Opinion ID: 2052163
Heading Depth: 2
Heading Rank: 1

Heading: Statutory and Regulatory Framework of the Medicaid Waiver Program

Text: [¶ 3] A state may seek approval from the Centers for Medicare & Medicaid Services (CMS) of the federal Department of Health and Human Services to provide, in addition to the benefits already included in the state's Medicaid program, community-based services to individuals who would otherwise be institutionalized. 42 U.S.C.A. § 1396n(b)-(h) (West Supp.2005). A state's provision of home or community-based services is labeled a waiver program because the federal government waives certain Medicaid requirements that would otherwise constrain a state's ability to provide such services. [2] Id.; 42 C.F.R. § 430.25(d) (2004). The purpose of the waiver program is to provide services to avoid institutionalization. 42 C.F.R. § 441.300 (2004). The home or community-based services are for individuals for whom there has been a determination that but for the provision of such services the individuals would require the level of care provided in a hospital or a nursing facility. 42 U.S.C.A. § 1396n(c)(1). [¶ 4] A state that obtains permission from CMS for a waiver program must certify that the program will be cost-neutral; that is, (1) the state agency's total expenditures for community-based services and other Medicaid services for waiver program participants will not exceed the total expenditures if such persons were institutionalized; and (2) the average per capita expenditures under the waiver program will not exceed 100% of the average per capita expenditures that would have been made for the level of care provided in institutions. 42 U.S.C.A. § 1396n(c)(2)(D); [3] 42 C.F.R. § 441.302(e), (f) (2004). [4] [¶ 5] To be eligible for Maine's Medicaid waiver program, a person must have a chronic or permanent condition with functional impairments that interfere with the person's ability to provide for his own care or to perform daily living tasks without assistance. 14 C.M.R. 10 144 101-249 § 22.02(C)(7) (2001). The person must be eligible for the level of care provided by nursing facilities or hospitals. 42 C.F.R. § 441.302(c)(1), (c)(2), (g) (2004); 14 C.M.R. 10 144 101-246, -248 §§ 22.01-13, 22.02(B) (2001). [¶ 6] Maine obtained federal approval for its waiver program and received approval to renew the program for a five-year period. One of the strategies employed by DHHS to ensure compliance with the federal cost-neutrality requirements in its renewal application was promulgation of a regulation known as the 90% rule. The 90% rule provides that, in addition to other eligibility requirements that a consumer must meet, [t]he projected cost of Waiver services needed by the consumer is estimated to be less than 90% of the aggregate average monthly cost of care in a nursing facility per Waiver year. 14 C.M.R. 10 144 101-248 § 22.02(C)(2) (2001). [5]