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

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.  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 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 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. ) and, if optional, whether it 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 home- and community-based servicesLong-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 in the same state or for that same program in another state. In many states, the criteria for determining eligibility 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. 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 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 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 livingSkills 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 continence. 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, 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 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. .

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

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 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. ) programs should have eligibility criteria that appropriately measure the need 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. 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 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. needs caused by a wide range of chronic illnesses, conditions, and physical, cognitive, and other mental impairments.

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.

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. .

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 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. 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 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. ’ needs as appropriate.

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