HOME AND COMMUNITY-BASED WAIVERS
Medicaid's optional home and community-based services waiver program allows States to develop and implement creative alternatives to institutionalizing Medicaid-eligible individuals. States may request waivers of certain Federal rules which impede the development of Medicaid-financed community-based treatment alternatives. The program recognizes that many individuals at risk of institutionalization can be cared for in their homes and communities, preserving their independence and ties to family and friends, at a cost no higher than that of institutional care.
Federal law lists seven services which may be provided; case management, homemaker services, home health aid services, personal care services, adult day health, habilitation and respite care. Other services, such as transportation, in-home support services, meal services, special communication services, minor home modifications, and adult day care, may be provided, subject to HCFA approval. States have the flexibility to design each waiver program, and select the mix of waiver services to best meet the needs of the population they wish to serve. Waiver services may be provided statewide or may be limited to specific geographic subdivisions.
Waiver services may be provided to the elderly and disabled, the physically disabled, the developmentally disabled or mentally retarded and the mentally ill. Waivers may also be targeted to individuals with a specific illness or condition, such as technology-dependent children or individuals with AIDS. Under the waiver program, States can make home and community-based services available to individuals who would otherwise qualify for Medicaid only if they were in an institutional setting.
To receive approval to implement a waiver, a State Medicaid agency must assure HCFA that, on average, it will not cost more to provide home and community-based services than providing institutional care would cost. The Medicaid agency also must provide and document certain other assurances, including that there are safeguards to protect the health and welfare of recipients.
Post-eligibility treatment of income and resources of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care.
The agency must reduce its payment for home and community-based services provided to an individual specified in paragraph (b) of this section, by the amount that remains after deducting the amounts specified in paragraph (c) of this section from the individual's income.
This section applies to individuals who are eligible for Medicaid under Sec. 435.217 and are receiving home and community-based services furnished under a waiver of Medicaid requirements under Part 441, Subpart G of this subchapter. (c) In reducing its payment for home and community-based services, the agency must deduct the following amounts, in the following order, from the individual's total income (including amounts disregarded in determining eligibility):
(1) An amount for the maintenance needs of the individual. This amount must be based on a reasonable assessment of need but must not exceed the highest of -
- The amount of the income standard used to determine eligibility for SSI for an individual living in his own home, if the agency provides Medicaid only to individuals receiving SSI;
- The amount of the highest income standard, in the appropriate category of age, blindness, or disability, used to determine eligibility for an optional State supplement for an individual in his own home, if the agency provides Medicaid to optional State supplement recipients under Sec. 435.230; or
- The amount of the medically needy income standard for one person established under Sec.35.811 and 435.814, if the agency provides Medicaid under the medically needy coverage option.
(2) For an individual with only a spouse at home, an additional amount for the maintenance needs of the spouse. This amount must be based on a reasonable assessment of need but must not exceed the highest of -
- The amount of the income standard used to determine eligibility for SSI for an individual living in his own home, if the agency provides Medicaid only to individuals receiving SSI;
- The amount of the highest income standard, in the appropriate category of age, blindness, or disability, used to determine eligibility for an optional State supplement for an individual in his own home, if the agency provides Medicaid to optional State supplement recipients under Sec. 435.230; or
- The amount of the medically needy income standard for one person established under Sec.35.811 and 435.814, if the agency provides Medicaid under the medically needy coverage option.
(3) For an individual with a family at home, an additional amount for the maintenance needs of the family. This amount must -
- Be based on a reasonable assessment of their financial need;
- Be adjusted for the number of family members living in the home; and
- Not exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's AFDC plan or the medically needy income standard established under subpart I of this part for a family of the same size.
(4) Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party including -
- Medicare and other health insurance premiums, deductibles, or coinsurance charges; and
- Necessary medical or remedial care recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits the agency may establish on amounts of these expenses.
Based on 42 CFR Sec. 435.726
(46 FR 48539, Oct. 1, 1981, as amended at 50 FR 10026, Mar. 13, 1985)
FINANCIAL ELIGIBILITY FOR THE AGED, BLIND, AND DISABLED IN STATES USING MORE RESTRICTIVE REQUIREMENTS THAN SSI
THESE MATERIALS WERE EDITED FROM THOSE PROVIDED BY HEALTH CARE FINANCING ADMINISTRATION (HCFA). BECAUSE THESE MATERIALS HAVE BEEN EDITED AND BECAUSE RULES AND REGULATIONS CHANGE REGULARLY, WE SUGGEST THAT YOU CONTACT YOUR LOCAL AUTHORITIES AND QUALIFIED LEGAL COUNSEL PRIOR TO ACTING.
