Assistive Care Services and Assisted Living for the Elderly Waiver

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Assistive Care Services and Assisted Living for the Elderly Wavier Services Coverage and Limitations Handbook Requirements to Receive Services, continued Medicaid Application Responsibilities Individuals who have not applied for and been determined eligible for Medicaid at the time they need ALE services must complete or have a designated representative complete and submit a Request For Assistance (RFA) to the local Department of Children and Families (DCF), Office of Economic Self-Sufficiency. Prior to determining eligibility, DCF will require verification that the individual is a resident of an enrolled ALF, is receiving case management, has a level of care, and has been determined to need ALE services in order to remain in the ALF or in order to move into an ALF. Who Can Receive Services To receive ALE waiver services, recipients in this waiver must be 60 years of age or older and meet the following requirements: • Medicaid eligible; • Determined disabled according to Social Security standards if under 65 years of age; • Deemed appropriate for ALF placement by the facility administrator; • Moving out of a nursing facility or other institutional program, be an ALF resident needing additional services in order to remain in the ALF, or be living at home and determined at risk of nursing facility placement and desiring to move into an ALF; • Have a case manager employed by a waiver enrolled case management agency; and • Meet one or more functional criteria. Functional Criteria Functional criteria include limitations in activities of daily living (ADLs). ADLs are defined as bathing, dressing, grooming, ambulating, eating, toileting, and transferring. To qualify for ALE waiver assistance, the recipient must need an average of more than one hour of direct services per day and meet at least one of the following criteria: • Require assistance with four or more ADLs or three ADLs plus supervision or administration of medication; • Require total help with one or more ADLs; July 2001 5-2
Assistive Care Services and Assisted Living for the Elderly Wavier Services Coverage and Limitations Handbook Requirements to Receive Services, continued Functional Criteria, continued • Have a diagnosis of Alzheimer’s disease or another type of dementia and require assistance with two or more ADLs; • Have a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard ALF but are available in an ALF licensed for limited nursing or extended congregate care; or • Be a Medicaid-eligible recipient who meets ALF criteria, awaiting discharge from a nursing facility placement and who cannot return to a private residence because of a need for supervision, personal care, periodic nursing services, or a combination of the three. Level Of Care Level of care (LOC) determinations are made by the Department of Elder Affairs (DOEA) Comprehensive Assessment and Review for Long Term Care Services (CARES) unit. The level of care verifies that the recipient is at risk of institutionalization and gives the level of care the recipient would require upon institutional placement. An ALE waiver recipient must meet an Institutional Care Program (ICP) LOC requirement that is verified on a DOEA-CARES Form 603, Notification of Level of Care, which is completed by CARES. The LOC must be reviewed annually for all recipients and documented in the recipient’s case record. Case managers are required to track LOC reassessments to ensure that timely evaluations are conducted and should notify CARES whenever an overdue LOC reassessment is detected. Any applicant or consumer who is determined not to meet a level of care will be notified through the DCF Office of Economic Self-Sufficiency and notified of their right to request a fair hearing. Note: See Part II, Chapter 6, Appendix G of this handbook for fair hearing process information. July 2001 5-3
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Assistive Care Services and Assisted Living for the Elderly Waiver

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