Medical Eligibility is the cornerstone from which eligibility for ALTCS is based. If a person is not medically eligible then regardless of their compliance to the other consonants of eligibility the applicant will be denied benefits.
As a planner, Medical Eligibility is the one area I have little ability to directly impact. A person is going to medically qualify based on their diagnosis, care requirements and the ability to do their activities of daily living. It is possible for an individual to need custodial care because they are no longer able to live independently but this is not the level of care that ALTCS requires to be medically eligible. The standard that ALTCS requires is that the applicant is at risk of needing skilled nursing care. This does not mean that the individual has to be in a nursing home (see living arrangements).
How does the State make this determination? As with all things bureaucratic, they have a process and a form. The State conducts a Pre-Admission Screening (or PAS) to determine Medical Eligibility. The PAS has two parts. In the first part, the assessor goes out and interviews the potential applicant and asks a series of questions regarding the individual’s ability to perform his/her activities of daily living. This is oddly similar to the questions that are often used in the private sector to activate a long-term care policy. The answers are given a numeric score by the assessor and then are totaled. This part of the assessment is often called the “Functionality Portion” of the assessment.
The second portion of the PAS is Medical Conditions. A questionnaire is sent to the applicant’s primary care physician and any specialist to get a list of current diagnosis and medications that the individual is taking. The diagnosis tells the assessor what is going on and the medications and dosages tell them the severity. Many diagnoses garner points for this portion of the PAS.
The scores for both portions are added together with Sixty points (or more) passing the PAS.
We are able to help prepare our clients for the PAS interview and if necessary attend as well. Many find the interview questions invasive or “too personal”. We can offer a thorough review of the PAS so the individual or family members (in attendance) will not be surprised by the questions and can have formulated responses ahead of time.