Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. All Quality and Other Requirements of Each Authority Must Be Met

10/29/2010

For many states, combining two waivers or a waiver and a State Plan amendment will be an effective way to create the program desired while avoiding the greater burdens associated with a §1115 waiver. However, states must be prepared to meet the requirements of each authority they invoke (e.g., a program that combines managed care authority and HCBS authority must meet all the requirements of both). In addition, if partnering with a Medicare Special Needs Plan to create a program for dually eligible persons, the Special Needs Plan will be accountable to CMS for all Medicare managed care requirements.

In the area of quality, for example, a program under the authority of §1915(a), §1915(b), or §1932(a) must meet continuous quality improvement requirements for Medicaid managed care, including performance improvement projects for health status and outcomes. The state must also provide for an External Quality Review Organization to evaluate outcomes and access to care. In addition, for the first two renewals of a §1915(b) waiver, the state must provide to CMS an independent assessment on access and quality requirements. Under §1915(c), states must meet CMS quality requirements in several areas, including safeguarding waiver participants’ health and welfare.22 (See theAppendix for an overview of CMS requirements for quality management and improvement systems.)

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