Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Purpose, Audience, and Organization of the Primer


Medicaid offers a complex and varied set of home and community service options--with similarly complex rules and regulations--that can be bewildering for policymakers, state officials, advocates, and consumers. Even people who have spent years working in Medicaid state agencies do not always understand its many provisions. The extensive flexibility states have to combine these options has resulted in considerable variation among states’ Medicaid programs. As some wit has put it, “What state Medicaid programs have most in common is that they are all different.”

The Primer is designed to encourage states to use the Medicaid program to minimize reliance on institutions and maximize community integration for people with disabilities in a cost-effective manner. Its intended audience is policymakers, state Medicaid staff, and all stakeholders who wish to understand how Medicaid can be used--and is being used--to expand access to a broad range of home and community services and supports. In addition to providing comprehensive explanations of Medicaid home and community service options, the Primer presents examples of states that have used them to promote greater community integration of people with disabilities.

The service options reviewed address program modifications that states can implement as a State Plan option (without a special waiver of Federal law), as well as those for which Federal waiver approval must be obtained. While each chapter has been written to cover a specific topic, and as such, can be read independently of the rest of the Primer, it also assumes an understanding of basic Medicaid terms and provisions, such as comparability and statewideness, mandatory and optional services, State Plan and waiver services. Those unfamiliar with these basic terms should first read Chapter 1.

When a topic is covered in depth in one chapter, that chapter will be referenced in other chapters that address the topic.

  • Chapter 1 provides a brief overview of the legislative and regulatory history of Medicaid’s coverage of home and community services and current spending on these services.

The next two chapters describe the basic elements of Medicaid’s financial and service eligibility criteria.

  • Chapter 2 provides an explanation of Medicaid’s financial eligibility criteria, a complex area of Medicaid law. It first discusses the general eligibility criteria that all Medicaid beneficiaries must meet. It then focuses on the financial eligibility provisions most important for receiving services in home and community settings. The chapter also reviews the options states can select to ensure that people with disabilities can support themselves in home and community settings.

  • Chapter 3 focuses on Medicaid provisions related to the health and functional criteria states use to determine eligibility for State Plan home health services, State Plan personal care services, State Plan home and community-based services, and HCBS waiver programs. The chapter also discusses how states can design service criteria to ensure that they appropriately and adequately measure the need for services and supports among heterogeneous populations.

Chapters 4 and 5 describe service coverage options.

  • Chapter 4 presents the major service options for providing home and community services to people with disabilities. The factors states need to consider when choosing among the various options are also discussed.

  • Chapter 5 describes coverage options for providing services in a wide range of residential care settings that are provider-owned and/or operated, including foster care, group homes, and assisted living.

Chapters 6 and 7 focus on key policy goals related to coverage of home and community services.

  • Chapter 6 discusses factors states need to consider when developing initiatives to transition institutional residents to home and community settings. It also presents ways in which Medicaid can be used to facilitate transitions.

  • Chapter 7 describes Medicaid options to increase participants’ choice and control of home and community services.

  • Chapter 8 describes options for states to provide Medicaid home and community services through managed care delivery systems.

An appendix provides an overview of CMS requirements for quality management and improvement systems for HCBS waivers.

To make the Primer as useful as possible, each chapter includes a Resources section that provides information about key publications and links to websites from which the reader can obtain more detailed information about the chapter’s topic. The endnotes for each chapter include not just source citations, but additional technical information and--in many cases--web links to these citations and information. Thus, while the Primer can be read either in hard copy or online, the online version enables readers to access a considerable amount of additional information.

This Primer has been prepared by the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, and reviewed for accuracy by CMS staff. Designed to serve as a reference guide, it is written in easily understood language, but with sufficient annotation of source material to fulfill its technical support function.

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