Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Developing Methods to Circumvent HCBS Waiver Waiting Lists


Waiting lists for HCBS waiver services are a major transition barrier. States have several options available to deal with this problem. First, states can prioritize their waiver waiting lists so that individuals wanting to transition are placed at the top of the list (generally, after individuals who are at immediate risk of nursing home admission).

Second, states can increase the number of waiver slots and designate them solely for people who are transitioning. For example, Michigan authorized new waiver slots for persons who are transi tioning if they have been in a nursing facility for more than 6 months. Exceptions to the 6-month rule may be granted in a limited number of circumstances (e.g., if individuals are at risk of losing their housing). Additionally, for each successful move to the community, the State provides transition costs and waiver services for one additional Medicaid nursing facility resident without regard to their length of stay.

Money Follows the Person Demonstration20

To further encourage states to implement nursing facility transition programs and MFP policies, the Deficit Reduction Act of 2005 authorized the Secretary of HHS to award up to $1.75 billion in special MFP demonstration grants to states over a 5-year period to support the transition of individuals from institutional settings to the community.21 All states were eligible to participate in the 5-year demonstration program and had to commit to provide demonstration services for at least 2 years. As of 2009, 29 states and the District of Columbia had MFP grants. The Patient Protection and Affordable Care Act of 2010 extended the demonstration program until 2016.22

The MFP demonstration has four major objectives:

  • Increase the use of home and community services in place of institutional services.

  • Eliminate barriers or mechanisms that prevent Medicaid-eligible individuals from receiving appropriate and necessary services and supports in the settings of their choice.

  • Increase the ability of state Medicaid programs to ensure continued provision of services and supports to eligible individuals who choose to move from an institutional to a community setting.

  • Ensure that procedures are in place to ensure the quality of Medicaid home and community services, and to provide for continuous quality improvement in the furnishing of these services.

As an incentive to states to participate, CMS will increase Federal Medicaid matching funds for home and community services for each person transitioned for a 1-year period, after which the state must ensure that individuals transitioned will continue to receive HCBS as long as they are Medicaid eligible and need the services.

To qualify for the enhanced Federal match, individuals must transition to community living arrangements that they own or lease, their family home, or a community-based residential setting where no more than four unrelated people reside.

The MFP program is being rigorously evaluated and CMS is offering an ongoing series of reports completed as part of the MFP national evaluation.23

Third, if states are reluctant to increase the number of waiver slots, they can appropriate state funds to cover home and community services. When Georgia’s Systems Change NFT grant ended, the State appropriated $7.25 million for non-Medicaid covered transition expenses and the first year of home and community services for transitioning individuals for whom there were no waiver slots. The legislature specified a maximum of $50,000 per person for up to 145 individuals. Only when individuals have been supported with these funds for 1 year does the State create a new waiver slot to continue services.

Fourth, states can enact a global budget or an MFP policy to allow Medicaid funds budgeted for institutional services to be spent on home and community services when institutional residents move to the community.

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