Key State Policy Choices About Medicaid Home and Community-Based Services
Issue Brief
For additional background, see KFF, Streamlining Medicaid Home and Community-Based Services: Key Policy Questions (March 2016), https://www.kff.org/medicaid/issue-brief/streamlining-medicaid-home-and-community-based-services-key-policy-questions/; KFF, Medicaid Long-Term Services and Supports: An Overview of Funding Authorities (Sept. 2013), http://kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-authorities/.
KFF, Medicaid Home and Community-Based Services Enrollment and Spending (Feb. 2020), https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/.
Self-direction in NE does not include determining worker payment rates or allocating service budgets.
The remaining 10 states (AZ, CA, DC, FL, MS, NC, OR, VA, WA and WY) did not respond to this question.
Federal law exempts the following populations from most Medicaid cost-sharing: children under age 18, most pregnant women with incomes <150% FPL, individuals who are terminally ill, those residing in an institution, American Indians who either are eligible to receive or have received an item or service furnished by an Indian health care provider or through referral to contract services, and individuals covered under the breast and cervical cancer treatment program. KFF, Premiums and Cost-Sharing in Medicaid (Feb. 2013), https://www.kff.org/medicaid/issue-brief/premiums-and-cost-sharing-in-medicaid/.
FL’s copayment is per day, not per visit.
SC charges $3.30 per visit, while GA, KS, KY, ME, MS, and VA charge $3.00.
AZ, CA, DE, DC, FL, HI, IL, IN, IA, KS, KY, LA, MA, MN, MS, NE, NH, NM, NV, NJ, NY, OH, OR, PA, RI, TN, TX, UT, WA, WV, and WI.
The remaining states (CA, DC, MN and MS) did not specify a managed care authority.
This year’s survey changed the way this question was asked. In previous years, we asked states to report a minimum, maximum, and an average dollar rate paid to agencies, registered nurses, and home health aides. An average was calculated based on state responses. This year’s survey asked states to report only the average dollar rate per visit to agencies, registered nurses, and home health aides. A total of 45 states responded to some or all of this survey question. The six states not responding include DE, ME, NY, TN, UT, and WV.
The average includes 33 states that reported per visit rates, and four states that reported per hour rates.
The average includes 33 states that reported per visit rates, and six states that reported per hour rates.
In past years, DE did not separately report personal care enrollment and spending or complete the policy survey, as those services were included in its Section 1115 capitated managed care waiver.
CMS State Medicaid Manual § 4480, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html.
Id. Personal care services exclude skilled services that only may be performed by a health professional. Id.
Id.
KS and NM have CMS approval to offer personal care state plan services but deliver these services through Section 1115 capitated managed care waivers. These states did not separately report personal care state plan enrollment and spending and did not complete the policy survey.
This can include training on topics such as safety, transportation, shopping, social skills, and banking, as well as mentoring and parent education and training.
AK allows parents who are court-appointed to provide personal care services.
LA allows family members and friends other than a spouse, curator, tutor, legal guardian, responsible representative or power of attorney to provide long-term personal care services to a beneficiary over age 21 if the family member/friend is employed by an agency.
Other than InterRAI, OASIS, or CHOICES.
FL, ID, KS, LA, MA, MN, NV, NJ, NM, TX, UT, and WI.
This year’s survey changed the way this question was asked. In previous years, we asked states to report a minimum, maximum, and an average dollar rate paid to personal care agencies, and an average was calculated based on state responses. This year’s survey asked states to report only the average dollar rate per visit to agencies. 27 of 34 states responded to some or all of this survey question, with 25 responding with agency rates and 15 with direct provider rates. Six states (KS, NH, NM, NY, OK, and RI) did not respond to this survey question, while one state (VT) noted this question was not applicable since its personal care program is entirely self-directed with beneficiaries establishing provider payment rates, subject to a state minimum.
Section 1915 (k).
This option specifically applies to the 217 HCBS waiver group, individuals for whom the state has opted to expand the minimum Medicaid HCBS financial eligibility limit under the “special income rule” (up to a federal maximum of 300% SSI), who would be eligible under the Medicaid state plan if institutionalized, meet an institutional level of care, and would be institutionalized if not receiving waiver services. These individuals must be receiving at least one waiver service per month to qualify for CFC services.
42 C.F.R. § 441.510 (a), (b).
42 C.F.R. § 441.510 (d).
CFC services include hands-on assistance, supervision or cueing, and services for the acquisition, maintenance, and enhancement of skills necessary for individuals to accomplish self-care, household activity, and health-related tasks. Health-related tasks are those that can be delegated by a licensed health care professional to be performed by an attendant.
Backup systems include electronic devices as well as individuals identified by the beneficiary to ensure continuity of services.
Transition costs may include rent and utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies, and other required necessities.
These services may be covered to the extent that expenditures otherwise would be made for human assistance.
The remaining state (NY) did not respond to this survey question.
MI state plan amendment, #18-0008 (approved Dec. 19, 2018), https://www.michigan.gov/documents/mdhhs/1915i_SPA_18-0008_643796_7.pdf.
ID targets people with I/DD but offers different benefit packages for children vs. adults. IN targets 3 groups of people with mental illness: children, adults receiving habilitation services, and people receiving behavioral health and primary care coordination. NV serves seniors and people with physical disabilities, those with traumatic brain injuries, and those with “behavioral indicators,” but did not separate data by sub-population.
DC did not respond to this survey question.
See Victoria Peebles and Alex Bohl, CMS/Mathematica Policy Research, The HCBS Taxonomy: A New Language for Classifying Home and Community-Based Services (Aug. 2013), http://www.mathematica-mpr.com/~/media/publications/PDFs/health/max_ib19.pdf.
DC did not respond to this survey question.
Benefits under IN’s Section 1915 (i) behavioral health and primary care coordination program are limited to case management. IN does not expand financial eligibility for its other two Section 1915 (i) programs, which provide wrap-around benefits for children with mental health disabilities and habilitation services for adults with mental health disabilities.
These 12 states operate Section 1115 waivers without an accompanying Section 1915 (c) waiver. KS and NC are excluded from this list because they have joint Section 1115/1915 (c) waivers, with HCBS authorized under Section 1915 (c).
WA’s Section 1115 waiver includes 3 HCBS programs provided fee-for-service: (1) the Medicaid Alternative Care program, which offers a benefit package to support unpaid caregivers as an alternative to Medicaid-funded LTSS for people age 55 and older who are otherwise Medicaid eligible; (2) the Tailored Support for Older Adults programs, which creates a new eligibility pathway and provides a limited benefit package to people who are 55 and older and meet a nursing home level of care but do not currently financially qualify for Medicaid (this pathway covers people with income up to 300% SSI and resources up to $53,100); and (3) Foundational Community Supports, which provides (a) supported housing to those 18 or older with at least 1 health need (covering a range of behavioral health, physical health, and intellectual disabilities) and at least 1 risk factor (such as homelessness, frequent institutional stays, or frequent in-home caregiver turnover), and (b) supported employment to those age 16 or older with at least 1 health need (including behavioral health, physical health, and intellectual disabilities) and at least 1 risk factor (such as unable to obtain or maintain employment due to a disability (including TBI), multiple SUD inpatient treatment visits, or risk for deterioration of behavioral health condition). CMS, Special Terms and Conditions, Washington State Medicaid Transformation Project, #11-W-00304/0 (approved Jan. 9, 2017-Dec. 31, 2021), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wa/wa-medicaid-transformation-ca.pdf.
Other Medicaid managed care authorities include the Section 1932 state plan option and Section 1915 (a) and Section 1915 (b) waivers.
KS’s Section 1115 waiver authorizing capitated managed care was originally approved in January 2013. It operates concurrently with its Section 1915 (c) waivers for people with I/DD (KS-0224), children with autism (KS-0476), people with physical disabilities (KS-0304), medically fragile/technology dependent children (KS-4165), people with TBI (KS-4164), children with serious emotional disturbance (KS-0320), and frail seniors (KS-0303). CMS Special Terms and Conditions for KanCare, #11-W-00283/7 at ¶ 42 (p. 41) (approval period Jan. 2019-Dec. 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ks/ks-kancare-ca.pdf.
NC’s Section 1115 waiver was approved in October 2018, but implementation has been delayed. In the meantime, NC’s joint § 1915 (b)/(c) MLTSS waiver continues. The letter accompanying CMS’s October 2018 approval of NC’s Section 1115 waiver notes that “[t]he state requested to transition its 1915 (c) Home and community Based services (HCBS) waivers for Innovation Waiver Services [for children and adults with I/DD] (NC-0423.R02.00) and Traumatic Brain Injury services (NC-1326.R00.00) into the demonstration. CMS determined the state could effectively operate its HCBS waivers under the 1915 (c) authorities concurrently with 1115 authority requiring Medicaid beneficiaries, except those excluded or exempted, to enroll into a managed care plan to receive state plan and HCBS waiver services.” Letter from CMS Administrator Seema Verma to NC Deputy Secretary for Medical Assistance Dave Richard, at 3 (Oct. 19, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/nc-medicaid-reform-ca.pdf.
The transition will take place over five years, from January 2019 through December 2023. CMS Special Terms and Conditions, Rhode Island Comprehensive Section 1115 Demonstration, #11-W-00242/1 at ¶ 31 (p. 29) (approval period Jan. 1, 2019-Dec. 31, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ri/ri-global-consumer-choice-compact-ca.pdf.
Id. at II (e), p. 12.
Most of the decline in the total number of Section 1915 (c) waivers from FY 2017 to FY 2018 is attributable to states consolidating multiple waivers in an effort to streamline administration and reporting. For example, several states eliminated one or more Section 1915 (c) waivers but transferred those populations and services to another Section 1915 (c) waiver: FL moved three waivers serving individuals with HIV, individuals with TBI/SCI, and individuals with I/DD into its long-term care waiver, NE eliminated one waiver serving people with I/DD and transitioned another I/DD waiver into the state’s comprehensive HCBS waiver, NY continued to combine multiple waivers serving different groups of children with disabilities into a single children’s waiver, effective April 2019, PA moved five waivers to a Section 1915 (c) that operates concurrently with a Section 1915 (b) waiver to provide managed LTSS, WI moved two waivers serving individuals with I/DD and seniors and adults with physical disabilities to other existing HCBS waivers (Family Care or self-directed program), and WY transferred its TBI/SCI waiver enrollees to other existing HCBS waivers. In addition, CO and CT discontinued waivers serving individuals with I/DD and moved those services to state plan authority. VA was the only state to report eliminating a waiver (serving seniors and people with physical disabilities, specifically with Alzheimer’s disease or related dementia) without moving those services to another authority.
For the I/DD population, 46 states use only Section 1915 (c) waivers, three states (AZ, RI, and VT) use only Section 1115 waivers, and 2 states (NY and TN) use both waiver authorities.
For seniors and adults with physical disabilities, 39 states use only Section 1915 (c) waivers, nine states (AZ, DE, HI, NJ, NM, RI, TN, TX, and VT) use only Section 1115 waivers, and three states (CA, NY, and WA) use both waiver authorities.
Nearly all (21 of 25) states with TBI/SCI waivers use Section 1915 (c), while four (DE, RI, VT, and WA) use Section 1115. FL continues to serve people with TBI but consolidated its TBI wavier into its long-term care Section 1915 (c) waiver for seniors and people with physical disabilities in FY 2018. In addition, while it does not have eligibility criteria specific to people with TBI distinct from the criteria for adults with physical disabilities, the benefit package in NJ’s Section 1115 waiver includes services targeted to people with TBI.
Most (18 of 20) waivers that target children who are medically fragile or technology dependent are under Section 1915 (c), while two states (HI and RI) use Section 1115. States also may cover children with significant disabilities under the Katie Beckett/TEFRA state plan option. For more information, see Kaiser Family Foundation, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019), https://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey/.
Most (11 of 14) mental health HCBS waiver states use only Section 1915 (c), while two states (DE and RI) use only Section 1115, and one state (WA) uses both waiver authorities.
Five of eight states using HCBS waivers to cover people with HIV/AIDS use Section 1915 (c) authority, while three states (DE, HI, and RI) use Section 1115 for this population. FL continues to serve people with HIV but consolidated its HIV waiver into its long-term care Section 1915 (c) waiver for seniors and people with physical disabilities in FY 2018. AL’s HIV waiver was discontinued in FY 2017.
Specifically, IN does not apply an asset limit to two I/DD waivers and one TBI waiver, MA does not apply an asset limit to one I/DD waiver serving children; MO does not apply an asset limit to two I/DD waivers serving children; NE does not apply an asset limit to three I/DD waivers (including children and adults); ND does not apply an asset limit to two waivers serving medically fragile children and one I/DD waiver serving children; and WI does not apply an asset limit to one waiver serving children with I/DD.
Asset limits that exceed the SSI amount are $4,000 in DC, MS, NE, and RI; $3,000 in MN and ND; and $2,500 in MD, and NH.
MD applies a higher asset limit to one waiver for seniors and adults with physical disabilities; NE applies a higher asset limit to one waiver for seniors and adults with physical disabilities and one waiver for people with TBI; and ND applies a higher asset limit to one waiver for people with I/DD, one waiver for seniors and adults with physical disabilities, and one waiver for adults with physical disabilities.
CT is one of eight states that elects the Section 209 (b) option, which allows states to use financial and functional eligibility criteria that differ from the federal SSI rules, as long as they are no more restrictive than the rules the state had in place in 1972.
Such individuals are eligible for Medicaid by reason of a Section 1915 (c) HCBS waiver because they would be eligible under the Medicaid state plan if institutionalized, meet an institutional level of care, and would be institutionalized if not receiving waiver services. 42 U.S.C. § 1396a (a)(10)(A)(ii)(VI). They sometimes are referred to as the “217-group,” because they are described in 42 C.F.R. § 435.217.
42 C.F.R. § 435.726 (c).
AZ, IA, LA, MD, NJ, OK, TN, and TX.
CA, NE, RI, and WA.
AK, DE, GA, HI, ID, KS, KY, ME, MN, MT, ND, OH, OR, VA, and VT.
DC and IL did not respond to this survey question.
DC, IL and NC did not respond to this survey question.
DC, IL and NC did not respond to this survey question.
This section includes Section 1915 (c) and Section 1115 HCBS waivers. Section 1115 waiver services were assigned to the main population targeted by the waiver: seniors/adults with physical disabilities and/or people with I/DD.
AR does not offer self-direction as a waiver service but does allow waiver enrollees to self-direct attendant care services using § 1915 (j) authority.
Some states apply different self-direction policies to agency-employed vs. independent providers.
In Ohio, legally responsible family members are permitted to perform nursing services, but they must be employed by a home health agency.
This total reflects individuals on waiting lists in 40 of 41 states reporting waiting lists for Section 1915 (c) and/or Section 1115 HCBS waivers. It omits New York, which reports a waiting list for people with mental health disabilities but was unable to report the number of individuals on that list. It also includes partial data for California, which reported waiting list enrollment for its Section 1915 (c) waivers serving seniors and/or adults with physical disabilities and people with HIV/AIDS, but did not report enrollment on its Section 1115 waiting list for seniors and adults with physical disabilities. In addition, the following states did not respond to the question about whether there is a waiting list for the following target populations: New Jersey for people with I/DD, and New York for seniors and adults with physical disabilities and people with TBI/SCI.
These states include IA, IL, ND, OH, OK, OR, SC, and TX. Ohio began screening individuals on the I/DD waiting list in late 2018 but reported no to this survey question.
The new assessment is used statewide as of September 2018 for new waiting list enrollees, and those already on the waiting list will be assessed using the new tool by December 2020. For more information, see Ohio Dep’t of Developmental Disabilities Rule 5123-9-04, Home and community-based services waivers – waiting list with appendix – Ohio Assessment for Immediate Need and Current Need (Dec. 14, 2018), https://dodd.ohio.gov/wps/portal/gov/dodd/forms-and-rules/rules-in-effect/5123-9-04 and https://dodd.ohio.gov/wps/portal/gov/dodd/forms-and-rules/rules-in-effect/5123-9-04%2Bappendix.
Ohio Colleges of Medicine Government Resource Center, What Are We Waiting For? Waiver Supported Services Needed by Individuals and their Caregivers (Feb. 2014), https://ddc.ohio.gov/Portals/0/waiting-list-study-2-21-14.pdf.
LA’s new assessment tool is the Screening for Urgency of Need (SUN).
Beginning in FY 2016, totals include Section 1915 (c) and Section 1115 HCBS waiver waiting lists; prior years include only Section 1915 (c) waiver waiting lists. FY 2018 data omit New York, which reports a waiting list for people with mental health disabilities but was unable to report the number of individuals on that list. It also includes partial data for California, which reported waiting list enrollment for its Section 1915 (c) waivers serving seniors and/or adults with physical disabilities and people with HIV/AIDS, but did not report enrollment on its Section 1115 waiting list for seniors and adults with physical disabilities. In addition, the following states did not respond to the question about whether there is a waiting list for the following target populations: New Jersey for people with I/DD, and New York for seniors and adults with physical disabilities and people with TBI/SCI. FY 2017 data is used for DC, FL (seniors/physical disabilities only), IL, LA (I/DD only), ME (I/DD only), OH, and SD, because these states did not report FY 2018 data.
Another 4 states (IL, ME (I/DD), OH, and SC) were unable to report FY 2018 waiting list data for some or all waiver populations.
Not all states provided data for all waivers. The 8 states unable to report this data for any waiver waiting lists are IL, ME, MS, NH, NY, OH, SD, and VA.
Thirty-seven of 51 states with waivers serving people with I/DD report waiting lists. In addition, NJ did not report whether it has a waiting list for people with I/DD.
Twenty of 51 states with waivers serving seniors and/or adults with physical disabilities report waiting lists. Waiting list enrollment reflects partial data for CA, which reported waiting list enrollment for its Section 1915 (c) waivers serving seniors and/or adults with physical disabilities but was unable to report waiting list enrollment for its Section 1115 waiver serving these populations. In addition, NY did not report whether it has a waiting list for its Section 1115 waiver serving seniors and adults with physical disabilities.
Five of 20 states with waivers serving children who are medically fragile or technology dependent report a waiting list.
Seven of 25 states with waivers serving people with TBI/SCI report a waiting list. In addition, NY was unable to report whether its TBI/SCI waiver has a waiting list.
Four of 13 states with waivers serving people with mental health disabilities report a waiting list. Waiting list enrollment includes three states. The other state, NY, reports unknown enrollment on its waiting list for people with mental health disabilities.
One of eight states with waivers serving people with HIV/AIDS reports a waiting list.
Of the 41 states reporting one or more waivers with a waiting list in FY 2018, 30 reported average wait time for at least one waiver with a waiting list (AL, AK, CA, CO, CT, IN, IA, KS, KY, LA, MD, MI, MN, MO, MS, MT, NE, NV, NM, NC, ND, OK, OR, PA, SC, SD, TN, TX, WV, and WY), and 11 (AR, FL, GA, IL, ME, NH, NY, OH, UT, VA, and WI) did not report average wait time for any waivers with waiting lists.
The exceptions are ND, OR and WV.
Within a state, some waivers prioritize only one group, while other waivers may give priority to more than one group.
The 14 other states with waiver waiting lists were unable to report this data (CA, GA, IL, KS, ME, MS, NM, OH, SC, SD, TX, UT, VA and WY).
These utilization controls are state policies, separate from the federal cost neutrality requirement for HCBS waivers. Under federal law, the state’s estimated average per capita expenditures for home and community-based waiver services must not exceed the state’s reasonable estimate of the cost of average per capita expenditures that would have been incurred without waiver services. 42 U.S.C. § 1396n (c)(2)(D). In addition, under long-standing federal policy, Section 1115 waivers generally are subject to federal budget neutrality, which requires that federal costs under the waiver cannot exceed estimated costs without the waiver.
States with exceptions to hour caps are CA, DE, FL, KY, MD, MA, MO, MT, NY, NC, ND, OH, SD, TN, and TX.
States with exceptions to cost caps are CA, DE, FL, GA, IA, IL, KY, LA, MD, MA, MN, MO, MT, NH, NM, NY, OH, OK, SC, SD, TN, TX, VT, WA, and WY.
Financial accountability includes the state’s payment methods and other program integrity considerations.
National Core Indicators- Aging and Disabilities (last accessed Jan. 29, 2020), https://nci-ad.org/.
National Core Indicators (last accessed Jan. 29, 2020), https://www.nationalcoreindicators.org/.
Medicaid.gov, CAHPS Home and Community-Based Services Survey, (last accessed Jan. 29, 2020), https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/cahps-hcbs-survey/index.html.
DC, FL, IL, KY and MA report using quality of life measures but did not indicate which tool is used.
Seven states (FL, IL, KY, MA, ME, SD, and WY) did not specify a tool.
Six states (FL, MA, ME, MN, TX, and WY) did not specify a tool.
Two states (ME and NJ) did not respond to this survey question. The eight states without a waiver ombuds program include AL, MI, MO, NC, ND, OK, PA, and WV.
The 2016 Medicaid managed care rule requires states using capitated MLTSS to offer an independent beneficiary support system, in health plan contracts beginning on or after July 1, 2018, that provides the following services for people who use or wish to use LTSS: (1) an access point for complaints and concerns; (2) education on enrollee rights and responsibilities; (3) assistance in navigating the grievance and appeals process; and (4) review and oversight of data to guide the state in identifying and resolving systemic LTSS issues. KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.
As of its January 2017 Section 1115 waiver renewal, VT is now considered a non-risk prepaid inpatient health plan. Letter from Vikki Wachino, Director CMS Center for Medicaid & CHIP Services to Hal Cohen, Secretary, Vermont Agency of Human Services (Oct. 24, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/Global-Commitment-to-Health/vt-global-commitment-to-health-ext-appvl-10242016.pdf; CMS Special Terms and Conditions, Global Commitment to Health Section 1115 Demonstration, No. 11-W-00194/1 (approved Jan. 1, 2017-Dc. 31, 2021, amended Dec. 5, 2019), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-ca.pdf.
AR’s Provider-led Arkansas Shared Savings Entities (PASSE) program, using a joint Section 1915 (b)/(c) waiver, was implemented in FY 2018 with case management only and expanded to include risk-based managed care in FY 2019. AR-07, Section 1915 (b) waiver approval, Provider-Led Arkansas Share Savings Entity (PASSE) Model, amended March 1, 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/AR_Provider-Led-Care-Coordination-Program_AR-07.pdf. See also Benjamin Hardy, “Open enrollment delayed for Medicaid managed care companies,” Ark. Times (April 30, 2019), https://arktimes.com/arkansas-blog/2019/04/30/open-enrollment-delayed-for-medicaid-managed-care-companies; Andy Davis, “Deal sets up insurer for stakes in 2 managed-care firms in Arkansas,” Ark. Democrat-Gazette (Sept. 15, 2019), https://www.arkansasonline.com/news/2019/sep/15/deal-sets-up-insurer-for-stakes-in-2-ma/.
LA uses a joint Section 1915 (b)/(c) waiver. LA Section 1915 (b) waiver, Healthy Louisiana and Coordinated System of Care (Feb. 1, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/LA_LBHP_LA-04.pdf.
PA’s waiver was approved in July 2017, with the first enrollment effective in January 2018. Pennsylvania, Section 1915 (b) waiver, Community Health Choices (approved July 24, 2017, amended Aug. 24, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/PA_Community-HealthChoices_PA-10.pdf; Community Health Choices Timeline for Implementation (Feb. 2019), http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_227013.pdf.
NC’s joint Section 1115/1915 (c) waiver was originally approved in October 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/Medicaid-Reform/nc-medicaid-reform-demo-demo-appvl-20181019.pdf, and revised with technical corrections in April 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/nc-medicaid-reform-ca.pdf.
CA did not report the type of financial incentive offered to its health plans.
The states without financial incentives are IL, MA, MI, NM, OH, and TX. Another six states did not respond to this survey question (AR, ID, LA, NC, RI, and VA).
Four states (IL, KS, MA, NC) did not respond to this question.
Nine capitated MLTSS states (AR, IL, MA, MN, NJ, NC, OH, RI, SC) did not respond to this question. In addition, two states without capitated MLTSS (IN and KY) responded that they planned to implement VBP for HCBS in the future. TX is currently participating in a CMS Innovation Accelerator Program project, VBP for HCBS, and plans to develop quality measures and support for health plans to implement additional VBP models. TX reports that some health plans have voluntarily implemented VBP models for HCBS.
National Association of Medicaid Directors, Medicaid Value-based Purchasing: What is it & Why does it Matter? (January 2017), http://medicaiddirectors.org/wp-content/uploads/2017/01/Snapshot-2-VBP-101_FINAL.pdf.
Health Care Payment Learning and Action Network, Alternative Payment Model APM Framework (2017), https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf.
NY did not specify the type of VBP model used.
Benjamin Hardy, “Open enrollment delayed for Medicaid managed care companies,” Ark. Times (April 30, 2019), https://arktimes.com/arkansas-blog/2019/04/30/open-enrollment-delayed-for-medicaid-managed-care-companies; Andy Davis, “Deal sets up insurer for stakes in 2 managed-care firms in Arkansas,” Ark. Democrat-Gazette (Sept. 15, 2019), https://www.arkansasonline.com/news/2019/sep/15/deal-sets-up-insurer-for-stakes-in-2-ma/.
KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/. The revised regulations build on and incorporate elements from CMS’s May 2013 best practices for MLTSS waivers. CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs (May 2013), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf.
For a summary of the proposed changes, see KFF, CMS’s 2018 Proposed Medicaid Managed Care Rule: A Summary of Major Provisions (Jan. 2019), https://www.kff.org/medicaid/issue-brief/cmss-2018-proposed-medicaid-managed-care-rule-a-summary-of-major-provisions/.
The informational bulletin indicates that the “use of enforcement discretion will be applied based on state-specific facts and circumstances and focused on states’ specific needs.” CMS Informational Bulletin, Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates (June 30, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.
Two states (MA and NC) did not respond to this survey question.
The November 2018 proposed rule would change the general network adequacy requirement for time and distance standards for certain provider types as well as the specific requirement for time and distance standards for LTSS providers to whom enrollees must travel. KFF, CMS’s 2018 Proposed Medicaid Managed Care Rule: A Summary of Major Provisions (Jan. 2019), https://www.kff.org/medicaid/issue-brief/cmss-2018-proposed-medicaid-managed-care-rule-a-summary-of-major-provisions/.
AZ, DE, FL, ID, LA, MI, NY, SC, TN, TX, VA, and WI.
IL and MA did not respond to this survey question.
Arizona responded no to the independent enrollment options counseling question.
Along with personalized choice counseling, the beneficiary support system must include assistance to beneficiaries with understanding managed care and assistance for enrollees who use or wish to use LTSS. KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.
MA did not respond to this survey question.
KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.
AR and MA did not respond to this survey question.
KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.
11 states did not respond to this survey question (AR, CA, ID, IL, KS, LA, MA, NY, NC, OH, TX).
KFF, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.
CMS, Measures for Medicaid Managed Long Term Services and Supports Plans, Technical Specifications and Resource Manual (May 2019), https://www.medicaid.gov/medicaid/managed-care/downloads/ltss/mltss_assess_care_plan_tech_specs.pdf.
These findings include personal care services delivered under state plan or waiver authority and home health state plan services. We did not survey states about EVV for home health services delivered under HCBS waivers.
42 U.S.C. § 1396b (l)(5)(A); see also CMCS Informational Bulletin, Electronic Visit Verification (May 16, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/cib051618.pdf; see generally Medicaid.gov, Electronic Visit Verification (EVV) (last accessed Jan. 29, 2020), https://www.medicaid.gov/medicaid/hcbs/guidance/electronic-visit-verification/index.html.
CMCS Informational Bulletin, Electronic Visit Verification (May 16, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/cib051618.pdf.
EVV applies to personal care services provided under Sections 1905 (a)(24), 1915 (c), 1915 (i), 1915 (j), 1915 (k), and Section 1115 and to home health services provided under 1905 (a)(7) or a waiver. 42 U.S.C. § 1396b (l)(5)(B) and (C).
The original legislation required states to comply with EVV requirements for personal care services by January 1, 2019, but subsequently was amended to extend the date to January 1, 2020. 21st Century Cures Act, § 12006, 130 STAT. 1033 (Dec. 13, 2016), https://www.govinfo.gov/content/pkg/PLAW-114publ255/pdf/PLAW-114publ255.pdf.
KS, MD, MO, OK, TX, WV.
Federal matching fund reductions for non-compliance with EVV for personal care services are 0.25% in 2020, 0.5% in 2021, 0.75% in 2022, and 1% in 2023 and thereafter. 42 U.S.C. § 1396b (l)(1)(A).
42 U.S.C. § 1396b (l)(4).
Some states requested exemptions for personal care services only, while others requested exemptions for both personal care and home health services. Medicaid.gov., Good Faith Effort Exemption Requests: State Requests (last accessed Jan. 29, 2020), https://www.medicaid.gov/medicaid/hcbs/guidance/electronic-visit-verification/good-faith-effort-exemption-requests/index.html.
Federal matching fund reductions for home health services are 0.25% in 2023 and 2024, 0.50% in 2025, 0.75% in 2026, and 1% in 2027 and thereafter. 42 U.S.C. § 1396b (l)(1)(A).
Four states (CA, IL, IA, and NY) reported their EVV model for personal care services as undecided, and DC did not respond to this survey question.
Four states (AK, AL, IA and IL) reported their EVV model for home health services as undecided. Six states (CA, DC, MS, NY, OR and WA) did not respond to this survey question.
There are five major models among which states can choose, including provider choice, managed care plan choice, state mandated external vendor, state mandated in-house system, and open vendor. States also can choose to adopt a hybrid approach, using more than one model. CMCS Informational Bulletin, Electronic Visit Verification (May 16, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/cib051618.pdf;
KY (open vender for personal care, state-mandated external vendor for home health); LA (other model for personal care, state-mandated in-house system for home health); MD (state-mandated external vendor for personal care, open vendor for home health); NV and SC (other model for personal care, open vendor for home health); ND and VA (open vendor for personal care, provider choice for home health),
One state (MA) did not respond to this survey question.
42 C.F.R. § 441.301 (c)(4)-(6). The settings rule applies to HCBS provided under Section 1915 (c) waivers, the Section 1915 (i) state plan option, and Community First Choice. CMS has indicated that it also will apply the settings rule to Section 1115 waivers that authorize HCBS. CMS, Questions and Answers – 1915 (i) State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and 1915 (c) Home and Community-Based Services Waivers – CMS 2249-F and 2296-F, https://www.medicaid.gov/medicaid/hcbs/downloads/final-q-and-a.pdf.
CMCS Informational Bulletin, Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria (May 9, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf.
AK, AR, CT, DE, DC, ID, KY, MN, ND, OK, OR, TN, UT, WA, and WY. Medicaid.gov, Statewide Transition Plans (last accessed Jan. 29, 2020), https://www.medicaid.gov/medicaid/hcbs/transition-plan/index.html.
These states are AL, AZ, CA, CO, FL, GA, HI, IN, IA, KS, LA, MD, MI, MS, MO, MT, NE, NH, NM, NC, NY, OH, PA, RI, SC, SD, VT, VA, WV, and WI. The six remaining states are in “clarifications and/or modifications required for initial approval status” (IL, MA, ME, NJ, NV, TX). Id.
Among these states, 27 identified settings that need to be modified both in FY 2018 and a prior year, nine states identified settings that needed to be modified prior to FY 2018, and three states have identified settings that need to be modified in FY 2018. One state (AR) did not respond to this survey question.
CO, DC, FL, GA, IL, MT, NV, NC, PA, TN, UT, and WI were not able to provide the number of settings that must be modified.
These settings were identified in both FY 2018 and a prior year (10 states), prior to FY 2018 (9 states), and in FY 2018 (1 state). One state (AR) did not respond to this survey question.
CO, KY, NH, NY, OR, TN, and WI were unable to provide the number of settings that cannot be modified.
These settings were identified in both FY 2018 and a prior year (16 states), prior to FY 2018 (8 states), and in FY 2018 (2 states).
CO, CT, FL, ID, MT, NE, NV, NY, PA, TN, and UT were unable to provide the number of settings.
These actions took place in both FY 2018 and a prior year (8 states), prior to FY 2018 (5 states), and in FY 2018 (9 states). One state (AR) did not respond to this survey question.
CT, FL, ID, IL, MO, RI, TN, UT, and WI were unable to provide the number of settings.
CMS released guidance on the heightened scrutiny process. CMS, SMD #19-001, Home and Community-Based Settings Regulation – Heightened Scrutiny (March 22, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/smd19001.pdf.
U.S. Dep’t of Labor, Home Care, Minimum Wage and Overtime Pay for Direct Care Workers (last accessed Jan. 29, 2020), https://www.dol.gov/whd/homecare/; 29 C.F.R. § § 552.3, 552.6, 552.101, 552.102, 552.106, 552.109, 552.110.
Specifically, CMS anticipated that “many states will determine that, for purposes of the FLSA, home care workers in self-direction programs have joint third party employer(s) [such as the state or another entity] in addition to being employed by the beneficiary,” requiring the state or other entity to comply with minimum wage and overtime requirements. CMS Informational Bulletin, Self-Direction Program Options for Medicaid Payments in the Implementation of the Fair Labor Standards Act Regulation Changes (July 3, 2014), https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-03-2014.pdf.