Home and Community Based Services: An Introduction

What are Home and Community Based Services?

Millions of Americans, including children, adults, and seniors, need long-term care services because of disabling conditions and chronic illnesses. Medicaid is the primary payer across the nation for long-term care services. Medicaid allows for the coverage of these services through several vehicles and over a continuum of settings, ranging from institutional care to community-based long-term services and supports (LTSS). Two significant components of LTSS are Institutional services and Home and Community Based Services (HCBS).

Home and Community Based Services - An Introduction

Home and Community-Based Services (HCBS) are person-centered care delivered in the home and community. HCBS programs address the needs of people with functional limitations who need assistance with everyday activities, like getting dressed or bathing. HCBS are often designed to enable people to stay in their homes rather than move to a facility for care.

Home and Community-Based Services (HCBS) allow Medicaid beneficiaries to receive services in their home or community rather than institutions or other isolated settings. These programs serve a variety of targeted population groups, such as people with intellectual or developmental disabilities, physical disabilities, or mental illnesses. Over 3.5 million individuals receive HCBS through various Medicaid Waiver programs.

History and Options:

Home and Community-Based Services (HCBS) first became available in 1983 when Congress added section 1915© to the Social Security Act, giving states the option to receive a waiver of Medicaid rules governing institutional care. In 2005, HCBS became a formal Medicaid State plan option. Several States include HCBS services in their Medicaid State plans. Forty-seven states and DC are operating at least one 1915© waiver.

Home and Community Based Services A Timeline

State Medicaid agencies have the following four HCBS options:

1915© - HOME AND COMMUNITY-BASED WAIVERS

Within broad Federal guidelines, States can develop home and community-based services waivers (HCBS Waivers) to meet the needs of people who prefer long-term care services and supports in their home or community rather than in an institutional setting.

Nearly all states and D.C. offer services through HCBS Waivers. States can operate as many HCBS Waivers as they want — currently, more than 300 HCBS Waiver programs are active nationwide.

State HCBS Waiver programs must:

Demonstrate that providing waiver services won’t cost more than providing these services in an institution

Ensure the protection of people’s health and welfare

Provide adequate and reasonable provider standards to meet the needs of the target population

Ensure that services follow an individualized and person-centered plan of care

1915(I) - STATE PLAN HOME AND COMMUNITY-BASED SERVICES

States can offer services under a State Plan Home and Community Based Services (HCBS) benefit. People must meet state-defined criteria based on need and typically get a combination of acute-care medical services (like dental services and skilled nursing services) and long-term services (like respite, case management, supported employment, and environmental modifications) in home and community-based settings.

1915(J) - SELF-DIRECTED PERSONAL ASSISTANCE SERVICES UNDER STATE PLAN

Self-directed personal assistance services (PAS) are personal care and related services provided under the Medicaid State plan or section 1915(c) waivers the State already has in place.

Participation in self-directed PAS is voluntary

Participants set their own provider qualifications and train their PAS providers. Participants determine how much they pay for a service, support, or item

1915(J) STATE OPTIONS

States can:

Target people already getting section 1915© waiver services

Limit the number of people who will self-direct their PAS

Limit the self-direction option to some regions of the State, or offer it Statewide

At the States option, people enrolled in 1915(j) can:

Hire legally liable relatives (such as parents or spouses)

Manage a cash disbursement

Purchase goods, supports, services, or supplies that increase their independence or substitute for human help (to the extent they’d otherwise have to pay for human help)

Use a discretionary amount of their budget to purchase items not otherwise listed in the budget or reserved for permissible purchases

1915(J) PERSON-CENTERED AND DIRECTED PLANNING PROCESS

Service plan is based on...