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, Ernest McKenney, and Robin Cooper updated the chapter.

  2. States may also use §1115 Research and Demonstration waivers to provide long-term care services, as do Arizona and Vermont.

  3. Sections 1902(a)(10)(B) and 1902(a)(1) of the Social Security Act.

  4. Section 1915(c) of the Social Security Act. The relevant Federal statute authorizes the Secretary of Health and Human Services to grant these waivers. Medicaid also provides other options for targeting services to specific groups, including the targeted case management benefit and various managed care authorities, and most recently, the §1915(i) authority.

  5. State Medicaid Director Letter, August 6, 2010. Available at http://www.cms.gov/SMDL/SMD/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=1&sortOrder=descending&itemID=CMS1238355&intNumPerPage=10 .

  6. For example, it is increasingly common for states to offer, under HCBS waiver programs for people with developmental disabilities, supplementary dental services over and above the dental benefits available under the State Plan, which are typically very limited. This “extended” coverage option can be and is employed for other Medicaid State Plan services as well, such as rehabilitation therapies, vision services, and prescription drugs.

  7. Exceptions include targeted case management services, among others.

  8. Connecticut Home Care Program for Elders. Information available at http://www.ct.gov/dss/cwp/view.asp?a=2353&q=305170 and http://www.ct.gov/dss/lib/dss/documents/fee-for-servicechcp_xls.xls .

  9. These services are listed in §1905(a) of the Social Security Act.

  10. Adding or changing coverage of home and community services that Federal law permits to be covered under the Medicaid State Plan requires a state to take various formal steps. A state adds, deletes, or changes a service in its Medicaid State Plan by filing a State Plan amendment with CMS, which reviews the coverage and approves it if it conforms to Federal law and regulations.

  11. Section 1905(a)(24) authority.

  12. The 1997 regulations can be found at 42 CFR 440.167.

  13. This state option was added in §1915(g) of the Social Security Act.

  14. CMS guidelines concerning targeted case management services are in Sections 4302 et seq. of the State Medicaid Manual. See the Resources section of this chapter for a web link to the manual.

  15. Activities related to eligibility determinations and service authorization may be reimbursed as administrative expenses.

  16. States are required to ensure that appropriate transportation is available. See the transportation provisions in 42 CFR 431.53. Transportation may also be provided as a service under the State Plan.

  17. Defined in 42 CFR 440.90 with additional CMS guidelines in §4320 of the State Medicaid Manual.

  18. Defined in 42 CFR 440.130(d).

  19. Teaching parents to anticipate and deal with a child’s rage is an example of an activity that directly supports the Medicaid beneficiary. Marriage counseling for the child’s parents does not and is not covered.

  20. Much of the information provided here on the Rehabilitation benefit is drawn from Koyanagi, C. and Brodie, J. (July 1994). Making Medicaid Work to Fund Intensive Community Services for Children with Serious Emotional Disturbances. Washington, DC: Bazelon Center for Mental Health Law. This publication is no longer available because it has been updated and re-published as two new reports. The reports are available for purchase at the Bazelon Center’s website at http://www.bazelon.org/News-Publications/Publications/CategoryID/20/List/1/Level/a/ProductID/51.aspx?SortField=ProductNumber%2cProductNumber and at: http://www.bazelon.org/News-Publications/Publications/List/1/CategoryID/20/Level/a/ProductID/32.aspx?SortField=ProductNumber%2cProductNumber .

  21. No data are available to determine how many states offer targeted case management to a specific group.

  22. 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.

  23. P.L. 109–171, Section 6086(a).

  24. Eligibility for a §1915(c) waiver requires that an individual meets the state’s institutional level-of-care criteria.

  25. Statutory authority for HCBS waiver programs is contained in §1915(c) of the Social Security Act. Applicable Federal regulations are found at 42 CFR 441 Subpart G. These regulations were last modified in 1994. CMS guidelines concerning HCBS waiver programs are contained in Sections 4440 et seq. of the State Medicaid Manual. These guidelines are updated periodically.

  26. 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.

  27. With respect to services a state proposes to cover that depart from those that appear in the waiver application, the definition of each waiver service must describe goods and services in concrete terms, along with any conditions that apply to the provision of the service. The definition of a service cannot use terms such as “including but not limited to . . .,” “for example . . .,” “including . . .,” or “etc.” CMS will not approve vague, open-ended, or overly broad service definitions. The service must be defined in a manner to make it clear exactly what will be furnished to the beneficiary.

  28. Although Medicaid cannot pay for food, services such as home-delivered meals and the provision of a meal and snack in adult day health settings are reimbursable because they do not constitute a complete daily diet. (Core service definition. Attachment to the Instructions to Appendix C for the HCBS Waiver Application, Version 3.5. See the Resources section of this chapter for a web link to the application and instructions.)

  29. Persons of all ages with many different types of disabilities can benefit from habilitation services. Coverage of habilitation has generally been provided only to people with developmental disabilities, which are defined as those occurring before age 22. However, a CMS letter to State Medicaid Directors clarifies that neither Medicaid law nor implementing regulations restrict who may receive habilitation services in an HCBS waiver. Individuals who do not have an intellectual disabilityor other developmental disabilities, such as persons with traumatic brain injury or physical disabilities that occurred after age 22, may also receive habilitation services through a waiver program.

  30. Smith, G. (1999). Closing the Gap: Addressing the Needs of People with Developmental Disabilities Waiting for Supports. Alexandria, VA: National Association of State Directors of Developmental Disabilities Services.

  31. Among individuals with developmental disabilities who live with their families, about 25 percent live with parents who themselves are older than 60.

  32. Smith, G. (1999). Serving and waiting: An update. In A Supplement to Closing the Gap: Addressing the Needs of People with Developmental Disabilities Waiting for Supports. Alexandria, VA: National Association of State Directors of Developmental Disabilities Services.

  33. This type of HCBS waiver program is sometimes called a middle-range program, because it fills the gap between limited state-funded family support programs and HCBS waiver programs intended mainly to buy specialized group home and similar residential services.

  34. The average is based on the average daily HCBS waiver census. Lakin, K.C., Larson, S., Salmi, P., and Scott, N. (2009). Residential Services for Persons with Developmental Disabilities: Status and Trends through 2008. Minneapolis, MN: University of Minnesota, Research and Training Center on Community Living. Available at http://rtc.umn.edu/risp08 . Print copies may be requested by contacting Naomi Scott at scot0387@umn.edu or 612-624-8246.

  35. Smith, G., Agosta, J., Fortune, J., and O’Keeffe, J. (April 2007). Gauging the Use of HCBS Supports Waivers for People with Intellectual and Developmental Disabilities: Final Project Report. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/2007/gaugingfr.htm .

  36. While states must safeguard health and safety under all waivers, it becomes more difficult in a waiver that has a cap that is well below what comprehensive waivers permit. Caps in supports waivers tend to be in the $15-25,000 range and the state must be able to ensure health and safety whatever the cost. If a waiver participant’s needs increase but there is no opportunity to move to another waiver and the person does not want to go to an ICF/ID, the state must supplement the services solely with state dollars if the person is to stay enrolled on the supports waiver. The lower cap poses issues, particularly when individuals need only a modest increase above the cap, because for cost containment reasons the state does not want to enroll them in the comprehensive waiver, which opens up the service menu and can lead to much greater increased costs (e.g., residential services instead of in-home supports).

  37. The §1915(j) authority may also be used to provide supports to people in their own home.

  38. Among the states that offered personal care services in 2008, annual per capita outlays for such services (i.e., total personal care expenditures divided by the state’s total population) ranged from less than $0.10 to a high of $151.02. 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 . (A few of the states included in the data analysis cover personal care services only for children covered by the EPSDT mandate, which likely accounts for the very low amount spent in some states.)

  39. The limits each state imposes are listed in U.S. General Accounting Office. (May 1999) Adults with Severe Disabilities: Federal and State Approaches for Personal Care and Other Services. GAO Publication No. GAO/ HEHS-99-101. Washington, DC: GAO.

  40. Health Care Financing Administration Medicaid Manual Transmittal Part 4, No. 73, September 17, 1999.

  41. State Medicaid Director Letter: Olmstead Update Number 3. July 25, 2000. Available at http://www.cms.hhs.gov/smdl/downloads/smd072500b.pdf.

  42. For the first time since the Federal Poverty Level (FPL) guidelines began to be issued in 1965, the annual average Consumer Price Index has decreased from the figure for the previous year. Therefore, the Department of Health and Human Services poverty guidelines have been frozen until at least May 31, 2010 at 2009 levels in order to prevent a reduction in eligibility for certain means-tested programs, including Medicaid, Supplemental Nutrition Assistance Program, and child nutrition. Additional information is available at http://aspe.hhs.gov/poverty/09extension.shtml .

  43. The text of §1915(j) is located at http://www.paelderlaw.com/pdf/DRA_Provisions.pdf .

  44. They may also do so under a §1115 waiver.

  45. Case management activities are also covered routinely as a component of another service. For example, home health agencies that provide home health services are required to perform certain case management activities.

  46. The amount of FFP for services is called the Federal Medical Assistance Percentage, which cannot exceed 83 percent or go below 50 percent. The FFP for administrative claiming is 50 percent.

  47. The cost of HCBS waiver case management services can also be claimed at the service rate.

  48. States can recoup the costs of service coordination furnished to individuals returning to the community through the HCBS waiver program when the person is enrolled in the HCBS waiver after discharge. As with targeted case management services, FFP is available for service coordination furnished during the 180-day period preceding institutional discharge. These service coordination activities are considered completed when the person enrolls in the waiver program.

  49. Solutions exist for this problem, but they can involve their own complications.

  50. To the extent that driving a beneficiary to a doctor’s appointment is necessary, it could be paid for as a Medicaid State Plan service rather than as a targeted case management service. The person’s case manager may certainly transport the individual to a physician’s appointment. Although the costs involved cannot be claimed as case management (because the service is direct), they may be reimbursed as a transportation service under the Medicaid State Plan, or as an administrative expense.

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