Long-Term Services and Supports Program Eligibility Criteria

Federal law and regulations specify the general eligibility and coverage requirements for mandatory and optional Medicaid long-term services and supports (LTSS). States use additional criteria to determine who, within the general eligibility group, will receive services. States use a number of different terms to describe these criteria: medical necessity criteria, health and functional criteria, level-of-care criteria, and service criteria. The degree of flexibility that states have in setting these criteria depends on whether the service is federally mandated—for example, institutional skilled-nursing care—or a state option such as home and community-based services (HCBS). It may also depend on whether a service is offered under the Medicaid State Plan or through a waiver program. People who apply for HCBS through a waiver program must meet the same level-of-care eligibility criteria as those who apply for nursing facility care.

Medicaid criteria vary among states and among LTSS programs within a state. People who would be eligible for services in one program may not be eligible for another program in the same state or for that same program in another state.

People of all ages may need LTSS because of functional limitations caused by a range of physical and mental impairments as well as by chronic health conditions. Most people with disabilities need non-medical LTSS. In many states, the criteria for determining LTSS eligibility have a medical bias. That means medical and nursing needs are given more weight than functional needs. The functional limitations and needs of people with cognitive impairments, in particular, are often not adequately measured and considered in determining eligibility.

Difficulties in performing self-care are typically assessed using two scales that measure different types of impairments. The first is the activity of daily living (ADL) scale, which includes eating, transferring (e.g., from bed to chair), toileting, dressing, bathing, and managing incontinence. The second is the instrumental activity of daily living scale. It includes the ability to manage medications and personal finances, do housework and laundry, shop, and use a telephone and public transportation.Many states have level-of-care criteria that do not include appropriate measures of functional limitations caused by cognitive impairment and behavioral problems. For example, the need for supervision to safely perform an ADL is an important eligibility criterion for people with cognitive impairment. But many states consider people who need such supervision to be less impaired than those who need physical assistance.