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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.

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

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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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)

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. ≠ ≠ ≠ ≠ ≠ 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

  15. 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

  16. States with 1915(i) State plan HCBS* • Iowa • Nevada • Colorado • Washington • Wisconsin • Idaho *as of July 2011

  17. 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 Kathryn.Poisal@cms.hhs.gov

  18. 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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