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Home and Community-Based Services Waiver
Provides Home and Community-Based (HCBS) Services to individuals meeting income, resource, and medical (and associated) criteria who otherwise would be eligible to reside in an institution.
- Community income rules for medically needy population
Application submitted electronically via electronic §1915(c) HCBS waiver application.
Initial application: 3 years
Renewal: 5 years
Administered by the Single State Medicaid Agency (SSMA).
May be operated by another state agency under an interagency agreement or memorandum of understanding.
Required between providers and the SSMA.
Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services. Requires written specification of delegated activity.
May use institutional income and resource rules for the medically needy (institutional deeming).
May include the special income group of individuals with income up to 300% of SSI.
Must meet institutional level of care.
Individuals receiving any waiver services must reside in CMS approved allowable HCB settings as per 42 CFR §441.301
Per 42 CFR §441.304(f) public input must be sufficient in light of the scope of the changes proposed. The state must share with the public the entire waiver. State must provide at least two (2) statements of public notice and public input procedures, with one being web-based. The state must provide at least a 30 day public notice and comment period, which must be completed at a minimum of 30 days prior to submission of the proposed change to CMS.
- Aged or disabled
- Intellectually disabled or developmentally disabled
- Mentally ill (under age 22-or over age 64)
- Any subgroup of the above
- May service multiple target groups within one 1915(c) waiver
May serve multiple target groups within one waiver program and/or have multiple waivers.
Room & board costs except for allowable transition services.
Special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.
Conflict of interest requirements apply under
42 CFR §441.301(b)(vi)
Person-centered planning requirements apply under
42 CFR §441.301(c)(1)
- Case management services
- Homemaker/home health aide services & personal care services
- Adult day health services
- Habilitation services
- Respite care
- “Other services requested by State as Secretary may approve”
- Day treatment or other partial hospitalization services*
- Psychosocial rehabilitation services*
- Clinic services*
*For individuals with chronic mental illness
HCB settings rules apply
42 CFR §441.301
Determined by state, subject to CMS approval.
Required if participant direction is offered. May be a waiver service, an administrative function, or performed directly by the SSMA.
Participant may be the employer of record under a Fiscal/Employer Agent model or the entity may be the employer of record under an Agency with Choice model
Required. State may use alternative voluntary option of an Organized Health Care delivery System to make payments.
Exception allowed under §447.10 Prohibition against reassignment of provider claims:
§447.10(g)(4): In the case of a class of practitioners for which the Medicaid program is the primary source of service revenue, payment may be made to a third party on behalf of the individual practitioner for benefits such as health insurance, skills training and other benefits customary for employees.
Payment item must be listed in the service plan (plan of care), provided by an enrolled provider, and provided prior to reimbursement.
Must be cost-effective.
Average annual cost per person served under §1915(c) cannot exceed average annual cost of institutional care for each target group served.
Extensive quality management and quality improvement activities required per the HCBS Waiver Application, including how state will comply with all waiver assurances and how state will conduct quality oversight, monitoring and discovery, remediation, and improvement of issues relating to quality.
Participants have access to and must utilize state plan services before using identical extended state plan services under the waiver.
Waiver services may not duplicate state plan services.
Individuals may be eligible for and receive State plan, §1915(c), §1915(i), §1915(j)/§1915(k) services simultaneously.
May be combined with other waivers such as §1915(a) or (b).