Summary of States Core Standardized (CSA) Instruments March 2015 The Balancing Incentive Program requires states to use a Core Standardized (CSA) instrument(s) to 1) determine eligibility for Medicaid-funded community long-term services and supports (LTSS), 2) identify individuals support needs, and 3) inform their service and support planning (e.g., plan of care). The CSA instrument(s) and process should be uniform for a given population across the state. In addition, the CSA instrument(s) should capture a Core Dataset (CDS). The CDS contains five domains: activities of daily living (ADLs), instrumental activities of daily living (IADLs), medical conditions/diagnoses, cognitive functioning/memory, and behavior concerns. Four of these domains (ADLs, IADLs, cognitive functioning/memory, and behavior concerns) contain topics (sub-domains) that are also required components of the CDS. The table below describes state CSA instruments by population, as presented in Work Plans and through quarterly progress report updates. For more information, please see Work Plans posted on Medicaid.gov: http://www.medicaid.gov/medicaid-chip- Program-Information/By-Topics/Long-Term-Services-and- Supports/Balancing/Balancing-Incentive-Program.html.
Glossary of Acronyms ABAS (Adaptive Behavior System) ABI (Acquired Brain ) ADLs (Activities of Daily-living) ADRC (Aging and Disability Resource Center) AIF (ADRC Intake Form) ANSA (Adult Needs and Strengths ) (Child and Adolescent Needs and Strengths) CDS (Core Dataset) CHA (Community Health ) CMH (Community Mental Health) CMI (Care Management Instrument) CSA (Core Standardized ) (Comprehensive Social Health ) DD (Developmental Disability) DDRT (Developmental Disabilities Resource Tool) DLA (Daily Living Activities) DON (Determination of Need) HC (Home Care) HCB (Home and Community Based) HSP Need (Home Services Program) IADLs (Instrumental Activities of Daily-living) ICAP (Inventory for Client and Agency Planning) ICF (Intermediate Care Facilities) ID () IEP (Individualized Education Program) INDA (Integrated Need for Discharge ) LCD (Level of Care Determination) LTSS (Long-term Service and Support) LOCSI (Level of Care Screening Instrument) LOCUS (Level of Care Utilization System) MASSCAP (Massachusetts Association for Community Action) (Minimum Dataset Home Care) MEA (Medical Eligibility ) MED (Medical Eligibility Determination) NF (Nursing Facility) OA (Outcome Information Set) PASRR (Preadmission Screening and Resident Review) PCA (Personal Care Assistant) PDN (Private Duty Nursing) SIB (Scales of Independent Behavior) (Support Intensity Scale) UAS-NY (Uniform System for New York) UAT (Uniform Tool) VABS (Vineland Adaptive Behavior Scales)
AR interrai CMH interrai ID CT Home grown based on the interrai Home grown based on the interrai GA Under revision Health Risk Screening Tool Intermediate Level of Care for ICF-MR Home grown based on the interrai Intermediate Level of Care for NF Participant Form Home grown based on the interrai; Intermediate Level of Care for NF Participant Form Home grown based on the interrai; IA LOCUS Mayo-Portland IL IN** UAT under development Mental Health Report (per Rule 132) LOCUS (as required) ANSA UAT under development Current tool is ICAP LOCSI KY LOCUS MAP 351 Medicaid Waiver (current); however, seeking new population-specific UAT under development Statewide Comprehensive Needs Form DON for Combined Case Management and Eligibility Screen MAP 351 Medicaid Waiver (current) Seeking new populationspecific UAT under development DON HSP Needs for Combined Case Management and Eligibility Screen MAP 351 Medicaid Waiver Seeking new population-specific UAT under development DON HSP Needs Map 351 Medicaid Waiver ABI Seeking new population specific
LA** MA* LOCUS OA Application, Evaluation for PCA Services, Consumer ICAP Louisiana Plus s from School IEP or standardized educational by licensed professionals MASSCAP, Vineland II or ABAS II OA Application, Evaluation for PCA Services, Consumer OA Application, Evaluation for PCA Services, Consumer OA Application, Evaluation for PCA Services, Consumer MD DLA-20 with revisions Under re-evaluation OA Application, Evaluation for PCA Services, Consumer ME For adults: LOCUS; ANSA; ISP; PASRR I and II For children: MED Kids-KB ; MED Kids- PDN ; For adults: DS Comprehensive/Support HCB Waiver (BMS-99); PASRR II Psychosocial/Function Evaluation #3; PASRR I For children: MED Kids-KB ; MED Kids-PDN ; MED For adults: MED For children: MED Kids-KB ; MED Kids-PDN ; Brain Tool for Section 97 Eligibility for Residential Services MO DLA-20 Prioritization of Need for DD Services MO HealthNet Application/ Eligibility MO HealthNet Application/
Statement Eligibility Statement MS ICAP NH NJ NV NY OH ANSA interrai Tool or other comparable tool Trigger questions for MI population on Level 1 Screen INDA AIF ABAS VABS For adults: interrai CMH; interrai CHA For children: -NY Home-grown tool, still in development. interrai Tool or other comparable tool Trigger questions for DD population on Level 1 Screen DDRT AIF VABS interrai DD Tool; CAS Home-grown tool, still in development. Medical Eligibility (MEA) NJ CHOICE (interrai ) Screen for Community Services AIF interrai CHA UAS-NY Community Home-grown tool, still in development. MEA NJ CHOICE (interrai ) Screen for Community Services For adults: interrai CHA; UAS-NY Community For children: interrai Pediatric 0-3; UAS-NY Community ; interrai Pediatric 4-17 Home-grown tool, still in development. NJ CHOICE (interrai ) Screen for Community Services interrai CHA UAS-NY Community
PA Community Support Plan TX ANSA PA Plus Adult Autism Waiver (AAW) & Adult Community Autism Program (ACAP) Eligibility Worksheet MA-51 New tool being researched ICAP and Form 8662: Related Conditions Form 8578: ID CMI LCD Form 2060, Needs Form 2060b CMI LCD Form 2060, Needs Form 2060b * MA provides much of its community LTSS through state plan services; therefore, s to develop plans of care are often based on type of service and not population type. ** As of 12/31/2014, state is no longer participating in the Program. CMI LCD