Using the HCBS waiver as authorized under §1915(c) of the Social Security Act, states have great flexibility to design programs that meet the unique needs of individuals with disabilities. Collectively, 48 states and the District of Columbia operate 314 distinct HCBS waiver programs.26 Some states, such as Texas and Florida have 10 or more waivers for specific populations (see Table 4-1 for a list of Texass waiver programs).
|TABLE 4-1. Texas Home and Community-Based Waiver Programs
|Medically Dependent Children Program
||Children (under age 21) at risk of nursing facility placement because of complex medical needs.
|Home and Community-Based Services
||People of all ages who qualify for ICF/ID services.
|Community Living Assistance and Support Services
||People of all ages who have a disability--other than an intellectual disability--that originated before age 22 and that affects their ability to function in daily life.
|Deaf-Blind Multiple Disabilities
||People age 18 or older who are deaf, blind, and have multiple disabilities who qualify for ICF/ID/Related Conditions (RC) services.
|Community Based Alternatives
||Adults (age 21 or older) who qualify for nursing facility services.
||Adults (age 21 or older) who qualify for nursing facility services and live in designated counties in the State. Services are provided through a §1915(b) waiver and a §1915(c) waiver program.
|Consolidated Waiver Program Two waivers: One for ICFs/ID/RC and one for nursing facilities.
||People of all ages in Bexar County who qualify for nursing facility services or ICF/ID/RC services.
|Texas Home Living
||People of all ages, living with their families or in their own home, who qualify for ICF/ID services and meet the SSI income limit.
|Youth Empowerment Services
||Children between 3 and 18 years of age with Severe Emotional Disturbance who qualify for a Hospital Inpatient Psychiatric Facility for Individuals under 21 as provided for in 42 CFR 440.16.
To assist states in submitting requests to begin waiver programs, CMS issued a standard HCBS waiver application format in the early 1990s. Since November 2006, CMS has offered a web-based version of the application. Conversion to a web-based application streamlined the preparation of waiver applications and amendments, and improved communication concerning waiver requests between CMS and the states. CMS encourages states to employ the web-based application to submit new waivers, waiver renewals, and amendments. The application is linked to specific instructions for completing it and also includes technical guidance regarding its use. (See the Resources section of this chapter for a link to the latest version of the application and accompanying instructions.)
The services a state may offer under the HCBS waiver authority are not limited to those defined in the waiver instructions and technical guidance. States are free to accept the CMS definition, modify it to reflect other features and considerations important to the state, and/or propose a new service entirely and provide its definition. Many states use the CMS definitions--often with modifications--but many others have proposed alternative definitions to ensure that the service description exactly matches the service they want to provide.
Because the CMS service definitions may not be an exact match for what a state wants--and be-cause CMS requires a precise definition of what will be furnished to waiver participants27--it is best to begin by developing a clear understanding of what the state intends. This analysis should encompass the types of services and supports to be delivered, as well as how, where, and by whom. Gaining a comprehensive understanding of its objectives puts a state in a good position to decide how well the definitions in the standard format fit. A good rule of thumb in considering CMS-predefined coverage is, If it fits, use it. If it almost fits, change it to fit. If it doesnt fit at all, propose a new service. See the Box below for Colorados definition of Personal Assistant Services provided under its Supported Living waiver for people with developmental disabilities.
HCBS waivers cover many different services, including protective services and home-delivered meals;28 family counseling to deal with behavioral and other problems; substance abuse counseling/services; training in child and infant care for a parent with a disability; crisis intervention services; behavioral services, generally for individuals with developmental disabilities and acquired brain injuries; community participation supports; and housing coordination to assist individuals in locating and obtaining community housing.
The wide range of services makes it clear that no exact formula exists for deciding which services and supports to include in a particular HCBS waiver program. States HCBS waiver programs differ in significant ways, but some of the large differences among the programs that serve similar target populations are less significant than meet the eye. Some states, for example, elect to break down their services into many distinct coverages, whereas others pull together several closely related services into one coverage category. For example, Colorados Supported Living Services waiver program for people with developmental disabilities provides a service it has named Environmental Engineering, which covers both home modifications and assistive technology. Other states choose to offer them as discrete services. How exactly services and supports are packaged and defined is less important than making sure they are covered in one way or another.
Again, the best starting point for designing and selecting HCBS waiver coverage is for the state to assess the needs of the service population and develop concrete ideas about how those needs can best be met.
A more substantive reason why state waiver services vary so widely is differences among states in the services already covered under the Medicaid State Plan. In states that have broad, comprehensive State Plan coverages, the services a state offers under its HCBS waiver program will consist mainly of those that cannot otherwise be covered under the State Plan. This explains why, for example, some states cover therapeutic services under their waiver programs and others do not. It also explains why HCBS waiver programs that principally serve children usually offer fewer services than programs that principally serve adults with disabilities. Because the EPSDT mandate requires states to provide the full array of mandatory and optional State Plan services to children, whether or not they are actually covered under the State Plan, HCBS waiver programs for children furnish a more limited array of additional services.
Colorado Supported Living HCBS Waiver: Personal Assistant Services Definition
Personal assistant services provide necessary personnel and supports to meet the daily living needs of a person with a developmental disability [on a less than 24-hour basis]. These services and supports, including evaluation and assessment, are provided to ensure adequate functioning in the persons own home, someone elses home, in the home of their natural or adoptive family, or for accessing and/or participating in the community.
Personal assistant services may include assistance or training with a wide range of activities necessary to meet the daily living needs of the person in the home and community including
Personal care such as hygiene, bathing, eating, dressing, grooming, bowel and bladder care, menstrual care, transferring, basic first aid, giving medications, relief to a family who normally provides personal care, emergency response in the form of human assistance, and operating medical equipment.
Household maintenance such as meal preparation, shopping and chores, assistance with money management and personal finances, cleaning, laundry, and household repairs and maintenance related to the persons disability.
Mentorship activities such as planning; decision making; assistance with his/her participation on private and public boards, advisory groups, and commissions; person-specific training costs associated with providing unique supported living services to an individual, such as training in child and infant care for parent(s) who themselves have a developmental disability.
Supported living consultation such as assistance with decision making, planning daily activities, and direct assistance to access community resources and/or service providers.
Differences among target populations may also be important. As discussed earlier, several types of waiver services cut across disability categories (e.g., personal care/personal assistance, service coordination, and home modifications). These--and other services--are needed by people with different types of disabilities and are covered in nearly all HCBS waiver programs.
However, there are also some differences among individuals that are linked to their disabilities and how those disabilities need to be addressed. For example, habilitation training is particularly important for people with developmental disabilities, because of the nature of their disability.29 (Indeed, the provision of habilitation usually accounts for a significant share of the expenditures in HCBS waiver programs that serve people with developmental disabilities and is one reason why these waiver programs tend to be relatively costly to operate.) However, habilitation training is not relevant in meeting the needs of most elderly individuals. Thus, state coverage decisions are very much tied to the specific needs of individuals in the target population.
Yet another substantive reason why states differ in the services and supports they offer through their HCBS waiver programs is that services and supports continue to evolve. Approaches that seemed appropriate in the past give way to new approaches, and states vary in how quickly they adopt these changes. One of the most useful features of the HCBS waiver is that it is sufficiently flexible to change over time. States have considerable latitude to modify and/or totally change their HCBS waiver coverages. Each year, states submit numerous amendments to their HCBS waiver programs, which add, delete, and/or modify the services and supports states offer. As a consequence, waiver programs that have been in operation for a relatively long period, usually have changed considerably since they were first approved. Coverages can be fine-tuned based on feedback from waiver participants and service providers concerning problems or gaps.
The Application for a §1915(c) Home and Community Based Waiver [Version 3.5] Instructions, Technical Guide and Review Criteria has attached to its instructions--in Appendix C--an excellent description of and guidance on the service options included in the HCBS waiver application format. (See the Resources section of this chapter for a link to the application and to a website where copies of each states approved waiver applications are available.)
A Frequent Problem in Designing Waiver Coverages: Tendency to Tie Them to Particular Service Settings
In designing HCBS waiver programs it is helpful to remember that services can be furnished in both the home and a wide range of community settings. Historically, in developmental disabilities services, states have tended to identify day habilitation with particular sites. This has had the effect of preventing habilitation services from being furnished to individuals in everyday community settings where training could be used to assist the individual in mastering skills important in community life. Several states are now removing the ties of this service to specific sites, and at least two states no longer offer facility-based day programming.
Another example of problems that can be caused by tying a service to a particular setting can be found in the area of personal care/assistance services. These services can be defined in a way that ties their delivery to a persons living arrangement. But they can also be defined more flexibly, to permit their provision both in and outside the home (as Michigans HCBS waiver program for people with developmental disabilities allows). Defined in this alternative fashion, these services can be furnished more flexibly and more in accordance with an individuals specific needs and preferences.
HCBS Waivers for Adults with Serious Mental Illness or Children with Severe Emotional Disturbance
Some states provide services for adults with serious mental illness and children with severe emotional disturbance using §1915(c) waivers. Colorado, Montana, and Wisconsin serve adults using nursing facility level-of-care waivers. Indiana, Kansas, Michigan, New York, Texas, Wisconsin, and Wyoming provide services to children and youth using the hospital level of care for an inpatient psychiatric facility for individuals under age 21, as provided in 42 CFR §440.160.