Streamlining Medicaid Home and Community-Based Services: Key Policy Questions

Medicaid’s current home and community-based services (HCBS) programs represent a 35 year incremental approach to system design. Since the early 1980s, Congress has amended the law numerous times, seeking to ameliorate the program’s institutional bias by creating new authorities and incentives for states to offer HCBS. While substantially increasing beneficiary access to HCBS, these initiatives also have resulted in a patchwork of options, contributing to administrative complexity for states and confusion for individuals seeking services. Recently, policymakers have begun discussing how states and beneficiaries might be helped by a streamlined Medicaid state plan authority. This issue brief draws on features of the various existing Medicaid HCBS programs to identify key policy questions raised by initiatives to streamline Medicaid HCBS. These include:

• How would financial eligibility for HCBS be determined?
• How would states manage program enrollment?
• How would beneficiaries functionally qualify for services?
• How would HCBS be incentivized?
• How would the program be administered, monitored, and evaluated?

Streamlining Medicaid HCBS might alleviate some of the complexity and administrative costs associated with the program and support further progress in increasing beneficiary access to HCBS. The existing Section 1915(i) option for states to provide HCBS as Medicaid state plan benefits, as amended by the Affordable Care Act, has streamlined some program elements, such as the menu of available services. States’ experiences with implementing Section 1915(i), instead of offering HCBS through waivers, can inform the design of a streamlined HCBS option. Any changes to Medicaid HCBS programs will have to address how to ensure adequate financing, which is central to any streamlining effort, and how to manage program enrollment over time. Next steps in streamlining Medicaid HCBS could include engaging a variety of stakeholders; considering options to address potential concerns; and exploring financing mechanisms and the federal and state fiscal implications of a streamlined program.