Community Medicaid is a government funded, need-based program that cover’s long term care services in one’s home. This means that recipients who qualify can have a home health aide help them in their home. There are two main assessments needed to qualify for Community Medicaid. The financial assessment determines if the applicant is below certain income and asset levels. After meeting the financial guidelines, the applicant undergoes a care assessment. Typically, the care assessment will determine how many hours per day, days per week, Medicaid will cover the cost of a home health aide.
Many clients inquire about the “maximum” number of hours that Medicaid will cover. The answer is that it depends on the evaluation. There three different options:
Medicaid Weekly Hours Award
The first option occurs when the nurse authorizes a set number of weekly hours, for example, fifty-six (56) hours per week or eight (8) hours per day. This would mean that an aide would come to the house at a set time each day and then leaves at a set time.
Medicaid Live-In Aide
The live-in option occurs when the applicant needs full time care but can sleep at night without assistance. A live-in aide is paid for thirteen hours per day and then is “off the clock” the remaining time. This allows the aide to get some rest, but still be available during the night if the applicant needs help (i.e. going to the bathroom). The rule of thumb is that so long as the aide is getting five hours of uninterrupted sleep per night, live-in care is usually appropriate.
The live-in option is not popular with home health aides because it keeps them away from their families while only paying for thirteen hours of twenty-four they are in the home. The 13-hour policy assumes that workers get three hours off for three meals each day and eight hours of sleep each night.
The third option, split shift, is when one aide works a full twelve-hour shift and then a second aide comes to the home and works another twelve-hour shift. A split shift is authorized when the applicant needs active assistance both day and night.
How to Get Authorized for Split Shift
To have split shift approved, the applicant must show a substantial need for assistance both day and night. For example, if the applicant is unable to move in bed unaided and there is a high risk of bed sores, split shift may be authorized if an aide must “turn” the applicant every few hours. Or if the applicant wakes up frequently at night to walk around or use the toilet and the live-in aide is unable to get the five hours of sleep, split shift may be authorized. The assessment may find that a person’s nighttime needs can be met by using adaptive equipment or supplies, such as a bedside commode or diapers. There may informal caregivers who can help at night.
Split shift is the most expensive option because Medicaid pays the aides for a full 24-hour period. Unlike live-in care, where the aide is only paid for 13 hours. With the added expense, applicants have a difficult time persuading the nurse to recommend split shift.
An applicant can always appeal if the desired level of care is denied or decreased. Our attorneys always advocate for the maximum number of hours our clients need to live safe, independent lives at home. When necessary, we bring a “fair hearing” on behalf of client to object to the care assessment. A fair hearing forces the judge to review the care plan and determine if the higher level of care is necessary.