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Medicaid (Title XIX of the Social Security Act)
Plan Amendments Expanding Criteria for Home and Community-Based Care


e.) Plan Amendments Expanding Criteria for Home and Community-Based Care

States may amend their plans to include coverage of home and community-based services for individuals who meet objective, needs-based criteria established by the state.111  The state must conduct an independent assessment of every individual’s support needs and capabilities.112  The assessment must include:113

  • A face-to-face evaluation of the individual (including an objective evaluation of the individual’s inability to perform at least two activities of daily living);
  • An examination of his history, medical records, care and support needs;
  • A consultation with professionals caring for him and, where appropriate, a consultation with his family, guardian or other responsible individual; and
  • An evaluation of the individual’s (or his representative’s) ability to self-direct the purchase or control the receipt of such services, if the state provides this option.

On the basis of this independent assessment, the state must establish a written plan of care for the participant,114 developed in consultation with the participant and his treating health care professional and, where appropriate, his family, caregiver or representative.115  The plan must identify the necessary home and community-based services to be furnished to or funded for the participant and must be reviewed annually and whenever there is a significant change in his circumstances.116  The state must annually report the projected number of individuals receiving home and community-based services via plan amendment.117




  • 111. Social Security Act § 1915(i)(1), 42 U.S.C. 1396n(i)(1) (In this circumstance, the state need not determine whether the individual would require the level of care provided in a hospital, nursing facility or ICF-MR).
  • 112. Social Security Act § 1915(i)(1)(D), 42 U.S.C. 1396n(i)(1)(D).
  • 113. Social Security Act § 1915(i)(1)(F), 42 U.S.C. 1396n(i)(1)(F).
  • 114. Social Security Act § 1915(i)(1)(G)(i), 42 U.S.C. 1396n(i)(1)(G)(i).
  • 115. Social Security Act § 1915(i)(1)(G)(ii)(I), 42 U.S.C. 1396n(i)(1)(G)(ii)(I).
  • 116. Social Security Act § 1915(i)(1)(G)(ii), 42 U.S.C. 1396n(i)(1)(G)(ii).
  • 117. Social Security Act § 1915(i)(1)(C), 42 U.S.C. 1396n(i)(1)(C).