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 specify 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 (e.g., institutional skilled-nursing care) or a state option (e.g., home- and community-based LTSS) and, if optional, whether it is offered under the Medicaid state plan or through a waiver program. (People who apply for home- and community-based services 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 in the same state or for that same program in another state. In many states, the criteria for determining eligibility for LTSS have a medical bias, such that medical and nursing needs are given more weight than the need for services to overcome or address functional limitations. The functional limitations and needs of people with cognitive impairments, in particular, are often not adequately measured and considered in determining eligibility. People of all ages may need LTSS because they have limited ability to perform a variety of physical or cognitive activities.
Difficulties in performing self-care are typically assessed using two scales that measure different types of impairments or needs. The first is the activity of daily living scale, which includes eating, transferring (e.g., from bed to chair), toileting, dressing, bathing, and continence. The second is the instrumental activity of daily living scale, which includes the ability to manage medications and personal finances, do housework and laundry, shop, and use a telephone and public transportation. But existing means of measuring cognitive and mental impairments have limited effectiveness for determining whether a person can function independently and for identifying individuals who need services. The need for supervision, for example, is critical in determining cognitive impairment and is an important eligibility criterion. More services are needed for people in need of supervision, which could also relieve some pressure from family caregivers.
There is a growing preference among people with disabilities to enhance self-empowerment and self-determination. They assume informed risks and make their own decisions about their care. Policymakers should recognize that the majority of services and supports that people with disabilities require are nonmedical in nature.
ENSURING APPROPRIATE ELIGIBILITY CRITERIA FOR LONG-TERM SERVICES AND SUPPORTS PROGRAMS: Policy
Accuracy of eligibility criteria for functional limitations
Federal and state long-term services and supports (LTSS) programs should have eligibility criteria that appropriately measure the need for LTSS with no bias toward medical rather than functional limitations. Individuals should not be required to have a medical/nursing need in order to qualify for services if their functional limitations are extensive.
Measures used in eligibility criteria must accurately assess the need for assistance among individuals with LTSS needs caused by a wide range of chronic illnesses, conditions, and physical, cognitive, and other mental impairments.
People should be eligible for LTSS on the basis of functional needs.
People with physical impairments should become eligible for some LTSS benefits if they have difficulty performing at least two of the five basic activities ofADLs or Activities of Daily Living are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. IADLs or Instrumental Activities of Daily Living are activities related to independent living and include preparing meals, managing money, shopping for… daily living.
Programs should include appropriate functional criteria, such as measures of cognitive and other mental impairments, as well as physical impairments.
Ensuring the use of uniform assessment instruments
States should develop uniform assessment instruments for use in all state LTSS programs. These instruments should include modules to address the unique needs of specific populations, for example, people with severe mental illness and developmental disabilities. The instrument should also assess family caregivers’ needs as appropriate.
Assessments should be valid and reliable, and core items should be uniform across populations.