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Medical Eligibility

Nursing homes provide 24-hour nursing care and supervision. An individual must meet certain medical eligibility requirements to be approved for admission to a nursing home if his or her care is to be paid for by a third party payer.

Determining Medical Eligibility if:

The Individual lives at home

If you feel that your loved one can no longer live at home and you wish to know what type of facility is appropriate, request that staff from your local Adult Evaluation and Review Services (AERS) assess your loved one's care needs. There is no charge for this evaluation service. The AERS team, which is part of the local health department, consists of a nurse, social worker and as needed, a physician, psychiatrist and psychologist. This team will come to your loved one's home to perform a comprehensive evaluation that includes medical/nursing, environmental and psychosocial assessments. This AERS evaluation serves as a pre-admission screening to determine if a nursing home is the most appropriate setting to meet the individual's care needs.

To request an AERS evaluation, call your local health department. In Baltimore County, the number is 410-887-2754. For other counties or Baltimore City, call the local Senior Information and Assistance Office and ask for the AERS office in your area.

The Individual is in the Hospital

If your loved one is in the hospital and needs continued care after a major illness or injury, the physician may recommend nursing home placement. The hospital discharge planner is responsible for arranging for your loved one to be assessed by the appropriate agency to determine if nursing home care is appropriate and, if it is, to assign the appropriate level of care. If it appears your loved one will be eligible for skilled care under the Medicare program, the evaluation will be done by staff from the nursing homes you are considering. If it appears that your loved one's care will be paid for by Medical Assistance, now or in the near future, then KePRO will evaluate him or her. If your loved one is eligible for nursing home care, the hospital discharge planner may offer assistance in finding a suitable vacancy. He or she will also make sure that the following information is provided to the nursing home by the hospital staff at the time of transfer:

  • The level of care determination from KePRO, if it is needed
  • The physician's discharge summary
  • Other discharge summaries as needed (for example, from nursing, rehabilitation therapists, social workers, etc.)
  • A list of current medications and treatments prescribed by the physician

The discharge planner will make the transportation arrangements to the nursing home as well.

KePRO
A nursing home can tell you if they can provide the kind of care your loved one needs. However, Medical Assistance will pay only if KePRO, an independent review agency, determines that the applicant is medically eligible for nursing home care. In order for KePRO to determine medical eligibility, the individual's doctor must complete a standardized form known as DHMH Form 3871B. In this document, the doctor will provide information about the individual's diagnoses, medications, need for assistance with activities of daily living (bathing, dressing, transferring, eating and toileting) and need for supervision and ongoing medical care. KePRO uses this information to determine if the individual is in need of nursing home care and to determine a level of care.

If the individual does not medically qualify for nursing home level of care, he or she may be eligible for the services of an assisted living facility or may be able to remain in the community and have necessary services brought into the home.

Financial Eligibility

In order to be admitted to a nursing home, one must:

  • Need skilled nursing care or rehabilitation services or health-related services above the level of room and board
  • Need these services on a daily basis
  • Need these services on an in-patient basis
  • Need continuous supervision
  • Need at least some assistance with activities of daily living (bathing, eating, walking, personal grooming and the like)
  • Have the services ordered by and provided under the direction of a physician

Financial Assistance

An individual wishing to apply for financial assistance to pay for nursing home care must meet the eligibility criteria of the program for which he or she is applying. Each program has it own income and asset limits. If the person has finances above the limits established by these programs, he or she will need to pay privately for care until he or she becomes eligible for third-party payment. Sources of funding for nursing homes include:

Each of these programs serves only eligible individuals in need of specific levels of care; for example, Medicare only pays for skilled care for eligible enrollees. It does not pay for intermediate, or custodial, care.