Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Endnotes: Citations, Additional Information, and Web Addresses

10/29/2010

  1. Janet O’Keeffe and Gary Smith co-authored the original chapter. Janet O’Keeffe updated the chapter.

  2. States may make provision for “outliers”--those individuals whose condition responds less well than expected for their condition, and who, as a consequence, may receive more services for a longer period.

  3. The ADL and IADL scales are based on a developmental model: children learn to eat, toilet, bathe, and dress themselves before they develop the mental ability to do more cognitively complex activities such as using the telephone and managing money. When cognitive abilities start to deteriorate (as in a person who develops dementia) the ability to perform activities that require more complex mental functioning (IADLs) is generally lost before the ability to perform ADLs. States are not bound by the definitions implied by this developmental model; they can, for example, define ADLs to include whatever tasks/activities they consider important to determine a need for long-term care.

  4. People who work with individuals who have cognitive impairments or behavior issues need specialized training.

  5. Section 1902(a)(10)(d) of the Social Security Act.

  6. 42 CFR 440.230(c) and 42 CFR 440.240.

  7. State Medicaid Director Letter, July 25, 2000. Available at http://www.cms.hhs.gov/smdl/downloads/smd072500b.pdf.

  8. The frequency of further physician review of a beneficiary’s continuing need for medical equipment and supplies is determined on a case-by-case basis, based on the nature of the item prescribed.

  9. Skubel v. Fuoroli. (No. 96-6201). United States Court of Appeals, Second Circuit. Decided May 13, 1997. Ruling available at http://openjurist.org/113/f3d/330 .

  10. 42 U.S.C. §1396d(a)(7). When Medicaid was first enacted in 1965, coverage of home health services was optional. In 1970, Congress made coverage of home health services mandatory for individuals entitled to skilled nursing facility services under a State Plan.

  11. While CMS has not issued formal guidance on allowing states to provide home health services outside an individual’s home, CMS hassupported and will continue to support such flexibility when analyzing State Plan amendments related to the Home Health benefit.

  12. These examples are drawn from Colorado’s eligibility criteria for the Home Health benefit in the year 2000. At the time of publication, it was not possible to determine if the State still uses these criteria.

  13. State Medicaid Manual, Part 4--Services, §4480.

  14. Ibid.

  15. Kassner, E., and Jackson, B. (1998). Determining Comparable Levels of Functional Disability. Washington, DC: AARP, Public Policy Institute. Spector, W.D., and J.A. Fleishman (1998). Combining activities of daily living with instrumental activities of daily living to measure functional disability. Journal of Gerontology. 53(B):S46-S57.

  16. At §1902(a)(10)(B) of the Social Security Act.

  17. Zaharia, R., and Moseley, C. (2008). State Strategies for Determining Eligibility and Level-of-Care for ICF/MR and Waiver Program Participants. New Brunswick, NJ: Rutgers Center for State Health Policy. Available at http://www.hcbs.org/moreInfo.php/doc/2305;Hendrickson, L., and Kyzr-Sheeley, G. (2008). Determining Medicaid Nursing Home Eligibility: A Survey of State Level of Care Assessment. New Brunswick, NJ: Rutgers Center for State Health Policy. Available at http://www.hcbs.org/moreInfo.php/doc/2216.

  18. Eligibility for ICF/ID services is limited to persons with intellectual disabilities or related conditions (42 CFR 435.1010; 42 CFR 440.150). Eligibility for home and community-based services furnished under §1915(c) or §1915(b)(c) “managed care” Medicaid waivers is directly linked to the ICF/ID level of care. For both ICFs/ID and HCBS waiver programs, states must determine during the level-of-care evaluation process that potential service recipients (a) have a diagnosis of an intellectual disability or a related condition (42 CFR 435.1010; 42 CFR 441.302), and (b) require the level of services provided by an ICF/ID. Intellectual disability (and the former term “mental retardation”) are not specifically defined; related conditions are defined functionally. (States have generally interpreted the term “related condition” to mean developmental disabilities other than an intellectual disability. Ernest McKenney, personal communication, December 8, 2009.)

    Eligibility for home and community-based services under the waiver program is extended to individuals who, “but for the provision of waiver services,” would otherwise require the level of support and assistance furnished by an ICF/ID program (42 CFR 442.302(c)(1)). States are required to use level-of-care evaluation instruments or processes for waivers that yield equivalent outcomes to those used for the ICF/ID program. After a person is admitted to the waiver program, states are required to certify at least annually that he or she continues to need the “level of care provided” (42 CFR 441.302 (c)(2)), during an annual level-of-care determination process.” Unless noted otherwise, text above is taken verbatim from Zaharia, R., and Moseley, C. (2008), op. cit.

  19. States may use different evaluation instruments and processes for determining eligibility for waiver services than for institutional placement as long as they can explain in their waiver application how and why they differ and also provide assurances that the outcome of a different assessment instrument or process is “reliable, valid, and fully comparable to the outcome for institutional evaluation. In particular, the state must be able to demonstrate that individuals who meet level of care via the application of the waiver instrument also would meet level of care when the institutional instrument is employed.” Appendix B: Participant Access and Eligibility, Item B-6-e in Application for a §1915(c) Home and Community-Based Waiver, [Version 3.5], Instructions, Technical Guide and Review Criteria. See the Resources section of this chapter for the web link.

  20. 42 U.S.C. 15002 Sec. 102.

  21. The term ‘‘developmental disability’’ means a severe, chronic disability of an individual that (i) is attributable to a mental or physical impairment or combination of mental and physical impairments, (ii) is manifested before the individual attains age 22, (iii) is likely to continue indefinitely, and (iv) results in substantial functional limitations in three or more of the following areas of major life activity: (I) self-care; (II) receptive and expressive language; (III) learning; (IV) mobility; (V) self-direction; (VI) capacity for independent living; (VII) economic self-sufficiency; and (VIII) reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of life-long or extended duration and are individually planned and coordinated (42 U.S.C. 15002 Sec. 102). Note, this definition is more expansive than the regulatory definition of a “related condition” at 42 CFR 435.1010. The text that this endnote references, and the endnote itself, are taken verbatim from Zaharia, R., and Moseley, C. (2008), op. cit.

  22. Maryland Dept. of Health and Mental Hygiene v. Brown, 177 Md. App. 440, 935 A.2d 1128 (2007), affirmed and opinion adopted, 406 Md. 466, 959 A.2d 807 (2008).

  23. States should not use an MMSE score as an eligibility criterion because the MMSE and similar mental status tests were not designed to determine whether or to what extent an individual needs long-term care services. These tests were developed as clinical screening tools to determine whether more in-depth assessment is needed to make a diagnosis of dementia. Most importantly, as the Advisory Panel on Alzheimer’s Disease has noted, these tests are not correlated with the specific functional limitations or service needs of people with dementia. O’Keeffe, J., Tilly, J., and Lucas, C. (May 2006). Medicaid Eligibility Criteria for Long-Term Care Services: Access for People with Alzheimer’s Disease and Other Dementias. Washington, DC: Alzheimer’s Association. Additionally, the MMSE is insensitive to the functional limitations common in certain types of dementia. Many individuals with dementia who have extensive functional limitations will never reach the score specified in this eligibility criterion. Donald Royall, M.D., Professor and Chief, Division of Aging and Geriatric Psychiatry, University of Texas Health Science Center at San Antonio. Personal communication, June 28, 2010.

  24. Maryland Department of Health and Mental Hygiene (July 1, 2008). Maryland Medical Assistance Program. Nursing Home Transmittal No. 213. Available at: http://www.msba.org/sec_comm/sections/elder/docs/ nursinghometransmittal213.pdf .

  25. Section 1919(a)(1) of the Social Security Act.

  26. O’Keeffe, J. (1996). Determining the Need for Long-Term Care Services: An Analysis of Health and Functional Eligibility Criteria in Medicaid Home and Community-Based Waiver Programs. Pub. #9617, Washington, DC: AARP, Public Policy Institute.

  27. For reimbursement purposes, many states distinguish between those who need a skilled level of care and those who need lower levels of care; others use case mix reimbursement. The need for medical and skilled nursing services is always assessed when determining if a person needs a skilled or high level of care. It is when assessing applicants for ICF or minimal levels of care that states differ widely in the measures they use--some using functional measures only, some nursing measures only, and most a combination of both. O’Keeffe, J. (1996). Determining the Need for Long-Term Care Services: An Analysis of Health and Functional Eligibility Criteria in Medicaid Home and Community-Based Waiver Programs. Washington, DC: AARP, Public Policy Institute.

  28. Application for a §1915(c) Home and Community-Based Waiver, [Version 3.5], Instructions, Technical Guide and Review Criteria. Glossary, p. 304. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  29. Most of the people interviewed in this study were able to remain in the community because they had extensive informal care supplemented by small amounts of privately paid care. O’Keeffe, J., Long, S.K., Liu, K., and Kerr, M. (1999). How do They Manage? A Case Study of Elderly Persons Functionally Eligible for Medicaid Waiver Services but Not Receiving Them. Washington, DC: AARP, Public Policy Institute.

  30. In a study of 42 states’ nursing facility level-of-care criteria, respondents in states that used less stringent criteria said that most beneficiaries with lower levels of need could be safely served in the community. O’Keeffe, J. (1996). Determining the Need for Long-Term Care Services: An Analysis of Health and Functional Eligibility Criteria in Medicaid Home and Community-Based Waiver Programs. Washington, DC: AARP, Public Policy Institute.

  31. P.L. 109–171. §6086(a).

  32. The lack of functional criteria is more likely to be an issue for ICF/MR level-of-care criteria (which in some states is largely determined by diagnosis) than for nursing facility level-of-care criteria.

  33. State Medicaid Director Letter, August 6, 2010. Available at http://www.cms.gov/smdl/downloads/SMD10015.pdf.

  34. Section 2401 of the Affordable Care Act, amending §1915 of the Social Security Act.


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