Section 1915 (c) or Section 1115 waivers
Federal Link: www.cms.hhs.gov/medicaid/1915b/1915bc.asp
What is it: The law allows Medicaid waivers to expand or change specific provisions of Medicaid law, especially to allow use of managed care and nursing alternatives. Most HCBS waivers are relatively small -- half of the waivers in the database indicate that they served fewer than 1,000 individuals.
Section 1115: EXPAND COVERAGE - States can obtain
federal Medicaid matching funds to provide services that Medicaid
otherwise could not cover and/or to cover individuals who otherwise
would not be eligible for the Medicaid program.
Section 1915(b) MANAGED CARE - allows states to waive Medicaid's "freedom-of-choice" requirement by creating managed care. Generally, states use the savings generated by managed care to promote additional benefits or services for Medicaid beneficiaries. Covered services are limited to providers in the approved network. To obtain approval, the waiver request cannot negatively affect beneficiary access to services or quality of care, and must be cost effective, meaning it will not cost federal taxpayers more than it would cost without the waiver. These waivers initially are granted for two years.
Section 1915(c) HOME AND COMMUNITY-BASED SERVICES - allows states to develop creative alternatives to placing Medicaid beneficiaries in nursing homes, hospitals or other institutions. To obtain a waiver, the state must show that its proposal includes safeguards to protect the health and welfare of residents and that the services provided under the waiver will cost federal taxpayers no more than the expected costs without a waiver. These waivers are initially approved for three years, and may be renewed for additional five-year periods.
- Use the waiver to cover individuals who would qualify for Medicaid if placed in an institution
- Provide home- and community-based services - including home health aide services and personal care services - to help individuals stay out of institutional settings and thus preserve their independence and ties to family and friends.
Olmstead Decision - What is it and the Impact to States
www.ilru.org/olmstead/olmstead/olmstead.htm
www.worksupport.com/Archives/Olmstead.asp
In Olmsteadv. L.C., 527 U.S. 581, 119 S.Ct. 2176 (1999) (the Olmstead decision”), the Supreme Court construed Title II of the Americans with Disabilities Act (ADA) to require states to place qualified individuals with mental disabilities in community settings, rather than in institutions, whenever treatment professionals determine that such placement is appropriate, the affected persons do not oppose such placement, and the state can reasonable accommodate the placement, taking into account the resources available to the state and the needs of others with disabilities. The Department of Justice regulations implementing Title II of the ADA require public entities to administer their services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.
In Olmstead, the Supreme Court stated that institutional placements of people with disabilities who can live in, and benefit from, community settings perpetuates the unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life. The Supreme Court state that “recognition and unjustified institutional isolation of person with disabilities is a form of discrimination reflect[ed] two evident judgements”: 1) “Institutional placements of people with disabilities who can live in, and benefit from, community settings perpetuates the unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life”; and 2) “confinement in an institution severely diminishes everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” Olmstead, 119 S.Ct. 2176, 2179, 2187 [emphasis added]. This decision effects not only all persons in institutions and segregated settings, but also people with disabilities who are at risk of institutionalization, including people with disabilities on waiting lists to receive community based services and supports.
Who qualifies: Individuals must
- meet state’s criteria, such as age and diagnosis or condition and
- meet service criteria, usually the level-of-care criteria used to determine eligibility for either a hospital, nursing facility, or ICF/MR (42 CFR § 435.217.)
A determination that a person meets the required level-of-care criteria is based on information gathered through a formal assessment process carried out when a person applies for services. Activities of Daily Living (ADL) is an assessment tool that is used.
www.geri-ed.com/modules/assess/assess/katz_index_of_activities_of_daily_living.htm
www.psychpage.com/learning/library/advpract/adl.htm
What it covers: Program varies from state to state. States can provide a wide array of home and community-based services. States can limit the number of people served through a HCBS waiver. Services:
- Medical care
- Home health care:
- Physician must authorize and direct home care services.
- Services must be intermittent and medically reasonable.
- Person must be essentially homebound and need skilled care.
States may also:
- Provide some non-medical services to eliminate the need for participants to be placed in an institution.
- Serve the elderly, people with physical or developmental disabilities, mental retardation or mental illness, and those with a specific illness or condition, such as technology-dependent children or people with AIDS.
- Provide supportive services, such as: adult day care and chore and housekeeping services.
- Require beneficiaries to enroll in managed care plans;
- Create specialty care delivery systems, such as managed behavioral care;
- Create programs that are not available statewide
What it costs:
FOR THE INDIVIDUAL – Cost varies from state to state, some have sliding scale on ability to pay/buy-in, other states pay for total care.It is still cost effective than youth or families attempting to pay for all costs out-of-pocket.
FOR SOCIETY AND COMMUNITY - State Waivers offer a considerable savings, as typical institutional care starts at $41,000 year.
The National Conference of State Legislatures, which curiously enough filed an amicus in favor of Olmstead, reported in its January, 1999, State Legislative Report that "in 1996, institutional care cost an average of $94,348 per person, compared with $14,902 per person for community-based services.... States across the country have realized significant savings by offering services that allow people with disabilities [of all ages] to live in the community rather than in nursing homes or other institutions."
Impact for YOUTH: Without waiver services being delivered in the home setting, some youth might be unable to live in their community or have needed supports for the workplace. This either leads to family caregiver burnout – or – possible institutionalization.
How to Apply: Contact State Medicaid Office. http://www.cms.hhs.gov/medicaid/consumer.asp
HHS-OFFICE FOR CIVIL RIGHTS
New Freedom Initiative - Disability
Most Integrated Setting - The Olmstead Decision
www.hhs.gov/ocr/mis.htm
Resources and links to information, press releases, documents pertaining to the Olmstead Decision and state’s implementation efforts.
Guides:
GEORGE WASHINGTON UNIVERSITY
CENTER FOR HEALTH POLICY RESEARCH
Understanding Medicaid Home and Community Services: A Primer
aspe.hhs.gov/daltcp/reports/primer.htm
Medicaid now offers so many options for providing home and community services that they can be confusing for policymakers, state officials, advocates, and consumers alike. It does not help that the details of these expanded options tend to be buried in the minutiae of Medicaid legislative and regulatory provisions. To add to the confusion, the extensive flexibility states have to combine these options has resulted in 50 different state Medicaid programs. Even people who have spent years working in Medicaid do not always understand its many provisions.
This Primer is designed to encourage use of the Medicaid program in a manner that minimizes reliance on institutions and maximizes community integration in a cost-effective manner. Its intended audience is policymakers and others 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, and to promote consumer choice and control. In addition to comprehensive explanations of program features states can implement to achieve these goals, the Primer presents examples of state programs that have taken advantage of Medicaid’s flexibility to expand home and community services for people of all ages with disabilities.
NATIONAL ASSOCIATION OF PROTECTION AND ADVOCACY SYSTEMS, INC.
Olmstead vs L.C.
www.protectionandadvocacy.com/lcolmste.html
Olmstead Information about States/advocates efforts to develop comprehensive, effectively working state plans for moving unnecessarily institutionalized persons into the community with support . Tools, legislative briefs.
Resources:
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
CMS-Approved Medicaid Waivers
www.cms.gov/medicaid/waivsers/
Summaries of approved Medicaid waivers and copies of some waiver documents.
CMS-State-By-State Medicaid Program Descriptions
www.cms.gov/medicaid/statemap.asp
Profile of each state. Provides information: location of state office, Waivers, eligibility and related resources.
CMS-State-By-State Approved HIFA Demonstrations
cms.hhs.gov/hifa/hifaadem.asp
Health Insurance Flexibility and Accountability (HIFA) Initiatives
CMS-Eligibility For Home and Community-Based Care Waivers & Services
 www.cms.go v/ medicaid/1915c/regular.pdf
State-by-state Eligibility for home and community-based care waivers and the services covered in each state.
CMS-State Waiver Programs and Demonstrations
www.cms.gov /medicaid/waivers/waivermap.asp
CENTER FOR MEDICARE ADVOCACY
Secretary Issues Clarification To Medicare Homebound Definition: Directs Providers To Be More Flexible In Order To Protect Beneficiaries
www.medicareadvocacy.org
www.medicareadvocacy.org/HomeHealth_homeboundQandA.htm
On July 26, 2002 Tommy Thompson, Secretary of the United States Department of Health and Human Services, issued a Press Release and changes to the Medicare Home Health Agency Manual. The Secretary directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria.
This is important to elders and disabled Medicare beneficiaries as an individual must be confined to home (homebound) in order to qualify for Medicare home health coverage. Under the new instructions, those Medicare beneficiaries who qualify as homebound will not lose home health services should they need to leave their homes for a short time for special occasions, such as family reunions, graduations and funerals. The new language in the program manual clarifies that the determination of homebound status should be made over a period of time, rather than on a daily or weekly basis. In addition, the new guidelines expand the list of reasons for occasional absences from the home and include late stages of amyotrophic lateral sclerosis, or ALS, or other neurodegenerative disabilities as examples of conditions that would "indicate that a patient cannot leave his or her home."
NATIONAL CONFERENCE OF STATE LEGISLATURES
The States' Response To The Olmstead Decision: How Are States Complying? 2002
www.ncsl.org/programs/health/forum/olmsreport.htm
This paper is the third in a series of NCSL reports designed to better understand the effects of the Olmstead ruling on state policy. NCSL's first 50-state survey, published on NCSL's Web site in March 2001, provided an overview of the choices states were making as they acted on their obligations under the Olmstead decision. Building on this work, NCSL issued a second study in January 2002 that reviewed state Olmstead planning activities. This paper follows up on the preceding two papers with an additional focus on implementation.
Decreasing revenues and rising Medicaid costs caused tight budgets in most states in FY 2001 and FY 2002 and continued concern in FY 2003. The November 2002 election of new state legislators and governors marks a change in leadership in many of the states. The effect of these developments on long-term care reforms in the states is uncertain. A number of states are considering cost-containment options, many of which affect long-term care programs and services.
NIDRR-INSTITUTE FOR COMMUNITY LIVING, UNIVERSITY OF MINNESOTA
Residential Supports/Medicaid
rtc.umn.edu/res/index.html
The RTC gathers and analyzes statistics and generates reports and other information on residential and in-home supports for people with intellectual and developmental disabilities and their families and the Medicaid programs that pay for them.
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