Sample Criteria for Applying for Medicaid Home Aides

Below is an example of a policy used to decide if someone is eligible for Medicaid home aides. Exact criteria will vary by state. If you have too much money for Medicaid, you may still be able to qualify: How to Apply for a Medicaid Waiver When You Have Too Much Money


Three Ways to Qualify

One: Mix of Cognitive and Physical Impairments

  • Rated dependent in 2+ Activities of Daily Living AND
  • Rated either semi-dependent or dependent in behavior pattern AND
  • Rated either semi-dependent or dependent in orientation AND
  • Either semi-dependent in joint motion OR dependent in medication administration.

Two: Physical Impairments Only

  • Rated dependent in 5+ Activities of Daily Living AND
  • Rated dependent in mobility

Three: Different Mix of Cognitive and Physical Impairments

Rated semi-dependent in 2+ of the Activities of Daily Living AND

  • Rated dependent in mobility AND
  • Rated dependent in behavior pattern AND
  • Rated dependent in orientation.

Additional Criteria

  • Have medical nursing needs plus
  • Be at risk for placement in specialized care / nursing home

What is an Activity of Daily Living?

  1. Bathing
  2. Dressing
  3. Toileting
  4. Transferring
  5. Eating/Feeding
  6. Bowel/Bladder Continence
  7. Mobility

What is Dependent in Bathing? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷 Human Help: Supervision. Individual needs prompting and/or verbal cues to safely complete washing the entire body. This includes individuals who need someone to teach them how to bathe.

🌷 Human Help: Physical Assistance. Someone fills the tub or brings water to the individual, washes part of the body, helps the individual get in and out of the tub or shower, and/or helps the individual towel dry. (Individuals who only need human help to wash their backs or feet would not be included and would be coded as “Does Not Need Help)”

🌷 Both Mechanical and Human Help. Individual usually needs equipment or a device and requires assistance of other(s) to bathe. For examples of human help, see above. Examples of mechanical help: Individual usually needs equipment or a device such as a shower/tub chair/stool, grab bars, pedal/knee controlled faucet, long-handled brush, and/or a mechanical lift to complete the bathing process.

🌷 Performed by Others. Individual is completely bathed by other(s) and does not take part in the activity at all.

What is Dependent in Dressing? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷 Human Help: Supervision (Verbal Cues, Prompting). Individual usually requires prompting and/or verbal cues to complete the dressing process. This category also includes individuals who are being taught to dress.

🌷 Physical Assistance (Set-up, Hands-On Care). Individual usually requires assistance from another person who helps in obtaining clothing, fastening hooks, putting on clothes or artificial limbs, etc.

🌷 Mechanical and Human Help – Individual usually needs equipment or a device and requires assistance of other(s) to dress. Examples of mechanical help: Individual usually needs equipment or a device such as a long-handled shoehorn, zipper pulls, specially designed clothing or a walker with an attached basket to complete the dressing process.

🌷 Performed by Others. Individual is completely dressed by another individual and does not take part in the activity at all.

🌷 Is Not Performed. Refers to bedridden individuals who are considered not dressed.

What is Dependent in Toilet? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷 Human Help: Supervision (Verbal Cues, Prompting). Individual requires verbal cues and/or prompting to complete the toileting process.

🌷 Physical Assistance (Set-up, Hands-On Care). Individual usually requires assistance from another person who helps in getting to/from the bathroom, adjusting clothes, transferring on and off the toilet, or cleansing after elimination. The individual participates in the activity.

🌷 Mechanical and Human Help. Individual usually needs equipment or a device and requires assistance of other(s) to toilet. Examples of mechanical help: Individual needs grab bars, raised toilet seat or transfer board and manages these devices without the aid of other(s). Includes individuals who use handrails, walkers, wheelchairs, or canes for support to complete the toileting process. Also includes individuals who use the bathroom without help during the day and use a bedpan, urinal, or bedside commode without help during the night and can empty this receptacle without assistance.

🌷 Performed by Others. Individual does use the bathroom, but is totally dependent on another’s assistance. Individual does not participate in the activity at all.

🌷 Is Not Performed. Individual does not use the bathroom.

What is Dependent in Transferring? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷  Human Help: Supervision (Verbal Cues, Prompting). Individual usually needs verbal cues or guarding to safely transfer.

🌷  Physical Assistance (Set-up, Hands-On Care). Individual usually requires the assistance of another person who lifts some of the individual’s body weight and provides physical support in order for the individual to safely transfer.

🌷  Mechanical and Human Help. Individual usually needs equipment or a device and requires the assistance of other(s) to transfer.  Examples of mechanical help: Individual usually needs equipment or a device, such as lifts, hospital beds, sliding boards, pulleys, trapezes, railings, walkers or the arm of a chair, to safely transfer, and individual manages these devices without the aid of another person.

🌷  Performed By Others. Individual is usually lifted out of the bed and/or chair by another person and does not participate in the process. If the individual does not bear weight on any body part in the transferring process; he/she is not participating in the transfer. Individuals who are transferred with a mechanical or Hoyer lift are included in this category.

🌷 Is Not Performed. The individual is confined to the bed.

What is Dependent in Eating? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷 Human Help: Supervision (Verbal Cues, Prompting). Individual feeds self, but needs verbal cues and/or prompting to initiate and/or complete the eating process.

🌷 Physical Assistance (Set-up, Hands-On Care). Individual needs assistance to bring food to the mouth, cut meat, butter bread, open cartons and/or pour liquid due to an actual physical or mental disability (e.g., severe arthritis, Alzheimer’s). This category must not be checked if the individual is able to feed himself but it is more convenient for the caregiver to complete the activity.

🌷 Mechanical and Human Help. Individual usually needs equipment or a device and requires assistance of other(s) to eat. Examples of mechanical help: Individual usually needs equipment or a device, such as hand splints, adapted utensils, and/or nonskid plates, in order to complete the eating process. Individuals needing mechanically adjusted diets (pureed food) and/or food chopped are included in this category.

🌷 Performed By Others. Includes individuals who are spoon fed; fed by syringe or tube, or individuals who are fed intravenously.

What is Dependent in Bowel or Bladder?

If someone meets any ONE of these criteria, they are considered dependent:

Bowel

🌷 Incontinent Weekly or More. The individual has involuntary elimination of feces at least once a week. Individuals who use incontinence supplies such as briefs, pads, or diapers and do not correctly dispose of them should be coded here.

🌷 Ostomy – Not Self-Care. The individual has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy) and another person cares for the ostomy: stoma and skin cleansing, dressing, application of appliance, irrigations, etc.

Bladder

🌷 Incontinent Weekly or More. The individual has involuntary emptying or loss of urine at least once a week. Individuals who use incontinence supplies such as briefs, pads, or diapers and do not correctly dispose of them should be coded here.

🌷 External Device – Not Self-Care. Individual has an urosheath or condom with a receptacle attached to collect urine. Another person cares for the individual’s external device.

🌷 Indwelling Catheter – Not Self-Care. Individual has a hollow cylinder passed through the urethra into the bladder. Another person cares for the individual’s indwelling catheter. This category includes individuals who self-catheterize, but who need assistance to set-up, clean up, etc.

🌷  Ostomy – Not Self-Care. Individual has a surgical procedure that establishes an external opening into the ureter(s). Another person cares for the individual’s ostomy.

What is Dependent in Mobility? 

If someone meets any ONE of these criteria, they are considered dependent:

🌷  Supervision (Verbal Cues, Prompting). Individual usually requires assistance from another person who provides supervision, cues, or coaxing to go outside.

🌷  Physical Assistance (Set-up, Hands-On Care). Individual usually receives assistance from another person who physically supports or steadies the individual to go outside.

🌷  Mechanical and Human Help. Individual usually needs equipment or a device and requires assistance of other(s) to go outside. Examples of mechanical help: Individual usually needs equipment or a device to go outside. Equipment or device includes splint, special shoes, leg braces, crutches, walkers, wheelchairs, canes, handrails, chairlifts, and special ramps.

🌷  Confined – Moves About. Individual does not customarily go outside of his or her residence, but does go outside of his or her room.

🌷  Confined – Does Not Move About. The individual usually stays in his or her room.

What are Medical/Nursing Needs?

A person has medical needs if they have ONE of the following:

🌷  Medical condition requires observation and assessment to assure evaluation of the need for modification of treatment or additional medical procedures to prevent destabilization and the person, as developmentally appropriate, has demonstrated an inability to self – observe or evaluate the need to contact skilled medical professionals. Or…

🌷  Due to the complexity created by multiple, inter-related medical conditions, the potential for the child’s medical instability in high or medical instability exists. Or….

🌷  The person requires at least one ongoing medical or nursing service. Ongoing refers to the need for daily direct care and/or supervision by a licensed nurse that cannot be managed on an outpatient basis.

What is At-Risk for Placement with Specialized Care or Nursing Home? 

A person is considered at risk for placement if there is evidence that (without home care services through Medicaid) the individual’s current condition and available support are insufficient to enable the individual to remain in their home. Evidence of one of the following:

🌷  Behaviors increasing

🌷  Medical condition worsening

🌷  Change in family situation (new child, deployment, new demands from other family members)

🌷  No change in condition or support, but evidence that functional, medical or nursing needs are not being met, or cannot be met without support from Medicaid home care.

What is Imminent Risk?

This regulation does not require that the person would be put in a nursing home or specialized care facility if they don’t get help. The individual meets the Imminent Risk criteria if:

🌷  They have been accepted to a specialized care facility

🌷  Their health is deteriorating such that they WILL require a specialized care facility placement in 30 days

🌷  Even if their health is NOT deteriorating, if a doctor certifies that they have health care needs that cannot be met at home without these services

For Children

For children, there are more specific charts to detailing each these categories based on the child’s age. Starting on page four of the UAI Guidance for Children.

Learn More

How To Get a Home Aide Through a Medicaid Waiver

How to Find Medicaid Home Aide Programs in Your State

How Did You Get Home Care? (Survey Results)

How to Have a Screening Interview for a State Home Aide Program

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