Medical Necessity for Houston Nursing Home Medicaid

In order to establish nursing home Medicaid eligibility the applicant must have “medical necessity” to be in a nursing home. If you do not have a valid medical necessity then you will not be eligible for Medicaid.

What is “medical necessity?”

A Medical necessity exists when a person meets all of the following criteria:

(1) The individual must demonstrate a medical condition that:

(A) is of sufficient seriousness that the individual’s needs exceed the routine care which may be given by an untrained person; and

(B) requires licensed nurses’ supervision, assessment, planning, and intervention that are available only in an institution.

(2) The individual must require medical or nursing services that:

(A) a physician orders;

(B) are dependent upon the individual’s documented medical conditions;

(C) require the skills of a registered or licensed vocational nurse;

(D) are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and

(E) the individual requires on a regular basis.

Who Decides?

This decision is initially made by the staff at the nursing home. When you apply for Medicaid, the HHSC reviews the file to make their own determination. In many cases they reach the same conclusion although occasionally they do conflict. It is a medical decision, but your Woodlands Medicaid Attorney can appeal it if the staff made a wrong decision. Get help today if your loved one needs nursing home Medicaid benefits.

What If You Don’t Have Medical Necessity?

If your parent or spouse doesn’t have “medical necessity” then they will not qualify for nursing home Medicaid. However, they may qualify for other benefits to help them live at home or with a family member.

Don’t Forget Everything Else

Medical necessity is one of the many criteria you have to prove to create nursing home Medicaid eligibility in The Woodlands.

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