Assistive Care Services and Assisted Living for the Elderly Waiver

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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
Assistive Care Services and Assisted Living for the Elderly Wavier Services Coverage and Limitations Handbook Covered Service Assistive Care Services W-9659 Assistive care services are an array of services provided on a daily basis by or through ALFs, AFCHs, or RTFs. The following components may be included in the assistive care service plan: • Health support; • Assistance with activities of daily living (ADLs); • Assistance with instrumental activities of daily living (IADLs); and • Assistance with self-administration of medication. The criteria for provision of each component are explained below. Health Support Component Health support is defined as requiring the provider to: • Observe the recipient’s whereabouts and well-being on a daily basis; • Remind the recipient of any important tasks on a daily basis; and • Record and report any significant changes in the recipient’s appearance, behavior, or state of health to the recipient’s health care provider, designated representative, or case manager. Assistance with Activities of Daily Living (ADLs) Component Assistance with activities of daily living (ADLs) is defined as providing assistance with one or more of the following activities: individual assistance with ambulating, transferring, bathing, dressing, eating, grooming, and toileting. At least one service component must be required daily. July 2001 2-5
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Assistive Care Services and Assisted Living for the Elderly Waiver

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