Medicaid Waivers

A. What are Medicaid Waivers?

1. In general, there are two types of Medicaid waivers that can be provided
within HCFA: "program" waivers and "research and demonstration" waivers.
2. In contrast to research waivers, which can be quite broad in scope and
permit experimentation in many areas, program waivers are usually limited in
scope. In the Medicaid program, there are two types of program waivers:
a. home- and community-based service (HCBS) waivers, and
b. freedom of choice (FOC) waivers.

B. Home- and Community-Based Waivers

1. Medicaid home- and community-based service (HCBS) waivers afford States
the flexibility to develop and implement creative alternatives to placing
Medicaid-eligible individuals in medical facilities such as nursing homes.
The HCBS waiver program recognizes that many individuals at risk of being
placed in a medical facility 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.
2. Under section 1915 (c) of the Social Security Act (the Act), States may
request waivers of certain Federal requirements which impede the development
of Medicaid-financed community-based treatment alternatives. The
requirements that may be waived are in section 1902 of the Act and deal with
statewideness, comparability of services, community income and resource
rules, and rules that require States to provide services to all persons in
the State who are eligible on an equal basis.
3. The Act specifically lists seven services which may be provided in HCBS
waiver programs: case management, homemaker services, home health aide
services, personal care services, adult day health, habilitation, and
respite care. Other services, requested by the State because they are needed
by waiver participants to avoid being placed in a medical facility (such as
transportation, in-home support services, meal services, special
communication services, minor home modifications, and adult day care) may
also be provided, subject to HCFA approval. The law further permits day
treatment or other partial hospitalization services, psychosocial
rehabilitation services, and clinic services (whether or not furnished in a
facility) for individuals with chronic mental illness.
4. States have the flexibility to design each waiver program and select the
mix of waiver services that best meets the needs of the population they wish
to serve. HCBS waiver service may be provided statewide or may be limited to
specific geographic subdivisions.
5. States can make home- and community-based services available to
individuals who would otherwise qualify for Medicaid only if they were
residents of a medical facility. Federal regulations permit HCBS waiver
programs to serve the elderly and disabled, the physically disabled, the
developmentally disabled, or the mentally retarded or mentally ill. States
may target 1915(c) waiver programs to individuals with a specific illness or
condition, suchas technology-dependent children or individuals with AIDS.
6. To receive approval to implement HCBS waiver programs, State Medicaid
agencies must assure HCFA that, on average, the cost of providing home- and
community-based services will not exceed the cost of care for the identical
population in an institution. The Medicaid agency must also document that
there are safeguards in place to protect the health and welfare of
beneficiaries.
7. HCBS waiver programs are initially approved for 3 years and may be
renewed at 5- year intervals.
8. HCFA's first home- and community-based waiver program was established in
1981. There are currently over 200 HCBS waiver programs in effect, serving
more than 250,000 people as cost effective and humane alternatives to
confinement in a medical facility. All States except Arizona have at least
one such program. Arizona is a technical exception, though, because it runs
the equivalent of an HCBS waiver program under section 1115 demonstration
waiver authority.
9. HCBS waiver programs are currently the responsibility of the Medicaid
Bureau's Office of Long-Term Care Services within HCFA.

CA 0129.91 Approved 03/10/93 Effective 10/1/92
To provide HH aide, personal care, respite, habil, asst'd living, skilled
nursing, homemaker, environ mods, spec med equpmt and supplies, chore, PERS,
psychology svcs, communication aides, mobile crisis intervention, crisis
intervention facility svcs, vehicle adapts, recreation therapy, nutrition
counseling, ext'd PT and OT, adult foster care, & transp to MR/DD and
persons with DD who are tech. dependent. (Replaces 0129 which expired
05/15/93 & 0129.90) (9/8/92)

CA 0129.91.01 Approved 06/20/94 Effective 10/1/93
Waiver mod. to 0129.91 to include indivs discharged from St. develop. ctrs &
persons w/DD who are tech. dependent, increase waiver clients & add
homemaker, environ mods, spec. med. eqpmt & supplies, chore, PERS,
psychology svcs, communication aides, mobile crisis intervent, crisis
intervent. facility svcs, vehicle adapts, recreation therapy, nutrition
counseling & ext'd PT & OT. (12/30/93)

CA 0129.91.02 Approved 06/23/95 Effective 1/1/95
Waiver mod to 0129.91 to substitute asst'd living for resident habil, add
adult foster care & increase C value (4/17/95)

CA 0129.91.R1 Pending, Clock Stopped Effective 8/12/97
To provide homemaker, HH aide, personal care, respite, resident'l care, day
habil, skilled nursing, non-med transp spclzd med eqpmt & supplies, chore,
PERS, mobile crisis intervent'n, crisis intervent'n facilities communication
aids, vehicle adapts, nutritional consult, ext'd PT, OT & psychological svcs
to MR/DD indivs. & persons W/DD who are tech. dependent.(Replaces 0129.91
which expires 12/30/97) (05/14/97)