Activities of Daily Living and Medicaid Eligibility
Activities of Daily Living
There are six standards of Activities of Daily Living (referred to as ADLs). They include whether the Medicaid applicant can do the following six activities:
The first three activities of daily living refer to functional activities:
1. Dress themselves
3. Transfer (e.g. go from sitting to standing, and vice versa) and maneuver to a chair or to their bed
The next three activities of daily living refer to activities necessary for hygiene and sustenance:
4. Bathe/Shower themselves
5. Feed themselves
6. Use a toilet themselves
If the Medicaid applicant can do all six activities of daily living, they would not be considered in need of care and would be rejected from the program.
If the Medicaid applicant has great difficulty with only one out of the six activities of daily living, they would qualify for the lowest level of care: “adult care.”
If the Medicaid applicant was unable to perform two out of the six ADLs, they would qualify for a medium level of care: “assisted living.”
If the Medicaid applicant required assistance with three out of the six ADLs, their condition would be deemed to require “nursing facility level of care” - the highest level of care
A doctor’s diagnosis of “severe dementia” will also qualify a Medicaid applicant for nursing facility level of care.
How Florida Medicaid Looks at Activities of Daily Living - ADLs
Florida medicaid will only pay for those who need nursing facility level of care (three or more impaired ADLs). Those who require a lower level may be able to obtain assistance through a Medicaid waiver or Medicaid diversion program.
In order to qualify for Medicaid, the DCF caseworker is checking to see if the Medicaid Institutional Care Program (ICP) applicant meets the Medicaid eligibility standards. There are three broad tests:
Medicaid Asset Test: The Medicaid applicant must have $2,000 or less in countable assets (certain assets are exempt and will not be counted toward the Medicaid resource limits)
Medicaid Income Test: The Medicaid applicant must gross less than $2,349.00 per month in income from all sources (e.g. social security, pension withdrawals,annuity payments, investment income, and wages) as of 2020.
You should talk to an elder law attorney / Medicaid planning attorney to discuss ways to legally and ethically qualify you or your loved one for Medicaid.
Medicaid Needs Test
After the income and asset standards are met, there must be a medical need for Medicaid’s long-term care services (referred to as ICP). Before being admitted into a nursing home (under the Medicaid ICP program). The Department of Elder Affairs representative will conduct a Comprehensive Assessment and Review for Long Term Care Services. This is also referred to as a CARES Assessment or the CARES Program.
How does the CARES program evaluate activities of daily living?
CARES conducts a pre-screening program to review the “level of care” required for a nursing home applicant or for someone looking for home and community based services (such as through the Adult Cystic Fibrosis Waiver, AIDS Care Waiver, Traumatic Brain Injury/Spinal Cord Injury Waiver, Familial Dysautonomia Waiver or Florida Managed Care Long-Term-Care Program). This Waiver program will also pay for some home health care (the hours approved depend on the applicant's ability or inability to conduct their activities of daily living; and a portion of an ALF bill.
Once someone applies to the Medicaid ICP or waiver program, a CARES assessment will be triggered.
The CARES Assessment will be evaluating the Medicaid applicant’s ability to perform their typical activities of daily living. Part of our service is to coach our client's (or their designated representatives) through the screening process to get Medicaid benefits started as quickly as possible.
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