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Understanding the Pillars of the HCBS Waiver

Understanding the Pillars of the HCBS Waiver. A waiver means that the regular rules are “waived”, that is not applied The HCBS waiver began in 1981 when Congress amended Section 1915(c) of the Social Security Act as a means to correct the “institutional bias” of Medicaid funding

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Understanding the Pillars of the HCBS Waiver

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  1. Understanding the Pillars of the HCBS Waiver

  2. A waiver means that the regular rules are “waived”, that is not applied • The HCBS waiver began in 1981 when Congress amended Section 1915(c) of the Social Security Act as a means to correct the “institutional bias” of Medicaid funding • The “bias” is that individuals could get support services while institutionalized, but if they wanted to return to the community they could not get similar services What is a HCBS Waiver??

  3. The Centers for Medicare and Medicaid Services (CMS) provides states with an application to fill out (called the waiver format or template) • The state fills in the template, submits the plan to CMS State/federal partnership

  4. CMS reviews and approves the application (sometimes after considerable negotiation) • The waiver application must conform to all HCBS waiver regulations found in the CMS Technical Guide • HCBS Waivers are approved for a three year period initially and can be renewed for five-year periods State/federal partnership

  5. The person must be eligible for Medicaid (in Massachusetts individuals must be in certain eligibility categories) and • Meet what’s called the level of care (LOC) for nursing home, ICF-MR, hospital or other Medicaid-financed institutional care (the person does NOT have to seek or want institutional care) Who can a HCBS waiver serve?

  6. Level of Care (LOC) • LOC means that the person has needs that could make them eligible for institutional care “but for the provision of HCBS services” • States decide how to figure out the LOC, CMS approves the process

  7. Okay, it is a federal program andthere are some rules…so let’s first take a look at what you can’t do, so we know what we can do with a waiver… Waiver cans and can’ts

  8. Okay, it is a federal program and there are some rules...so you: Can't give cash directly to a waiver participant or parent…(but consumer-directed and controlled services are perfectly permissible) Can't pay for room and board with Medicaid money (except for respite, nutritional supplements, or one meal/day like Meals on Wheels or lunch at a day program) Waiver can'ts

  9. Waiver can'ts... • Can't pay for exactly the same stuff under the waiver that is covered by an Medicaid card until you first use up Medicaid card services • Can't pay for services that Vocational Rehabilitation or the public schools are supposed to pay for • Can’t do general home repair with waiver dollars

  10. Waiver can’ts • Can't cover a few services such as recreation**, guardianship or institutional services other than respite • Can't serve folks who don't meet the Medicaid eligibility rules your state got approved under their waiver **but “therapeutic” recreation is okay…

  11. These are things the state MUST do. The state must promise the feds that the waiver: • is cost-effective. This means the average cost per person under the waiver can’t be more than the average cost per person in an ICF-MR. Community $ < or = Institutional $ (Individual costs can vary widely) And there are requirements...

  12. And there are "havetas"... • Everyone has an individual plan of care developed by qualified individualsbased on assessment of need and approved by the state • The waivers services must be of direct benefit to the enrolled person

  13. And there are "havetas"... • Must have provider standards, designed by the state and approved by CMS, that make sure the people giving support know what they are doing • Necessary safeguards have been taken to protect health and welfare

  14. More things the state MUST do: • Freedom of choice of providers. This means people can choose any provider they want that is qualified , under state rules, to do the work.Portability of funding Medicaid money “follows the person”, i.e. the benefit “belongs” to the individual, not the provider • Informed choice of institutional or community-based services.

  15. More things the state MUST do: • Financial accountability for all funds. This means the state has to know how the money is spent, for what people and what services.

  16. More things the state MUST do: • State has a formal system to monitor health and safety.

  17. Monitoring health and safety includes: • State oversight of the services system through reviewing data and information and through visits to providers and consumers • Getting information from waiver participants about how they like their services • A formal system to prevent, report and resolve instances of abuse or neglect

  18. More things the state MUST do: • Offer waiver services statewide unless the state has special permission to only have the waiver in some areas. • Make sure everyone on the waiver can generally get the same types of services all over the state—called access to service

  19. More things the state MUST do: • Make sure that people with the same type of needs get the same amount of money to spend on services—called equity of services

  20. And the biggest "haveta" of all.. • States MUST do what they said they were going to do in the waiver application approved.. (but that doesn’t mean the waiver can’t be changed as things change)

  21. Just a bit of advice… • The state proposes • CMS negotiates and approves the waiver • So good advice is: • Ask for what you want the way you want it to be • Take advantage of the flexibility of the waiver regulations to tailor your waiver to the needs and preferences of your citizens

  22. Acronyms and Definitions Assessment: learning about what the consumer and/or family need and their preferences Equity: means equal or the same CMS: Center for Medicaid and Medicare Services, formerly HCFA-the federal Medicaid agency FFP: Federal Financial Participation-federal share of Medicaid Funds HCBS: Home and community-based services ICF-MR: Intermediate care facility for the mentally retarded-a Medicaid-funded type of institution

  23. Acronyms and Definitions Level of care: means the intensity of need for services the person has. The person must be eligible for care in an institution. Medicaid: Medical Assistance or M.A; the state and federal money that pays for medical and HCBS services SSI: Supplemental Security Income Waiver: A waiver means to set aside the existing rules

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