Elder Law Plans and Medicaid Eligibility – The Role of Activities of Daily Living in Long-Term Care Plans

Elder Law Attorney’s take into account client’s ability to achieve Activities of Daily Living, without human assistance. These ADLs quantify an individual’s ability to accomplish necessary daily tasks on one’s own or if assistance is required. Also, Medicaid uses ADLs to determine eligibility.

ADLs are what a person does each day. For example, she gets up and out of bed. She gets ready to dressed. She moves around the home, uses the toilet, bathes, and eats. A person’s ability to accomplish the following categories determines whether a long-term care diagnosis is appropriate:

  • Feeding
    • A person feeds one’s self. That is to say, she gets food from plate to mouth alone.
    • However, this does not include food preparation. Also, the ability to take medication either falls under this category or under a different measure of activity but is not measured separately.
  • Toileting/Continence
    • The person can bathroom by one’s self and maintains self-control of urination and defecation.
  • Dressing
    • She can selecting proper attire and put the clothes on with little to no assistance.
  • Bathing/Showering/Personal Hygiene
    • A person is able to shower or take a bath with very limited assistance for any particular area of the body.
    • Also, the person is able to clean his self after using bathroom and between bathing.
  • Transferring
    • The person can get out of or into bed or a chair without assistance of another person.
  • Ambulatory
    • She walks without human assistance. May use a walker or cane to assist, but she uses it on her own.

Be aware, some organizations modify the above list slightly. However, this list represents the core measurement criteria . To determine if a person qualifies for nursing home care or in-home, Medicaid waivered services, the person needs assistance with 3 or more of the above listed activities.

The term used in the evaluation process is “The person shows a deficiency in Activities of Daily Living (or ADLs).” A deficiency occurs if the cannot accomplish the task without the assistance of person or a piece of equipment.

Your Elder Law Attorney should initially assess these deficiencies by talking to a spouse or children to understand the client’s needs. Deficiencies are necessary to determine the need for Long-Term Care. Nursing homes require a documented need for long-term care. The Elder Law Attorney should explain the number of deficiencies necessary to be Medicaid eligible or to trigger a long-term care insurance policy. A clear deficiency assessment is an essential element for Medicaid eligibility.

Expect your Elder Law Attorney to explain the ways a person can have this assessment completed:

  • During the course of a hospital stay or rehabilitation, a doctor’s assessment determines a person needs long-term care due to an illness or physical limitation(s);
  • A representative from a local Area Agency on Aging* (AAA) conducts an assessment of the person in his or her home. The agent conducts the onsite person’s interview and evaluates the person’s ability to complete the ADLs; or
  • An emergency determination by a doctor, which is then processed by the AAA to admit a person to a nursing home.

Long-Term Care Insurance Policies use ADLs to determine when coverage can be claimed. Some plans (e.g., some John Hancock policies) require a deficiency of 2 ADLs. However, many have an elimination period. The elimination period is the time between qualifying for coverage and payment for coverage. It is important to “get the clock started” for coverage to allow payment sooner. Your Elder Law Attorney can assist you so do not wait too long to have an assessment completed.

As a service to you, ask your Elder Law Attorney to review your policy and explain the policy coverage to you.

If you have questions about planning for long-term care expenses or would like clarification about things you have heard about Medicaid, nursing homes, In-Home Care or to have your policy explained, complete the form to the right or call today – (219) 230-3600 – to schedule a thirty-minute complimentary consultation.

* Some AAAs include Real Services (South Bend-area, including LaPorte County), Area IV Agency on Aging (Lafayette-area), and Northwest Indiana Community Action (Northwest Indiana).

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Founder/Attorney, CCSK Law
I create customized solutions for families to address their planning needs.
I provide plans clients understand. Also, they make sure they know when to use them, and do so affordably. I love the opportunity to break through the legal jargon to clarify issues. We find success when we work through a person’s situation and put the law to work for them.

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