Key Issues in State Implementation of the New and Expanded Home and Community-Based Services Options Available Under the Affordable Care Act

The Affordable Care Act (ACA) provides a number of new and expanded options for states to offer home and community-based services (HCBS) to Medicaid beneficiaries.  While states have made overall progress in rebalancing their long-term care systems in favor of HCBS, state adoption of the new and expanded ACA HCBS options has been relatively slow to date, despite the growing need for HCBS among beneficiaries and the enhanced federal funding associated with several of these options.  To explore these issues, the Kaiser Commission on Medicaid and the Uninsured convened a roundtable meeting on July 16, 2013 with a group of federal and state officials and experts. This brief summarizes the key issues identified and discussed by the invited participants.

States are interested in increasing access to Medicaid HCBS, but participants agreed that designing and implementing the new and expanded ACA HCBS options presents administrative complexities.  In addition, adoption of the ACA HCBS options is competing with state efforts to implement the ACA’s Medicaid eligibility and enrollment changes in 2014, and taking place in an environment of state budgetary pressures.  While beneficiary need for HCBS is growing, more information is necessary to determine which services are needed and whether current programs are providing the proper type and amount of services.

The needs assessment process is a fundamental part of HCBS access, and participants discussed consolidating and standardizing this process and incorporating elements such as beneficiary goals and needs in the critical areas of housing and employment and quality of life.  States and beneficiaries recognize the importance of being able to provide services when beneficiaries have a need for HCBS, even if their needs have not yet risen to an institutional level of care.  In addition, some states are interested in integrating HCBS into their managed care programs, particularly in the absence of other options to coordinate services across all populations receiving LTSS.  The opportunity for beneficiaries to self-direct services also was cited as an important element of HCBS.

Participants identified several areas for additional inquiry to further the expansion of HCBS and state adoption of the new ACA options.  Coordination between the aging and disability communities and among various subpopulations within the disability community is a critical part of expanding access to HCBS.  Looking ahead, participants agreed that future work is needed to better understand beneficiary needs, evaluate service quality, improve the needs assessment process, facilitate the provision of services before beneficiaries require institutional care, and streamline the various Medicaid HCBS authorities.   Extending options that currently have statutory expiration dates also could facilitate state adoption of the ACA options.  Continued attention to these issues can help to realize the ACA’s promise of expanded access to Medicaid HCBS and increased community integration for people with disabilities.