Will I Get Approved? (Or Why Didn’t I Get Approved?)

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If you are applying for a state home aide program, there are three criteria:

🎀 Your finances – Don’t be scared off by anyone who tells you that you must qualify for Medicaid. Even the people who work at the Medicaid office often do not always know and understand the rules for this program. It is not possible in all cases, but for many people, here’s How to Apply for a Medicaid Waiver When You Have Too Much Money

🎀 Your disability – In most states, you do not have to be approved for Social Security disability. They will have their own forms that can be used to determine if you are disabled. Some of our readers found that they were told incorrect information about this topic: Do I Need to Be On Disability to Get Medicaid Home Care?

🎀 Your care needs – You must have a certain level of care needs to qualify. Learn more below.

If you do not qualify for state home aide program, you may wish to see if there is anything else available in your area: Other Caregiver Programs.

How Does Someone Qualify?

To answer that question, first you have to know the difference between household care and personal care:

🎀 Household care is laundry, shopping, cooking, errands, and cleaning. These are sometimes called “Instrumental Activities of Daily Living” or IADLs.

🎀 Personal care is bathing, dressing, feeding, mobility, transferring, and toilet.  Sometimes medication management also counts as personal care. These are sometimes called “Activities of Daily Living” or ADLs.

Do I Need Personal Care?

Before answering that question too quickly, take a look here: 21 Questions To Ask Yourself About Personal Care

Will I Qualify? 

The rules are different in each state. In most programs:

🎀 Yes. You will qualify: You need help with household care plus you need personal care help in all areas (bathing, dressing, feeding, mobility, transferring, and toilet).

🎀 Maybe. You might qualify: You need household care plus you need personal care in some areas, but not all (for example, you can feed and dress yourself, but need assistance with mobility and bathing)

🎀 Maybe. You might qualify: You need household care plus you need personal care some of the time (for example, only on your bad days)

🎀 Maybe. You might qualify: You need household care plus you need partial personal care in some areas (for example, in the area of dressing, you can put on shirts and pants but need help for coats and shoes)

🎀 Maybe. You might qualify: In some states, you may qualify if you have significant mental health issues or cognitive impairments that mean you need to be supervised or reminded to do personal care activities. (For example, you will not bathe, eat, or dress unless someone reminds and supervises you).

🎀 No. You will not qualify: In most states, you will not qualify if you need only household care and never need any kind of personal care assistance. There are exceptions to this rule in California and New York, and some smaller local programs.

The Good Life in California

If you live in California you do not need to focus on everything on this page. California has a program called IHSS that does not require personal care and is much easier to qualify for. Some other areas have programs like this as well, but they are more rare and more limited.

The Point System

Some states will use a formula or a point system when deciding if you are approved and how many hours you receive. Example of point system in the category “dressing”:

🎀  Supervision 0-1 points – You will not change your clothes unless someone brings you clothes to your bed and/or reminds you to change your clothes. You need supervision, you may get one point or zero points, depending on the state.

🎀  Limited Assistance 1-2 points – You can get dressed yourself most of the way, but you have trouble bending, so you need someone to put on your shoes and socks. Or you use special compression stockings and you cannot get these on without help. You need limited assistance, you get one or two points.

🎀  Extensive assistance 3 points – You need help with all or most parts of dressing, including help that is physical or weight-bearing.  You need extensive assistance, you get three points.

🎀  Total Assistance 4 points – You cannot participate in dressing in any way. Someone must perform all parts of dressing for you. You need to total assistance, you get four points.

🎀  Bonus points – You may get more or less points depending on how often you need the help.

What Are The Rules to Qualify?

This will depend on your state. Most programs will look at these areas: bathing, dressing, feeding, mobility, transferring, and toilet.  Some states include other areas, such as bowel/bladder care and medication management also counts.

🎀 In some states you can only qualify if you need help and at least five areas.

🎀 In other states you can qualify if you need help in just two areas.

🎀 In some states, if you have a significant cognitive or mental impairments (for example dementia or developmental disabilities or severe cognitive problems) you may be able to qualify even if you only need supervision or assistance in one area.

Frequency of Care

Some states base their decision based on the number of times per week you need assistance in each area. For example: If you need assistance with dressing 4 or more times per week.

Weight Bearing Assistance

Some states make a distinction between weight bearing assistance and non-weight bearing. For example, if your aide assists you in putting on your sweater, do they need to help physically support your weight while doing this?

The Past Seven Days

Some states look at the amount of care you received or needed in the past seven days.

For example: If someone assisted you with bathing in the last seven days.

Another example: If you were unable to bathe in the past seven days because you had no one to assist you.

Institutional Care Needs

Most states will ask your doctor to complete a form. This form will often have a question asking if you need an “institutional level of care” or “nursing home level of care.” The doctor must check yes to this question, or your entire application will be automatically disqualified.

It’s a really good idea to meet with your doctor and discuss this form. Some doctors are afraid to check yes to this question, because they are worried their patient will be forced into an institution. If this happens, you can explain to your doctor that the program you are applying for is designed to keep people out of institutions, checking yes to this will not place you in an institution, it will provide you with home care so you can stay in your home.

After You Are Approved

After you are approved, most programs will provide you with assistance in the areas of shopping, cooking, and cleaning. However, you cannot bet approved based on these needs.

Sample Policies

Each state has different rules about how many personal care areas are required to get approved. If you feel unsure, you can ask the person doing the assessment how many “activities of daily living” are required to qualify. Here’s a few Sample Policies for Washington, Virginia, Oregon, Florida, Nebraska, Michigan, and Colorado

Here’s three examples of people who qualified in Washington state and how many hours they received:

🎀  A person with significant mobility limitations and severe mental limitations needing help with taking medications, sometimes bathing, extensive meal prep and being handed food and drinks gets 67 hours per month.

🎀 An almost totally paralyzed person needing full dressing, bed and toilet transfers gets 360 hours per month

🎀 A person with cognitive impairments needing medication, bathing, and dressing reminders, shower supervision, and a steadying hand to walk when dizzy gets 40 hours per month.

Cognitive Problems

Many states have different rules for people with significant cognitive impairments (trouble remembering, concentrating or focusing). For example:

🎀 If you do not have significant cognitive impairments, Virginia requires 5 personal care areas.

🎀 If you do have significant cognitive impairments, Virginia requires 2-4 personal care areas.

🎀 If you do not have significant cognitive impairments, Washington state requires 2-3 personal care areas.

🎀 If you do have significant cognitive impairments, Washington state requires only 1.

Cognitive impairments may include developmental disabilities, traumatic brain injuries, serious mental illness, and memory/focus/concentration problems caused by illnesses such as ME, Lyme, and MCS, if they are severe enough to cause problems with orientation, safety, and basic functioning.

Exception to Personal Care Rules

Some states offer programs for people do not need any personal care. These programs will usually offer less hours and less services, and may not allow you to select your own aide. Programs have been cut in many states, but still exists in a few places. For example, here’s  a few programs in MassachusettsCalifornia, and New York. If you know of programs in other states, please comment below and let us know.

Contact your local Area Agency on Aging to ask about your area. Also check this page for other home aide programs that may be able to help with household chores: How to Get a Caregiver. Unfortunately, not available in many areas.

What are the Rules?

The criteria is different in different states. Usually, you will need to require help in a certain number of personal care areas.

If you do not know the rules in your state, you may be able to find them online. Or you may be able to ask the person who is doing your assessment: “Can you please tell me what the criteria is for someone to get approved for this program?” or “Can you please tell me where I can find the written policy for this?”

Make sure you are are talking directly to the person who handles screening for Medicaid Home Care programs. Many people who work at Medicaid or other agencies will not know the answer to this, and may give you incorrect information.

Learn more

The Sleepy Girl Guide to State Home Aides