Assistive Care Services and Assisted Living for the Elderly Waiver

Assistive Care Service and Assisted Living for the Elderly Wavier Services
Coverage and Limitations Handbook
Requirements to Receive Services, continued
Functional and
Health Criteria
Eligible Medicaid recipients must have at least the following functional
capabilities:
• Ambulatory, with or without assistance;
• Does not exhibit chronic inappropriate behavior which disrupts the
facility’s operations or is harmful to self or others;
• Is capable of taking his or her medication with assistance;
• Does not have any stage 3 or 4 pressure sores; and
• Does not require 24-hour nursing supervision.
Definition of
Medical Necessity
Chapter 59G-1.010, F.A.C., defines medical necessity as medical or allied
care, or services furnished or ordered that must:
• Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;
• Be individualized, specific, and consistent with symptoms or confirmed
diagnosis of the illness or injury under treatment, and not in excess of the
patient’s needs;
• Be consistent with generally accepted professional medical standards as
determined by the Medicaid program, and not experimental or
investigational;
• Be reflective of the level of service that can be safely furnished and for
which no equally effective and more conservative or less costly treatment
is available; and
• Be furnished in a manner not primarily intended for the convenience of the
recipient, the recipient’s caregiver, or the provider.
Need for Assistive
Care Services
A recipient of ACS must require an integrated set of services on a 24-hour
basis and must have a health assessment establishing the medical necessity of
at least two of the four service components described below.
July 2001 2-4