Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Major Considerations in Setting Service Criteria: A Recap


Federal policies with respect to service criteria establish a framework within which states have wide latitude to select service criteria that best suit their unique long-term care service system. Three considerations, in particular, should guide state choices in setting their service criteria:

  • Service criteria should be developed with an eye toward the full constellation of services and supports a state offers--both through the Medicaid program and with other state and local resources. In other words, criteria should not be crafted for specific programs without considering the criteria for other long-term care service programs in the state. The criteria should fit together so that all individuals needing long-term care services in the state are able to obtain the services and supports that will meet their needs.

  • It is important to recognize that there is a constant tug-and-pull among state policy aims. On the one hand, states desire to make services and supports broadly available. On the other hand, states must manage their budgets. States, for example, may sometimes impose stringent service criteria for cost containment reasons, which then undermines their ability to promote appropriate access. Careful management of different components of the benefit package and establishment of an efficient service delivery system can help a state to work its way between these potentially conflicting objectives.

  • Concern that using less stringent criteria (with respect to the institutional/waiver eligibility linkage) will result in higher demand for--and expenditures on--institutional services, seems to be misplaced.

Experience confirms that most individuals want to remain in their homes and in the community. Their ability to do so is strengthened through the provision of home and community services.

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