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1 1 (March 21, 2017)

handle is hein.crs/govcfut0001 and id is 1 raw text is: FF.ri E.$~ & March 21, 2017 Waiting Lists in Medicaid Section 1915(c) Waivers The Social Security Act (SSA) authorizes several waiver and demonstration authorities that give states flexibility in operating their Medicaid programs. Each waiver authority has a distinct purpose and specific requirements. Medicaid waivers provide states the opportunity to try new or different approaches to the delivery of health care services or to adapt programs to the special needs of particular geographic areas or groups of Medicaid enrollees. For example, waiver programs allow states to extend benefits that are, among other things, neither comparable across groups nor statewide. The term Medicaid waiver is so-named because states may request that the Secretary of the Department of Health and Human Services (HHS) waive certain statutory requirements that would normally apply to services covered under Medicaid state plans. For each waiver, states must submit a waiver application for review and approval by the Centers for Medicare & Medicaid Services (CMS). Unlike Medicaid state plan benefit coverage, Medicaid waiver benefit coverage is time-limited for the duration of the waiver (e.g., three or five years) and must be renewed by the state subject to CMS approval. Section 1915(c) Home and Community-Based Services (HCBS) Waiver authority authorizes the Secretary of HHS to waive certain requirements of Medicaid law, thereby allowing states to cover a broad range of HCBS (including services not available under the Medicaid state plan) for certain persons with long-term care needs. Specifically, under SSA Section 1915(c) states may waive rules regarding statewideness and comparability of services. States may also apply certain income-counting rules to persons in HCBS waivers that allow an individual to be eligible for Medicaid who might not otherwise qualify. For FY2014, Medicaid expenditures for Section 1915(c) HCBS waivers were $41.5 billion. 55 C7ict S9 S C' ~ W t Section 1915(c) waivers are designed to expand opportunities for states to provide home and community- based care to additional groups of persons with long-term services and supports (LTSS) needs while containing Medicaid costs. Under this authority, states with approved applications may provide home and community-based care to persons who, without these services, would require Medicaid-covered institutional care. Section 1915(c) waivers permit states to cover services beyond the medical and medically related benefits that have been the principal focus of the Medicaid program. Under this authority, states can cover a wide variety of nonmedical, social, and supportive services that allow individuals to live independently in the community. The Medicaid statute specifies a broad range of services that states may provide to waiver participants. These services include case management, homemaker/home health aide, personal care, adult day health, habilitation, rehabilitation, and respite care. States also have flexibility to offer additional services, when approved by the HHS Secretary. For individuals with chronic mental illness, states may cover day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility) under a waiver. Section 1915(c) waivers may not cover room and board in a community-based setting, such as an assisted living facility. States must target a Section 1915(c) waiver to a specific population, such as individuals under age 65 with physical disabilities, individuals with intellectual or developmental disabilities, individuals aged 65 and older, or individuals with mental illness. As a result, states typically have more than one approved Section 1915(c) waiver, with each waiver program offering a specialized package of HCBS to a specific population. A CMS final rule published in 2014 gives states the option to combine target groups within one waiver program. Prior to this change, a Section 1915(c) waiver could serve only one of the following three target groups: (1) older adults, individuals with disabilities, or both; (2) individuals with intellectual disabilities, developmental disabilities, or both; or (3) individuals with mental illness. Eligible waiver participants must meet certain financial requirements (including income and resource requirements) and state-defined level-of-care criteria that demonstrate the need for LTSS. That is, individuals must have a level of need for LTSS that would otherwise be covered under a Medicaid institutional benefit, such as nursing facility care, Intermediate Care Facility for people with Intellectual Disability (ICF/ID), or hospital care. There are no statutory or regulatory requirements that define or describe waiting lists for Medicaid Section 1915(c) waiver programs. Under the Sectionl915(c) waiver authority, states may cap the number of individuals served in a waiver program by setting a numerical limit (no less than 200) on the number of individuals participating in the waiver. Such limitations must be specified in the state's application for a Section 1915(c) waiver, which is subject to CMS approval. Because state Medicaid programs often have greater demand for HCBS than the number of available waiver slots for a given program, limiting the number of individuals receiving HCBS is one way for states to contain costs. As a result, many states maintain waiting lists (sometimes referred to as interest lists, planning lists, p\w -- , gn'a', goo mppm qq\ a , q 'S I 11LIANJILiN,

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