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Medicaid Coverage of Home and Community Services: Overview 9down to $29 in Mississippi. 9Major Contours of the MedicaidProgram’s Home and CommunityService ProvisionsThe remainder of this chapter presents a briefoverview of the Medicaid law, regulations, andpolicy that give states the flexibility to create comprehensivehome and community service systemsfor persons of all ages with all types of physicaland mental disabilities. To provide context for thediscussion, Table 1-1 lists the major relevant provisionsof Medicaid law. This chronological summaryillustrates the progressive expansion ofMedicaid long-term care services away from a primaryfocus on institutional care. (Chapters 4 and 5discuss service options and factors to considerwhen choosing among them.)Home Health ServicesThere has been some misunderstanding about thecoverage criterion for home health servicesbecause it is linked to the coverage criterion fornursing homes. States are mandated to covernursing home care for categorically eligible personsage 21 and older. This mandate entitles personsage 21 and older to nursing facility care.States have the option to cover nursing home carefor other Medicaid beneficiaries as well—e.g., personsunder age 21 and the medically needy. Instates choosing this option, the medically needyand persons under age 21 would also be entitled tonursing home care. However, being entitled tonursing home care does not mean that one is eligiblefor nursing home care. In order to receiveMedicaid covered nursing home care, entitledpersons must also meet nursing home eligibilitycriteria (called level-of-care criteria).Since 1970, home health services have beenmandatory for persons entitled to nursing facilitycare. 10 Confusion about eligibility for home healthservices has arisen because the term entitled tonursing facility care has sometimes been erroneouslyinterpreted to mean that people must beeligible for nursing facility care—i.e., that theymust meet a state’s nursing facility level-of-carecriteria—in order to receive home health benefits.This erroneous interpretation has persisted notwithstandingits conflict with home health regulationsprohibiting a state from conditioning eligibilityfor home health services on the need for ordischarge from institutional care. 11 The MedicaidAssistance Manual further clarifies that statesmay not limit home health services to individualswho require a skilled level of health care asdefined by Medicare (i.e., needing skilled nursingor therapy services). 12 (See Chapter 3 for additionalinformation on the home health benefit.)Federal regulations require that home healthservices include nursing, home health aides,medical supplies, medical equipment, and appliancessuitable for use in the home. States have theoption of providing additional therapeutic servicesunder home health—including physical therapy,occupational therapy, and speech pathologyand audiology services. 13 States may establishreasonable standards for determining the extentof such coverage based on such criteria as medicalnecessity or utilization control. 14 In doing so,as noted, a state must ensure that the amount,duration, and scope of coverage are reasonablysufficient to achieve the purpose of the service. 15In 1998, following the ruling of the U.S. Court ofAppeals for the Second Circuit in DeSario v.Thomas, HCFA sent a letter to state MedicaidDirectors clarifying that states may develop a listof pre-approved items of medical equipment as anadministrative convenience but must provide areasonable and meaningful procedure for requestingitems that do not appear on such a list. 16 (SeeAppendix II for the complete text of the HCFA letter.)All home health services must be medicallynecessary and authorized on a physician’s ordersas part of a written plan of care.Home health services are defined in Federal regulationas services provided at an individual’splace of residence. In 1997, however, the FederalCourt of Appeals for the Second Circuit ruledthat home health nursing services may be providedoutside the home, as long as they do notexceed the hours of nursing care that would havebeen provided in the home. 17 The states covered