Medical Eligibility

Only those persons with a medical need are eligible for Medicaid and not all persons needing help receive Medicaid. In Georgia, medical eligibility determinations for nursing home facility care are performed by the facility using Form DMA-59. Determinations for CCSP (HCBS) are made by the CCSP RN Care coordinator.

• 2240 – Level of Care

As part of the technical criteria, long-term care Medicaid usually includes a length of stay requirement and long-term care COAs typically require nursing facility level care. A nursing home resident must be confined to an institution for 30 days or more to establish eligibility. [Note 12]

Note 12: 42 U.S.C. § 1396a(a)(10)(A)(ii)(V).

Separate from the technical criteria, each State is responsible for the administration and enforcement of Pre-screening and Annual Resident Reviews (PASRR). [Note 13]. The purpose of the PASRR is to determine whether institutional placement (if applicable) is medically appropriate. [Note 14]. While medical eligibility is evaluated for each class of assistance [Note 15], here we limit the inquiry to long-term care Medicaid. The inquiry would be different, for example, in the context of a Katie Beckett waiver.

Note 13: 42 C.F.R. § 483.104. See 42 CFR Subpart C – Preadmission Screening and Annual Review of Mentally Ill and Mentally Retarded Individuals.

Note 14: 42 U.S.C. § 1396r(e)(7). Although the PASRR requirement pre-dates Olmstead v. L.C. by 10 years, it is consistent with the holding that mentally ill individuals should not be institutionalized for convenience. There must be a medical need.

Note 15: See, e.g., Georgia Medicaid Manual § 2101 (overview of various classes of assistance).

An applicant must demonstrate that he or she meets the medical criteria for Medicaid eligibility. A separate application form, called a “Pre-Admission Evaluation” must be completed and sent to Medicaid for processing and approval. [Note 16]. For discussion purposes, we address the Tennessee rules, although the criteria and procedure are similar in Georgia.

Note 16: https://www.tn.gov/content/dam/tn/tenncare/documents/PAEFormActive.pdf. In Georgia, the form is a DMA-59. State definitions of medical necessity for EPSDT benefits are listed at the National Academy for State Health Policy website.

The PAE needs to be approved within 90 days of the person’s admission to the nursing facility. Tenn. Comp. Rules and Regs Rule 1200-13-1-.10(2)(e) (May 2021). The individual must also undergo a Pre-Admission Screening and Annual Resident Review (PASRR) Level 1 assessment by the Tennessee Department of Mental Health and Mental Retardation to determine if there is a need for mental health services that can only be provided in a long term care setting. Tenn. Comp. Rules and Regs. Rule 1200-13-1-.10(2)(h) (Oct. 2003); Smith v. Chattanooga Medical Investors, Inc., 62 S.W.3d 178 (Tenn. App. 2001). [Note 17].

Note 17: In Georgia, the Department of Community Health is the Medicaid agency, but DCH has contracted with the Department of Family and Children Services to make eligibility determinations. See O.C.G.A. § 31-2-4 and O.C.G.A. § 49-4-142.

To demonstrate medical eligibility for nursing home care, the applicant must need long term nursing home care. In Tennessee, there are three levels of care: CHOICES Groups 1, 2 and 3. Choices 1 is limited to Tenncare members who qualify for and are receiving Tenncare reimbursed nursing facility services. Choices 2 and 3 are limited to Tenncare members receiving Choices HCBS. Tenn. Comp. Rules and Regs Rules 1200-13-1-.05(3). See also Tenn. Comp. Rules and Regs Rules 1200-13-1-.10(4) through (6) (May 2021). [Note 18].

Note 18: Medicare will pay for 100% of days 1 through 20 if the necessity for skilled care continues following a qualifying hospital stay. If additional skilled care is necessary, then after the nursing home resident pays the daily co-pay (in 2021, $185.50), Medicare pays the balance. Some Medi-gap policies provide coverage for the daily co-pay. It should be noted, however, that Medicare days are not guaranteed; if skilled care is no longer necessary, Medicare coverage terminates.

Applicants must have a physical or mental condition, disability, or impairment that, as a practical matter, requires daily inpatient nursing care. The Applicant must be unable to self-perform needed nursing care and must meet one (1) or more of the following criteria on an ongoing basis. Tenn. Comp. Rules and Regs. Rule 1200-13-1-.10(4). See also Georgia ABD Manual section 2240.

These conditions are expected to be continual and ongoing, and not a matter of an isolated lapse or exceptional occurrence. See Jaco v. Department of Health, Bureau of Tenncare, 1999 WL 346241 (Tenn. App. 1999).