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

Issue Brief
  1. Dep’t of Health and Human Servs., Fiscal Year 2017 Budget in Brief, Strengthening Health and Opportunity for All Americans at 95, available at http://www.hhs.gov/sites/default/files/fy2017-budget-in-brief.pdf; Dep’t of Health and Human Servs., HHS FY 2016 Budget in Brief, Serving Americans at Key Stages of Life, Advancing Comprehensive Medicaid Long-Term Care, (Feb. 4, 2015), available at http://www.hhs.gov/about/budget/budget-in-brief/index.html.

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  2. Bipartisan Policy Center, Initial Recommendations to Improve the Financing of Long-Term Care (Feb. 2016), available at http://bipartisanpolicy.org/library/americas-long-term-care-crisis/.

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  3. Long-Term Care Financing Collaborative, Convergence Center for Policy Resolution, A Consensus Framework for Long-Term Care Financing Reform (Feb. 2016), available at http://www.convergencepolicy.org/wp-content/uploads/2016/02/LTCFC-FINAL-REPORT-Feb-2016.pdf.

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  4. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Medicaid Beneficiaries Who Need Home and Community-Based Services:  Supporting Independent Living and Community Integration (March 2014), available at https://www.kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supporting-independent-living-and-community-integration/.

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  5. Victoria Peebles and Alex Bohl, CMS/Mathematica Policy Research, The HCBS Taxonomy:  A New Language for Classifying Home and Community-Based Services (Aug. 2013), available at http://www.mathematica-mpr.com/~/media/publications/PDFs/health/max_ib19.pdf.

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  6. Kaiser Commission on Medicaid and the Uninsured, Serving Low-Income Seniors Where They Live:  Medicaid’s Role in Providing Community-Based Long-Term Services and Supports (Sept. 2015), available at https://www.kff.org/medicaid/issue-brief/serving-low-income-seniors-where-they-live-medicaids-role-in-providing-community-based-long-term-services-and-supports/.

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  7. Id.

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  8. Id.

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  9. This analysis is limited to the civilian noninstitutionalized population and includes seniors. The definition of disability used by the Census Bureau does not exactly track the criteria required to qualify for Medicaid based on a disability. U.S. Census Bureau, Americans with Disabilities:  2010 at 5 (July 2012), available at http://www.census.gov/prod/2012pubs/p70-131.pdf.

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  10. Id.

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  11. Id. (ages 21 to 64).

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  12. See generally Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years After the Supreme Court’s Olmstead Decision (June 2014), available at https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.

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  13. Id.

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  14. Eiken, S., Sredl, K, Burwell, B, Saucier, P. Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2013:

    Home and Community-Based Services were a Majority of LTSS Spending, Truven Health Analytics, (June 30, 2015).

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  15. See also Kaiser Commission on Medicaid and the Uninsured, Medicaid Long-Term Services and Supports:  An Overview of Funding Authorities (Sept. 2013), available at https://www.kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-authorities/.

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  16. Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs:  2012 Data Update (Nov. 2015), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/.

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  17. Id.

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  18. Id.

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  19. See generally Kaiser Commission on Medicaid and the Uninsured, How is the Affordable Care Act Leading to Changes in Medicaid Long-Term Services and Supports Today?  State Adoption of Six LTSS Options (April 2013), available at https://www.kff.org/medicaid/issue-brief/how-is-the-affordable-care-act-leading-to-changes-in-medicaid-long-term-services-and-supports-ltss-today-state-adoption-of-six-ltss-options/.

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  20. Kaiser Family Foundation, State Health Facts, Section 1915(i) Home and Community-Based Services State Plan Option (Oct. 2015), available at https://www.kff.org/medicaid/state-indicator/section-1915i-home-and-community-based-services-state-plan-option/.

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  21. Kaiser Commission on Medicaid and the Uninsured, Medicaid Reforms to Expand Coverage, Control Costs and Improve Care:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 (Oct. 2015), available at https://www.kff.org/report-section/medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-long-term-services-and-supports-reforms/.

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  22. Kaiser Family Foundation, State Health Facts, Section 1915(k) Community First Choice State Plan Option (Dec. 2015), available at https://www.kff.org/medicaid/state-indicator/section-1915k-community-first-choice-state-plan-option/.

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  23. Kaiser Commission on Medicaid and the Uninsured, Medicaid Reforms to Expand Coverage, Control Costs and Improve Care:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 (Oct. 2015), available at https://www.kff.org/report-section/medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-long-term-services-and-supports-reforms/.

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  24. Jane, K., Traylor, C., Ghahremani, K., Texas Medicaid and CHIP in Perspective. 10th ed. (Feb. 2015).

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  25. See generally Kaiser Commission on Medicaid and the Uninsured, The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities (April 2014), available at https://www.kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  26. States that elect the § 209(b) option are permitted to use definitions of disability or financial eligibility standards that are more restrictive than the federal SSI rules, so long as the state’s rules are not more restrictive than those in effect in January 1972. Section 209(b) states must allow SSI beneficiaries to establish Medicaid eligibility through a spend-down by deducting unreimbursed out-of-pocket medical expenses from their countable income. Section 209(b) states also must provide Medicaid to children who receive SSI and who meet the state’s financial eligibility rules for the AFDC program as of July 16, 1996.

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  27. Kaiser Commission on Medicaid and the Uninsured, Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015 (March 2016), available at https://www.kff.org/medicaid/report/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015/.

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  28. Beneficiaries eligible in the ACA expansion group who are medically frail must have access to the traditional Medicaid state plan benefit package, to the extent that it differs from the state’s alternative benefit package for expansion adults. See generally Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Oct. 2014), available at https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

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  29. The ACA eliminated asset tests for people who are eligible through the expansion group (as well as other poverty-related pathways, including pregnant women, parents, and children). States also can use Section 1915(i) to provide state plan HCBS to people who are eligible for Medicaid through another coverage group, and other coverage groups based on age or disability may at state option include an asset test.

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  30. Kaiser Commission on Medicaid and the Uninsured, Money Follows the Person:  A 2015 State Survey of Transitions, Services, and Costs (Oct. 2015), available at https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.

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  31. Kaiser Commission on Medicaid and the Uninsured, Medicaid Balancing Incentive Program:  A Survey of Participating States (June 2015), available at https://www.kff.org/medicaid/report/medicaid-balancing-incentive-program-a-survey-of-participating-states/.

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  32. Kaiser Commission on Medicaid and the Uninsured, Money Follows the Person:  A 2015 State Survey of Transitions, Services, and Costs (Oct. 2015), available at https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.

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  33. Kaiser Commission on Medicaid and the Uninsured, Medicaid Balancing Incentive Program:  A Survey of Participating States (June 2015), available at https://www.kff.org/medicaid/report/medicaid-balancing-incentive-program-a-survey-of-participating-states/.

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  34. Kaiser Commission on Medicaid and the Uninsured, Medicaid Reforms to Expand Coverage, Control Costs and Improve Care:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 (Oct. 2015), available at https://www.kff.org/report-section/medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-long-term-services-and-supports-reforms/.

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  35. In addition, Kansas uses a Section 1115 waiver to administer managed LTSS with concurrent Section 1915(c) authority for HCBS. Kaiser Commission on Medicaid and the Uninsured, Key Themes in Capitated Managed Long-Term Services and Supports Waivers (Nov. 2014), available at https://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/.

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  36. CMS, Special Terms and Conditions, Minnesota Reform 2020:  Pathways to Independence (Oct. 2013-June 2018), available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mn/mn-reform-2020-ca.pdf.

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  37. Washington State Health Care Authority and Dep’t of Social Servs., Washington State Medicaid Transformation Waiver Application (Aug. 2015), available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wa/wa-medicaid-transformation-pa.pdf.

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  38. Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs:  2012 Data Update (Nov. 2015), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/.

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  39. Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs:  2012 Data Update (Nov. 2015), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/.

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  40. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Medicaid Health Homes:  A Profile of Newer Programs (Aug. 2014), available at https://www.kff.org/medicaid/issue-brief/medicaid-health-homes-a-profile-of-newer-programs/.

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  41. Kaiser Commission on Medicaid and the Uninsured, Rebalancing in Capitated Medicaid Managed Long-Term Services and Supports Programs:  Key Issues from a Roundtable Discussion on Measuring Performance (Feb. 2015), available at https://www.kff.org/medicaid/issue-brief/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-key-issues-from-a-roundtable-discussion-on-measuring-performance/; Kaiser Commission on Medicaid and the Uninsured, Measuring Long-Term Services and Supports Rebalancing (Feb. 2015), available at https://www.kff.org/medicaid/fact-sheet/measuring-long-term-services-and-supports-rebalancing/.

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  42. See, e.g. National Quality Forum, Addressing Performance Measure Gaps in Home and Community-Based Services to Support Community Living:  Synthesis of Evidence and Environmental Scan (Dec. 2015), available at http://www.qualityforum.org/Measuring_HCBS_Quality.aspx .

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  43. Kaiser Commission on Medicaid and the Uninsured, Proposed Rule on Medicaid Managed Care:  A Summary of Major Provisions (July 2015), available at https://www.kff.org/report-section/proposed-rule-on-medicaid-managed-care-issue-brief/.

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  44. 79 Fed. Reg. 2948-3039 (Jan. 16, 2014), available at http://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf.

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  45. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016:  Findings from a 50-State Survey (Jan. 2016), available at https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/.

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