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1915(c) Waivers

Medicaid home and community-based service (HCBS) waivers afford States the flexibility to develop and implement creative alternatives to placing Medicaid-eligible individuals in hospitals, nursing facilities or intermediate care facilities for persons with mental retardation. The HCBS waiver program recognizes that many individuals at risk of being placed in these facilities 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.

Under section 1915 (c) of the Social Security Act (the Act), States may request waivers of certain Federal requirements in order to develop of Medicaid-financed community-based treatment alternatives. The three requirements that may be waived are in section 1902 of the Act and deal with state wideness, comparability of services and community income and resource rules for the medically needy.

The Act specifically lists seven services which may be provided in HCBS waiver programs: case management, homemaker/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 non-medical transportation, in-home support 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. Room and board is excluded from coverage except for certain limited circumstances.

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.

Federal regulations permit HCBS waiver programs to serve the elderly, persons with physical disabilities, developmental disabilities, mental retardation or mental illness. States may also target 1915(c) waiver programs by specific illness or condition, such as technology-dependent children or individuals with AIDS. States can make home and community-based services available to individuals who would otherwise qualify for Medicaid only if they were in an institutional setting.

To receive approval to implement HCBS waiver programs, State Medicaid agencies must assure HCFA that, on an average per capita basis, 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.

HCBS waiver programs are initially approved for 3 years and may be renewed at 5- year intervals.

HCFA's first home and community-based waiver program was established in 1981. There are currently 240 HCBS waiver programs in effect. 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.