Lifecycle phase:BuildingMissouri Medicaid Home and Community Based Services Eligibility Issues
Problem Statement
In 2018, the Missouri Department of Health and Senior Services (DHSS) proposed a new algorithm for determining qualification for home and community based services (HCBS). The state put this Nursing Facility Level of Care (NF LOC) algorithm up for public comment, which used variables from the InterRAI assessment system. Testing by legal aid organizations, home and community based services providers, and outside researchers at Upturn, showed that the algorithm could disqualify as many as 66% of currently eligible people. The algorithm also contained some basic syntax errors that might have led to unintended results. The state published subsequent versions of the algorithm which decreased the percentage of beneficiaries who would likely be found ineligible, but all versions failed to capture many people’s needs.
Unlike many other cases, this algorithm was made publicly available for comment by the state, and no litigation has happened yet. Legal aid and home health care organizations worked together to understand the implications of the algorithm. Many problems were identified in rounds of public comment, especially about which variables from patients’ assessments are included in the algorithm and how they are considered. For example, the algorithm considered people’s mobility issues with getting in and out of bed, but not with getting up and down stairs. In 2020, Missouri DHSS contracted with Mercer Government Human Services Consulting to do an official analysis of the algorithm’s impacts.
Missouri DHSS postponed implementation of their final version (v2.3) of the algorithm from June 2021 to October 2024 due to federal funding obligations from the Public Health Emergency. During this time period, eligibility could be established by meeting either the previous criteria or the new algorithm’s criteria. As of October 1, 2024, Missouri DHSS switched to determining eligibility only using the new LOC algorithm.
Status of Issue
Now that the newest algorithm is in place, Legal Services of Eastern Missouri’s advocacy has shifted to helping individuals who have lost eligibility during redeterminations or who have been denied when newly applying for HCBS since October 2024. So far, losses in coverage have occurred, but not to the extreme level projected from earlier versions of the algorithm.
Links to More Information
Missouri DHSS LOC Transformation Project Website
Postponement announcement, June 2021
LOC Algorithm v2.2 Frequently Asked Questions
October 2024 Missouri Independent article about the new eligibility algorithm
Key Parties Involved & Contact
Legal Services of Eastern Missouri
Primary Advocate Contact: Jamie Rodriguez
HCBS providers
Upturn
Missouri Department of Health and Senior Services
Go Long Consulting
Mercer Consulting
interRAI
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