Ensuring Appropriate Eligibility Criteria for Long-Term Services and Supports Programs

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.