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56 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERer program. The chapter concludes with moredetailed descriptions and illustrations of coverageoptions—focusing first on services that may beoffered under the regular Medicaid state plan andthen on services that may be offered under anHCBS waiver program.MedicaidHome and CommunityServices: An OverviewHome and community services can be thought ofas falling into five overarching categories. It isuseful to consider these in generic terms beforeproceeding to a detailed discussion of how theyare treated in Medicaid law and policy.Personal Care and Assistance. Personal care andassistance involves helping individuals performeveryday activities when they have a physical ormental impairment that prevents them from carryingout those activities independently. Theseactivities can include Activities of Daily Living(ADLs) and Instrumental Activities of DailyLiving (IADLs). ADLs include eating, bathing,dressing, toileting, transferring from bed to chair,and maintaining continence. IADLs include activitiessuch as light housework, laundry, transportation,and money management. (ADLs andIADLs are discussed in more detail in Chapter 3.)Providing personal care and assistance can takethe form of a paid worker (e.g., a personal careattendant or a home health aide) helping the individualeach day in the home or elsewhere in thecommunity. This assistance is also furnished toindividuals in other community living arrangements,such as group homes and assisted livingfacilities.Individuals with various types of disabilitiesoften require this form of basic assistancethroughout their lives. Hence, it is a major, if notthe primary, reason many individuals seekMedicaid long-term care services. States use severaldifferent terms to describe assistance withADLs and IADLs, which may be provided as partof the home health benefit, as a personal careoption under the state Medicaid plan, or througha waiver program.Health-Related Services. Long-term health andhealth-related services include a wide range ofskilled and unskilled nursing services to addresschronic conditions (e.g., tube feedings, catheterization,range of motion exercises).These services are covered under Medicaid’shome health benefit, but can also be coveredunder a waiver program. The major source of primaryand acute health care benefits for personswith disabilities is the basic Medicaid state plan.States also have the option to offer additionalhealth care services to supplement these benefitsthrough an HCBS waiver program. These servicesmay be provided under a state’s personal carebenefit through the state plan when they are delegatedby a nurse and when the practice is recognizedand permitted under state law. (Nurse delegationis discussed in detail in Chapter 7.)Specialty Services. Specialty services encompassan enormous range of services related to the specificnature of an individual’s impairment. By andlarge, these services share the common aim ofassisting individuals to improve their functioning.Psychiatric rehabilitation services address theneeds of individuals who have a mental illness.Habilitation services enable persons with mentalretardation to acquire or improve skills to helpthem become more independent. Assistive technologyhelps persons with many different types ofdisabilities become more self-sufficient. Statesmay offer these services through various options,including an HCBS waiver program. Many typesof assistive technology (e.g., motorized wheelchairs,communication devices) are forms of medicalequipment and supplies covered under themandatory home health benefit.Adaptive Services. In order to remain in theirown home or elsewhere in the community, manyindividuals with physical impairments benefitfrom home and vehicle modifications.Home modifications include installing wheelchairramps, widening doorways, and retrofitting bathroomsand kitchens so that individuals with physicalimpairments can get around their homes.Vehicle modifications include modifying a car ora van so that a person can get around the commu-