Patient qualification is the process of assessing, documenting, and formally attesting that a patient meets the specific criteria necessary to receive Long Term Care Pharmacy at Home services. Unlike traditional long-term care (LTC) patients who reside in institutional settings — where eligibility is inherent to their place of care (e.g., nursing facility) — patients receiving LTC-level pharmacy services at home require a higher level of documentation and validation.

• Who Is the Long Term Care Pharmacy at Home Patient?

  A Long Term Care Pharmacy at Home patient is an individual who resides in their private home or community setting but requires a level of pharmacy care typically associated with residents of institutional long-term care (LTC) facilities, such as nursing homes or assisted living centers. These patients qualify for institutional-level pharmacy services due to their complex medical needs, functional limitations, or skilled care requirements.

  Key Characteristics of an LTC Pharmacy at Home Patient

  • The patient is home-based, residing in a private residence rather than a nursing facility, assisted living facility, or other institutional care setting.

  • The patient meets criteria for institutional-level care due to one or more of the following:

    • Multiple chronic conditions requiring complex and ongoing medication management.
    • Cognitive impairments (e.g., dementia) or functional limitations (e.g., limited mobility) that necessitate specialized pharmacy services, such as adherence packaging, scheduled delivery, and pharmacist-led medication reviews.
    • Dependence on skilled services (e.g., home health nursing, physical therapy, occupational therapy, or personal care aides) to assist with activities of daily living (ADLs) and ensure safety in the home.

  • The patient may also be defined as an LTC Pharmacy at Home patient based on program participation or recent care transitions, including:

  • Enrollment in a qualifying Medicaid waiver program (such as a Home and Community-Based Services [HCBS] waiver or other long-term services and supports [LTSS] program) that certifies their need for skilled care at home.

    • Recent discharge from a skilled nursing facility (SNF) or from the skilled nursing floor of a hospital following a skilled length of stay, where the patient continues to require LTC-level pharmacy support upon returning home.

• Patient Qualification Process for Long Term Care Pharmacy at Home Services

  Pharmacies providing Long Term Care Pharmacy at Home services are responsible for verifying that patients meet established eligibility criteria before enrolling them in LTC-level pharmacy care. This qualification process ensures that services are provided only to those who truly require an institutional level of pharmacy support in the home, protecting patients, payers, and the integrity of the LTC Pharmacy at Home model.

  The qualification process is structured in two sections.

  Section 1: Qualification via Waiver, Program, or Recent Discharge

  Section 1 focuses on determining whether a patient qualifies for Long Term Care Pharmacy at Home services based on participation in a recognized program or recent transition from skilled care.

  Key pathways to qualification under Section 1:

  • 1A: The patient is currently enrolled in or qualifies for a Home and Community-Based Services (HCBS) program or another qualifying waiver, or Medicaid or Medicare program.
  • 1B: The patient was discharged from a long-term care facility, skilled facility, or skilled nursing floor of a hospital within the past six months.

  Section 2: Qualification via Patient Status

  Section 2 is used when a patient does not qualify through waiver status or recent discharge, or to further document patient needs. It evaluates the patient’s health conditions and functional limitations to determine eligibility for LTC Pharmacy at Home services.

  Qualification requirements under Section 2:

  • 2A: The patient has two or more barriers in Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs).
  • 2B: The patient has three or more chronic diseases consistent with CMS chronic condition criteria.
  • 2C: The patient is on prescribed maintenance medications for those chronic conditions.
  • 2D: The patient has limited mobility that makes leaving the home independently difficult.

  Important Considerations:

  • The patient must meet all four criteria (2A, 2B, 2C, and 2D) in order to qualify under Section 2.
  • Detailed documentation of each element should be included in the patient profile to ensure compliance and audit readiness.

• Patient Qualification Process for Long Term Care Pharmacy at Home Services

  Section 1: Qualification via Waiver, Qualifying Program, or Recent Discharge

  Patients may qualify for Long Term Care Pharmacy at Home services through enrollment in a Home and Community-Based Services (HCBS) waiver, another qualifying long-term services and supports (LTSS) program, another qualifying Medicare or Medicaid program, or recent discharge from a long-term care facility or skilled nursing floor of a hospital.

  These qualification routes reflect that the patient has already been formally assessed as needing an institutional level of care, even while living at home. Waiver programs certify that the patient requires skilled services in the community as an alternative to institutionalization. Similarly, a recent discharge signals that the patient was receiving institutional-level skilled care and, upon returning home, is at heightened risk of adverse outcomes without continued structured support.

  Pharmacies play a critical role during this period, providing the medication management and oversight necessary to support the patient’s recovery, reduce rehospitalization risk, and contribute to better health outcomes at a lower cost.

  1A – Waiver or Other Program Participation

  One of the primary ways a patient may qualify for Long Term Care Pharmacy at Home services is through enrollment in or qualification for a Home & Community-Based Services (HCBS) program, 1915(c) waiver, or another long-term services and supports (LTSS) waiver or Medicare and/or Medicaid program that certifies the patient’s need for skilled care at home.

  Medicare and/or Medicaid Funded Programs as a Basis for Qualification

  Patients enrolled in these programs have already been evaluated and certified by the state Medicaid agency or another authorized entity as requiring an institutional level of care — the same level of care that would be provided in a nursing facility, but delivered in the community or home.

  • Qualification occurs because:

    • The waiver enrollment process includes a formal determination of medical necessity and functional need consistent with long-term care facility eligibility.
    • Waiver and qualifying program participation demonstrate that the patient requires ongoing skilled care or assistance with activities of daily living
    • These programs are designed specifically to substitute or supplement care that would otherwise be provided in a nursing facility, ensuring the patient’s care needs align with the level of pharmacy service provided in LTC Pharmacy at Home.

  Examples of Waiver or Qualifying Programs That Determine Qualification

  Disclaimer: The below examples of waiver programs and qualifying services provided in this section are for illustrative purposes only and do not represent an exhaustive list of all programs that may or may not qualify a patient for Long Term Care Pharmacy at Home services. Pharmacies must exercise due diligence and are responsible for independently verifying that any waiver, program, or service cited as the basis for qualification includes an enrollment process and eligibility criteria that meet the patient status requirements for institutional-level pharmacy care in the home. Pharmacies should not rely solely on this webpage or its examples to determine eligibility. Always consult official program documentation, payer guidance, and contractual obligations to ensure compliance.

  • Medicaid 1915(c) Home and Community-Based Services (HCBS) Waivers
    • (e.g., aging and disability waivers, brain injury waivers, technology-dependent waivers)
  • Medicaid Managed Long-Term Services and Supports (MLTSS) Programs
  • Some Programs of All-Inclusive Care for the Elderly
  • State-specific long-term services and supports waiver programs
  • Other CMS-approved waivers or chronic disease programs that specify the patient meets the skilled level of care criteria

  1B – Recent Discharge

  One of the ways a patient may qualify for Long Term Care Pharmacy at Home services is if they were recently discharged (within the past six months) from a long-term care facility or a skilled nursing floor of a hospital. This criterion serves as a qualifying factor because such a discharge signals that the patient was receiving institutional-level skilled care and, upon returning home, is at heightened risk of adverse health outcomes without continued structured support.

  Recent Discharge as a Basis for Qualification

  A discharge from a long-term care facility or skilled nursing floor signifies that the patient required institutional-level care prior to returning home, care that involved daily skilled interventions and oversight. Because the patient’s condition was serious enough to warrant such care, the patient is presumed to require continued institutional-level pharmacy services during their transition back to the home environment. Providing LTC Pharmacy at Home services during this period ensures that the patient receives the same level of pharmacy support they would have had in the facility, helping to stabilize their condition, support recovery, and prevent costly complications.

  The Pharmacy’s Role in Reducing Risk and Cost

  • Pharmacies providing LTC Pharmacy at Home services during this critical transition period help fill the gap left as patients move out of 24-hour skilled care.
  • Services such as adherence packaging, monthly medication reviews, 24/7 pharmacist access, and coordinated delivery provide crucial safeguards to prevent medication-related complications.
  • By ensuring accuracy in medication regimens, supporting adherence, and facilitating communication with prescribers, pharmacies can:
    • Help patients safely manage their therapies at home
    • Reduce avoidable hospital readmissions
    • Contribute to lower total healthcare costs and better patient outcomes

  How to Define a Skilled Facility or Unit

  A skilled facility refers to a setting where the patient receives care that requires the involvement of licensed medical professionals — typically under Medicare or Medicaid definitions — to provide rehabilitation services, medical monitoring, or assistance with complex medical needs. Examples include:

  • A skilled nursing facility (SNF) covered by Medicare Part A, where patients receive daily skilled services (e.g., wound care, IV therapy, physical therapy) following hospitalization or due to chronic conditions.
  • A long-term care facility that provides institutional-level skilled nursing care on a continuous basis.

  A skilled nursing floor (or unit) within a hospital provides inpatient skilled care after surgery, severe illness, or injury. This care typically includes:

  • Rehabilitation following major surgery (e.g., joint replacement, cardiac surgery)
  • Skilled medical monitoring for complex conditions
  • IV therapy, wound management, or respiratory care

  Important Billing and Classification Points

  The discharge must be from a Medicare- or Medicaid-recognized skilled level of care setting (e.g., SNF or skilled hospital unit/floor).

  A discharge from a hospital stay where the patient was under observation status or a standard acute care hospital floor does not qualify.

  Simply being an inpatient for general medical treatment without documented skilled nursing or rehab care does not qualify.

  Skilled Nursing Facility or Skilled Unit Identification Support Materia

  To support pharmacies in accurately determining patient qualification under the recent skilled discharge criterion, this website includes a Skilled Facility / Skilled Unit Identification Guide. The guide provides practical steps for distinguishing skilled nursing facilities, hospital skilled floors, and qualifying rehab units from non-skilled settings, ensuring compliant patient eligibility determinations.

  The Skilled Nursing Facility or Skilled Unit Identification Guide is available to download here: [SKILLED FACILITY UNIT IDENTIFICATION GUIDE]

  Section 2: Qualifying via Patient Status

  When a patient does not qualify for Long Term Care Pharmacy at Home services through participation in a program or recent discharge from skilled care, eligibility may still be established by carefully assessing the patient’s health status, functional limitations, and care needs.

  Section 2 of the Qualification Form provides a structured process for evaluating whether the patient requires an institutional level of pharmacy care while living at home. This approach considers multiple factors — including barriers in activities of daily living (ADLs), the presence of chronic diseases, medication complexity, and mobility limitations — to ensure that pharmacy services are appropriately directed to those with significant clinical needs.

  This pathway ensures that patients who truly need long-term care pharmacy support in the home receive it, even if they are not enrolled in a formal waiver program or recently discharged from an institutional setting. The documentation collected in this section demonstrates compliance with payer, PBM, and regulatory requirements while supporting the delivery of safe, effective care.

  • 2A – ADL / IADL Assessment
    

    The first step in qualifying a patient via patient status is to evaluate the patient’s ability to independently manage essential daily tasks using an Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) assessment.

  What are ADLs and IADLs?

  • Activities of Daily Living (ADLs) refer to basic self-care tasks necessary for fundamental functioning. These typically include:
    • Bathing
    • Dressing
    • Toileting/Continence
    • Transferring (e.g., moving from bed to chair)
    • Eating
    • Grooming/Mouth Care
    • Communicating
    • Walking
    • Climbing Stairs
  • Instrumental Activities of Daily Living (IADLs) refer to more complex tasks required for independent living. These include:
    • Managing medication
    • Preparing meals
    • Managing finances
    • Using the telephone
    • Shopping
    • Housekeeping/housework
    • Transportation (self-driving or using public transportation)

  How to Perform the ADL / IADL Assessment

  Review the patient’s ability to independently perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) using direct patient or caregiver interviews, care plans, or other clinical records.

  Evaluate each activity individually to identify where the patient requires assistance, cueing, or supervision.

  Confirm whether the patient has two or more barriers, meaning they require assistance or are unable to independently perform at least two of the listed activities.

  How to Document the ADL / IADL Assessment

  • On the qualification form, the ADL / IADL section includes
    • A checklist of individual ADLs and IADLs.
  • The reviewer checks off the specific activities where the patient has barriers or requires assistance.
  • A minimum of two ADL or IADL barriers must be checked on the qualification form for the patient to move forward to Section 2B.
  • Additional details about the nature of the barriers, type of assistance required, and source of verification (e.g., caregiver statement, care plan) should be documented in the pharmacy management system (PMS) or other clinical record.
    • Example: “Patient requires daily assistance with bathing and medication management. Verified during caregiver interview on 7/15/25.”

  Source of ADL/IADL Standards

  The list of ADLs and IADLs used for this qualification process is based on well-established definitions found in publications of the National Institutes of Health (NIH), particularly through the National Library of Medicine (NLM). These standards are widely referenced in government, healthcare, and social services programs as benchmarks for evaluating functional independence. These benchmarks are also consistent with the criteria used by CMS, state Medicaid agencies, and long-term care insurance plans for determining level-of-care needs.

  • For reference, visit:
    • National Institute of Health, National Library of Medicine. Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). StatPearls. © 2025; Bookshelf ID: NBK 470404. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470404/

  • 2B – Chronic Disease Evaluation

    The second step in qualifying a patient via patient status is to assess whether the individual has three or more chronic diseases that reflect the need for institutional-level pharmacy support in the home.

  What Are Chronic Diseases and How Are They Defined?

  In the context of Long Term Care Pharmacy at Home qualification, chronic diseases are defined as conditions that meet specific, standardized criteria established by government agencies—primarily the Centers for Medicare & Medicaid Services (CMS). CMS defines chronic diseases using diagnostic codes and utilization patterns based on Medicare and Medicaid claims data, as well as criteria used in their Chronic Condition Special Needs Plans (C-SNP).

  Chronic diseases are conditions that last for an extended period of time, often persisting for a year or more, and typically require ongoing medical attention, management of symptoms, and coordination of care. These conditions can limit a person’s ability to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs), increase the risk of hospitalization, and contribute to higher overall health care costs.

  Key characteristics of chronic diseases:

  • Persistent over time, typically requiring long-term management
  • Associated with complex medication regimens and a higher risk of medication-related problems
  • Often linked to functional decline or the need for skilled services in the home

  How to Perform the Chronic Disease Evaluation

  • Review the patient’s medical record, current medication profile, care plans, and/or prescriber documentation.
  • Identify all chronic conditions from the CMS-recognized lists, including the Chronic Conditions Data Warehouse (CCW) and the Chronic Condition Special Needs Plan (C-SNP) list.
  • Confirm that at least three chronic conditions relevant to long-term care pharmacy services are present.

  How to Document the Chronic Disease Evaluation

  On the qualification form, this section is streamlined for efficiency:

  • A checkbox with a list of chronic diseases is provided to indicate whether the patient meets the minimum requirement of three or more chronic conditions.
    • 3 or more chronic diseases should be checked in order for a patient to qualify for Long Term Care Pharmacy at Home services.
  • Detailed documentation of each condition—including the diagnosis, related medications, and source of verification—can be recorded in the pharmacy management system (PMS) or another designated clinical documentation tool.
    • Reference the CMS source list (e.g., “CCW condition flag” or “C-SNP condition”) when recording conditions.
    • Link conditions to corresponding medications where applicable.

  Chronic Disease List on the Qualification Form

  The chronic disease section of the Long Term Care Pharmacy at Home Patient Qualification Form includes a core list of common chronic conditions. These conditions are pre-populated on the form and represent those most frequently identified by CMS as requiring long-term care level services and medication management.

  • Abuse (Alcohol/Drug/Substance)
  • Acute MI
  • Alzheimer’s & related dementia
  • Anemia
  • Asthma
  • Atrial fibrillation
  • Autism Spectrum Disorders
  • BPH
  • Breast Cancer
  • Colorectal Cancer
  • Lung Cancer
  • Prostate Cancer
  • Chronic Kidney Disease
  • COPD
  • Congestive Heart Failure
  • Depression
  • Diabetes
  • Glaucoma
  • Hepatitis B/C
  • HIV/AIDS
  • Hyperlipidemia
  • Hypertension
  • Ischemic Heart Disease
  • Osteoporosis
  • Rheumatoid Arthritis
  • Schizophrenia/psychotic disorders
  • Stroke/TI

  An “Other” field for additional chronic conditions

  In recognition that some patients may have less common but still qualifying chronic conditions, the form provides an “Other” field where the pharmacy may document additional chronic diseases that contribute to the patient’s eligibility.

  Important guidance for using the “Other” field:

  • The chronic condition written into this field must appear on an official CMS-recognized chronic condition list, such as the CCW Chronic Condition Algorithm List or the C-SNP Chronic Disease List.
  • Conditions that are not directly referenced by CMS (e.g., isolated symptoms, risk factors without diagnosis, or non-chronic conditions) do not qualify as chronic diseases for the purpose of LTC Pharmacy at Home eligibility.
  • The pharmacy is responsible for ensuring that any condition entered as “Other” is supported by documentation (e.g., prescriber notes, care plans) and clearly traceable to CMS sources.

  Where to Reference the Source for Chronic Diseases for LTC Pharmacy at Home Qualification

  Pharmacies must reference official chronic disease lists published or endorsed by CMS to ensure consistency and compliance in the qualification process. These sources provide standardized definitions that align with payer expectations, audit standards, and regulatory requirements.

  • CMS Chronic Conditions Data Warehouse (CCW)

    • The CCW provides a list of chronic conditions identified through claims data algorithms used for Medicare and Medicaid populations.
      • https://www2.ccwdata.org/web/guest/home

  • CMS Chronic Condition Special Needs Plan (C-SNP) Chronic Disease List

    • This list outlines the chronic conditions that qualify patients for C-SNP enrollment and reflects conditions requiring coordinated, specialized care.
      • https://www.cms.gov/medicare/health-plans/specialneedsplans/c-snps

  2C – Medication Complexity

  
  

  The next step in qualifying a patient via patient status is to assess the complexity of the patient’s medication regimen as it relates to their chronic conditions. Medication complexity is a key indicator of the need for institutional-level pharmacy services, as patients with multiple chronic conditions often require intricate medication management to ensure safety, adherence, and therapeutic effectiveness.

  How to Perform the Medication Complexity Evaluation

  Review the patient’s current medication list in the Pharmacy Management System (PMS), provided by a prescriber and/or home care agency, and during patient/caregiver interviews.

  Confirm that the patient is actively prescribed and taking maintenance medications that are directly associated with the chronic conditions documented in Section 2B.

  • The patient must have active prescribed maintenance medications for the chronic conditions identified in Section 2 B.

  Maintenance medications are defined as those prescribed for ongoing management of chronic diseases, not short-term or acute treatments (e.g., antibiotics for infection, short-course steroids).

  How to Document Medication Complexity on the Qualification Form

  On the qualification form, Section 2C is designed for simplicity and efficiency:

  The form provides a Yes/No checkbox to indicate whether the patient is taking prescribed maintenance medications for their documented chronic conditions.

  There is a space to record the total number of maintenance medications the patient is taking.

  Detailed documentation of the specific medications, corresponding chronic conditions, doses, and any relevant clinical notes should be completed within the pharmacy management system (PMS).

  This can be recorded using prescription ICD-10 coding fields, prescription notes, or designated clinical documentation sections in the PMS.

  The pharmacy is responsible for ensuring that this documentation is complete and audit-ready.

  • 2D – Limited Mobility Assessment

    The final step in the patient status qualification process is to evaluate whether the patient’s mobility significantly restricts their ability to leave the home safely and independently. This ensures that Long Term Care Pharmacy at Home services are provided to patients who require pharmacy support at the same level as those residing in long-term care facilities.

  How to Perform the Limited Mobility Evaluation

  The limited mobility evaluation is based on the question: “Does this patient have mobility issues that make leaving the home independently difficult?” This question helps determine whether the patient’s functional status warrants Long Term Care Pharmacy at Home services, ensuring pharmacy care is appropriately aligned with the patient’s needs. The evaluation focuses on identifying physical, cognitive, or safety barriers that prevent safe, independent community mobility.

  Gather Information from Multiple Sources:

  • Interview the patient and/or caregiver directly.
  • Review any available care plans, prescriber notes, or home health assessments.
  • Consider information from prior facility discharges or case management records

  Assess Functional Ability to Leave the Home Independently:

  Ask or review:

  • Can the patient leave the home without assistance from another person?
  • Does the patient require assistive devices (e.g., wheelchair, walker, cane) and, if so, can they use them without assistance?
  • Are there physical, cognitive, or safety-related barriers that prevent the patient from navigating public spaces independently?

  Identify Barriers to Mobility:

  Common qualifying examples include:

  • The patient requires caregiver assistance to leave the home safely due to balance, strength, or coordination issues.
  • The patient is unable to drive and cannot use public transportation alone.
  • The patient has conditions (e.g., severe arthritis, stroke, advanced Parkinson’s disease, COPD) that limit endurance or mobility, creating a high risk of harm if attempting to leave the home unaided.

  Examples of Situations That Would Meet This Criterion

  • The patient requires a wheelchair, walker, or cane and cannot safely manage these without assistance from a caregiver.
  • The patient suffers from severe arthritis, Parkinson’s disease, or stroke-related deficits that impair gait or balance.
  • The patient has a neurological condition(s) that limits their ability to navigate independently outside the home.
  • The patient experiences chronic shortness of breath that makes ambulation beyond the home extremely difficult without support.
  • The patient cannot drive or access public transportation and cannot arrange alternative transportation independently due to their health status.

  Examples of Situations That Would Not Meet This Criterion

  • The patient chooses not to leave the home but is physically capable of doing so without assistance.
  • The patient relies on others for transportation for convenience, not due to a medical or functional limitation.

  Breaking Down the Meaning of the Assessment Question

  • Limited mobility: This refers to a patient’s reduced ability to move freely and safely due to physical, neurological, or functional impairments.
  • Makes leaving the home independently difficult: The patient cannot leave the home without assistance from another person or specialized equipment and would be at risk of harm if they attempted to do so alone.
  • The question aims to capture whether the patient’s condition creates a level of functional limitation comparable to that of an institutionalized individual, where pharmacy services must be brought to the patient

  How to Document the Limited Mobility Assessment on the Qualification Form

  • The form includes a single Yes/No checkbox with the question:

    • “Does this patient have limited mobility that makes leaving the home independently difficult?”

      • Yes must be selected for the patient to meet this qualification criterion and proceed toward approval for LTC Pharmacy at Home services.

  Documentation Best Practices

  The Yes/No checkbox is used to capture the determination on the form.

  Supporting details—such as the nature of the mobility limitation, equipment used, or caregiver assistance required—can be documented in the pharmacy management system (PMS) or clinical notes.

  • Example: “Patient unable to ambulate outside home without caregiver assistance due to Parkinson’s-related balance deficits.”

  Limited Mobility Assessment Support Material

  • Limited Mobility Assessment Guide

    • A copy of the Limited Mobility Assessment Guide can be downloaded here:

      [LINK LIMITED MOBILITY ASSESSMENT]

  • Limited Mobility Assessment Checklist

    • A copy of the Limited Mobility Assessment Checklist can be downloaded here:

      [LINK LIMITED MOBILITY CHECKLIST]