Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. III. Gatekeeping and Supervision Functions: Eligibility, Needs Assessment, Case-Management, Medical Supervision


A. Eligibility Determination

Income eligibility for Medicaid is determined by the state. Current Medicaid income eligibility is set at 74% of poverty level. Nurse Case Monitors are responsible for determining medical eligibility. Eligibility is based on functional limitations with activities of daily living (ADLs), and there is an appeal procedure for individuals who are denied eligibility. There is no formal scoring system: functional eligibility is based on professional discretion. The assessment is sent to the applicant's doctor to see if s/he concurs with the case monitor that PAS would be appropriate for the applicant. The doctor must have seen the applicant within the past 6 months.

State administrators suggest that because there is no reimbursement for doing eligibility assessments unless the client is deemed eligible, there may be a tendency to allow people into the program who have a relatively low degree of functional limitation. The lack of explicit medical eligibility criteria was indicated by the state as one reason for the program caseload growth which has occurred.

B. Needs Assessment

During the eligibility determination, the nurse case monitor assigns a level of need: some daily ADL needs (level I), extensive ADL needs (level II), and ADL needs at all times (level III). A fourth level has been developed for people with AIDS who need very high levels of skilled care (i.e. home health aides), but this has not been implemented as yet. Advocates point out that the levels of service are clearly inadequate, especially for clients with a high degree of functional limitation. The state seems to concur, and is considering eliminating level I entirely, in order to cut costs and provide more resources for level II and III consumers.

C. Case Management

Nurse case monitors are required to visit recipients every 60 days. During this visit, they review the plan of care, assess the need for service, and monitor the attendant.

In 10-12 counties, the local health department hires nurses on a contract basis, but in most counties several independent nurses compete for clients. Some nurses have become entrepreneurs, forming agencies and maintaining a staff of nurse case monitors. They each may have case loads of up to 50 people, and are reimbursed $40 per month per active case. There are clear financial incentives for keeping caseloads near this level, and this is also identified by state administrators as a factor in program growth.

D. Medical Supervision

A physician must authorize services annually. The nurse case monitors check the medical condition of consumers during their review of the consumer's plan of care every 60 days.

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