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1915(i) State Plan Home and Community-Based Services (HCBS). Kathy Poisal (Additional material added by R. Cooper). Center for Medicaid, CHIP, and Survey & Certification (CMCS) Disabled and Elderly Health Programs Group Division of Long Term Services and Supports.

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1915 i state plan home and community based services hcbs

1915(i) State Plan Home and Community-Based Services (HCBS)

Kathy Poisal (Additional material added by R. Cooper)

Center for Medicaid, CHIP, and Survey & Certification (CMCS)

Disabled and Elderly Health Programs Group

Division of Long Term Services and Supports

1915 i state plan hcbs key features
1915(i) State Plan HCBS — Key Features

Section 1915(i) established by DRA of 2005. Effective January 1, 2007

State option to amend the state plan to offer HCBS as a state plan benefit

Unique type of State plan benefit with similarities to HCBS waivers

Breaks the “eligibility link” between HCBS and institutional care now required under 1915(c) HCBS waivers

1915(i) was modified through the Affordable Care Act with changes that became effective October 1, 2010

1915 i services
1915(i) Services
  • Case management
  • Homemaker
  • Home Health Aide
  • Personal Care
  • Adult Day Health
  • Habilitation
  • Respite Care
  • For Chronic Mental Illness:
    • Day treatment or Partial Hospitalization
    • Psychosocial Rehab
    • Clinic Services

Any of the statutory 1915(c) services:

Through changes under the Affordable Care Act, States can also offer “Other” services

examples of other services
Examples of Other Services
  • Behavioral Supports
  • Cognitive rehabilitative therapy
  • Crisis intervention
  • Exercise and health promotion
  • Health monitoring
  • Housing counseling
  • Assistive technology
  • Live-in caregiver payment
  • Housing and vehicle modifications
  • Dental services
  • Family training
  • Neuropsychology services

Added by R. Cooper

who may receive state plan hcbs
Who May Receive State plan HCBS?

Must be eligible for medical assistance under the State plan

States must provide needs-based criteria to establish who can receive the benefit

Must reside in the community

Must have income that does not exceed 150% of Federal Poverty Level

Through changes included under the Affordable Care Act, states also have the option to include individuals with incomes up to 300% of SSI and who are eligible for a waiver

1915 i needs based criteria
1915(i) Needs-Based Criteria
  • Determined by an individualized evaluation of need (e.g., individuals with the same condition may differ in Activities of Daily Living ADLS)
  • May be functional criteria such as ADLs or Instrumental ADLs (IADLs)
  • ADLs: Eating, bathing dressing, hygiene, mobility, toileting, transferring
  • IADLs: Preparing meals, shopping, transportation, money management, managing meds

Additional material added by

R. Cooper

needs based criteria
Needs-Based Criteria
  • May include State-defined risk factors
    • Behavioral
    • Memory, judgment, or cognitive concerns
    • Additional medical risks
  • Needs-based criteria are not:
    • descriptive characteristics of the person, or diagnosis
    • population characteristics
    • institutional levels of care
needs based criteria who the benefit may cover
Needs-Based Criteria — Who the benefit may cover
  • The lower threshold of needs-based eligibility criteria must be “less stringent” than institutional and HCBS waiver LOC.
  • But there is no implied upper threshold of need. Therefore the universe of individuals served:
    • Must include some individuals with less need than institutional Level of Care (LOC)
    • and May include individuals at institutional LOC, (but not in an institution)
needs based criteria universe

Institutional LOC

HCBS Criteria

Needs-Based Criteria — Universe

Example

  • Eligibility criteria for HCBS benefit may be narrow or broad
  • HCBS eligibility criteria may overlap all, part, or none, of the institutional LOC:

Optional Coverage

Required

Coverage

1915 i state options
1915(i) State Options
      • Under the ACA changes to 1915(i):
  • States may offer HCBS to specific, targeted populations for a 5-year period with option to renew with CMS approval
  • States can have more than one 1915(i) benefit in their State Plan
  • * Note: States may no longer limit the number of participants who may receive the benefit and the benefit must be offered state-wide
  • Other Options:
  • Option to not apply income and resource rules for the medically needy
  • Self-Direction of HCBS: budget and/or employer authority
self direction in 1915 i
Self-Direction in 1915(i)
  • State Option
  • Modeled on 1915(c) application
  • May apply to some or all 1915(i) services
  • May offer budget and/or employer authority
  • Specific requirements for the service plan
under 1915 i states are to provide
Under 1915(i) States are to provide:
  • Independent Evaluation to determine program eligibility
  • Individual Assessment of need for services
  • Individualized Plan of Care
  • Projection of number of individuals who will receive State plan HCBS
  • Payment methodology for each service
  • Quality Improvement Strategy: States must ensure that HCBS meets Federal and State guidelines
similarities hcbs under 1915 i state plan 1915 c waivers
Similarities: HCBS Under1915(i) State plan & 1915(c) Waivers

Evaluation to determine program eligibility

Assessment of need for services

Plan of care

Quality Assurance requirements

Service Options

Self-Direction Option

Option to not apply income and resource rules for the medically needy

differences hcbs under 1915 i state plan 1915 c waivers

Differences: HCBS Under1915(i) State plan & 1915(c) Waivers

Institutional care requirements

Length of time for operation (without targeting)

Option to Limit Number of Participants

Option to Limit Statewideness

Financial estimates

mental health
Mental Health
  • Opportunity: 1915(i) does not include an institutional level of care nor cost neutrality requirement
  • Specific services for persons with chronic mental illness (but not limited to):
    • Day Treatment or Partial Hospitalization
    • Psychosocial Rehabilitation
    • Clinic Services
states with 1915 i state plan hcbs
States with 1915(i) State plan HCBS*
  • Iowa
  • Nevada
  • Colorado
  • Washington
  • Wisconsin
  • Idaho

*as of July 2011

state plan hcbs resources
State plan HCBS: Resources
  • Regulation published as NPRM April 4, 2008 (comment period ended June 3, 2008).

Complete proposed rule (CMS2249P) at

http://www.cms.hhs.gov/MedicaidGenInfo/08_Medicaidregulations.asp

  • State Medicaid Directors Letter released April 4, 2008
  • State Medicaid Directors Letter released August 6, 2010 (regarding changes to 1915(i) under the Affordable Care Act)
  • CMS Contacts:
  • Regional Office Representative
  • CMS Central Office:

Kathy Poisal [email protected]

acronyms
Acronyms
  • ACA: Affordable Care Act
  • ADLs: Activities of Daily Living
  • CMS: Centers for Medicare and Medicaid
  • DRA: Deficit Reduction Act
  • FPL: Federal Poverty Level
  • HCBS: Home and Community Based Services
  • IADLs: Instrumental activities of daily living
  • LOC: Level of Care
  • SSI: Supplemental Security Income
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