Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Ensuring Correct Application of Eligibility Criteria

10/29/2010

States contracting with private managed care organizations to provide the Medicaid Home Health benefit must specify in their managed care contracts who will determine eligibility for the benefit and whatservice criteria will be used. Clear and precise terms are crucial. Eligibility criteria that are framed in very general terms--medical necessity, for example--can be interpreted very differently in a managed health care plan that customarily provides primary and acute health care benefits but not long-term care services.

Home health services can be provided as acute, post-acute, and/or long-term care services. If a state has an HCBS waiver program administered, for example, by an Area Agency on Aging, but the state’s capitated health programs control the Home Health benefit, the two systems will need to collaborate to ensure that individuals entitled to and eligible for home health services receive them.

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