How do I get the insurance to approve more hours for care?

Who takes care of your mom while you work?

The way you get an increase is to have a case worker do an evaluation and determine changed needs. You've done that. If you disagree with the outcome you can file an appeal. The description of how to do that should be included in the results you are sent.

It is extremely important that the answers given during this evaluation be accurate. Case workers understand that recipients hate to admit they need help, but they are required to listen to their answers. So if Mom says "Yes, I can get my own lunch" the worker has to accept that. But you can remind Mom that she can take out a cold lunch that you have prepared for her. It is possible but the evaluater is not seeing the full range of services your mom needs. You should always be present during the evaluation interview.

Also, can her doctor order in-home PT?

Thank you for your response, my Mom has a caregiver that comes to my house to assist with her care. I was present during the last evaluation but my mother kept responding, I can do this and that. My mother made me looked like, I exaggerated the amount of care she needed. I will definitely ask the doctor, if an in home PT can be ordered.

bosfred, your mother kept responding and made you look like you were exaggerating her needs -- I can so appreciate that! But believe me, these workers are trained to expect the clients to exaggerate what they can do. They count on you to set the record straight.

Don't be embarrassed to speak up. Certainly don't exaggerate, but be sure the truth is heard. If Mom says "I do my own laundry" you can say, "yes, Mother it is really helpful that you put your dirty clothes in the hamper most of the time, so I can sort them and wash them. You also help me by folding towels."

These interviewers get no kick out of turning people down, but they have to be able to justify their recommendations. Be firm about that.

I think you might want to appeal on the grounds that your mother does not accurately represent her own needs.

And in-home PT is a very good idea!

Thank you. I appreciate y'all.

I'm interested to know how it might work in the States: if this lady were living on her own and had a clear wish to remain at home, what kind of support would be available to her then? Is it Medicaid policy to try to keep people living in their own homes for as long as possible, even if they don't live with family members?

So what happens to people who don't have any family? :(

CM, the federal/state/county boundaries here may be hard for a non-citizen to understand. Heck, it is hard for me to understand!

Medicaid is a federal program so it seems fair to ask what Medicaid's attitude is. But the program is administered by each state. There are certain hard-and-fast rules that all states must comply with, but there is also a fair amount of discretion in how each state sets up the program. The program is actually executed on the county level. And there, again, there is some discretion.

So it is really hard to say what "Medicaid's" attitude is. What county are you in? :)

If there is a bias throughout the system, I'd say that it is to look for cost-effective solutions. A person living with a family member may be able to get by with limited in-home care while the family member works or has respite. That is far, far less than paying for full time care in a facility. Medicaid likes that. A person living alone might need around-the-clock hired help. That is more expensive than a facility. Nope. Medicaid will opt for the care center. It is about cost. And, after all, the more costs can be contained the more people can be served. Not a bad motivator, really.

If you have some kind of chronic condition and you need help to stay in your home and you qualify for Medicaid (which is considered welfare, not an earned right), will they pay for a bath aide for you? Yup. Arrange for a meal to be delivered daily? Yup. Have someone clean your apartment weekly and do your laundry? Sure. But have 3 shifts of aides make sure you are never alone? Nope -- more cost-effective to do that in a facility.

My state, Minnesota, was ahead of the curve in pursuing solutions that make sense economically as well as humanely. It is a model for other states reforming their systems. The counties I have had loved ones in have done well by these people. The case workers have been uniformly trying to find good solutions for their clients. I don't think that is true in every county in the US.

Peek at a map again. This is a huge, huge country, and our traditions of "state's rights" along side federal rule complicates almost everything.

~~~

Here in Minnesota, we kept our mom in her apartment as long as we possibly could, even after the dementia started being apparent. Through the county and Medicaid we arranged to have meals delivered, a visiting nurse to try to keep her on her medications, housekeeping, laundry, and probably some other things I've forgotten. Eventually that was not enough. Mom moved in with my sister. That county provided incontinence supplies, all medicines, and an allowance for a certain number of in-home care hours each week. After 14 months it was no longer feasible to deal with Mom's deteriorating conditions in a private home. Mom is now in a nursing home. This is far, far more expensive that the other measures, but it could not be helped.

What if Mom did not have family to arrange things and advocate for her and supplement the country's aid? She would have been placed where she could get 24-hour help right from the beginning. That would have been far more expensive for the county for about 5 or 6 years longer than it was.

Minnesota counties have a bias to keep elders and others with chronic conditions in their homes or their family's homes as long as it is feasible and cost-effective.

Does that help, CM?

It does help, and it also makes sense, albeit in a sad sort of way. It's what we over here call a 'post code lottery' (post code = zip code, roughly). Services here are much more centrally controlled, of course, but all the same you do get wide variations in standards and priorities from one local authority/health trust to the next.

So how is Medicaid funded - where does it gets its money from? Is it partly through local taxation?

According to a government publication: "The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based on criteria such as per capita income."

In other words, it is complicated!

Criteria such as per capita income.

But certainly not voting intentions. No no no perish the thought.

I'm beginning to think the differences are merely ones of degree! Thank you for the quotation.

Seriously, CM, do a google search on size of uk vs us and look at at map of the UK superimposed on the US. We are HUGE. And we have 50 high-level governing units, each with a few dozen smaller divisions. It is complicated! :)

I do realise, Jeanne - only what's also notable is that while the population comparison (in millions) is 323:65, the land mass (in square kilometres) is 9857:244 - we are very squashed! Just out of interest I did chuck in Australia, as a token additional English speaking European culture, and they've got only 24 million people in 7,692 km2, which I call greedy. Though granted most of it is desert, vineyard and/or full of kangaroos.

I glumly discover that we also have 326 Local Authorities (who govern social care) and 470 NHS Trusts (health services of all sorts); and that's not including the actual, national civil service who are nominally in charge of the whole sorry mess.

And about 5 people per city putting elders to bed and helping them with their shopping, as far as I can tell. It all gets very dissatisfying!