When applying for Medicaid’s long-term care coverage, in addition to the strict income and asset limits, you must meet medical eligibility criteria. This required level of care is referred to as “nursing facility clinically eligible” (NFCE).

Whether you are applying for nursing home coverage or through a Medicaid waiver program for coverage at home, you must be NFCE. Each state has its own criteria for determining if you meet this standard, and the criteria are far from clear.

The state looks at an applicant’s functional, medical, and cognitive abilities to determine if care in a nursing home is called for. In general, you must be unable to care for yourself or pose a danger to yourself without outside help. The following are the factors usually considered when making a level-of-care determination:

  • You need help with two or more “activities of daily living” (such as bathing, dressing, eating, moving, and going to the bathroom).
  • You need frequent medical care, such as assistance with medication, injections, IVs, or other medical treatment.
  • Your cognitive ability is impaired by Alzheimer’s disease or another form of dementia, you have trouble making decisions on your own, or you are unable to process information.
  • You have behavior problems, such as wandering away from home or aggressiveness.

In Pennsylvania, each County’s Area Agency on Aging makes that determination for persons in nursing homes. For those seeking “Waiver” benefits for care at home, that call is made by a private independent enrollment broker, Maximus.

Financial eligibility determinations are made by the state’s Department of Human Services at designated field offices. That process can be long and difficult. The lawyers at Vasiliadis Pappas Associates have extensive experience in helping applicants qualify for Medicaid benefits.

Contact Vasiliadis Pappas Associates for assistance if you or a loved one encounters this situation.