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

12/01/2003

To be eligible for waiver services, a person must meet the nursing home level-of-care criteria and several CBA waiver specific criteria. They must:

  • choose CBA waiver services in lieu of institutional care based on an informed choice;
  • have an individual service plan for waiver services with an estimated annual cost not exceeding 100 percent of the individual's actual Texas Index for Level of Effort (TILE) payment rate;6
  • have ongoing needs for waiver services whose projected costs indicated on their service plan do not exceed the maximum service ceilings set for the services listed below:
    • Adaptive Aids and Medical Supplies cannot exceed $10,000 per individual per service plan year;
    • Minor Home Modifications service category cannot exceed $7,500.00 per individual;
  • receive waiver services within 30 days after waiver eligibility is established;
  • reside either in their own home or in a licensed assisted living facility or adult foster care home contracted with the Texas Department of Human Services to provide CBA waiver services.

6. The TILE classification system was developed by the Department of Human Services to group nursing home residents on the basis of their clinical conditions and functional abilities.

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