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

Three major groups are involved with eligibility determination: regional case managers, regional prior approval nurses, and agency nurse supervisors. The caseworker determines income eligibility and functional eligibility. Medicaid income eligibility in Texas is set at 74 % of poverty level for individuals.

The agency nurse does a detailed medical assessment, linking diagnosis and functional need. After all documentation is turned into the regional office, the regional Medicaid nurses review all documentation to determine that there is evidence of a medical need, and that the tasks authorized are within the program's definition of nonskilled services given the medical condition of the client. After the regional nurse gives prior approval, the agency has up to 7 days to begin service delivery.

A functional assessment tool is used to determine limitations with activities of daily living (ADLs), and the score is used as one of the eligibility screens. It consists of an inventory of twenty activities, which were chosen because they were the "best predictors of need for the community care the programs provide." The case manager rates the client from 0 (no functional impairment) to 3 (total functional impairment) on each activity. Assessment is based on what an individual can do at the point of waking - e.g. can the individual get him/herself out of bed and in position to be able to cook, rather than, can s/he cook once she is in position to be able to cook. State administrators consider the measures both objective and reliable.

The functional eligibility level was increased, from a low of 18 ADL points to the current 26, in order to contain program growth. State studies have shown that almost all those with a score of 26 need direct personal care as defined in the PHC program. The eligibility level has remained at 26 since 1986, because the program has convinced the legislature that raising the level above 26 would jeopardize peoples' health. Recipients must also need at least 6 hours of PAS per week to receive services.

B. Needs Assessment

While the initial needs assessment involves medical condition and functional ability, a detailed service plan takes into account other supports the individual may have in the household. If the caseworker thinks that adequate family supports are available, the applicant may be denied services. The service plan is developed with the caseworker and agency RN supervisors and the prior approval nurse determines that the service plan concurs with the assessment and recommendations of referring physician.

C. Case Management

Regional case managers have an average caseload of 140 Primary Home Care recipients. They are required to have a college degree and/or related work experience. They do initial intakes, needs assessment, and work with agencies to develop service plans. They are required to do at least one home visit every 6 months (although more visits frequently occur). Agency nurses often function as case-managers as well, because of their direct contact with the recipients and attendants.

D. Medical Supervision

The physician can authorize services for up to six months, but may authorize for shorter periods of time if s/he thinks that frequent medical visits are necessary. This requirement was considered excessively stringent by some nurse supervisors and case-managers for consumers with chronic but stable conditions.

The agency nurse supervisors are required to do home visits every 60 days, but often do visits more frequently. A detailed nursing assessment must be done every 6 months. Medicaid prior approval nurses each do an average of 50 home visits per quarter as part of their utilization review activities.

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