Care in an Institution

The Medicaid program offers a broad set of services for those who have special health care needs. Sometimes, the best solution for a person with a severe disability or medically unstable condition is care in an instution such as a nursing home or an intermediate care facility for people with mental retardation and/or developmental disabilities. Currently, the Ohio Medicaid program pays for approximately 70 percent of the nursing home costs in the state of Ohio.

Application Process

When applying for institutional care through Medicaid, applicants will need to show proof of income, resources, disability, citizenship (if not a U.S. citizen) and other health insurance. Individuals must also meet Transfer of Resources provisions. Once it is determined that financial requirements are met, a level of care assessment will be conducted to identify the appropriate type of long-term care Medicaid will provide.

Once the care needs of the individual are determined, an additional computation is completed to establish how much of their income will be applied to the cost of care in the institution. This is called the Patient Liability.

How this will affect the family members

If an individual is in need of care in an institution has a spouse or dependent family members, it is possible that some of that person’s income and assets can be kept to support those who remain at home. This is called Spousal Impoverishment and was established as a provision in the Medicare Catastrophic Coverage Act (MCCA) of 1988. Its purpose is to protect the community spouse from becoming “impoverished”.

How it works

A resource assessment is conducted to determine the amount that will be given to the spouse and dependents at home. In Ohio, the maximum amount a spouse or dependent family member can keep is $99,540. and the minimum is $19,908. In addition, the spousal impoverishment law also allows one year for the institutionalized spouse to transfer assets to the community spouse. From here, the patient liability is determined.

Ohio Home Care is Medicaid’s integrated program of home care services, consisting of four benefit packages: Core, Core Plus, Ohio Home Care Waiver, and Transitions Waiver. All four packages include “core” services of nursing, daily living, and skilled therapies. Skilled therapies include physical and occupational therapy and the services of a speech/language pathologist.

• The Core Benefit Package is designed to meet the basic home care needs of most consumers who require up to 14 hours of nursing and/or daily living services per week.
• The Ohio Home Care Waiver Benefit Package is designed to meet the home care needs of consumers whose medical condition and/or functional abilities would qualify them for Medicaid coverage in a nursing home or hospital. In addition to the core services of nursing, daily living, and skilled therapies, waiver services included:
  1. Home-delivered meals
  2. Emergency response systems
  3. Home modifications
  4. Supplemental Adaptive/assistive devices
  5. Adult day health services
  6. Out of home respite
  7. Supplemental transportation
  8. Nutrition/social work counseling
  9. Care coordination
• The Transitions Waiver Benefit Package provides the identical services, providers, and administration as the Ohio Home Care Waiver benefit package but serves consumers who were transferred from the Individual Options Waiver because they were identified as having ICF-MR level of care.

Home care case management, a service incorporating case management, overall care coordination, and data collection for the determination of program eligibility and cost range assignments, is provided to consumers enrolled in the Ohio Home Care Waiver, and Transitions Waiver benefit packages by our contracted case management agency, Care Star.

Consumers and families are viewed as members of a team responsible for the consumer’s care and are involved in every point in the service planning development and delivery. Several consumer options allow consumers to have flexibility in directing their care and selecting providers.

ODJFS monitors compliance with the requirements for the Ohio Home Care Program through a comprehensive quality assurance program. ODJFS monitoring activities include outcome-based consumer interviews, consumer satisfaction surveys, contractor and provider site visits, and review of consumer, contractor, and provider records.