Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Endnotes: Citations, Additional Information, and Web Addresses


  1. Gary Smith and Janet O’Keeffe co-authored the original chapter. Janet O’Keeffe updated the chapter. In addition to the sources noted in the citations, a major source of historical information for this chapter is the Medicaid Source Book: Background Data and Analysis (1993). Washington, DC: U.S. Government Printing Office.

  2. Overall, the Federal Government finances an average of 57 percent of all Medicaid costs annually. National Health Policy Forum. (January 2009). The Basics, FMAP: The Federal Share of Medicaid Costs. Available at http://www.nhpf.org/library/the-basics/Basics_FMAP_01-15-09.pdf.

  3. The Olmstead Supreme Court decision increased state responsibility to provide a range of home and community service options. The Court ruled that states must provide services in the most integrated setting appropriate to the needs and wishes of people with disabilities. Failure to do so could constitute discrimination under the Americans with Disabilities Act. Information about the application of the Olmstead decision to the Medicaid program is available from the CMS website in State Medicaid Director Letters. Use the word Olmstead to find the relevant letters. Available at http://www.cms.hhs.gov/SMDL/SMD/list.asp#TopOfPage.

  4. Burwell, B. (2000). Memorandum: Medicaid Long-Term Care Expenditures in FY 1999. Cambridge, MA: The MEDSTAT Group.

  5. Burwell, B., Sredl, K., and Eiken, S. (2009). Medicaid Long-Term Care Expenditures in FY 2008. Cambridge, MA: Thomson Reuters. Available at http://www.hcbs.org/moreInfo.php/doc/2793.

  6. Eiken, S., and Burwell, B. (2009). Medicaid HCBS Waiver Expenditures: FY 2003 through FY 2008. Cambridge, MA: Thomson Reuters. Available at http://www.hcbs.org/moreInfo.php/doc/2795.

  7. Section 1902(a)(10)(d) of the Social Security Act. If a state chooses to cover nursing facility care for the medically needy, Home Health services become mandatory for this group as well.

  8. The coverage criterion for Home Health services is often misunderstood because it is linked to the coverage criterion for nursing homes. The confusion has arisen because the term entitled to nursing facility care has sometimes been erroneously interpreted to mean that people must be eligible for nursing facility care--that is, they must meet a state’s nursing facility level-of-care criteria in order to receive the Home Health benefit. This erroneous interpretation has persisted, notwithstanding its conflict with Federal Home Health regulations prohibiting a state from conditioning eligibility for Home Health services on the need for or discharge from institutional care (42 CFR 441.15(c)).

  9. 42 CFR 440.70(b).

  10. 42 CFR 440.230(d).

  11. 42 CFR 440.230(b)

  12. Health Care Financing Administration. (September 4, 1998). Letter to State Medicaid Directors. Available at http://www.cms.hhs.gov/smdl/downloads/SMD090498.pdf.

  13. Skubel v. Fuoroli. (No. 96-6201). United States Court of Appeals, Second Circuit. Decided May 13, 1997.

  14. Social Security Amendments of 1965 (P.L. 89-97).

  15. Social Security Amendments of 1967 (P.L. 90-248).

  16. P.L. 90-248, effective July 1970.

  17. Act of December 14, 1971 (P.L. 92-223).

  18. Social Security Amendments of 1972 (P.L. 92-603). This institutional coverage provides the “institutional alternative” for waiver services for this group.

  19. Section 1619 P.L. 96-265 of the Social Security Act.

  20. Omnibus Budget Reconciliation Act of 1981 (OBRA 81, P.L. 97-35).

  21. P.L. 103-66. Section 13601 (a1/5)8. Section 134 of TEFRA contains the amendment.

  22. Consolidated Omnibus Reconciliation Act of 1985 (P.L. 99-272). The provision became effective April 1986.

  23. Ibid.

  24. Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360).

  25. Omnibus Reconciliation Act of 1989.

  26. Omnibus Reconciliation Act of 1993. Section 13601 (a1/5)8 (P.L. 103-66). The changes took effect on October 1, 1994. In November 1997, CMS issued new regulations (42 CFR 440.167) concerning optional Medicaid State Plan personal care services to reflect these statutory changes.

  27. P.L. 106-170.

  28. Omnibus Reconciliation Act of 1989.

  29. The Omnibus Budget Reconciliation Act of 1993 (§13601(a)(5)); Social Security Act (§1905(a)(24)).

  30. Individuals who reside in institutions--nursing facilities, ICFs/ID, hospitals, and institutions for mental disease--cannot receive personal care services through the Personal Care benefit.

  31. 42 CFR 440.167.

  32. Congressional Research Service. Analysis of CMS Medicaid Statistical Information System, FY 2005. More recent data are not available.

  33. Section 6087 of DRA-2005. The text of §1915(j) is located at http://www.paelderlaw.com/pdf/DRA_Provisions.pdf.

  34. Section 915(g) was added to the Social Security Act.

  35. CMS guidelines concerning targeted case management services are found in the State Medicaid Manual in Sections 4302 et seq. The link to the Manual can be found in the Resources section of this chapter.

  36. Information about the §1915(i) authority is from the State Medicaid Director Letter, August 6, 2010. http://www.cms.gov/SMDL/SMD/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=1&sortOrder=descending&itemID=CMS1238355&intNumPerPage=10.

  37. Section 1902(a)(10)(B).

  38. CMS plans to issue a Notice of Proposed Rule Making related to this provision in early 2011.

  39. Section 440.130(d). Other licensed practitioners of the healing arts, within the scope of their practice under state law, may also authorize services under the Rehabilitation option. The statutory definition is qualified by other provisions in the law.

  40. Mary Sowers, CMS. Personal communication, January 29, 2010.

  41. However, a state does not have to offer a particular type of institutional service--such as an ICF/ID--in order to offer services under an HCBS waiver program. For example, states--such as New Hampshire--which have closed all of their ICFs/ID, can cover services for persons with developmental disabilities through an HCBS waiver.

  42. Smith, G., Director of Special Projects, National Association of State Directors of Developmental Disabilities Services. Personal communication, July 2000.

  43. Federal regulations concerning the program are found at 42 CFR 441 Subpart G, available at http://www.gpoaccess.gov/cfr/retrieve.html. CMS guidelines concerning the HCBS waiver program are contained in Sections 4440 et seq. of the State Medicaid Manual and are updated periodically. The link to the Manual can be found in the Resources section of this chapter.

  44. Eiken, S. and Burwell, B. (2009), op. cit.Available at http://www.hcbs.org/moreInfo.php/doc/2795.

  45. Ibid. The high level of spending for HCBS waiver programs serving individuals with developmental disabilities is primarily a function of the higher per capita costs, because a significant proportion of waiver participants with developmental disabilities receive supports on a 24-hour basis.

  46. Ibid. Waivers that target people with brain injuries, medically fragile children, adults with mental illness or children with a serious emotional disturbance, and people with HIV or AIDS.

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