What happens at the annual reassessment?

Why does a reassessment happen every year?

Because the waiver is an alternative to a nursing home, and eligibility for it has to be re-established rather than assumed. Once a year the case manager checks two things: that the member still needs a nursing-home level of care, and that the plan of care still describes what is actually happening in the house.

That is the administrative reason. The practical reason is better. Needs drift slowly, and families adapt without noticing. A daughter who has quietly taken over the medications, the bathing and the night-time bathroom trips over eighteen months often does not think to mention it. The reassessment is the moment that drift gets written down and, where the rules allow, resourced.

What gets reviewed

The reassessment covers more ground than most families expect.

• Function. How much help the person needs with bathing, dressing, moving around, using the bathroom, eating, and managing medications. This is scored with the DON-R, the standard Georgia assessment tool for level of care.
• The medical picture. Diagnoses, medications, recent hospital stays, treatments, and anything a clinician has changed since the last review. The DMA-6 is the medical form behind this.
• Supervision and safety. Memory, judgment, wandering, falls, whether the person is safe alone and for how long.
• The home. Steps, bathrooms, heating, whether equipment that was ordered is being used.
• The caregiver. Who is actually providing unpaid care, how much, and whether they are coping. A caregiver reaching the end of their capacity is a change in the member’s situation, not a separate issue.
• The services themselves. Whether each service in the plan is being delivered, whether it is the right amount, and whether anything in the plan is no longer being used.

The plan of care that comes out of it is approved by the member’s physician or by the case management agency’s medical director, under General Services §602.11.

What should we have ready?

Nothing has to be perfect, but a little preparation changes what the assessment can see.

• A current medication list, including anything started or stopped this year
• Discharge paperwork from any hospital or rehab stay
• Names of any new doctors or specialists
• A short, honest note of what has got harder since last year – falls, confusion, incontinence, refusals, night-time needs
• A note of what is not working in the current plan: visits that get missed, hours at the wrong time of day, a service nobody uses

Write the difficult parts down before the visit. In the room, with the member present, families routinely soften what they say, and the softened version is what gets recorded.

What if needs have grown?

Then the plan can be revised to reflect that. More hours of personal support, adding respite, adult day health, or a service that was not needed a year ago. Some of this happens at the review; some of it needs authorization before it can start, which takes time. Ask directly what has to be approved and by whom, so the wait is not a surprise.

What if needs have eased?

That is a real outcome too, and the plan should follow. A member who has recovered function may need fewer hours. A member who no longer meets the nursing-home level of care can lose waiver eligibility altogether.

If that happens, it is a decision that must be given in writing, and it can be appealed. Do not treat a reduction or a termination as settled because someone said it out loud. The written notice states the reason, the deadline and how to challenge it. The page on appeals and fair hearings explains how that process is structured.

Nothing on this page is a determination of eligibility. Only the assessment and Medicaid’s own review can decide that.