Mandatory Long-Term Services
States are required to cover the following services for individuals who are in a mandatory eligibility category.
Institutional Care
Nursing Facility Care
- Eligibility
- Individuals must be over 21 and meet the clinical/functional eligibility requirements for care, in addition to being eligible for Medicaid. Clinical/functional eligibility is typically based on the need for ongoing assistance with a certain number of activities of daily living (ADLs), such as bathing, or instrumental activities of daily living (IADLs), such as using a phone or managing money. Individuals may need care because of a physical disability or medical condition. States set these criteria.
Non-Institutional Care (Home- and Community-Based Services)
Home Health Services
- Eligibility
- States are required to cover home health services for people over age 21 who are in a mandatory eligibility category. States can extend home health services to optionally eligible populations, like the medically needy, or higher-income individuals, if the state offers Medicaid nursing facility services to those individuals.
- States cannot limit home health services to individuals who meet their level of care requirements for nursing facility care.
- Services
- This benefit covers home care that is provided under physician orders. Covered care includes the following: (1) part-time or intermittent nursing services; (2) home health aide services; and (3) medical supplies, equipment, and appliances that are suitable for use in the home.
- States have wide latitude to set limits on the services provided. States can set visit limits and require prior authorization or prior hospitalization.
