Level of Care Transformation

Effective October 1, 2024, Transformed Level of Care fully implemented. All assessments on or after this date will utilize only the transformed eligibility criteria.

Overview

The Home and Community Based Services (HCBS) program operated by the Division of Senior and Disability Services (DSDS), provides essential services to seniors and people with disabilities to remain in the least restrictive environment for as long as safely possible. The HCBS program, whose eligibility criteria was last updated in regulation in 1982, has seen many changes since its inception 38 years ago. Though the program has continued to increase in participant numbers, the State continues to measure participant need of services using criteria that no longer reflects the 21st century medical advancements and growth of Missouri’s aging population. The need for hands-on care in a participant’s home has only increased as Missouri’s population has aged. Moreover, as the program continues to grow, it is vital the state is able to focus on ensuring Medicaid resources are correctly allocated. The transformed eligibility guidelines for this program will ensure the right services, to the right people, in the right setting, at the right time.

Past attempts to adjust eligibility guidelines to Nursing Facility Level of Care (NF LOC) have focused on changes to point values within the 1982 developed model. DSDS began the LOC Transformation process in 2017 to address the underlying systemic problem of NF LOC. Through national research of best practices and robust stakeholder feedback, DSDS identified the foundation to the right LOC model is measuring need rather than symptoms. These needs are measured through a blend of points and automatic eligibility triggers. The triggers are a representation of the common sense approach of the entire transformation. Triggers are a mechanism by which those with certain characteristics of need become automatically eligible for NF LOC regardless of any other combination of points.

DSDS has identified two key pieces to the LOC Transformation project. First, the NF LOC eligibility needs to be updated to reflect the appropriate criteria to determine the needs of individuals. Second, in an enhanced focus is needed on ensuring timely, consistent, and accurate assessments. DSDS recognizes while updating the eligibility criteria is important, it is equally important to ensure assessments and care planning are consistently and accurately conducted utilizing the new criteria.

For more information, contact us at QIQA@health.mo.gov.