A Compendium of Current Federal Initiatives in Response to the Olmstead Decision. PRIMER FOR THE MEDICAID PROGRAM


Funding Organizations:

  • Office of the Assistant Secretary for Planning and Evaluation (ASPE)
  • Health Care Financing Administration (HCFA)

Implementing Organizations:

  • Office of the Assistant Secretary for Planning and Evaluation (ASPE)
  • Health Care Financing Administration (HCFA)


The Primer for the Medicaid Program describes the many options states have to use the Medicaid program to fund long-term care services and supports; and is designed to encourage use of the Medicaid program in a manner that minimizes reliance on institutions and maximizes community integration in a cost-effective manner.


The Primer spans the full range of Medicaid choices. It addresses program modifications states can implement as a state plan option (without special waiver of federal law), as well as those for which federal waiver approval must be obtained. In addition to comprehensive explanations of program features states can implement to achieve these goals, the Primer presents examples of state programs that have taken advantage of Medicaid's flexibility to expand home and community-based services (HCBS) for people of all ages with disabilities. Designed to serve as a reference guide, it is written in easily understood language, but with sufficient annotation of source material to fulfill its technical support role. Some issues remain unresolved, because particular provisions of Medicaid regulations and state interpretations thereof are being challenged in the courts. Major unresolved issues are discussed where relevant.

Its intended audience is policymakers and others who wish to understand how Medicaid can be used--and is being used--to expand access to a broad range of HCBS and supports, and to promote consumer choice and control. The Primer is written with the notion that it is up to state policymakers working with the disability and aging communities to identify the unique needs and goals of the state, and then use the Primer (a) to choose the options best suited to a particular state and (b) to decide how the options chosen can be best used in that state. The design of the Primer results from a series of discussions among federal officials, state policymakers, service providers, and advocates on maximizing the document's utility.

The information below outlines the content of the Primer by chapter:

  • Chapter One provides a brief overview of the legislative and regulatory history of Medicaid's coverage of HCBS and information on current home and community expenditures.

  • Chapter Two through Chapter Five present the basic elements involved in Medicaid's financial and functional eligibility criteria and service coverage alternatives.
    • Chapter Two provides an explanation of Medicaid's financial eligibility criteria, one of the most complicated areas of Medicaid law. It first discusses the general eligibility criteria all Medicaid beneficiaries must meet. It then focuses on the financial eligibility provisions most important for receiving services in home and community settings. It also discusses the options states can select to ensure that people with disabilities will be able to support themselves in home and community settings.
    • Chapter Three focuses on Medicaid provisions related to health and functional criteria used to determine service eligibility for home health services, the personal care option, and the waiver program. It presents examples of states with service criteria that support a social model of long-term services and supports rather than a medical model. And it discusses ways in which states can design service criteria to ensure that they appropriately and adequately measure the need for services and supports among heterogeneous populations.
    • Chapter Four presents the major service options states have to provide home and community services to people with disabilities and discusses the factors states need to consider when choosing among the various options.
    • Chapter Five provides an in-depth discussion illustrating different coverage alternatives in the context of two specific services: case management and assisted living for elderly persons.

  • Chapter Six through Chapter Nine focus on key policy goals in the provision of home and community services and supports.
    • Chapter Six discusses factors states need to consider when developing initiatives to transition institutional residents back to home and community settings. It also presents ways in which Medicaid can be used to facilitate this transition.
    • Chapter Seven discusses options under Medicaid to increase consumer choice and control of home and community services.
    • Chapter Eight discusses ways in which Medicaid can support informal caregiving and family support through various optional services.
    • Chapter Nine addresses system design issues and discusses how Medicaid can be used to create comprehensive, cost-effective long-term care systems.

  • The Primer concludes with a series of appendices that provide additional information about the Medicaid program. Each chapter contains an annotated bibliography, with full information on how to obtain each publication.

Contact Information:

Ruth Katz, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, H.H. Humphrey Building, Room 424E, 200 Independence Avenue, S.W., Washington, DC 20201, (202)690-6443

This report is available from ASPE's website: http://aspe.hhs.gov/daltcp/reports/primer.htm.

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