Recent changes in federal law30 allow states to provide HCBS services, without a waiver, as optional benefits by making a Medicaid SPA. The purpose of 1915i is to expand access to HCBS to persons with disabilities who are not at an institutional level of care. Therefore, states that want to add this optional benefit must establish needs-based criteria that are less stringent than the criteria for institutional services. However, states must provide statewide coverage for these optional services and cannot set limits on the total number of people who can receive these services. This makes it difficult for many states to balance the goal of obtaining FFP through Medicaid with the need to control their own Medicaid budgets.
Service-providers and advocates for homeless people and people with disabilities have explored using the authority provided by 1915i to support Medicaid reimbursement for HCBS services in supportive housing. However, at the time of the site visits conducted for this project in 2011, no states had amended their Medicaid State Plans to provide coverage for these optional benefits with needs-based service criteria that would be likely to target chronically homeless people or PSH residents.
The first state to do so is Louisiana, which has submitted and received CMS approval (in December 2011 and January 2012) for several SPAs for waivers and new optional benefits as integral parts of major changes Louisiana is making to its behavioral health system. One SPA adds HCBS benefits covered under the 1915i option. Covered services related to mental illness, addictions disorders, and co-occurring disorders include services that will be linked to housing assistance for people with disabilities who have been homeless, as well as people who need support to live in the community instead of in institutional settings. Services linked to PSH are described in more detail in Section 6.4.