Medicaid will pay for skilled nursing home care only if it is medically necessary and the person is otherwise qualified and meets the financial eligibility requirements. Unless a nursing home stay is expected to last less than 30 days, a pre-admission screening is required to determine if an individual living outside of a nursing facility meets the level of care for Medicaid payment of long-term care services. No screening is required for individuals who have lived in a nursing home for longer than 30 days. Individuals who do not live in a nursing facility and wish to enroll in Medicaid must be screened and approved before Medicaid will authorize payment (assuming the individual meets the financial and other eligibility requirements). The Department of Social Services will send a representative to meet with and evaluate the individual, and this evaluation will typically be conducted by a nurse or social worker.
Virginia uses a form called the Virginia Uniform Assessment Instrument to determine if an individual medically needs skilled nursing home care. To qualify medically, the individual must have a physical or mental condition that requires services, such as nursing supervision and dependence in at least two activities of daily living (such as bathing, dressing, toileting, transferring, and feeding). The screener will determine how much assistance the person typically needs to complete those activities. The assessment team will also assess the individual’s mental orientation and behavior, mobility, joint motion, and ability to self-administer medications. When an individual is going through a medical needs assessment, it is important for a family member or advocate to inform the team of all the things with which the person needs help. If the pre-admission screening team determines that the person is not functionally or medically in need of long-term care services, the decision can be appealed to the Department of Medical Assistance Services (“DMAS”) in Virginia.
Written by Heather W. Winter