**Home and Community‑Based Services Waivers**

[Program:]{.underline} Medicaid

[Statutory Authority:]{.underline} Section 1915(c) of the Social
Security Act, originally enacted in 1981, modified several times since
then.

[Purpose:]{.underline} Provide home or community‑based services (other
than room and board) as an alternative to Medicaid‑funded institutional
care for individuals in a nursing facility (NF), intermediate care
facility for the mentally retarded (ICF/MR), or hospital. Home and
community-based services (HCBS) waivers are requested by States and may
be approved by the Centers for Medicare & Medicaid Services (CMS) when
the requests meet all statutory and regulatory requirements. There is no
limit to the number of waivers a State may operate at any one time.

[Duration:]{.underline} Initial waivers are approved for 3‑year periods,
renewals are granted for periods of 5 years.

[Statutory sections waived:]{.underline} States have the flexibility to
request waiver of any or all of the following‑

1.  Section 1902(a)(1) of the Act, regarding Statewideness. This allows
    States to target waivers to particular areas of the State where the
    need is greatest, or perhaps where certain types of providers are
    available.

2.  Section 1902(a)(10)(B) of the Act, regarding comparability of
    services. This allows States to make waiver services available to
    people at risk of institutionalization, without being required to
    make waiver services available to the Medicaid population at large.
    States use this authority to target services to particular groups,
    such as elderly individuals, technology-dependent children, or
    persons with mental retardation or developmental disabilities.
    States may also target services on the basis of disease or
    condition, such as Acquired Immune Deficiency Syndrome.

3.  Section 1902(a)(10)(C)(i)(III) of the Act, regarding income and
    resource rules applicable in the community. This allows States to
    provide Medicaid to persons who would otherwise be eligible only in
    an institutional setting, often due to the income and resources of a
    spouse or parent. States may also use spousal impoverishment rules
    to determine financial eligibility for waiver services.

[Services:]{.underline} In addition to the medical services available to
the Medicaid population at large, States may, by waiver, provide for
case management, homemaker, home health aide, personal care, adult day
health services, habilitation, respite care and other services approved
by CMS which are cost‑effective and necessary to prevent
institutionalization. Waivers for persons with chronic mental illness
may provide partial hospitalization, psychosocial rehabilitation and
clinic services (whether or not furnished in a facility). Waivers may
also provide services designed to foster independence and assist
individuals in integrating into their communities, such as prevocational
and supported employment services, and supported living services.

[Service Providers:]{.underline} Providers may be formal (paid) or
informal (unpaid family, neighbors, friends, relatives). All providers
must meet the standards or qualifications set by the States to ensure
the health and welfare of the individual. States must monitor services
to ensure that standards are met.

[Monitoring:]{.underline} States must establish standards for service
provision that will ensure the health and welfare of the waiver
participants. These standards must include minimum standards for
provider participation. States are also required to monitor the
provision of services to ensure that standards are met, and must report
to CMS annually on the results of this monitoring. The law also requires
CMS to monitor the implementation of waivers and to take appropriate
action if this oversight shows that a waiver has failed to live up to
expectations.

[Availability:]{.underline}

-   49 States and the District of Columbia have home and community based
    services waivers. (Arizona, the 50th State operates a similar
    program under a research and demonstration authority.)

-   Target groups include aged, persons with disabilities, individuals
    with mental retardation or developmental disabilities, persons
    living with AIDS, individuals with traumatic brain injury, and
    others.

[Administration:]{.underline} Most States design their waivers to
coordinate with other sources of assistance, such as Medicare, Area
Agencies on Aging, or Departments of Developmental Disabilities.
Administrative responsibilities are typically shared among a number of
State agencies. Many waivers also train family members to provide
services, a move towards strengthening the family unit and enabling the
individual to remain at home. Waivers often provide respite care (either
at home or in an out-of-home setting) as a service, to allow family
members some relief from the constant strain of care giving. This has
been identified as a significant factor in the prevention of "caregiver
burnout." Increasingly, waivers are being used by States to support
programs of self-determination to assist individuals in making choices
in their lives.

[Alternative Living Arrangements:]{.underline} Many States allow waiver
services to be provided in group homes, assisted living facilities, or
other alternative living arrangements, when these are found to be the
most integrated settings appropriate to the person's needs. Individuals
may receive services in these alternative living arrangements on a short
or long term basis. Although Medicaid does not pay for room and board,
the waiver program often pays for the service components of these living
arrangements. When an individual elects to live in a congregate
facility, services may be provided by or through the facility itself, or
the individual may choose to have independent service providers for
different elements of his/her service plan. The congregate living
arrangements in which Medicaid HCBS waiver services are provided *may
not* be licensed or certified as NFs or ICFs/MR.

[Special Rules for Children]{.underline}**:** Medicaid-eligible children
under age 21 qualify for Medicaid's Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) program. The EPSDT program is designed
to serve a twofold purpose. It serves as Medicaid's well-child program,
providing regular screening, immunizations and access to care. However,
when a screening reveals the existence of a problem, EPSDT is used to
establish the diagnosis and furnish appropriate treatment. Under EPSDT,
States *must* provide any medically necessary service that Medicaid
could pay for under Federal law if the State's Medicaid program were as
broad as Federal statute would permit. When the screening identifies a
need, the EPSDT program pays for the service for the child. Since most
children can have their needs met under the EPSDT program, HCBS waivers
are used mainly to provide Medicaid eligibility to children whose
parents' income and resources exceed usual community thresholds. By
waiving these financial eligibility rules, HCBS waivers allow States to
provide care at home or in their communities to children who would
otherwise be eligible for Medicaid only if they were institutionalized.
States coordinate their HCBS waivers with their EPSDT programs to ensure
that the children's health and welfare are safeguarded, and to be
certain that their special needs are met.