Medical Necessity

Anyone who applies for Nursing Home Medicaid benefits has to meet the medical necessity test.  While the statistical chances of it happening are slim, the law is designed to prevent someone from just deciding to move into a nursing home and live off of the government for the rest of their life.  Thus, all applicants must meet medical necessity.

According to the State of Texas Medicaid Eligibility Handbook, “Medical necessity (MN) [ means ] The determination that a person requires the services of a licensed nurse in an institutional setting to carry out a physician’s planned regimen for total care.”  What this doesn’t say is at least as important as what it does say.

It does not say that a physician’s statement is enough to meet the test.  The test is functional, not diagnostic.  There are many people whose families believe that they really do need care, who do not need a “nurse” daily.

On the other hand, since only nurses can dispense certain types of medications or provide certain types of physical support, there are many people who seem to be quite well, and simply aged, that do meet this test.

The best way to find out if someone will qualify under the medical necessity test, other than simply winding up in Skilled Nursing and being told so, is to engage a Geriatric Care Manager.  These professionals focus their efforts on helping people to understand their loved ones abilities and needs and make good decisions.

This article is written by an attorney at Attorney Donald Wyatt PC. Always consult an attorney before making any legal decisions. To make an appointment today for a free consultation, please click here to contact us.