Jane: Hi Ruby – did you get a chance to read Mr. Kaye’s background?

Ruby: Yeah. Sounds like Mr. Kaye is a good candidate for the HCBS waiver. I’m anxious to get to work and see what we can do to help, but I’m a little confused about my role.

Jane: How so?

Ruby: Well, according to the file Mr. Kaye already has a Level of Care (LOC) assessment. I thought that was part of my job – I always did LOC’s at my last job?

Jane: No wonder you’re confused. Remember when we were talking about the HCBS waiver program, and how every state applies to CMS for permission to operate a HCBS waiver?

Ruby: Yes…

Jane: Well, although states have to make an Assurance to CMS that they’ll use an LOC process, each state can design that process differently. Some things are standard, like each state has to assure that participants meet institutional level of care criteria, but states can make their own decisions about who will conduct the LOC and how. In this state, our Medicaid Agency contracts with a private agency to do all LOC determinations, so we don’t receive a referral until the LOC is completed.

Ruby: So, is the level of care requirement different here too? I mean, at my last job a person was eligible for home based services only if they needed help with certain ADL’s and therefore would be eligible for nursing home level of care.

Jane: That’s what LOC determination means throughout the HCBS waiver program: HCBS is an alternative to nursing home care. But each state defines nursing home level of care a bit differently. I’ll get you the criteria we use in this state so you can be familiar with them.

Ruby: OK. So the only thing that is really different is that I won’t have any responsibilities toward the LOC process?

Jane: Well, not so fast! It’s true that you won’t be involved in the initial LOC. But remember, another part of the CMS Assurance is that LOC determinations must be revisited at least once a year – more frequently if a person’s status changes. You’re still responsible for keeping an eye on each person you work with, and if there is a change, or if a year has passed and no reassessment has been done, you make the referral.

Ruby: I suppose that means more forms to fill out? I mean, if I make a referral for a reassessment?

Jane: Yes, but remember what I’ve been telling you about the paperwork. All of this paper serves a purpose. First, it helps our state provide evidence to CMS that we’re complying with the Assurances. In fact, we get reviewed regularly by the state, and that audit includes a review of our records. But more important to our participants, the data we collect helps our agency, our state and CMS figure out what works and what doesn’t work in HCBS services. We’ve learned a lot through all that paperwork!

Ruby: I’m beginning to get that picture. Well, I think I’m ready to get out there and get started. So, what’s the next step, do I set up a meeting with Mr. Kaye and his family?

Jane: First let’s review our protocol for service planning, and then we can talk about your visit with Mr. Kaye.

Ruby: Sounds great.