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Health and Functional Criteria for Service Eligibility 47for themselves if they did not have a disability.Assistance may be in the form ofhands-on assistance (actually performing apersonal care task for a person) or cueingso that the person performs the task byhim/herself. Such assistance most oftenrelates to performance of activities of dailyliving (ADLs) and instrumental activitiesof daily living (IADLs).” 11Persons with cognitive impairments can also beoffered services through the personal care option.As the Medicaid Manual states:“An individual may be physically capableof performing ADLs and IADLs but mayhave limitations in performing these activitiesbecause of a cognitive impairment.Personal care services may be requiredbecause a cognitive impairment preventsan individual from knowing when or howto carry out the task. For example, an individualmay no longer be able to dresswithout someone to cue him or her on howto do so. In such cases, personal assistancemay include cueing along with supervisionto ensure that the individual performsthe task properly.” 12Given the Federal Medicaid definition of personalassistance, it follows that appropriate service criteriashould be based on a need for assistance withADLs or with IADLs. There is a considerable bodyof research on ADLs and IADLs to guide states indesigning their service criteria. Generally, ADLsare more frequently used than IADLs to determineservice eligibility, because they are widelybelieved to measure a greater level of need. But anumber of states use both ADLs and IADLs intheir service criteria. This is consistent withresearch showing that dependencies in multipleIADLs also indicate a high level of need. 13Limitations in performing some IADLs, such asmeal preparation and medication management,may actually pose a greater health risk than anADL limitation in bathing and dressing. Recentresearch has shown, for example, that inability touse the telephone actually indicates a very highlevel of impairment. 14An important consideration when selecting servicecriteria is that the level of impairment requiredfor eligibility match the services covered. Forexample, if a state requires applicants to beseverely impaired, the maximum number of servicehours permitted should be sufficient to enablesuch people to remain in the community even ifthey have little informal care. Otherwise, requiringtoo high a level of impairment could preventthose without informal care from receiving necessaryservices.It is also important to ensure that assessment andauthorization methodologies do not inadvertentlyexclude certain categories of potential beneficiaries,such as persons with cognitive impairment.Failure to include criteria that measure the functionallimitations relevant to these individuals—such as the need for cueing to perform ADLs—canlead to their exclusion. States may be inadvertentlymaking such exclusions. Even though 26 statesoffered personal care services in their state plans,for example, a survey of state agencies servingpersons with developmental disabilities foundthat services through the personal care optionplay little or no role in paying for long-term servicesfor this group. 15Historically, Michigan used to be the most noteworthyexample of a state that optimized the personalcare benefit as a means of funding home andcommunity services for people with developmentaldisabilities. Michigan built many of its communityservices on personal care as the baselinecore benefit, for example, weaving it into fosterhome settings and other types of living arrangements.However, in the 1995 amendments to thestate’s HCBS waiver program for people withmental retardation and developmental disabilities,Michigan started moving to waiver fundingof services for these groups.In effect, states have a very high level of discretionto determine who will receive personal care servicesthrough the state plan. However, states maynot violate Medicaid comparability requirementsby restricting services to those with a particulardiagnosis or condition (e.g., by making benefitsavailable only to people with spinal cord injuriesor people who use wheelchairs, or to people whoare likely to require nursing facility services).
48 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERIllustrative Service Criteria for Personal Care Services: State ExamplesMassachusettsTo be eligible for personal care services in Massachusetts, Medicaid beneficiaries must have a permanent,chronic disability. The service criteria are specified in terms of hours of assistance needed—rather than type,number, or level of ADL and IADL impairments. Individuals must need a minimum of 10 hours per week of assistancewith ADLs, or 14 hours of assistance with a combination of ADLs and IADLs. The average hours for mostconsumers is 42 per week. The program serves both self- and non-self-directing consumers and allows surrogatesto manage services for those who cannot do so themselves.Massachusetts specifies as ADLs to be assessed all aspects of mobility (walking, transferring, using durable medicalequipment); bathing, personal hygiene, and grooming; dressing and undressing; basic exercises such asrange of motion; preparation and ingestion of meals and clean up; assistance with bowel and bladder needs; andassistance with medication administration. The IADLs the state assesses are housekeeping, laundry, shopping,ability to make visits to health care providers, and unique needs (e.g., care and maintenance of wheelchairs).ArkansasTo be eligible for personal care service in Arkansas, a person must have physical dependency needs and requireassistance to perform the following tasks and routines: eating, bathing, dressing, personal hygiene, bladder andbowel requirements, taking medications, laundry, incidental housekeeping, and shopping for personal maintenanceitems.New YorkTo be eligible for personal care services in New York, individuals must need some or total assistance with a widerange of tasks connected with daily living, nutritional and environmental support functions, and health-relatedtasks. The services must be essential to maintain the individuals’ health and safety in their own home. Tasks thatare considered include bathing, dressing, feeding, grooming, toileting, walking in and outside the home, transferring,meal preparation in accordance with modified diets, medication administration, and skin care. Nutritionaland environmental support functions include meal preparation, housekeeping, laundry and ironing, shopping,bill payment, and other essential errands.Given that personal care services are subject tostatewideness and comparability requirements,states understandably have cost concerns aboutincreasing access to these services by using lessstringent service criteria, even though they cancontrol costs by limiting the amount, scope, andduration of services. As mentioned at the beginningof this chapter, there is no “correct” decisionregarding service criteria. Whether or not particularservice criteria are appropriate and make sensedepends on the broader context of a state’s policygoals for its entire long-term care system (i.e.,whether the criteria fit logically into the overallplan for providing services to people with longtermcare and support needs through multipleprograms).To ensure that their programs do make sensewithin their particular service systems, somestates design “wraparound” state-funded programsto provide services to people who do notmeet either Medicaid’s financial criteria or thestate’s service criteria. The Connecticut HomeCare Program for Elders has three levels of service,for example, with Level One and Level Twofunded solely with state funds. Level One servespeople who meet neither the Medicaid asset testnor the waiver service criteria. Level Two servespeople who meet the waiver service criteria butnot the asset test. 16 Level Three serves those whomeet both financial and service criteria. In thisframework, the stringency of the institutionalservice criteria is not a major issue, because thereis an alternative source of services for those whodo not meet them.HCB Waiver Program ServicesTo be eligible for HCB waiver services, individu-
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Understanding MedicaidHome and Comm
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