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The Medicaid system is maturing and showing promise of improving nursing home alternatives compared to the few meaningful alternatives to nursing home care that existed when we began our elder law career almost quarter century ago. Back then, almost every dementia or stroke patient had to be institutionalized in a nursing home to receive adequate supervisory and therapeutic care. Today, the depth and breadth of non-nursing home care alternatives is growing to include a full range of care between home health care and full nursing home care.

Generally, Medicaid pays for nursing home care when an adult qualifies financially and needs help with multiple activities of daily living (ADLs), such as eating, bathing, dressing, toileting, taking medication, etc. The aged and disabled waiver (commonly referred to as “A & D Waiver”) program provides a home health care alternative for some patients needing nursing home level of care. More recently, the assisted living waiver system has provided Medicaid eligibility to provide nursing home level of care for disabled patients in Medicaid-certified assisted living facilities.

The A & D Waiver system works well for a patient that lives with a healthy spouse or other family members, who can provide care in the evening and part of the day. Lake Medicaid for nursing home care, the A & D Waiver system requires the patient satisfy financial eligibility requirements. Additionally, the Area Agency on Aging must determine that that the patient needs nursing home level of care, but can live at home with substantial assistance. Qualifying patients can receive Medicaid assistance to pay nurses and therapists for home visits to provide some of the kinds of care that nursing homes provide to their residents. Medicaid also pays respite workers to supervise a patient and give family caregivers time away from home for recreation, shopping, and other out of home activities that caregivers need to maintain their own physical and mental health.

The A & D Waiver system does not work for everyone. If a patient does not have family members that are willing and able to live with the patient and provide 18 hours or more of care daily, a dementia patient that wonders or a stroke patient that needs regular assistance every 2 or 3 hours may not be able to live safely without such supervision. Patients in rural communities often struggle to find rural communities with sufficient leave reliable and professionally trained caregivers to do the job.

The assisted living waiver provides an intermediate solution for patients that need more care than they can receive at home, but less care than nursing homes provide. An assisted living facility must receive authority from the Indiana family and social services administration to provide Medicaid-reimbursed assisted living care, and not all assisted living facilities have such authority. Therefore, it is necessary for a patient and the patient’s family members to consider an assisted living facility’s Medicaid certification before applying for admission for residency in the facility, or the patient may have experience a disruptive move to a Medicaid-certified assisted living facility.

State and federal budgets have limited alternative care innovation and development over the years. The A & D Waiver system was so understaffed and underfunded in past years that some patients’ families had to choose between waiting as much as a year for critical home health care assistance, and admitting their loved ones to nursing homes, where the patients could receive important care immediately, but lose the familiar comforts of home. Assisted living waivers have suffered similarly frustrating budgetary and administrative setbacks.

State and federal agencies are beginning to clear roadblocks and improve service delivery. In the fall 2016, an Indiana Family and Social Services Administration official informed lawyers at the Indiana Elder Law Institute that the agency is exploring ways to compensate non-certified caregivers, such as unemployed or underemployed family members, to provide the in-home supervisory care.

These promising developments offer future aged and disabled patients hope for more desirable health care alternatives, while saving millions of taxpayer dollars. Indiana elder law attorneys constantly monitor the Medicaid system to help aged and disabled patients and their families use their financial resources cost-effectively and access Medicaid assistance when necessary to obtain the best possible care.

Jeff R. Hawkins and Jennifer J. Hawkins are Trust & Estate Specialty Board Certified Indiana Trust & Estate Lawyers and active members of the Indiana State Bar Association and National Academy of Elder Law Attorneys. Both lawyers are admitted to practice law in Indiana, and Jeff Hawkins is admitted to practice law in Illinois. Jeff is also a registered civil mediator, a Fellow of the American College of Trust and Estate Counsel and the Indiana Bar Foundation;  a member of the Illinois State Bar Association and the Indiana Association of Mediators; and he was the 2014-15 President of the Indiana State Bar Association.

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