The overall assessment process is vital for an individual to receive necessary and appropriate care.  Ideally, an assessment will be usable for both determining eligibility for and planning of services.  It must include all aspects of an individual’s life relevant to whether the enrollee will be able to live in a house, apartment, or other community-based setting.

  • States must develop, and require MCOs to use uniform assessment tools and processes that must be used for both determining eligibility and planning services.  Processes must include requirements that the tool be administered by persons who are knowledgeable about LTSS, and specifically the scope and availability of HCBS services and supports that are or could be made available in the state and locally.
  • States must establish conflict-of-interest standards for the persons conducting assessments, including the requirement that a person developing an assessment should not be a service provider for the individual, related by blood or marriage to the individual or to a service provider for the enrollee, a person financially responsible for the individual, or a person empowered to make financial or health-related decisions for the individual.
  • MCOs must be required to conduct assessments in person, unless the individual has indicated a preference for a telephonic assessment. The individual should be providing the option of an in home or in office assessment.
  • States must require that MCOs perform assessments when there is a significant change in an individual’s condition or circumstances, at the individual’s request, or at least once every 12 months.
  • States must develop uniform assessment instruments and processes that must be used for both determining eligibility and planning services.
  • States and MCOs must require that assessments include information related to the individual’s ability to remain in, or move to, a house, apartment, or other community-based setting, and their interest in doing so.
  • The assessment must include services and supports currently available to the individual, as well as those that are not currently available but are needed.
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