There are several reasons seniors should get a health or care assessment different from an annual physical – to qualify for Medicaid long-term care, to activate long-term care insurance benefits, and to establish a baseline for their overall health and care needs, which can be essential information for caregivers and family members. A senior’s primary care provider can complete a health assessment, which may include a referral to specialists like a geriatrician or a neurologist. This may be enough in some situations, but seniors might need a more comprehensive private pay health assessment to be certain of Medicaid eligibility, insurance triggers and qualifications for other benefits programs.
Planning is essential when it comes to providing the best quality of life and healthcare for our aging loved ones. In order to create a useful plan, understanding the senior’s health is critical. This will help seniors and their families know what kind of care they might need, when they might need it and if they’re eligible for any benefits programs, like Medicaid. Seniors who planned ahead and bought a long-term care insurance plan will also need a health assessment to determine when they are ready for the insurance to kick in and start covering long-term care.
As a senior’s health changes, or if they are moving to a new location or getting a new caregiver, it’s important to understand their current health condition and care needs with an assessment. The assessment can establish a foundation for caregivers and family members so they know how to best assist a senior in the moment, as well as in the future. This can be especially helpful for family member caregivers who may be new to the role and have little or no formal training.
A baseline health understanding should include a knowledge of all current physical ailments and conditions, any cognitive issues, the senior’s family history, major health events or issues from the senior’s past, and a list of all their care providers along with after-hours and emergency contact information and upcoming appointments. It should also include a complete list of all the prescription medication and over-the-counter supplements the senior takes, along with dosages.
In order to qualify for the majority of Medicaid’s long-term care programs, applicants must require a Nursing Facility Level of Care (NFLOC). Knowing in advance whether the applicant will meet this requirement is critical. The rules and procedures for assessments used for this purpose can vary by state, but our Level of Care Assessment service will provide seniors with documentation they can submit along with their Medicaid application in any state.
In general, needing a NFLOC means needing the kind of constant supervision and care normally associated with nursing homes, but the exact definition of a NFLOC can vary by state. In some states, needing help with two of the Activities of Daily Living (mobility, bathing, dressing/grooming, eating, toileting) is required for a NFLOC designation. In others, needing help with three of those activities might be the requirement for a NFLOC. Some states may put more emphasis on cognitive condition than others, while some may emphasize mobility issues above all else.
Needing a NFLOC is a requirement for Medicaid’s nursing home coverage in all states. This coverage is critical for many seniors due to the high cost of nursing home care – $111,325/year for a semi-private room, on average, in the U.S. in 2024, according to the Cost of Care Survey conducted by Genworth and CareScout. And Medicaid is the only public benefits program that will pay for long-term care in nursing homes. Medicare only covers rehabilitation nursing home stays for up to 100 days.
Medicaid will also cover long-term care services and supports in beneficiaries’ homes, the homes of loved ones and, in most states, assisted living residences and other locations in the community through one of its Home and Community Based Services (HCBS) Waivers. To qualify for most of these waivers, applicants must also require a NFLOC, although a few waivers only require applicants to be at risk of needing a NFLOC.
In addition to a medical requirement, Nursing Home Medicaid and HCBS Waivers applicants also need to meet two financial requirements – an asset limit and an income limit.
Long-term care insurance is purchased when people are still healthy, usually when they are in their 50s or 60s. The policy kicks in when the policyholder “needs” long-term care. When they “need” care is established in the policy and determined by the health of the policyholder, which will need to be evaluated by a health assessment. The trigger is often tied to requiring help with a certain number of the Activities of Daily Living (mobility, bathing, dressing/grooming, eating, toileting), just like with the Nursing Facility Level of Care (NFLOC) designation discussed above. An assessment from a primary care provider may be enough for some policies, but others will require a more comprehensive assessment. A private assessment is sometimes necessary if an insurance company declines the policyholder’s claim for payments and the family disagrees with the company’s decision.
After the policy kicks in, it will pay for some or all of the policyholder’s long-term care expenses. The amount it pays out, usually measured in dollars per day or month, depends on the policy and how much the holder paid in premiums before the coverage was triggered.
A health assessment from a primary care provider will typically focus on the medical evaluation. It can also include referrals for services covered by insurance, which for seniors usually means a geriatrician (eldercare specialist) or a neurologist (brain and cognition specialist). It should be noted these specialists are often in high demand and it can be difficult to book an appointment with a geriatrician or a neurologist that is covered by insurance and doesn’t come with a waiting period measured in months. When the initial appointment does come around, it may only be a 15-minute consultation that won’t suffice for Medicaid eligibility or long-term care insurance purposes.
It’s a good idea for a family member to accompany an aging loved one to their health assessment. The family member should bring a notebook so they can record any important information. They can also come prepared with questions like, what health changes should they be watching for, what tests does the senior need, should they see a specialist, what are the side effects of any relevant medications, etc.
Private pay health assessments, in general, are more comprehensive than evaluations from a primary care provider. Private pay services typically include medical assessments that cover diagnoses, medications and cognition; guidance on suitable care plans and locations; insights into how the senior’s needs align with Medicaid and other insurance programs; results and documentation that should be accepted by Medicaid, long-term care insurance and other programs.
In addition to the services mentioned above, the Level of Care Assessment service at Eldercare Resource Planning also includes guidance on whether or not the senior should apply for Medicaid now or later. If it’s in the future, we will provide a timeline for the eventual application process. If it’s now, we will provide documentation that can be submitted with the Medicaid application to prove functional (medical) eligibility. This documentation will be ready within seven business days of the assessment, which can be especially helpful for seniors with a sudden need for care. If the application is denied due to medical eligibility, we support our clients through the appeals process at no extra charge.
Even though they are so thorough, private pay assessments can be scheduled and completed in a much shorter time frame, in general, than assessments from a primary care provider or geriatrician. So, seniors who have a sudden change in health or living situation and have an urgent need for an assessment will usually need to use a private pay company in order to get the results in time.
When it comes to deciding between a health assessment from a primary care provider or a private company, there are a few rules of thumb:
A private company is the best choice for seniors if:
-They’re applying for Medicaid now or in the future.
-They want to trigger their long-term care insurance
-They have an urgent need for an assessment and time is a factor such as being currently in a nursing home funded by Medicare and they are approaching the end of the allowed days.
A primary care provider may be the best choice if:
-The main purpose of the assessment is a medical evaluation
-Cost is a prohibitive factor.
After the assessment is complete, the senior, their family and their caregivers can create a new care plan or update an old one. This might include applying for Medicaid as soon as possible because the senior needs care or because the program they want has a waitlist. Or they could plan for a future Medicaid application by spending down assets or protecting their home. The plan could include activating a long-term care insurance policy.
The senior and their family should also evaluate their medical team. If the senior is having issues with any aspect of their care, they should consider other options. Issues might include not being able to make an appointment, rushed visits, the doctor ignoring complaints or failing to explain conditions, etc. If there is a new caregiver, it’s important to promptly ensure they have all of the senior’s medical records.
Our team of Certified Medicaid Planners™ will help you navigate the difficult landscape of Medicaid for long-term care.
