Authority Comparison Chart

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Title	1915(c) 1915(c) Home and Community- Based Services Waiver	1115 1115 Research and Demonstration Project Waiver
Authority Type	Waiver Information found at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html	Demonstration Waiver Information found at: https://www.medicaid.gov/medicaid/section-1115-demonstrations/index.html
Original Effective Date and Governing Regulations	Enacted into statute: 1981 This rule was revised and added to the existing 1915 (c) regulations Issued: January 16, 2014 (effective March 17, 2014) Settings that were in the state’s HCBS delivery system prior to the effective date of the rule (3/17/14) must comport with the settings requirements in the final rule by 3/17/2023. Settings that are new to the state’s HCBS delivery system after March 17, 2014 must comport with the final rule settings requirements prior to HCBS being delivered in those settings. All other requirements in this final rule, including conflict of interest mitigation and person-centered planning requirements, became effective on March 17, 2014. Link to 1915(c) Regulations	Enacted into statute: 1990 Final Rule: February 27, 2012 Link to 1115 Regulations
Purpose	The 1915(c) waiver authority permits a state to offer home and community-based services to individuals who: (a) are found to require a level of institutional care; (b) are members of a target group that is included in the waiver; (c) meet applicable Medicaid financial eligibility criteria; (d) require one or more waiver services in order to function in the community.	Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve their programs.
Requirements That May Be Waived or Disregarded (for state plan options)	State-wideness Comparability Community income rules for medically needy population	Secretary may waive multiple requirements under §1902 of the Social Security Act if waivers promote the objectives of the Medicaid law and intent of the program.
Application Process and Application Templates/Preprints	Information on waiver processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html Application submitted electronically via §1915(c) HCBS waiver application. Application and instructions available at: https://wms-mmdl.cms.gov/WMS/faces/portal.jsp	Standardized application requirements found at: 431.412(a)(1): https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html Depending on the nature and scope of the 1115 application, different processes may apply. It is advisable for states to contact CMS to discuss application intentions prior to submission.
Approval Duration and Requirements for Amendments	Initial application: 3 years (5 year-approvals available if the program serves individuals eligible for both Medicare & Medicaid) Renewal:5 years States may make amendment to the approved waiver at any time during the approved waiver period. Waiver amendments with substantive changes may only take effect on or after the date when the amendment is approved by CMS. Substantive changes also must be accompanied by information on how the state has assured smooth transitions and minimal adverse impact on individuals impacted by the change.	Initial application: 5 years Renewal: 5 years
Reporting Requirements	Annual reports. (CMS 372 reports on statistical data and quality). Evidence Based Review process prior to renewal. Link to process: https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf	Monthly progress calls, quarterly and annual progress reports and other reports as required in the approved STCs.
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.	Administered by the Single State Medicaid Agency (SSMA). Certain provisions may be operated by other entities as approved by CMS.
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 and a voluntary reassignment of payment by the provider of services.	Required unless otherwise stipulated in the approved standard terms and conditions and approved waiver authorities.
Medicaid Financial Eligibility	A state may specify the Medicaid eligibility groups that are served in the waiver. In order for an eligibility group to be included in the waiver, it must already have been included in the state plan. States are permitted to use institutional income and resource rules for the medically needy (institutional deeming). May include the special income level group of individuals and may permit income up to 300% of SSI.	State defines eligibility categories and may expand or propose modified eligibility within the 1115 demonstration.
Target Groups (if applicable) and Other Eligibility Criteria	Individuals must meet institutional level of care. Waivers are limited to one or more of the following target groups or any subgroup thereof: Aged or disabled, or both; Individuals with Intellectual Disabilities or a developmental disability, or both; Persons with mental illnesses. States may also specify age ranges within the target groups and/or subgroups served. Additional targeting criteria may include but are not limited to: Nature or type of disability; Specific diseases or conditions; Functional limitations (e.g., extent of assistance required in activities of daily (ADLs) and/or instrumental activities of daily living (IADLs). Additional criteria also may be specified in order to align the waiver to service population eligibility criteria that are specified in state law.	The approved Special Terms and Conditions as approved by the Secretary set forth the eligibility requirements for benefit packages and/or services.
Public Input	42 CFR 447.205. for payment methodology The state is required to establish a public input process specifically for HCBS waiver changes that are substantive in nature. Consistent with 42 CFR 441.304(f) stipulates that a state must share with the public the entire waiver. In addition, the state’s public input process must have included at least two (2) statements of public notice and public input procedures, with at least one being web-based AND at least one being non-electronic to ensure that individuals without computer access have the opportunity to provide input. This state must provide at least a 30-day public notice and comment period, and be completed prior to submission of the proposed change to CMS.	States must provide at least a 30-day public notice and comment period for applications for new demonstrations and extensions of existing demonstrations. This process is followed by a federal public comment period. Information about the process can be found at https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-transparency-requirements/index.html.
Other Unique Requirements	States may operate multiple 1915(c) HCBS waivers Cannot cover: Room & board costs. Habilitation does not include special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.	State must operate in accordance with the approved Special Terms and Conditions. Cannot cover: Room & Board costs.
Limits on Numbers Served	Allowed.	State estimates numbers served. Operates as an entitlement to all who are eligible.
Waiting Lists	Allowed.	May depend on state’s approved STPs.
Caps on Individual Resource Allocations or Budgets	Allowed.	Budget neutrality must be maintained. Caps or benefit limits may apply pursuant to approved STPs.
Allowable Services	Statutory Services: Case management services Homemaker/home 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 Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final rule.	State decides what services are covered, subject to CMS approval.
Provider Qualifications	Reasonable standards identified by the state, subject to CMS approval.	Determined by state, subject to CMS approval.
Participant-directed Services	Allowed at state election.	Allowed subject to approved STCs.
Hiring of Legally Responsible Individuals	Allowed at the state election.	Allowed at state election.
Cash Payments to Participants	Direct cash payments not permitted.	Direct cash payments not permitted.
Financial Management Services	Required if participant direction is offered. May be covered as a waiver service or a Medicaid administrative activity.	Subject to specific requirements set forth in the approved STPs.
Employer Status for Participant Direction	States may identify what options are available for employer authority in a participant directed model of service: Co-Employment. Under this approach, the participant is supported by an agency that functions as the common law employer of workers recruited by the participant. Also known as “agency with choice.” Common Law Employer. Under this approach, the participant is considered the legally responsible employer (common law employer) of workers whom he or she (or his or her representative) hires, supervises and discharges directly. The participant or his or her representative is liable for the performance of necessary employment-related tasks and uses a Government or Vendor Fiscal/Employer Agent.	Subject to specific requirements set forth in the approved STPs.
Goods and Services	Permitted as a waiver service.	Permitted subject to the approved STCs.
Direct Payment of Providers	Required (state may offer options that can be utilized voluntarily by providers to meet this requirement). Can be coupled with a managed care authority for different payment arrangements.	Required (state may offer options that can be utilized voluntarily by providers to meet this requirement) unless otherwise stipulated in approved STCs.
Provider Payment Rates	State must describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination.	Payment rates and methodologies subject to the provisions approved within the STCs.
Cost Requirements	Cost-neutrality. Average annual Medicaid costs per waiver participant cannot exceed average institutional cost per person for each level of care.	Budget neutrality. Federal spending under the waiver cannot exceed what it would have been spent in absence of the waiver.
Quality Improvement	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.	Extensive data collection and evaluation plans to assess the effectiveness of the project or demonstration as established within the state’s approved STCs. HCBS requirements apply if the 1115 contains HCBS.
Interaction with State Plan Services, Waivers, & Amendments	Participants have access to and must utilize state plan services provided under 1905(a) (including all EPSDT benefits) 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 services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services. HCBS waivers may be operated concurrently with other authorities, for example 1915(a) or 1915(b).	State defines relationship to state plan, waivers, and amendments, subject to CMS approval.
Conflict of Interest	Requirements at 42 CFR 431.301(c)(1)(vi). Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person centered service plans in a geographic area also provides HCBS. In these cases, the State must devise conflict of interest protections including separation of entity and provider functions within provider entities, which must be approved by CMS. Individuals must be provided with a clear and accessible alternative dispute resolution process Under no circumstances can a direct service provider determine eligibility – this applies to financial and functional eligibility. The requirements listed are the minimum; states may impose additional criteria.	If HCBS are included in 1115, COI provisions will apply subject to approved STCs.
Person Centered Planning	Must meet the requirements regarding the person centered plan and process at 42 CFR 441.301(c)(1), (2) and (3). The person centered plan must be based on an independent assessment. In addition to specific requirements regarding the process used to develop the plan, the regulations establish that the person-centered service plan must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.	If HCBS are included in 1115, provisions will apply subject to approved STCs.