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Home and Community-Based Services Waiver

HCBS Authority: 
1915(c)
Applicable CFR Sections: 
42 CFR §441.300 to 310
Purpose: 

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.

Medicaid Requirements That May Be Waived: 
  • Statewideness
  • Comparability
  • Community income rules for medically needy population
Application Process: 

Application submitted electronically via electronic §1915(c) HCBS waiver application.

Application & Instructions

 

Approval Duration: 

Initial application: 3 years

Renewal: 5 years

Administration & Operation: 

Administered by the Single State Medicaid Agency (SSMA).

May be operated by another state agency under an interagency agreement or memorandum of understanding.

Provider Agreements: 

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.

Medicaid Eligibility: 

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.

Other Eligibility Criteria: 

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

Public Input: 

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.

Target Groups: 
  • 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
Other Unique Requirements: 

May serve multiple target groups within one waiver program and/or have multiple waivers.

Cannot cover:

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.

Case Management: 

Conflict of interest requirements apply under

42 CFR §441.301(b)(vi)

Person-centered planning requirements apply under

42 CFR §441.301(c)(1)

Limits on Numbers Served: 

Allowed.

Waiting Lists: 
Allowed.
Combining Service Populations: 
States may combine service populations.
Caps on Individual Resource Allocations or Budgets: 
Allowed.
Allowable Services: 

Statutory Services:

  • 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

Allowable Participant Settings: 

HCB settings rules apply

42 CFR §441.301

Regulations and CMS Guidance

Provider Qualifications: 

Determined by state, subject to CMS approval.

Participant-directed Services: 
Allowed.
Hiring of Legally Responsible Individuals: 
Allowed at the State’s discretion.
Cash Payments to Participants: 
Direct cash payments not permitted.
Financial Management Services: 

Required if participant direction is offered. May be a waiver service, an administrative function, or performed directly by the SSMA.

Employer Status for Participant Direction: 

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

Goods and Services: 
Permitted as a wavier service.
Direct Payment of Providers: 

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.

Provider Payments: 

Payment item must be listed in the service plan (plan of care), provided by an enrolled provider, and provided prior to reimbursement.

Cost Requirements: 

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.

Quality Management: 

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.

Interaction with State Plan Services, Waivers & Amendments: 

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).