State Options to Expand Medicaid HCBS: Examples & Evaluations of Section 1115 Waivers


Key Section 1115 Waivers with Approved HCBS Provisions as of 7/7/21
State Demonstration Name Key HCBS Provisions
AZ Arizona Health Care Cost Containment System Expanding financial eligibility rules: AZ uses 1115 authority to remove the LTSS estate recovery penalty for acute care enrollees age 55 or older who receive long-term care services.
DE Delaware Diamond State Health Plan Serving new populations by expanding eligibility rules: New eligibility pathway (“TEFRA-Like Group”) for children with disabilities under age 18 up to 250% SSI who do not meet institutional level of care criteria for Katie Beckett state plan option, but are at risk of institutionalization absent the provision of services.
NJ New Jersey FamilyCare Comprehensive Demonstration Streamlining eligibility and enrollment processes: At the time of application for LTC and HCBS, NJ accepts self-attestation in lieu of an asset transfer review for applicants up to 100% FPL. Applicants complete a self-attestation form attesting that no transfers were made during the five-year look-back period.

Expanding financial eligibility rules: NJ also provides supports and services to adults over age 21 with developmental disabilities up to 300% SSI who live with family members or in their own homes (“Supports Program”). In determining HCBS financial eligibility for this population, NJ disregards Social Security benefits based on parent’s work history.

NY New York Medicaid Redesign Team Expanding financial eligibility rules: Individuals discharged from an NF who would be eligible for HCBS but for spousal impoverishment rules (“Institution to Community” population) are subject to a special income standard that accounts for average rent. This standard is determined by subtracting 30% of the Medicaid income level for an individual from the regional Housing and Urban Development Fair Market Rent dollar amount.
RI Rhode Island Comprehensive Demonstration 1. Streamlining eligibility and enrollment processes by authorizing benefits during a presumptive eligibility period: Limited HCBS benefit package up to 90 days for new long-term care applicants who meet functional eligibility criteria and self-attest to financial eligibility criteria (while final financial eligibility determinations are pending).

2. Expanding financial eligibility rules: Increases personal need allowance by $400 for those in NFs for 90 days who are transitioning to the community and otherwise would be unable to afford community residence.

3. Serving new populations by expanding eligibility rules: New coverage group (“Beckett aged out”) for young adults (age 19-21) with disabilities aging out of the Katie Beckett group with incomes below 250% FPL, who are otherwise ineligible for Medicaid, and who are in need of services/treatment for behavioral health or medical/developmental diagnoses.

VT Vermont Global Commitment to Health Expanding financial eligibility rules: VT uses 1115 authority to increase the asset limit to $10,000 for beneficiaries in the Highest Need and High Need groups (part of the Choices for Care program) who own and reside in their homes and receive HCBS, but are at risk for institutionalization.
WA Washington Medicaid Transformation Project Medicaid Transformation Project Initiative 2 creates two alternatives to traditional LTSS for older adults & their caregivers:

1. Offering new services: Medicaid Alternative Care Program (MAC) provides supportive services for unpaid caregivers of adults age 55+ eligible for NF care who are financially eligible for Medicaid.

2. Serving new populations by expanding eligibility rules: Tailored Support for Older Adults (TSOA) provides the same supportive services for unpaid caregivers of adults age 55+ eligible for NF care who do not meet the financial qualifications for LTSS despite being at risk of impoverishment. TSOA additionally provides personal assistance services to individuals without an informal caregiver.

Streamlining eligibility and enrollment processes by authorizing benefits during a presumptive eligibility period for both MAC and TSOA enrollees.

Expanding financial eligibility rules: WA also removes the LTSS estate recovery penalty for MAC and TSOA enrollees.

DEFINITIONS: HCBS = home community-based services. LTC = long-term care. LTSS = long-term services and supports. NF = nursing facility. SSI = Supplemental Security Income.
SOURCE: KFF analysis of Section 1115 waivers and evaluations posted to and state websites.
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