DD-26 Assessment in Nebraska: How DHHS Determines Extraordinary Care for the LRI Program

What the DD-26 Assessment Is

The DD-26 is Nebraska DHHS's standardized assessment tool for determining whether a Medicaid waiver participant requires "extraordinary care" — care that goes beyond what a legally responsible family member (typically a spouse or parent of a minor) would normally be expected to provide.

This assessment matters because it gates access to the Legally Responsible Individual (LRI) program under the Aged and Disabled (AD) Waiver. The LRI program pays family caregivers — specifically spouses and parents — for providing direct personal care. But DHHS won't authorize payment unless the DD-26 confirms your parent's care needs exceed ordinary household assistance.

Without a qualifying DD-26 score, a spouse providing round-the-clock care for a partner with advanced dementia receives nothing from Medicaid for that labor. The assessment is the difference between a family running on empty and a family getting paid for work they're already doing.

What the DD-26 Measures

The assessment evaluates your parent's functional capacity across several domains. The DHHS service coordinator administers it during a face-to-face visit, typically in the home where care is being provided. Key areas include:

• Activities of Daily Living (ADLs) — bathing, dressing, grooming, toileting, transferring, eating, and mobility. The evaluator scores each ADL on a scale from independent to total dependence.
• Behavioral and cognitive factors — wandering, aggression, confusion, inability to recognize danger. A parent with moderate-to-severe dementia who requires constant supervision scores higher than one who simply needs help getting dressed.
• Medical complexity — wound care, catheter management, oxygen therapy, medication administration that requires skilled judgment (not just handing someone a pill). Tasks that would normally require a nurse or trained aide push the extraordinary-care determination.
• Nighttime care needs — whether the caregiver must wake during the night to reposition, toilet, or supervise the participant. Nighttime hours carry weight because they demonstrate that care demands extend beyond a normal waking schedule.

The core question the DD-26 answers: does this person's care require more than what a family member would reasonably do as part of normal household life? A spouse is expected to cook meals and keep a home clean. A spouse is not expected to perform manual transfers from a wheelchair to a bed six times a day or manage complex wound dressings.

How to Prepare for the Assessment

The DD-26 is part of the LRI eligibility process, so getting it right matters. Here's how to prepare:

Keep a care log for at least two weeks before the assessment. Document every task you perform: what time you woke up for nighttime repositioning, how long each bathing and dressing session takes, how many times you redirected a parent with dementia away from the stove or the front door. Specificity matters. "I help Mom with bathing" is vague. "I physically lift Mom into the tub chair, wash her because she can no longer grip the washcloth, and spend 40 minutes on the full process including dressing" is a DD-26 score driver.

Have medical documentation ready. The service coordinator reviews the care log alongside your parent's clinical records. A physician's letter or recent hospital discharge summary that documents cognitive decline, fall risk, or complex medical needs reinforces what the DD-26 evaluator sees in the home.

Be honest about what a bad day looks like. Families often understate care needs during assessments because they've normalized the difficulty. If your parent has episodes of aggression, incontinence, or sundowning that require hands-on intervention, describe them plainly. The evaluator needs to see the full picture, not the best-case version.

Don't clean up the adaptive environment. If you've installed grab bars, removed rugs, locked the kitchen, or placed alarms on doors, leave them visible. These modifications are evidence that your parent's care needs are extraordinary — they tell the evaluator that the home itself has been restructured around safety risks.

What Happens If the Score Is Too Low

If the DD-26 doesn't reach the extraordinary-care threshold, DHHS will not authorize LRI payments. Your parent can still receive AD Waiver services — personal care from an agency aide, respite care, home modifications — but the family caregiver won't be paid for their own labor.

You have two options:

Request a reassessment. If the initial assessment happened on a day when your parent was unusually lucid or cooperative (which happens — the "company effect" is real with dementia patients), ask the service coordinator to schedule another visit. Provide the care log showing the range of what typical days actually look like.

File a State Fair Hearing. If you believe the DD-26 was scored incorrectly — for example, the evaluator didn't observe nighttime care needs or didn't account for behavioral episodes documented in medical records — you can request a formal hearing within 90 days of the denial. Bring the care log, medical records, and any witness statements from other family members or home health aides who can describe the care demands.

Next Steps

The DD-26 is one piece of the AD Waiver enrollment process. Your parent must also meet Medicaid financial eligibility (countable assets at or below $4,000) and meet the Nursing Facility Level of Care criteria. If you're still working through those steps, the Nebraska Medicaid Long-Term Care & Asset Protection Guide covers the full eligibility process, spend-down strategies, and the documentation you need for both the Medicaid application and the waiver enrollment.

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