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Medicaid Waivers Bridges to Better Advocacy Austin, TX October 22, 2009 Sarah Somers. “Securing Health Rights for Those in Need”. Session Overview. Medicaid Basics Home and community-based waivers Home and community-based state plan option 1115 Waivers. Medicaid Basics.
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Medicaid Waivers Bridges to Better Advocacy Austin, TX October 22, 2009 Sarah Somers “Securing Health Rights for Those in Need”
Session Overview • Medicaid Basics • Home and community-based waivers • Home and community-based state plan option • 1115 Waivers
Medicaid Basics • Cooperative federal-state program • Federal statute and regulations • Title XIX of the SSA, 42 U.S. Code 1396a-1396v • Federal agency – DHHS • Match of state expenditures (FFP) • State plan • Single state agency
Medicaid Basics • Optional and mandatory • Eligibility categories (§ 1396a(a)(10)(A)(i), (ii) mandatory and optional categorically needy, (a)(10)(C), medically needy) • Services (§§ 1396a(a)(10), 1396d(a)) • Other mandatory requirements • Comparability ((§ 1396a(a)(10)(B)) • Financial (income and resources) • Statewideness
Medicaid Basics • Entitlement • § 1396a(a)(10)(A), Schweiker v. Gray Panthers, 453 U.S. 34, 37 (1981)
Medicaid Basics • Home and community-based waivers • 1915c (§ 1396n(c)) • Need level of care provided in institution (NF, ICF-MR, Hospital) • 1915d (§ 1396n(d)) • Fragile elderly • 1915e (§ 1396n(e)) • Children under 5 w/ HIV/AIDS or drug dependent
Home and Community-Based Waivers • Services • Waiver services • “Other” services • State plan services • “Extended” state plan services
Home and community-based waivers • Cost Neutral • Aggregate v. individual • Assurances regarding health and welfare • Must inform individuals likely to need institutional services that alternatives under the waiver are available and may be chosen
Home and Community-Based Waivers • Waiver Services • Case management - Home modifications • Personal care • Adult day health • Respite • Habilitation • For individuals w/ MI: psycho-social rehab, day treatment, partial hosp., clinic services § 1396n(c)(4)(B)
Home and Community-Based Waivers • Habilitation • Distinction between habilitation and rehabilitation • Autism services, mental health services • Rescission of related Bush administration regulations
Home and Community-Based Waivers • “Other” services • Not expressly authorized as waiver service • Necessary to help avoid institutionalization • Services that could be included under the state plan but are not • E.g., personal emergency response system, assisted living 42 C.F.R. § 440.180(b)(9)
Home and Community-Based Waivers • State plan services • “Extended” state plan services • Augmented state plan services • Extension of amount, duration, or frequency of service (e.g. number of home health aide visits) • Does NOT include services that could be covered under the state plan but are not
Home and community-based waivers Hybrid: 1915(b) and 1915(c) waivers • Essentially targeted managed care • 1915(b) allows waiver of: • Freedom of choice of providers • Comparability • Statewideness
HCBS State Plan Option • Authorized by 1915(i) (42 U.S.C. § 1396n(i)) • No cost neutrality requirement • May place a cap on the number of individuals who qualify • Comparability applies • Standard of need for this option must be less than the standard for NF/HCBW • E.g., if must require assistance w/ 4 ADLs to qualify for NF, must require assistance w/3 ADLs to qualify for option
Demonstration Waivers (section 1115) • “Experimental, pilot, or demonstration” projects • “Likely to assist in promoting objectives of” Medicaid Act • Allows waiver of requirements found in § 1396a 42 U.S.C. § 1315
Demonstration Waivers • Requirements in § 1396a include • 1396a(a)(1) – statewideness • 1396a(a)(10)(A) – coverage of categories of individuals, entitlement to certain services • 1396a(v) – disability determination standards
1115 Authority • Distinction between section 1115 waiver and section 1115 expenditure • Extension of coverage to individuals not eligible for Medicaid • Secretary claims broader authority to excuse compliance with Medicaid requirements • Newton-Nations v. Rodgers (D. Ariz.), Portland Adventist Med. Ctr. v. Thompson, 399 F.3d 1091 (9th Cir. 2005); Spry v. Thompson, 487 F.3d 1272 (9th Cir. 2007)
1115 Authority • “Regular” Medicaid populations • Categorically needy • Optional and mandatory • Medically needy • “Expansion” populations • Childless, non-disabled adults not described in Medicaid Act