What is Medical Necessity

Medical Necessity


An applicant for nursing home Medicaid must demonstrate a “medical necessity” for long-term care. But what does “medical necessity” mean?

The State of Texas defines “medical necessity” as a medical condition that:

  • Is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person, and
  • Requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.

Additionally, the person must have a need for medical or nursing services that:

  • Are ordered by a physician,
  • Are dependent upon the individual's documented medical conditions
  • Require the skills of a registered or licensed vocational nurse,
  • Are provided either directly by or under the supervision of a licensed nurse in an institutional setting, and
  • Are required on a regular basis.

It is generally not enough that the person needs help with the activities of daily living, such as dressing, bathing, preparing meals, or toileting. Medicaid consider that to be “custodial care” only. To meet medical necessity the person must show they suffer from medical condition serious enough to require skilled care from a nurse on a regular basis in an institutionalized setting, such as a nursing home.

How is Medical Necessity Determined?


Typically, a nurse or other healthcare professional administers an initial assessment when the person enters the nursing home. This is called the “Minimum Data Set” or MDS and includes an evaluation of the person’s long-term care needs. The nursing home sends the MDS results to the Texas Medicaid and Health Partnership (“THMP”), the state claims administrator for Medicaid. THMP reviews the results and decides whether the person has a medical necessity.

Medical Necessity is a Mandatory Eligibility Requirement


To qualify for Medicaid the person must have an approved medical necessity and meet the program’s financial requirements. A person may be financially eligible for Medicaid but if they lack medical necessity they are ineligible for Medicaid.

Pre-Planning for Medicaid Eligibility


Often we will meet a family whose loved one requires daily custodial care, but their condition has not reached the point of medical necessity. A common example is someone who requires frequent hospital visits because of falls or other problems but they don’t yet need daily care by a nurse. That person does not meet medical necessity now, but likely will in the future.

But that doesn’t mean you should not consider Medicaid Planning. It’s never too early to being thinking about long-term care if you have an aging sibling or parent. Contact the Michels Law Firm to ask about Medicaid Eligibility Pre-Planning. We will develop a plan to meet Medicaid’s financial requirements in advance so they can file for Medicaid almost as soon as they enter the nursing home. Pre-Planning can save months of time and thousands of dollars in nursing home charges.