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Medicaid Waivers Bridges to Better Advocacy Austin, TX October 22, 2009 Sarah Somers

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

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  1. Medicaid Waivers Bridges to Better Advocacy Austin, TX October 22, 2009 Sarah Somers “Securing Health Rights for Those in Need”

  2. Session Overview • Medicaid Basics • Home and community-based waivers • Home and community-based state plan option • 1115 Waivers

  3. 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

  4. 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

  5. Medicaid Basics • Entitlement • § 1396a(a)(10)(A), Schweiker v. Gray Panthers, 453 U.S. 34, 37 (1981)

  6. 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

  7. Home and Community-Based Waivers • Services • Waiver services • “Other” services • State plan services • “Extended” state plan services

  8. 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

  9. 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)

  10. Home and Community-Based Waivers • Habilitation • Distinction between habilitation and rehabilitation • Autism services, mental health services • Rescission of related Bush administration regulations

  11. 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)

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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)

  18. 1115 Authority • “Regular” Medicaid populations • Categorically needy • Optional and mandatory • Medically needy • “Expansion” populations • Childless, non-disabled adults not described in Medicaid Act

  19. Questions?

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