Long-Term Services and Supports Program Eligibility Criteria

Background

Federal law and regulations specify the general eligibility and coverage requirements for mandatory and optional MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ( LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ). 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 ( HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. ). It may also depend on whether a service is offered under the MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. State Plan or through a waiver program. People who apply for HCBSLong-term services and supports provided in individuals’ homes or in community settings, including adult day services, assisted living and other residential care settings. through a waiver program must meet the same level-of-care eligibility criteria as those who apply for nursing facility care.

MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. criteria vary among states and among LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. 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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. 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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. . In many states, the criteria for determining LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. 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 livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. ( ADLActivities of Daily Living (ADL) are the skills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. ) 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 livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. 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 ADLActivities of Daily Living (ADL) are the skills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. 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.

LONG-TERM SERVICES AND SUPPORTS PROGRAM ELIGIBILITY CRITERIA: Policy

LONG-TERM SERVICES AND SUPPORTS PROGRAM ELIGIBILITY CRITERIA: Policy

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

People should be eligible for LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. on the basis of functional needs.

Eligibility criteria for federal and state LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. 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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

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 People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. , the family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. ’s needs and preferences should also be assessed and addressed (see also Support for Family Caregivers).

People with physical impairments should become eligible for some LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. benefits if they have difficulty performing at least two of the five basic activities of daily livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. .

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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. programs.

Assessment instruments should be valid and reliable, and core items should be uniform across populations. 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.