Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Level of Care Criteria


Waiver applicants have to meet the same level of care criteria as nursing home applicants. The eligibility determination is made on the basis of a comprehensive assessment and the professional judgment of the assessors who use guidelines provided by the state. The criteria considered in the level of care determination include health and nursing needs, physical and mental functioning, and behavior. The state uses a case mix classification to determine eligibility. A person must have either functional or nursing needs to be eligible.11

A reassessment of an Elderly Waiver client is conducted at least every 12 months and when there has been significant change in the client's functioning, e.g., after a hospital discharge.

11, O'Keeffe, J., People with Dementia: Can They Meet Medicaid Level-of-Care Criteria for Admission to Nursing Homes and Home and Community-Based Waiver Programs? AARP, August 1999.

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