Medicaid Changes 2012: A Two-Month Evaluation

evaluationAs far back as February, we knew that changes were afoot in Tennessee’s Medicaid benefits. In May we learned more details about the new points-system approach to determining whether seniors would or would not qualify for nursing home care. Health care professionals, seniors already on or seeking Medicaid benefits, and families of those seniors were all uncertain as to the results of the drastic changes to the qualification system.

The changes took effect on July 1. As this July 28 article from Kaiser Health News describes, the new system is designed to save care dollars for the State of Tennessee by targeting care more effectively. Now, after more than two months of the new system being in place, we are starting to get a sense of how it is working – or in some cases, not working.

As we knew would happen back in May, the new law creates three groups of seniors or disabled individuals who are eligible for Medicaid benefits. The group into which the individual falls is based on a weighted point scoring system. Group 1 includes individuals who score at least a 9 on the need acuity scale and who require or choose to receive care in a nursing home. Group 2 includes individuals who also score a 9 but instead choose to receive care in an assisted living facility or other community based setting. Group 3 is new and includes individuals who score between 6 and 9 on the need acuity scale. These individuals are considered “at risk” of needing nursing home care if they do not receive some kind of community-based support. Services for Group 3 individuals are subject to an annual $15,000 cost cap and are specifically excluded from residential care services.

As Care Coordinator for Elder Law of East Tennessee, I know that $15,000 a year is insufficient to meet the care needs of many who will be denied Group 1 or Group 2 approval. Moreover, if saving money is a goal of the new law, it is especially illogical that Group 3 individuals will not be able to choose to receive their care in an assisted living facility. Prior to July 1, individuals could receive up to $1,100/month ($13,200/year) for care in an assisted living facility, which falls well under the $15,000 annual cost cap for this group.

Yet another issue during this transition involves the process by which seniors’ health/functional status is reevaluated. Upon reevaluation of their health and functional status, some seniors previously approved for Group 1 or Group 2 are being shifted to the Group 3 “at-risk” category. In some instances these individuals have already sold their homes, spent all their assets, and have no place to go after being discharged from the nursing home or assisted living. This situation is putting both seniors and nursing home facilities in bad positions. Nursing homes are prohibited by law from making an “unsafe discharge,” meaning that some facilities are stuck with residents for whom the facility no longer receives reimbursement. And of course the seniors and their families have to endure a lot of stress as they seek alternatives to nursing home care in situations where there may not be any realistic alternative.

While the new Medicaid evaluation process may be well-intended, aiming to maximize seniors’ independence and comfort while spending fewer state dollars on long-term care, the law has some serious kinks that need to be straightened out before we can call it a true success. This transitional period has been predictably rough; what remains to be seen is if lawmakers will recognize the problems and get about fixing them before too many seniors, families, and facilities suffer ill effects.

If you find yourself in a fix as a result of the changes to Medicaid law, or if you want more information on the ins and outs of the new Medicaid qualification process, contact Elder Law of East Tennessee right away. We can help you to consider your options and assist you in making the best decisions for long-term care.