Personal care services provided through the State Plan are an optional benefit. When personal care services were first authorized in the mid-1970s, they had to be prescribed by a physician in accordance with a treatment plan. In 1993, Congress removed the requirement for physician authorization and gave states the option to use other methods to authorize the benefit in accordance with a state-approved service plan. There are no other Federal statutory or regulatory requirements regarding eligibility for services. Within the broad parameters of the Federal definition of personal care services, states are free to determine service criteria as well as the amount, scope, and duration of the services.
The State Medicaid Manual definition of personal care services provides the primary guidance for establishing these criteria:
Personal care services . . . may include a range of human assistance provided to persons with disabilities and chronic conditions of all ages, which enables them to accomplish tasks they would normally do for themselves if they did not have a disability. Assistance may be in the form of hands-on assistance (actually performing a personal care task for a person) or cueing so that the person performs the task by him/herself. Such assistance most often relates to performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).13
The Manual also states that people with cognitive impairments can be offered services through the Personal Care option:
An individual may be physically capable of performing ADLs and IADLs but may have limitations in performing these activities because of a cognitive impairment. Personal care services may be required because a cognitive impairment prevents an individual from knowing when or how to carry out the task. For example, an individual may no longer be able to dress without someone to cue him or her on how to do so. In such cases, personal assistance may include cueing along with supervision to ensure that the individual performs the task properly.14
Given the Federal Medicaid definition of personal assistance, service criteria should be based on a need for assistance with ADLs or with IADLs. There is a considerable body of research on ADLs and IADLs to guide states in designing their service criteria. Generally, ADLs are more frequently used than IADLs to determine service eligibility, because they are widely believed to measure a greater level of need. But research indicates that dependencies in multiple IADLs also indicate a high level of need (e.g., the inability to use the telephone actually indicates a very high level of impairment).15 Limitations in performing other IADLs, such as meal preparation and medication management, may actually pose a greater health risk than an ADL limitation in bathing and dressing. A number of states use both ADLs and IADLs in their service criteria.
An important consideration when selecting service criteria is that the level of impairment a state requires for eligibility matches the services available. For example, if a state requires applicants to be severely impaired, the maximum number of service hours permitted should be sufficient to enable them to remain in the community. It is also important to ensure that assessment methodologies do not inadvertently exclude certain groups, such as persons with dementia. For example, if the eligibility criteria require that an individual needs hands-on assistance with ADLs, a person who needs cueing and supervision to perform ADLs will be excluded.
In effect, states have a very high level of discretion when determining who will receive personal care services through the State Plan. However, states may not violate Medicaid comparability requirements by restricting services to those with a particular diagnosis or condition.
Given that personal care services are subject to Federal statewideness and comparability requirements, states understandably have cost concerns about increasing access to these services through the use of liberal service criteria. As mentioned, there is no correct decision regarding service criteria. Whether or not particular service criteria are appropriate and make sense depends on the broader context of a states policy goals for its entire long-term care system (i.e., whether the criteria fit logically into the overall plan for providing services to people with long-term care needs through multiple programs).
The Comparability Requirement
With few exceptions (such as the targeted case management benefit), service criteria for any State Plan benefit--mandatory or optional--are subject to the comparability requirement. Under this requirement, services must be available on a comparable basis to all Medicaid beneficiaries in an eligibility group in the state who need the service; that is, the State Plan may not offer a service only to persons who have a particular condition or offer it in different forms to different groups.16 Additionally, states must use the same eligibility criteria for all applicants, and any limits on service amount, scope, and duration must be applied equally to individuals currently receiving services and those applying for services.
The effect of these requirements is that states cannot have service criteria that target particular groups of people by diagnosis, or condition (e.g., requiring that individuals have a spinal cord injury). Additionally, any changes made in the service criteria--and in the amount, scope, and duration of service--must be applied equally to those currently receiving services and those applying for them. These provisions constitute the comparability requirement. HCBS waivers are not State Plan services and not subject to this requirement--they waive comparability.
The Statewideness Requirement
States cannot restrict the availability of State Plan services to particular geographic regions.
Some states design programs funded only with state dollars to provide services for people who do not meet Medicaids eligibility criteria but nonetheless need services. For example, the goal of the Connecticut Home Care Program for Elders is to avoid institutionalization of frail individuals age 65 or older. The program includes both a state-funded component and a Medicaid waiver component. Because many individuals who need services to avoid nursing home placement do not meet Medicaids financial eligibility criteria and/or the waivers level-of-care criteria waiver, this population is served in the state program, which has less stringent financial and service eligibility criteria than does the waiver program.