Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Chapter 3. Determining Service Eligibility


In addition to categorical and financial eligibility criteria required by Federal Medicaid law, states set additional eligibility criteria to determine who in the large group that is financially eligible and entitled to benefits is eligible to receive specific services, such as nursing home, home health, or personal care. These criteria are based on need and can include an assessment of medical/nursing needs, health and health-related needs, functional limitations, and/or other factors. The goal of these eligibility criteria is twofold: to define medical necessity and to manage overall utilization. This chapter discusses Federal provisions for determining eligibility for four major Medicaid benefits: the mandatory Home Health benefit, the Personal Care benefit, home and community-based services (HCBS) waiver programs, and the State Plan HCBS option (under the Section [§]1915(i) authority). It also discusses factors for states to consider when setting these criteria.1

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