HCBS Eligibility, Process & Program Limits

HCBS Eligibility, Process & Program Limits

Once Medicaid eligibility is established, the Division of Senior and Disability Services (DSDS) will assist you through each step, such as getting requests for help, determining if someone is eligible for services, and maintaining the person-centered care plan.

Minimum Eligibility Requirements

While some eligibility requirements for Home and Community-Based Services (HCBS) programs differ, the following are the minimum requirements for all HCBS programs:

  • Age: 18 years of age or older
  • Medicaid: Enrolled in Medicaid
  • Nursing Facility Level of Care: A nursing facility level of care (LOC) is required and determines how much help you need with everyday tasks such as bathing, dressing, and mobility
  • Unmet Needs: Personal care needs requiring support to be completed
  • Assessment: A needs-based assessment is completed in the home to evaluate your need for support with everyday tasks. Your need for support must be comparable to someone who resides in a skilled nursing facility.

Process

Here's how it works:

  1. Referral for Services: Anyone can make a referral for someone who might need HCBS. It could be you, a family member, a friend, or a doctor.
  2. Assessment for Eligibility: An assessment is completed with the individual or their legal representative to determine nursing facility level of care and how much help is needed to live safely at home or complete daily tasks without support.
  3. Developing a PCCP: If the individual qualifies, DSDS, along with the individual, creates an individualized plan of care. This plan, a participant-centered care plan (PCCP), focuses on supporting the individual’s needs to help them live as independently as possible in their home and community.
  4. Care Plan Changes: A PCCP can be adjusted to address unmet needs due to changes in health, safety and supports. This also includes provider change requests.
  5. Annual Eligibility Review: An annual reassessment will be completed to reassess your needs and ensure continued eligibility for HCBS.

Program Limits

HCBS programs are funded through Medicaid and have a limit on the amount of services that can be provided, called the cost maximum. The monthly cost of caring for someone in a skilled nursing facility serves as a guide for the HCBS cost maximum. This allows individuals to receive necessary care and support in their homes and communities as an alternative to nursing facility care while also ensuring cost efficiency.