In 1981, Congress authorized the waiver of certain Federal requirements to enable states to provide home and community services (but not room and board) to individuals who would otherwise require institutional services reimbursable by Medicaid (i.e., services in a skilled nursing facility, an intermediate care nursing facility, or an ICF/ID). The waiver programs are often called §1915(c) waivers (named after the section of the Social Security Act that authorized them), but are also called HCBS waivers, the term used in this Primer.43
Under the §1915(c) waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to prevent institutionalization. Services covered under waiver programs include case management, homemaker, home health aide, personal care, adult day health, habilitation, respite care, and such other services requested by the state as the Secretary of Health and Human Services (HHS) may approve. Services for individuals with a chronic mental illness were added in the late 1980s: day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility).
Neither the statute itself nor CMS regulations further specify or define the scope of the listed services. However, the law that created the waiver program expressly permits the Secretary of HHS to approve services beyond those specifically spelled out in the law, as long as they are necessary to avoid institutionalization and are cost-effective. In the 29 years since the waiver authority became available, CMS has approved a wide range of additional services.
In the early 1990s, CMS first issued a standard HCBS waiver application format for states to submit requests to operate an HCBS waiver program. The standard format included definitions of services states commonly cover in their HCBS waiver programs. The services listed in the standard format appear there because they are included in the listing contained in the statute, or are additional services that states frequently offer.
In 2005, CMS extensively modified its standard §1915(c) application to obtain greater detail about how the proposed program would operate. States must now provide specific information about how their programs comply with Federal standards, as well as detailed information about their quality improvement systems. Beginning in 2006, CMS began offering a web-based version of the application. The conversion to a web-based application streamlines the preparation of waiver applications and amendments, and improves communication between states and CMS about waiver requests.
The Waiver Application Instructions represent the most current guidance related to HCBS waivers. The instructions provide CMS-suggested definitions of services that states may cover under their HCBS waiver programs--identified as Core Service Definitions. The services a state may offer are by no means limited to those that appear in the standard format, nor are the proposed definitions required. (See the Resources section of this chapter for a link to all approved HCBS waivers and a link to the online waiver application and technical guidance document.)
During Federal fiscal year (FFY) 2008, 48 states and the District of Columbia operated 314 HCBS waiver programs. This number includes waivers that CMS had approved but that had not yet been implemented as of September 30, 2008. The two states that did not have HCBS waivers--Arizona and Vermont--provided similar services as part of Research and Demonstration waivers authorized by §1115 of the Social Security Act.44
Expenditures for waiver services totaled $30 billion in 2008 and roughly three-fourths was used to purchase services and supports for persons with developmental disabilities, including persons with autism spectrum disorders or intellectual disabilities.45 Almost all other waiver expenditures in the same year were for older adults and younger adults with physical disabilities; a few smaller population groups accounted for the remaining waiver expenditures.46