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 various terms to describe these criteria: medical necessity criteria, health and functional criteria, level-of-care criteria, and service criteria. The degree of flexibility 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 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 or chronic health conditions. Many 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. In particular, the functional limitations and needs of people with cognitive impairments are often not adequately measured and considered in determining eligibility. 

Difficulties in performing self-care are typically assessed using two scales that measure different 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 less impaired than those who need physical assistance. 



Accuracy and appropriateness in long-term services and supports (LTSS) eligibility criteria and assessment

People should be eligible for LTSS on the basis of functional needs. 

Eligibility criteria for federal and state LTSS programs should not prioritize medical needs over functional limitations. Individuals should not be required to have a medical/nursing need in order to qualify for services if they have extensive functional limitations. 

Measures used to determine eligibility must accurately assess the need for assistance among individuals with functional limitations caused by a wide range of chronic illnesses, conditions, and physical, cognitive, and other mental impairments. Assessments should focus on the individual’s current care needs and potential to live in the community with appropriate LTSS. 

When determining eligibility for individuals with cognitive impairments and behavioral problems, programs should use appropriate functional measures—including the need for supervision. 

When a care plan includes or involves a family caregiver, the family caregiver’s needs and preferences should also be assessed and addressed. The availability of a family caregiver or caregivers to assist an individual who qualifies for public long-term services and supports should not be used to deny or limit the services that would otherwise be authorized (see also this chapter’s section on Support for Family Caregivers). 

People with physical impairments should become eligible for some LTSS benefits if they have difficulty performing at least two of the five basic activities of daily living. 

Uniform assessment instruments

States should develop a comprehensive uniform assessment instrument to determine individual needs and develop a service plan. It should be used in all state LTSS programs. 

Assessment instruments should be valid and reliable, and core items should be uniform across populations. Assessment instruments should be validated regularly to ensure they do not create or perpetuate existing LTSS disparities. This is particularly important for those groups that have been historically discriminated against. 

They should include modules to address the unique needs of specific populations, for example, people with severe mental illness and those with developmental disabilities. 

The federal government should assist states in developing uniform eligibility criteria, assessment and data collection instruments, quality control standards, and outcome measures.