Assurance 1 - Level of Care
Participants enrolled in the HCBS waiver meet the level of care criteria consistent with those residing in institutions.
What are the requirements of this HCBS waiver assurance?
Your state must assure that people getting services under the HCBS waiver would otherwise qualify for Medicaid-reimbursed institutional care. Before CMS approves an HCBS waiver, a state must provide detailed descriptions of how level of care determinations will be made.
The state must show that it has:
Criteria and methods for determining qualifications for institutional level of care. (click here for more information on institutional level of care)Although federal assurances require that an assessment be done as part of level of care determination, the regulations do not specify how to conduct the assessment, what it should include, who completes it, or what criteria are used. Criteria and methods vary across states. However, CMS requires that a state use the same criteria for determining eligibility for HCBS waivers that it uses for determining eligibility for institutional care. In determining whether a person qualifies for institutional care, a state may consider some of the following factors: the individual’s general health, emotional/behavioral health, cognitive ability, and the ability to perform activities of daily living (e.g., ability to bathe, walk, eat).
Qualified agencies to conduct the level of care evaluations. (click here for more information on level of care evaluations)A state designates specific agencies or organizations to determine if an individual meets institutional level of care. This entity may be different from the one responsible for service plan development.
A schedule for evaluating, at least annually, that a person continues to meet institutional level of care. (click here for more information about schedule for evaluating level of care)If a person is approved for the HCBS waiver, the evaluation and level of care determination must be carried out at least once every year or, in some states, whenever there is a change in the participant’s status.
Medicaid participants who meet an institutional level of care may receive HCBS waiver services, provided there is a funded opening. If there is no opening, the person may be put on a state’s waiting list, even though they are eligible for services now. If a person is found not to be eligible, he/she can appeal the decision to the state.