Medicaid policy has continued to evolve over the last 10 years to better support options for community living by people of all ages with disabilities and/or chronic health conditions. The Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act of 2010 both created new options for states to provide home and community services without having to secure a federal waiver. In addition, the Centers for Medicare & Medicaid Services (CMS) has made numerous changes to the program to make it easier for individuals to live in the community, such as authorizing coverage of one-time transition expenses for home and community-based services (HCBS) waiver participants.
In this Primer, the term persons with disabilities includes persons of all ages--young children, adolescents, and working age or older adults--with all types of disabilities due to physical and mental impairments and/or chronic illnesses. Because the Primers focus is on Medicaid home and community services, the term people with disabilities refers primarily to those individuals who need long-term care services. However, not all persons with disabilities need these services.
The remainder of this chapter presents a brief overview of the Medicaid law, regulations, and policies that give states the flexibility to create comprehensive home and community service systems for people of all ages with all types of physical and mental impairments and/or chronic health conditions. To provide context for the discussion, Table 1-1 lists the major relevant provisions of Medicaid law. This chronological summary illustrates the historical expansion of Medicaid long-term care services away from a primary focus on institutional care.
The Rehabilitation option is not generally used to furnish long-term care to individuals with disabilities or chronic health conditions other than mental illness. During the 1970s and 1980s, a few states secured approval to cover daytime services for persons with developmental disabilities under either the Clinic or the Rehabilitation option. However, CMS ultimately ruled that the services being furnished were habilitative rather than rehabilitative and consequently could not be covered under either option by additional states. The main basis for the ruling was that habilitative services could only be furnished to residents of ICFs/ID under the Medicaid State Plan or through an HCBS waiver program for individuals otherwise eligible for ICF/ID services. States with existing programs serving individuals with intellectual disabilities and other developmental disabilities were grandfathered under the Omnibus Reconciliation Act (OBRA) of 1989.
Under the 1915(c) waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to prevent institutionalization. Services covered under waiver programs include case management, homemaker, home health aide, personal care, adult day health, habilitation, respite care, and such other services requested by the state as the Secretary of Health and Human Services (HHS) may approve. Services for individuals with a chronic mental illness were added in the late 1980s: day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility).
In the next several decades, as already noted, the U.S. population will age dramatically. Even if disability rates among older persons decline, more people will need long-term care services than at any other time in our nations history. Institutional care is costly. Given the projected demand for long-term care, it is advisable for states to continue working to create comprehensive long-term care service systems that will enable people with disabilities and/or chronic health conditions--whatever their age or the severity of their condition--to live in their homes and community settings rather than in institutions.
The Medicaid program can be the centerpiece of such a system--allowing states numerous options to provide home and community services that keep costs under control at the same time that they enable people of all ages with disabilities and/or chronic health conditions to retain their independence and dignity.
Personal care services . . . may include a range of human assistance provided to persons with disabilities and chronic conditions of all ages, which enables them to accomplish tasks they would normally do for themselves if they did not have a disability. Assistance may be in the form of hands-on assistance (actually performing a personal care task for a person) or cueing so that the person performs the task by him/herself. Such assistance most often relates to performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).13
To remain in their homes and communities, many people with disabilities and chronic conditions need long-term care services and supports, ranging from personal assistance to more specialized services, as well as assistive technology and environmental modifications. Federal Medicaid law and policy give states great latitude to offer individuals a wide range of home and community services through a states regular Medicaid program. States can also offer a comprehensive range of services by operating one or several home and community-based services (HCBS) waiver programs. This chapter discusses Medicaid coverage options, including important issues states need to consider in selecting the particular combination of home and community services and benefits that best suits their needs.1
Health-Related Services. Personal care can include assistance with health and health-related tasks, which encompass a wide range of skilled and unskilled nursing services that address chronic conditions and functional impairments (e.g., tube feedings, catheterization, range of motion exercises, and medication administration). However, assistance with skilled tasks may be provided only when delegated by a licensed nurse in accordance with state law.
Case Management/Service Coordination helps individuals who need services and supports funded by several sources. Some may be available through the Medicaid State Plan and others through other public programs such as state programs for person with disabilities and programs funded under the Older Americans Act. A common feature of home and community services is the provision of case managers, who may also be called care coordinators, service coordinators, or support coordinators. They frequently prepare--or facilitate preparation of--an individual service plan that describes how all the services and supports a person might need will be identified and delivered. They also play an active role in monitoring the quality and effectiveness of home and community services. Several Medicaid options are available for covering case management/service coordination, which are discussed later in this chapter.
As states consider which home and community benefits to offer, and how to offer them, it is helpful to keep in mind that no bright line distinguishes home and community services and supports from other types of Medicaid benefits. Many benefits not mentioned in this overview are very much a part of the mix required to meet the needs of individuals with disabilities and chronic conditions. For example, State Plan coverage of medical equipment and supplies can provide power wheelchairs and other mobility aids. The State Plan may also cover therapeutic services such as occupational and physical therapy, which many individuals need to improve or prevent a decline in their functioning. As a consequence, in crafting effective home and community service strategies, it is important to take stock of other services in the Medicaid State Plan and to modify or possibly supplement them if needed. This will help to ensure that the coverages chosen address the key needs of those being served.
Scope of services--Personal care services covered under a states program may include a range of human assistance provided to people with disabilities and chronic conditions of all ages, which enables them to accomplish tasks they would normally do for themselves if they did not have a disability. Assistance may be in the form of hands-on assistance (actually performing a personal care task for a person) or cueing so that a person performs the tasks by him/herself. Such assistance most often relates to performance of ADLs and IADLs . . . Personal care services can be provided on a continuing basis or on episodic occasions. Skilled services that may be performed only by a health professional are not considered personal care services.
Section 1915(i) allows states to include any or all of the services that are listed in 1915(c)(4)(B) of the Social Security Act. These services include case management, homemaker/home health aide, personal care, adult day health, habilitation, and respite care services. In addition, the following services may be provided to persons with chronic mental illness: day treatment, other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility). States may also offer such other services as the Secretary may approve. CMS has drafted an application for states to submit a State Plan amendment to add an HCBS benefit.
Because administrative claiming does not have a rule requiring states to contract with any qualified provider, (as they must with State Plan services) the state can limit which entities can make an administrative claim for case management. This can be especially advantageous for states that operate a single point of entry system through human service authorities that also administer the provision of non-Medicaid benefits. For example, some states use administrative claiming for a range of case management functions that are not specifically covered under the case management service for waiver beneficiaries (e.g., eligibility determination; administrative functions involving case managers such as program planning, development, and outreach; and certain licensing and contracting functions). 59ce067264