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

A client's degree of functional impairment is measured on a 60-point functional needs assessment to determine if the impairment is severe enough to qualify for services. Applicants for primary home care services must meet functional needs criteria as follows:

  • Must score 24 or above on the Client Needs Assessment Questionnaire.

  • Must have a medical need for assistance with personal care.

  • Must have a signed and dated Physician's Order for Primary Home Care.

  • Must require at least six hours of primary home care per week. An applicant/client requiring fewer than six hours per week may be eligible if she meets at least one of the following criteria:

    • scores at least 30 on the Client Needs Assessment Questionnaire and primary home care is essential to provide respite care to the caregiver or to enable the applicant/client to remain in the community;
    • lives in the same household as another individual receiving family care or primary home care; or
    • also receives congregate or home-delivered meals, participates in the day activity and health services program, or special services for handicapped adult day care.
  • For primary home care clients, the client's medical diagnosis(es) must be the cause of the client's functional impairment in performing personal care tasks. Although mental illness and mental retardation are not considered medical conditions, they do not disqualify a client for eligibility as long as the client's functional impairment is related to a coexisting medical condition.

To receive services the applicant/client must reside in a place other than a hospital, a skilled nursing facility, an intermediate care facility, or any other environment where family members or sources outside the primary home care program are available to provide personal care. Services cannot be authorized if the client lives in a home licensed as an assisted living facility (ALF). If the home is not a licensed ALF, services may be authorized under the following two circumstances:

  • Three or fewer persons live in the home. The proprietor can be the attendant for the client(s) who resides there. A client may not receive adult foster care services as well as primary home care services.

  • If the home provides only room and board to four or more persons living in the home, it does not require licensure as an assisted living facility. Services can be authorized for clients in this setting, but the proprietor, his agent, or employee cannot be the attendant for clients who reside in the home.

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