DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Center for Medicaid, CHIP and Survey & Certification   
 
   
  SMDL#  10-015  
  ACA # 6 
 
August 6, 2010 
   
                                                             Re:  Improving Access to Home and Community-Based Services 
             
Dear State Medicaid Director: 
 
The purpose of this letter is to inform you of several changes to Section 1915(i) of the Social Security Act 
(the Act) made by the Affordable Care Act (ACA)1.  These changes, which become effective October 1, 
2010, include revised and new 1915(i) provisions for removal of barriers to offering home and community-
based services (HCBS) through the Medicaid State plan.  This letter is intended to provide States guidance 
on those important changes to the law. 
 
Background 
Section 6086 of the Deficit Reduction Act of 2005 (DRA) added section 1915(i) to the Act.  While this 
State plan service package includes many similarities to options and services available through 1915(c) 
HCBS waivers, a significant difference is that 1915(i) does not require individuals to meet an institutional 
level of care in order to qualify for HCBS.  Section 1915(i) provides States an opportunity to offer services 
and supports before individuals need institutional care, and also provides a mechanism to provide State 
plan HCBS to individuals with mental health and substance use disorders.  As originally enacted, however, 
States were unable to target 1915(i) services to particular populations within the State, and could only serve 
individuals whose incomes did not exceed 150 percent of the Federal poverty level (FPL).  Additionally, 
the original service package available under 1915(i) included some, but not all, of the HCBS available 
through waivers.  
 
The changes to 1915(i) under the ACA enhance an important tool for States in their efforts to serve 
individuals in the most integrated setting and to meet their obligations under the Americans with 
Disabilities Act (the ADA) and the Olmstead decision.  In order to promote State utilization of 1915(i), the 
ACA includes changes that enable States to target HCBS to particular groups of people, to make HCBS 
accessible to more individuals, and to ensure the quality of the HCBS. 
 
Improvements to Section 1915(i) in the Affordable Care Act  
The following information summarizes major changes and additions to section 1915(i) under the ACA 1. 
 
                                                 
1 Section 2402(b) through 2402(f) of the Affordable Care Act (Patient Protection and Affordable Care Act, P.L. 111-148, 
enacted March 23, 2010, together with the Health Care and Education Reconciliation Act of 2010, P.L. 111-152, enacted arch 30, 
2010).  Page 2  State Medicaid Director                         
 
 
Number Served & Statewideness 
Under the ACA, States may continue to specify needs-based eligibility criteria but they are no longer 
permitted to limit the number of eligible individuals who can receive 1915(i) State plan HCBS or establish 
a waiting list for State plan HCBS.  Additionally, States may not limit the availability of 1915(i) services to 
specific geographic areas or political subdivisions of the State (statewideness).  As with other State plan 
services, 1915(i) State plan HCBS must be offered to all eligible individuals (as defined by the State) on a 
statewide basis.  However, States are afforded new flexibility to target specific 1915(i) services to State-
specified populations (see Targeted Benefits).  States are required to report to the Centers for Medicare 
& Medicaid Services (CMS) annually, to project the number of individuals who are expected to receive 
1915(i) State plan HCBS in a year, and to submit the actual number of individuals served.   
 
If enrollment of eligible individuals exceeds a States projected enrollment estimate provided in a CMS-
approved 1915(i) State plan amendment (SPA), as included under the DRA, Section 1915(i) continues to 
permit States to modify the non-financial needs-based eligibility criteria without prior approval by CMS.  
States need only to notify CMS and the public at least 60 days before exercising the option to modify 
needs-based eligibility criteria.  However, the ACA does revise the length of the grandfathering period for 
individuals under this adjustment authority specified at section 1915(i)(1)(D)(ii)(II).  If a State chooses to 
revise its needs-based eligibility criteria, it must continue offering 1915(i) services in accordance with 
individual service plans to participants who do not meet the new revised needs-based criteria, but continue 
to meet the former needs-based criteria, for as long as the State plan HCBS option is authorized. 
 
Financial Eligibility 
States continue to have the option to provide State plan HCBS to individuals with incomes up to 150 
percent of the FPL who are eligible for Medicaid under an eligibility group covered under the State plan 
without regard to whether such individuals need an institutional level of care.  All individuals served under 
1915(i), regardless of their income levels, must meet the non-financial needs-based criteria that the State 
establishes to access 1915(i) State plan HCBS.  As a reminder, each State requesting to add 1915(i) to its 
State plan is required to demonstrate that the needs-based criteria for 1915(i) services are less stringent than 
the States institutional level of care criteria. 
 
The ACA adds a new section to 1915(i) that allows States the option of providing services to individuals 
with income up to 300 percent of the Supplemental Security Income (SSI) Federal benefit rate (FBR)2.  
While individuals served in this new eligibility group must be eligible for HCBS under a 1915(c) , (d), or 
(e) waiver or 1115 demonstration program, they do not have to be enrolled and receiving services in either 
waiver program.  For this eligibility group, States are also permitted to use institutional eligibility and 
post-eligibility rules in the community, in the same manner they would under a 1915(c) waiver.  Post 
eligibility rules determine the amount (if any) for which an individual is liable to pay for the cost of 
their 1915(i) HCBS. 
 
Targeted Benefits 
With the changes enacted through the ACA, States may design service packages without regard to 
comparability, as described at 1902(a)(10)(B).  States are able to offer HCBS to specific, targeted 
populations.  States will also be permitted to offer services that are different in amount, duration, and scope 
                                                 
2 For 2010, 300 percent of SSI is equal to $2,022 per month.  Page 3  State Medicaid Director                         
 
 
to specific population groups, including eligibility groups as authorized under 1915(i)(6)(c), either through 
one 1915(i) service package, or multiple 1915(i) service packages.  For example, a State could propose to 
have one 1915(i) benefit that is targeted and includes specific services for persons with physical and/or 
developmental disabilities, and another 1915(i) benefit targeted to persons with chronic mental illness.  
Another State might implement one 1915(i) benefit that is targeted to children with autism and adults with 
HIV/AIDS, but specify different services to meet the needs for each targeted population group within the 
same overall benefit package. 
 
If a State chooses to implement this option to provide State plan HCBS to a targeted population(s), the 
ACA authorizes CMS to approve such a SPA for a 5-year period.  States will be able to renew approved 
1915(i) services for additional 5-year periods if CMS determines, prior to the beginning of the renewal 
period, that the State met Federal and State requirements and that the States monitoring is in accordance 
with the Quality Improvement Strategy specified in the States approved SPA.   
 
Services 
Section 1915(i) allows States to include any or all of the services that are listed in section 1915(c)(4)(B) of 
the Act. These services include case management, homemaker/home health aide, personal care, adult day 
health, habilitation, and respite care services.  In addition, the following services may be provided to 
persons with chronic mental illness:  day treatment, other partial hospitalization services, psychosocial 
rehabilitation services, and clinic services (whether or not furnished in a facility).  The ACA revised 
1915(i) so that States may now offer, such other services requested by the State as the Secretary may 
approve.  As a result of this change, States will now be permitted to propose other services (not 
including room and board) in a 1915(i) SPA that CMS will evaluate and possibly approve. 
 
States continue to have the option to offer self-direction to individuals receiving State plan HCBS, and 
CMS urges all States to afford participants the opportunity to direct some or all of their HCBS.  Self-
direction permits participants to plan and purchase their HCBS under their direction and control or through 
an authorized representative.  As with all 1915(i) services, the provision of these services must be in 
accordance with an individualized plan of care, which is based upon an independent assessment and a 
person-centered process driven by what is important to the participant.  The services that the participant or 
his/her representative will self-direct and the methods by which he/she will self-direct and the supports that 
are available to the participant all must be specified in the plan of care. 
 
Compliance  
States will be required to continue to comply with all other provisions of 1915(i) as well as other sections 
of the Act in the administration of the State plan under this Title.   
 
Submission Procedures 
These new and revised provisions will become effective October 1, 2010.  Regulations at 42 CFR 
430.12(c)(i) require States to amend their State plans to take account of changes in Federal law.  Therefore, 
States with approved 1915(i) services prior to this date that include provisions impacted by the changes 
under the ACA, should submit a SPA no later than December 31, 2010, that will take effect retroactive to 
October 1, 2010.  
  Page 4  State Medicaid Director                         
 
 
To incorporate a new 1915(i) service package into your State plan, or to revise existing approved 1915(i) 
services, please submit a SPA electronically to the Associate Regional Administrator for Medicaid in your 
CMS regional office.   
 
CMS encourages States to submit questions and comments to CMS regarding the statutory changes to 
1915(i) made in the ACA through the mailbox at CMCSPPACAQuestions@cms.hhs.gov.  If you have 
any additional questions, please contact Ms. Barbara Edwards, Director of the Disabled and Elderly Health 
Programs Group, at 410-786-0325. 
 
  Sincerely, 
 
  /s/ 
               
  Cindy Mann 
  Director 
Enclosure 
cc: 
 CMS Regional Administrators 
 
CMS Associate Regional Administrators 
 
Ann C. Kohler          
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.P.H. 
Director, Government Relations  
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy  Enclosure 
 
The Affordable Care Act 
Section 2402 (b) ADDITIONAL STATE OPTIONS.Section 1915(i) of the Social 
Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end the following new paragraphs: 
 
 
     
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
(6) STATE OPTION TO PROVIDE HOME AND     Allows States to add a new optional Medicaid eligibility 
COMMUNITY-BASED SERVICES TO INDIVIDUALS  group to provide 1915(i) to individuals who have income that 
ELIGIBLE FOR SERVICES UNDER A WAIVER.  does not exceed 300% of SSI Federal Benefit Rate and are 
(A) IN GENERAL.A State that provides home and  eligible for HCBS under a waiver. To be eligible, the 
community-based services in accordance with this subsection  individuals must still also meet 1915(i) needs-based criteria 
to individuals who satisfy the needs-based criteria  established by the State, as approved in a SPA.   
for the receipt of such services established under paragraph   
(1)(A) may, in addition to continuing to provide such services  This new provision gives States the option to offer HCBS to 
to such individuals, elect to provide home and community-  individuals with higher incomes (up to 300% of SSI FBR) 
based services in accordance with the requirements  who are eligible for an approved waiver in the State.  While 
of this paragraph to individuals who are eligible for home  individuals must be eligible for a 1915(c) waiver 
and community-based services under a waiver approved  (institutional and any specific waiver targeting criteria) or 
for the State under subsection (c), (d), or (e) or under  1115 demonstration program, they do not have to actually be 
section 1115 to provide such services, but only for those  enrolled and receiving waiver services in either waiver 
individuals whose income does not exceed 300 percent of  program.  
the supplemental security income benefit rate established   
by section 1611(b)(1).              AND 
            
            AND   
   
   
   
   
1 
       
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
2402(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE  For this eligibility group, States are also permitted to use 
FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING  institutional eligibility and post-eligibility rules in the 
HOME AND COMMUNITY-BASED SERVICES UNDER A  community, in the same manner they would under a 1915(c) 
STATE PLAN AMENDMENT.  waiver. 
(1) Section 1902(a)(10)(A)(ii) of the Social   
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
section 2304(a)(1), is amended 
(A) in subclause (XX), by striking or at the end; 
(B) in subclause (XXI), by adding or at the end; 
and 
(C) by inserting after subclause (XXI), the following 
new subclause: 
(XXII) who are eligible for home and community- 
based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i), or who are eligible for home and community- 
based services under paragraph (6) of such 
section, and who will receive home and community-based 
services pursuant to a State plan amendment 
under such subsection;.  
 
(2) CONFORMING AMENDMENTS. 
(A) Section 1903(f)(4) of the Social Security Act (42 
U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), 
is amended in the matter preceding subparagraph (A), 
H. R. 3590186 by inserting 1902(a)(10)(A)(ii)(XXII), after 
1902(a)(10)(A)(ii)(XXI),. 
(B) Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)), as so amended, is amended in the matter preceding 
paragraph (1) 
(i) in clause (xv), by striking or at the end; 
2 
       
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
(ii) in clause (xvi), by adding or at the end; 
and 
(iii) by inserting after clause (xvi) the following 
new clause: 
(xvii) individuals who are eligible for home and community- 
based services under needs-based criteria established 
under paragraph (1)(A) of section 1915(i), or who are eligible 
for home and community-based services under paragraph (6) 
of such section, and who will receive home and community-based 
services pursuant to a State plan amendment under such 
subsection,. 
(6)(B) APPLICATION OF SAME REQUIREMENTS FOR        
INDIVIDUALS SATISFYING NEEDS-BASED CRITERIA. When States choose to serve individuals through the new 
Subject to subparagraph (C), a State shall provide home and  optional eligibility category, all other requirements continue 
community- based services to individuals under this paragraph  to apply (ex., needs-based criteria evaluation and assessment, 
in the same manner and subject to the same requirements  person-centered planning). 
as apply under the other paragraphs of this subsection 
to the provision of home and community-based services 
to individuals who satisfy the needs-based criteria established 
under  paragraph (1)(A). 
(6)(C) AUTHORITY TO OFFER DIFFERENT TYPE,    For States that choose to add the new optional eligibility 
AMOUNT, DURATION, OR SCOPE OF HOME AND    group for individuals with incomes up to 300% SSI FBR, 
COMMUNITY-BASED SERVICES.  there is an additional flexibility to offer different types, 
A State may offer home and community-based  services to  amount, duration, or scope of HCBS to these eligible 
individuals under this paragraph that differ in type, amount,  individuals.  All services have to be those allowed under 
duration, or scope from the home and community-based services  1915(c)(4)(B), approved by CMS, and not include room and 
offered for individuals who satisfy the needs-based criteria  board.  
established under paragraph (1)(A), so long as such services are   
within the scope of services described in paragraph (4)(B) of 
subsection (c) for which the Secretary has the authority to approve 
a waiver and do not include room or board. 
3 
       
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
(7) STATE OPTION TO OFFER HOME AND COMMUNITY-   Allows States to provide HCBS to specific targeted 
BASED SERVICES TO SPECIFIC, TARGETED  populations. States are now also allowed the option to have 
POPULATIONS.  more than one 1915(i) benefit by target group.   
(A) IN GENERAL.A State may elect in a State plan 
amendment under this subsection to target the provision 
of home and community-based services under this subsection 
to specific populations and to differ the type, amount, duration, or 
scope of such services to such specific populations. 
(7)(B) 5-YEAR TERM.    (i) If States choose to target populations, the SPA will be 
(i) IN GENERAL.An election by a State under    approved for a 5-year period. 
this paragraph shall be for a period of 5 years.     
(ii) PHASE-IN OF SERVICES AND ELIGIBILITY   
PERMITTED DURING INITIAL 5-YEAR PERIOD. 
A State making an election under this paragraph may, during the 
first 5-year period for which the election is made, phase-in the 
enrollment of eligible individuals, or the provision of services to 
such individuals, or both, so long as all eligible individuals in the 
State for such services are enrolled, and all such services are 
provided, before the end of the initial 5-year period. 
 
(7)(C) RENEWAL.An election by a State under this paragraph    States may renew for additional 5-year periods if CMS 
may be renewed for additional 5-year terms if the  determines prior to beginning of renewal period that the State 
Secretary determines, prior to beginning of each such  met all quality and programmatic requirements. 
renewal period, that the State has 
(i) adhered to the requirements of this subsection 
and paragraph in providing services under such an 
election; and 
(ii) met the States objectives with respect to 
quality improvement and beneficiary outcomes.. 
 
1915(i)(c) REMOVAL OF LIMITATION ON SCOPE OF  This change allows   
4 
       
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
SERVICES.Paragraph (1) of section 1915(i) of the Social  States to provide 
Security Act (42 U.S.C. 1396n(i)), as amended by subsection (a),  other services as 
is amended by striking or such other services requested by the  permitted under 
State as the Secretary may approve.  1915(c) waivers.  
  States must continue 
to identify and define 
services (including 
provider 
qualifications) in a 
CMS-approved 
1915(i) SPA. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF  This provision   
ELIGIBLE INDIVIDUALS OR LENGTH OF PERIOD FOR  removes the option 
GRANDFATHERED INDIVIDUALS IF ELIGIBILITY  for a State to limit 
CRITERIA IS MODIFIED.Paragraph (1) of section  number of eligible 
1915(i) of such Act (42 U.S.C. 1396n(i)) is amended  individuals who can 
(1) by striking subparagraph (C) and inserting the following:  receive 1915(i) 
  services.  As a result, 
(C) PROJECTION OF NUMBER OF INDIVIDUALS TO BE  States may no longer 
PROVIDED HOME AND COMMUNITY-BASED  establish a wait list 
SERVICES.The State submits to the Secretary, in such form  for receipt of State 
and manner, and upon such frequency as the Secretary shall  plan HCBS. 
specify, the projected number of individuals to be provided home   
and community-based services.; and   
(2) in subclause (II) of subparagraph (D)(ii), by striking  This provision   
to be eligible for such services for a period of at least 12  removes the 12-
months beginning on the date the individual first received  month limit from the 
medical assistance for such services and inserting to continue  grandfathering 
to be eligible for such services after the effective date of the  period.  If a State 
modification and until such time as the individual no longer  decides to tighten its 
meets the standard for receipt of such services under such  needs-based criteria, 
5 
       
Statutory Provision  Changes to the  New Features for the 1915(i) Benefit 
  Existing 1915(i)   
Benefit 
pre-modified criteria.  it must continue 
offering 1915(i) 
services to 
individuals who were 
eligible and being 
served under the 
former standards. 
 
 
(f) ELIMINATION OF OPTION TO WAIVE  This provision  This provision also adds a new provision to allow States to 
STATEWIDENESS; ADDITION OF OPTION TO WAIVE  removes the ability  waive comparability.  States can now target 1915(i) to 
COMPARABILITY.Paragraph (3) of section  for States to limit the  specific populations. States are now also allowed the option 
1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking  availability of the  to have more than one 1915(i) benefit by target group. As 
1902(a)(1) (relating to statewideness) and inserting  1915(i) benefit to  with new Section 1915(i)(7), States that choose to target 
1902(a)(10)(B) (relating to comparability).  specific geographic  populations will be able to renew the approved 1915(i) 
  areas or political  benefit for additional 5-year periods if CMS determines, prior 
subdivisions of the  to the beginning of the renewal period, that States met 
State (statewideness).   Federal and State requirements and the States monitoring is 
As with other State  in accordance with the Quality Improvement Strategy (QIS) 
plan services, 1915(i)  specified in the States approved 1915(i) State plan service 
State plan HCBS  benefit.   
must be offered to all   
eligible individuals   
on a statewide basis.   
 
 
 
6