The assessments that decide your care — and your bill
Two different assessments stand between a family and care in the US: the community's, which sets the price, and the state's, which decides whether Medicaid pays. What each looks at, and how to prepare.
4 minute read
Families expect one assessment. There are two, they are run by different people for different reasons, and confusing them causes real problems.
The community's assessment decides whether they will take your parent and what they will charge.
The state's assessment decides whether Medicaid will pay.
The community's assessment
Before anyone moves in, a nurse from the community assesses your parent — usually in person, at home or in the hospital, sometimes over video.
What they look at. The activities of daily living: bathing, dressing, toileting, transferring between bed and chair, continence, eating. Then medication — how many, how often, whether injections are needed. Then cognition: memory, judgment, wandering, behavior at difficult times of day. Then mobility, falls, and medical needs like oxygen, wound care or dialysis.
What it produces. Two things. Whether they can accept your parent at all — each state licenses what an assisted living community may do, and the limits are real. And a care level, which is a surcharge on top of the base rate. The care level, not the base rate, is the number that moves.
How to prepare. Be accurate, and specifically do not minimize. Families routinely present a better version of their parent, out of loyalty or because they are afraid of a refusal. It backfires twice: the community sets a care level too low and revises it upward within weeks, and staff plan around needs your parent does not actually have.
Bring: the full medication list with doses, recent hospital discharge papers, the physician's contact, a note of falls in the last year, and an honest account of a bad day. Write down what you would find hard to say out loud — incontinence, aggression, the night-time wandering. The assessor has heard all of it.
Ask what tier they are placing your parent in and what that costs, before you sign anything. And ask what would move them to the next tier.
The state's assessment, for Medicaid
If Medicaid is going to pay — for a nursing home, or for assisted living through a waiver — your parent must clear two separate tests, and both have to pass.
The functional test: do they need this level of care? A state assessor evaluates need, usually against the same activities of daily living, plus cognition and medical needs. States set their own threshold, and it is generally higher for nursing home level of care than for a community waiver.
The financial test: income and assets. Strict limits, set by the state, on countable assets and often on income. Some things are usually excluded — a home within an equity limit while a spouse lives there, one vehicle, personal effects — and the detail differs everywhere.
The look-back. States review asset transfers over a period before the application, and gifts made within it can create a penalty period during which Medicaid will not pay. This includes ordinary generosity — helping a grandchild with tuition, signing the house over to a child. Talk to an elder law attorney before moving any money or property, not after. This is the most expensive mistake in the field.
Spousal protections exist. Rules prevent a healthy spouse from being impoverished by the other's care, allowing them to keep a share of assets and income. The amounts are set annually and differ by state.
How the two fit together
The order that usually works:
- Get a clear picture of need, from your parent's physician. Which level of care that points to determines everything downstream.
- If Medicaid is likely, start early. Applications take time, waiver programs have waiting lists, and the look-back rewards planning. Your Area Agency on Aging will tell you what your state offers and is free.
- Then have communities assess. Ask up front whether they accept Medicaid, and for which apartments — many accept it only after a period of private payment, and some not at all. A community that does not means a second move when the money runs out.
If you disagree with the result
A community's assessment is theirs to make, but the care level is negotiable in the sense that you can ask exactly what drove it and present evidence. If you think it is inflated, ask for the breakdown.
A state Medicaid decision can be appealed, and there are deadlines — usually short, stated in the denial letter. Denials are sometimes reversed on appeal, particularly where documentation was incomplete. An elder law attorney or your state's legal aid for older adults can help, and the long-term care ombudsman will point you to the right one.
The honest summary
The community's assessment is about what they will charge you. The state's is about whether anyone else will pay. Prepare thoroughly for the first, start the second earlier than feels necessary, and get legal advice before you move any assets.
This describes how these assessments are generally structured. Medicaid is administered state by state under different names and rules, and the income limits, asset limits and look-back period change — confirm anything you are relying on with your state Medicaid agency, your Area Agency on Aging, or an elder law attorney.