing that you need assistance with a certain number of “activities of daily living” (ADLs). ADLs are a list of general activities that allow an individual to function independently in a household. They are:

  1. Bathing: Includes the ability to clean yourself, get in and out of the shower, and perform other activities of personal hygiene (i.e. shaving, brushing teeth, etc.).
  2. Eating: Includes theability to feed yourself by getting food into the body from a plate, cup, table, feeding tube, or even intravenously.
  3. Dressing: Includes the ability to put on and take off clothes, including not struggling significantly with parts of clothing such as zippers or buttons.
  4. Toileting: Includes the ability to get on and off the toilet and perform any associated personal hygiene.
  5. Continence: Includes theability to control your bladder and bowel functions or if you are unable to control your bladder/bowel, then it is the ability to perform any associated personal hygiene such as using a catheter or colostomy bag.

How Many ADLs Must You Fail to Do to Qualify for Medicaid?

Typically, you must be unable to perform or need “hands-on assistance” with at least two of the above ADLs in order to medically qualify for Medicaid long-term care coverage. Hands-on assistance is defined as physical assistance (even a minimal amount) without which the individual cannot perform the ADL.

What Should You Do If You Need Help Paying for Long-Term Care?

Eligibility rules for Medicaid are complicated so it is best to get legal assistance. An experienced lawyer can help determine your financial eligibility for Medicaid including engaging in Medicaid planning to enable you to qualify if you have too much income or assets. Further, a lawyer can explain the medical and documentation requirements and work with you on the application process. 

Our attorneys have extensive experience helping families preserve their income and assets while qualifying for Medicaid. Complete the inquiry form here to set up your consultation. 


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