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52 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERponents of the benefit package and establishmentof an efficient service delivery system canhelp a state to work its way between thesepotentially conflicting objectives.• Concern that using less stringent criteria—especially with respect to the waiver/institutionaleligibility connection—will result inhigher demand for (and spending on) institutionalservices seems to be misplaced. Broadereligibility criteria have been shown to enable astate to obtain Federal financial participationto provide HCB waiver services to a greaternumber of individuals with substantial impairments,without experiencing an increasein requests for nursing facility and other institutionaladmissions. Experience confirms thatmost consumers want to remain in theirhomes and in the community. Their ability todo so is strengthened through the provision ofHCB services.Endnotes1. The primary contributors to this chapter are JanetO’Keeffe and Gary Smith.2. The ADL and IADL scales are based on a developmentalmodel: children learn to eat, toilet, bathe, anddress themselves before they develop the mental abilityto do more cognitively complex activities such asusing the telephone and managing money. When cognitiveabilities start to deteriorate (as in a person whodevelops dementia) the ability to perform activitiesthat require more complex mental functioning (IADLs)is generally lost before the ability to perform ADLs. Infact, states are not bound by the definitions implied bythis developmental model. States are free, for example,to define ADLs as whatever tasks/activities they considerimportant to define a need for long-term care.3. Assistants who work with individuals who havecognitive impairments or behavior issues need specializedtraining.4. States are permitted to make provision for “outliers”—thoseindividuals whose condition respondsless well than expected to the services for their condition,and who, as a consequence, may receive moreservices for a longer period.5. The frequency of further physician review of a beneficiary’scontinuing need for medical equipment andsupplies is determined on a case-by-case basis, basedon the nature of the item prescribed.6. Some states link their Medicaid home health benefitwith the Medicare benefit through state statutesand/or regulations. A number of states also tie theirMedicaid reimbursement methods directly to theMedicare home health reimbursement methods.Harrington, C., LaPlante, M., Newcomer, R.J., Bedney,B., Shostak, S., Summers, P., Weinberg, J., and Basnett,I. (January 2000). Review of Federal statutes and regulationsfor personal care and home and community based services:A final report. San Francisco: University ofCalifornia, Department of Social and BehavioralSciences.7. 42 CFR 440.230(c) and 42 CFR 440.240.8. 42 CFR 440.240.9. Skubel v. Fuoroli. (No. 96-6201). United States Court ofAppeals, Second Circuit. Decided May 13, 1997.10. When Medicaid was first enacted in 1965, coverageof home health services was optional. In 1970,Congress made coverage of home health servicesmandatory for those entitled to skilled nursing facilityservices.11. State Medicaid Manual, Part 4—Services, Section4480.12. State Medicaid Manual, Part 4—Services, Section4480.13. Kassner, E. and Jackson, B. (1998). Determining comparablelevels of functional disability. Washington, DC:AARP Public Policy Institute.14. Spector, W.D. and Fleishman, J.A. (1998).Combining activities of daily living with instrumentalactivities of daily living to measure functional disability.Journal of Gerontology. 53B: S46-S57.15. Gary Smith, Director of Special Projects, NationalAssociation of State Directors of DevelopmentalDisabilities Services. Personal communication, March12, 2000.16. Eligibility rules for Level One and Level Two of theConnecticut Home Care Program for Elders allowapplicants to retain up to $16,392 in assets. Allowableincome is the same for all three levels: $1500 per month.Cost sharing based on income is required.17. States may use different evaluation instruments andprocesses for determining eligibility for HCBS waiverservices than for institutional placement as long as theycan explain in their waiver application how and whythey differ and also provide assurances that the outcomeof a different assessment instrument or process is