How 1915(c) HCBS Medicaid Waivers Drive Community Care


Innovative care models are being tested around the country for vulnerable population groups such as those with mental illness, intellectual or developmental disabilities. One of the key issues at the heart of the healthcare debate is how to uniquely apply federal mandates in states and communities with these high-risk populations. Recognizing the flexibility that may be needed as communities try to accommodate federal guidelines to their unique situations, CMS strives to enable states, counties, and local providers to adhere to their guidelines without sacrificing quality of care for individuals in their community. Medicaid Waivers are one way CMS allows for this unique customization.

Waivers provide CMS with the federal statutory authority they need to exempt states from certain Medicaid requirements. It is important to note that these waivers are different from individual state plan amendments (which may require states to renew every 3-5 years) and may include enrollment limits or waiting lists as they are not considered entitlements.

Included in the list of Medicaid waivers is the 1915(c). First introduced by President Reagan’s Omnibus Reconciliation Act of 1981, the 1915(c) waiver allowed states to create a unique package of services targeting individuals requiring an institutional level of care. Under the 1915(c) waiver, patients would now be able to receive Home and Community-Based Services (HCBS) such as rehabilitation, transportation for services, and personal care in their homes or communities rather than institutional settings. These waivers, however, had limitations. For example, they could only serve one of three target groups. Recognizing this, CMS began soliciting input from providers and patients in 2009 regarding how they could improve waiver 1915(c).

As a result of feedback received, regulations were updated in 2014 and these waivers now allow providers to combine multiple conditions and populations under a single waiver, and can also be combined with a 1915(b) Freedom of Choice waiver to implement managed care. This change removes a barrier for states wishing to develop a waiver that meets the needs of multiple target populations. The rule specifies that if a state chooses the option of more than one target group under a single waiver, they must assure CMS that it is able to meet the unique service needs of individuals in each group, and that everyone covered by the waiver has equal access to all needed services.

State HCBS waiver programs must also meet the following additional guidelines:

  • Outline cost-effectiveness, such as illustrating how doing nothing over a 3-5 year period would affect costs versus implementing the proposed program.
  • Establish a quality assurance plan to protect patient’s health and welfare.
  • Provide reasonable standards for providers who serve the target population.

It is important to remember that at the heart of these initiatives is the drive to improve the quality and accessibility of Home & Community Based Services (HCBS). In 2014, 53% of all Medicaid long term care spending was for home & community based services. As part of their efforts to improve not only the quality, but also the accessibility of these efforts, CMS is working with the Office of the National Coordinator for Health Information Technology (ONC) to promote a Medicaid Health IT Toolkit. These efforts are to ensure that there is a functioning health IT ecosystem within each state that can advance and sustain Medicaid program objectives, including improving care and curbing costs.

There are numerous ways to incorporate health IT and interoperability considerations into a HCBS Medicaid program. It is hoped that as states implement the updated regulations regarding 1915(c) that their efforts will simultaneously support HCBS providers in their efforts to digitize their service delivery systems. Although use of the toolkit is voluntary, it can be a valuable asset as states craft new compliance plans with updated guidelines. As states apply for or renew Medicaid waivers, this toolkit can strengthen their applications as it is incorporated into their plan.

The toolkit is designed to reinforce the need for states to harmonize the HCBS program with other federal programs that are incorporating technology on a growing scale. Other programs the toolkit can help are State Innovation Models (SIM), the HER Incentive Program, Medicaid Management Information Systems (MMIS), and Medicare. At the heart of these efforts to coordinate resources is the growing awareness of the benefits that come from sharing person-centered data, such as how patients want their services delivered, and by whom, and what their desired outcomes and goals are for their personalized treatment.

According to the State Toolkit guidelines from June 2017, sharing this person-centered data through the Medicaid Health IT Toolkit can:

  • Support sharing standardized assessment information across populations and settings of care
  • Support individuals with person centered service delivery through transitions
  • Facilitate quality monitoring across providers and settings

The efforts to create a functioning health IT infrastructure will help HCBS programs and providers optimize the care they provide while curbing overall costs. Providing the Health IT Toolkit and updating their waiver guidelines make clear the mission of CMS to improve the accessibility and quality of care available to patients, as well as their concern to alleviate any burdens experienced by providers to achieve these aims. In short, the toolkit is a valuable yet voluntary tool that can help you join the effort to improve home and community based services for individuals in your community, and stay in compliance with improving federal statutes and waivers.

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