Waiver Basics
Background
Medicaid is a joint federal/state funding program that pays for most long term care provided to low income, older persons and persons with disabilities. For many years, nursing facilities and institutions were the only options for persons needing long term assistance. But when given the choice, many people choose to live in the community rather than in an institution.
Recognizing that preference, Congress established the Home and Community Based Services (HCBS) waiver as an alternative to care provided in institutions. The HCBS waiver allows states to use Medicaid funding to provide services and supports to persons living in their homes or in other community-based settings, such as group homes, adult foster homes or assisted living facilities. Persons are eligible to receive HCBS waiver services if they meet federal qualification criteria and if the cost of their home or community-based care does not exceed limits established by a state.
A state must apply to the Centers for Medicare & Medicaid Services (CMS) through an HCBS waiver application for permission to operate an HCBS waiver. States can be flexible in how they design their HCBS waiver with respect to:
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Number of people to be served
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Services provided
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Some states may choose to offer participants the ability to direct their own services under HCBS waivers. Self-direction promotes personal choice and control over the delivery of HCBS waiver services. Self-direction means that the participant can make decisions over some or all of her/his HCBS waiver services and accepts the responsibility for taking a direct role in managing them. The participant decides who provides services and how they are delivered. For example, the participant may, with support, recruit, hire, and supervise individuals who furnish daily supports. Self-directed HCBS waivers offer expanded opportunities for participant control but do not change a state’s responsibility to meet federal HCBS waiver assurances.
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Geographic areas served
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The first time a state submits an HCBS waiver application, CMS approves the program for three years; when a state submits a renewal application, CMS approves it for five years. A state’s HCBS waiver application must include the following elements:
- Waiver Design: the population and geographic area to be served, the mix of services offered, the quality standards, including provider qualifications, policies and payment methods.
- Performance Measures: the standards a State will use to evaluate how well the HCBS waiver is meeting each of the federal assurances.
- Discovery Methods: the data a state collects to measure how well it is meeting each performance measure; the method and frequency of data collection and analysis; and the person or entity responsible for using the data for decision-making.
- Remediation: how a state will take action when individual problems are found.
- System improvement: methods to prevent similar problems from happening to others or to make the HCBS waiver more effective and efficient.
