Question: We thank you for your column about the illegality of nursing homes requiring family members to guarantee the bills of residents. Our family had a different experience: A little over three years ago, when our mother felt she could no longer care for our father at home, my brother and I helped her place him in a nursing facility. At that time, our parents owned their home and had nearly $100,000 in certificates of deposit. My father receives a modest pension plus Social Security; my mother, who has never worked outside the home, receives only Social Security. At the time of admission, when we asked what would happen if my folks ran out of money and could no longer pay for the $3,500 per month for his care, we were told that as soon as my parents were financially eligible, Medicaid would step in and pick up the tab.

When my folks had "spent down" to $2,000 and their home, we applied for Medicaid and learned for the first time that Dad did not meet the medical qualifications. Because they had no more money and because my brother and I were not in a position to guarantee the payments, the nursing home discharged my father. My mother -- now three years older -- is caring for him again, but this time he's much more feeble than he was three years ago. Isn't there a law against this? What can we do?

Answer: Unfortunately there is no law against this or the bad advice you received. As you learned the hard way, in order to Medicaid to pay for long-term care, a resident must meet both financial and medical requirements. In most states, the individual must meet not only general, categorical, and financial eligibility requirements, but also medical or psychobehavioral and functional requirements as determined by a rather complex screening process. Unfortunately, the determination of the "medical necessity" for Medicaid purposes is very important, but often overlooked. But your family got hit with a double whammy:

From a financial standpoint, your parents did not have to spend $100,000 to find out if your father would qualify for Medicaid. Depending on your state of residence, your father could have applied for Medicaid when he had resources of up to $2,000 and your mother, as the community spouse, had countable resources of up to $79,020. These figures do not include the home and some other assets which are exempt from consideration. In other words, if your father's Medicaid application had been made in a timely fashion, even if your father did not meet the medical level of care requirements, your folks would have known early enough to have been able to make other plans before all their money was spent.

To qualify for skilled care, a person must need at least one of a number of skilled services and have at least one of a number of functional deficits. To qualify for intermediate level of care, an individual can either (1) require at least one of four intermediate services and have one of a number of functional deficits; or (2) have at least two functional deficits.

What to do? Unfortunately, your parents have few options as all of their assets where expended unnecessarily on your father's care. We suggest that each individual who is considering entry into a skilled or intermediate nursing facility be thoroughly screened by a geriatric care manager or other expert who can evaluate that individual's medical, psychosocial, functional, environmental, support system and service needs. After this evaluation is made, a recommendation can be made about the most appropriate, least restrictive environment where care can be provided to meet the individual's assessed needs. Think about it: If your father did not meet "level of care" today, he almost certainly would not have met it three years ago -- meaning that a care manager could have helped place him in assisted living or another level of care which would have been much less expensive.

To meet a skilled level of care, a person must need at least one of a number of skilled services and have at least one of a number of functional deficits. To meet the intermediate level of care criteria, an individual can either (1) require at least one of four intermediate services and have one of a number of functional deficits; or (2) have at least two functional deficits.

Generally, a person must need at least one of the numbered skilled services (Items 1-11) and have at least one of the numbered functional deficits listed below to qualify for skilled level of care. A person needing item 12 by itself qualifies for skilled level of care because this represents a total care individual. These lists are a restatement of the criteria for and examples of skilled services set forth in 42 C.F.R.409-.32-.35 (1989). All skilled services are ordered by a physician, require the skills of a professional or technical personnel, and are furnished directly by or under the supervision of such personnel as required by 42 C.F.R.409.31 (1989).