A Compendium of Current Federal Initiatives in Response to the Olmstead Decision. STATE MEDICAID LETTERS ISSUED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES


Funding Organization:

  • Centers for Medicare and Medicaid Services (CMS)

Implementing Organization:

  • Centers for Medicare and Medicaid Services (CMS)


As of July 2001, CMS has issued five state Medicaid letters designed to provide guidance and support to states in their efforts to enable persons with disabilities to live in the most integrated setting appropriate to their needs. State Medicaid letters are a mechanism which CMS uses to communicate administrative decisions on Medicaid statute and regulations on key programmatic issues.


Olmstead Letter No.1
January 14, 2000

The first Olmstead letter provides states with background information on the Americans with Disabilities Act (ADA) and the implications of the Supreme Court's decision in Olmstead v. L.C. on the interpretation of the ADA as it applies to publicly-funded programs for persons with disabilities. The letter clarifies that the Olmstead decision applies to all states programs, but acknowledges that Medicaid is the primary funding source for both institutional and community-based services for persons with disabilities, and therefore the implementation of Olmstead will have its most significant impact on state Medicaid programs.

The letter also addresses the Supreme Court's guidance to states regarding how they might come into compliance with the ADA by developing comprehensive, effectively working plans. The letter discusses key principles and practices which states should consider as they move forward with the development of plans. Finally, the letter discusses next steps for the Department of Health and Human Services in its own implementation of Olmstead, including providing consultation to states, addressing issues and questions raised by states, and providing technical assistance.

Olmstead Update No.2
July 25, 2000

The second state Medicaid letter provides a series of commonly asked questions and answers regarding state implementation of the Olmstead decision. It provides additional guidance on how states might develop comprehensive, effectively working plans, definitions of disability and populations covered by the ADA, and more information on how states can obtain assistance from the Department on ADA and Olmstead issues.

Olmstead Update No.3
July 25, 2000

In the third state Medicaid letter, CMS reports on the results of an internal review of federal Medicaid policies and regulations related to home and community-based services (HCBS), and makes a number of policy changes and clarifications to facilitate state efforts to provide services and supports to persons with disabilities in the most integrated setting. These changes include:

  • Clarifications regarding the earliest date of eligibility for waiver services for which federal financial participation can be claimed.

  • Clarifies services that may be covered under HCBS waiver programs.

  • Clarifies that Medicare "homebound" requirement does not apply to Medicaid home health services.

  • Clarifies coverage of case management services for individuals being transitioned from institutional settings.

  • Clarifies coverage of assessment for environmental modifications to improve accessibility of a waiver recipient's home or vehicle, as well as coverage for the cost of making modifications themselves.

  • Clarifies coverage of personal assistance services for periods when a waiver recipient is hospitalized or otherwise unavailable to receive services.

  • Clarifies coverage of services provided out-of-state.

  • Clarifies coverage of "nurse-delegated services."

Olmstead Update No.4
January 10, 2001

The fourth state Medicaid letter provides clarification on a number of additional questions related to state discretion in the design and operation of 1915(c) waiver programs. These include:

  • Clarifies that under Medicaid law, states may establish a limit on the number of persons who may receive services under a HCBS waiver.

  • Clarifies that states may limit the number of persons served by a HCBS waiver in accordance with state legislative appropriations for the waiver program.

  • Clarifies that states cannot arbitrarily limit the number of persons eligible to receive specific types of waiver services, although states may apply appropriate utilization control procedures based upon the need of individuals for specific services.

  • Clarifies CMS policy regarding the amount, duration and scope of services covered under HCBS waiver programs.

  • Clarifies instances in which states may seek amendments to approved waivers to reduce the total number of persons who may be served by the waiver.

  • Clarifies state discretion in establishing targeting criteria in HCBS waiver programs.

Olmstead Update No.5
January 10, 2001

The fifth state Medicaid letter announces the availability of some new tools that states can use in their efforts to expand access to long-term supports and services for persons with disabilities. These tools include:

  • A new CMS administrative interpretation of how states may use Section 1902(r)(2) of the Social Security Act expand financial eligibility criteria for persons applying for HCBS waiver programs. Specific examples are provided on how states may use Section 1902(r)(2) to facilitate eligibility for persons transitioning out of nursing homes, to overcome medically needy income limits applied under the general state plan, to encourage paid employment, and to implement simplified administrative procedures in determining financial eligibility.

  • The announcement of three new grant programs that provide funds to states and other entities to develop innovative models for HCBS service programs and to promote comprehensive systems change. These grant programs are: (1) Nursing Facility Transitions grants; (2) Community-Integrated Personal Assistance Services and Supports grants; and (3) Real Choice Systems Change grants. Total available funding for these grant programs is approximately $70 million. These grant programs are described in greater detail elsewhere in this report.

Contact Information:

Complete versions of the five state Medicaid letters are posted on the CMS ADA/Olmstead website at: http://www.hcfa.gov/medicaid/olmstead/olmshome.htm.

View full report


"olmstead.pdf" (pdf, 523.11Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®