Medicaid Eligibility and the Importance of ADL’s – Activities of Daily Living

By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Medicaid Attorney

Medicaid eligibility for Medicaid often centers on the existence of ADL’s. ADL’s are known as “the Activities of Daily Living”. They are the most crucial link between the individual and Medicaid evaluation of that individual for eligibility. Regardless of the medical diagnosis of any condition (Alzheimer’s, Dementia, Parkinson’s, ALS, etc.), the effect of that condition requires that the individual either (1) need assistance with at least three (3) ADL’s every day of the calendar week and/or (2) be a safety risk to himself or herself because of the impact of the condition on his/her ability to perform their Activities of Daily Living independently and without constant cueing by another person present.
The word “assistance” seems straightforward but in actuality it is not because New Jersey Medicaid requires an applicant for institutional and home based caregiver to “need hands-on assistance” with such things as clothing, bathing, toileting, ambulatory, transferring, eating. Hands on assistance means that another individual must be present to physically put his or her hands on the individual in order to accomplish those tasks.

The process Medicaid has selected to validate the need with assistance of daily needs is a pre-admission screening (commonly known as a PAS). The state will send out a nurse or other medical professional to perform this assessment usually at the place of the residence or current facility placement of the applicant. Often your physician completes a PA-4 form which is essentially a preliminary screening tool signed attesting to the fact that the applicant requires a nursing facility or assisted living residence within the immediate future. If the PAS is denied, then notwithstanding financial eligibility, the application will be denied. Note, a denial triggers an immediate right to a Fair Hearing Appeal, as discussed elsewhere on this site.
The take away from this discussion is to alert you to make an objective assessment of your loved one’s ability to independently perform his or her ADL’s. It’s the first test in a series of tests to qualify for Medicaid.

To discuss your NJ Medicaid, Medicare and Elder Care matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing consultations if you are unable to come to our office.