Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Home and Community Services under the Medicaid State Plan


Federal law distinguishes between services offered under a Medicaid State Plan and services that may be offered when the Secretary of Health and Human Services (HHS)--operating through the Centers for Medicare & Medicaid Services (CMS)--grants waivers for a state to operate an HCBS waiver program. The services that can be offered without a waiver are called Medicaid State Plan services. Some of these services must be provided by every state that operates a Medicaid program, for example, home health services. These are called mandatory services.9 Others can be provided at state option--called optional services.

When a state covers a service under its Medicaid State Plan, it may impose limits on exactly what will be provided and under what circumstances. Such limitations take four forms: (1) medical/functional need, (2) how often a person may receive a service (amount), (3) for how long (duration), and (4) the exact nature of what is provided (scope). However, Federal law requires that such limitations not undermine a person’s receipt of necessary assistance. Any limitations states establish must generally be based on clinical grounds. Although limits must not prevent the state from meeting the needs of most Medicaid beneficiaries most of the time, states are not required to meet all beneficiaries’ needs all the time.

A state’s decision to offer an optional service under its Medicaid State Plan amounts to a decision to make the service available to all individuals who require it, within whatever limitations on eligibility, amount, scope, and duration the state has established. This is why Medicaid beneficiaries are said to be “entitled” to State Plan services.10

A state has the option of covering under its State Plan four key home and community services that are especially important for people with disabilities: (1) personal care, (2) targeted case management, (3) clinic services, and (4) rehabilitative services. Additionally, the state can cover a wide range of home and community services under the new HCBS State Plan option created by the Deficit Reduction Act of 2005 (DRA-2005) and amended by the Affordable Care Act.

Each of these State Plan options will be discussed next, followed by a brief discussion of services that can be offered under an HCBS waiver program.

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