Medicaid's Home and Community-Based Services State Plan Option: Section 6086 of the Deficit Reduction Act

Medicaid’s Home and Community-Based
Services State Plan Option: Section 6086 of
the Deficit Reduction Act
Cliff Binder
Analyst in Health Care Financing
Domestic Social Policy Division
Summary
Section 6086 of the Deficit Reduction Act of 2005, (DRA, P.L. 109-171),
established a optional Medicaid benefit giving states a new method with which to cover
home- and community-based (HCBS) services for Medicaid beneficiaries, starting in
January 2007. Prior to DRA’s enactment, states needed HCBS waivers authorized in
Section 1915(c) of the Social Security Act (SSA) to cover these services. The HCBS-
state plan optional benefit, Section 1915(i), differs from both existing Medicaid state
plan benefits and Section 1915(c) waivers. This report outlines requirements of the new
1915(i) benefit and compares key features of this benefit with other Medicaid state plan
benefits and 1915(c) waivers. It will be updated periodically.
Background¹
Home and community-based services refer to a range of health and supportive
services (delivered in non-institutional settings) that are needed by individuals who lack
the capacity for self-care because of a physical, cognitive, or mental disability or chronic
condition resulting in functional impairment(s) for extended time periods. Medicaid has
covered home- and community-based services (HCBS) since the program’s inception in

1965 through various service categories.

From the start, Medicaid allowed states to cover a range of home health services and
required states to cover those services for individuals who otherwise would require
treatment in nursing facilities. Home health services include skilled nursing, aide
services, medical equipment and supplies, and, often, therapy. States also are permitted
to cover rehabilitation and private duty nursing services. Rehabilitation can include a

¹ Karen Tritz and Carol O'Shaughnessy, Specialists in Social Legislation, were the original
authors of this report.

range of medical or remedial services recommended by a physician or other licensed
practitioner to reduce the degree of physical or mental disability and restore functioning.²
Private-duty nursing is skilled nursing care for individuals who require services beyond
what is available under Medicaid’s home health or personal care benefits.
Over time, Congress and the Centers for Medicare and Medicaid Services (CMS)
authorized states to cover other types of HCBS services as optional benefits. States could
offer HCBS services, such as personal care and case management, by including these
services in their state plans.³ Personal care and case management services were added as
optional Medicaid benefits in 1978 and 1986, respectively. Through personal care,
beneficiaries are assisted with activities of daily living (e.g., dressing, bathing, eating),⁴
while case management includes services to assist Medicaid beneficiaries in gaining
access to needed medical, social, educational, and other services.
In addition to the Medicaid state plan benefits, in 1981, Congress authorized HCBS
waivers under Section 1915(c) of the Social Security Act (SSA). HCBS, 1915(c) waivers,
enable states to cover a range of services for beneficiaries who otherwise would require
institutional levels of care (i.e., nursing facility, hospital, or intermediate care facility for
individuals with mental retardation). Under HCBS-waivers, the Secretary of the
Department of Health and Human Services is permitted to waive Medicaid’s federal
“statewideness” requirement to allow states to cover HCBS services in limited geographic
areas. The Secretary also may waive the requirement that services be comparable in
amount, duration, or scope for individuals in particular eligibility categories. HCBS
waivers authorize states to limit the number of individuals served and to target certain
populations (e.g., individuals with developmental disabilities, brain injuries, or the aged).
For HCBS waivers to be approved, states also must meet other requirements, such as a
cost-effectiveness test, where average Medicaid expenditures for waiver participants do
not exceed costs that would have been incurred if these individuals resided in institutions.
All states cover HCBS for certain groups of Medicaid beneficiaries. In 2005, 35
states and the District of Columbia used the Medicaid personal care state plan benefit to
provide services for individuals with disabilities.⁵ Forty-nine states and the District of
Columbia have at least one HCBS-waiver for elderly individuals, younger adults with
physical disabilities, or individuals with mental retardation or developmental disabilities.
States also use HCBS waivers to provide services for other groups, such as individuals
with HIV/AIDS or brain injuries. Table 1 summarizes the number of states offering
HCBS benefits, the number of beneficiaries receiving services, and total expenditures.

² Section 1905(a)(13) of the Social Security Act (SSA).
³ To receive federal Medicaid funds, states must submit and have approved by the Secretary a
written Medicaid plan. State plans describe the nature and scope of states’ Medicaid programs,
including benefits, eligibility, and other program characteristics. Medicaid plans also give
assurances that states will conform to the federal Medicaid laws, and observe regulations and
other program guidance. When states substantively change covered benefits, eligibility, or other
program components, they must submit state plan amendments for the Secretary’s approval.
⁴ Section 1905(a)(24) of the SSA.
⁵ Medicaid At-a-Glance 2005, ^[^h^t^t^p^:^/^/^www.^c^m^s^.^h^h^s^.^g^o^v^/^M^L^N^P^r^o^d^u^c^t^s^/^d^o^wⁿ^l^o^a^d^s^/^M^e^d^G^l^aⁿ^c^e⁰⁵^.^p^d^f^].

Table 1. Medicaid Coverage of Home and Community-Based
Services: State Implementation, Number of Beneficiaries,
and Total Expenditures
Number of statesNumber of MedicaidTotal expenditures,
and DC coveringbeneficiaries, FY2005FY2005
Benefitsbenefit in 2005(in thousands)(in $ millions)
Home health511,192$5,355
Re habilitation 51 1,644 $6,427
Private duty nursing 2743$662
Personal care36932$8,413
Case management482,709$2,806
HCBS waivers501,064$20,475
^Source:^C^R^S^Aⁿ^al^y^sⁱ^s^of^C^M^S^Medi^cai^{d S}^t^atⁱ^s^tⁱ^cal^In^f^o^rm^atⁱ^oⁿ^S^y^s^t^em^(MS^I^S⁾^{, F}^Y^{2005 an}^d^Medⁱ^ca^id
^At^-a-G^l^{ance 2005}^[^h^t^t^p^:^/^/^www.^c^m^s^.^h^h^s^.^g^o^v^/^M^L^N^P^r^o^d^u^c^t^s^/^d^o^wⁿ^l^o^a^d^s^/^M^e^d^G^l^aⁿ^c^e⁰⁵^.^p^d^f^]^.
Home and Community-Based Services State Plan
Option: Section 6086 of the Deficit Reduction Act
Section 6086 of the Deficit Reduction Act of 2005 (DRA, P.L. 109-171) authorized
a new optional benefit that allows states to cover limited HCBS without waivers. The
requirements of this new optional benefit, Section 1915(i) of SSA, differ from other
Medicaid state plan benefits (e.g., home health and personal care) and the Section 1915(c)
HCBS-waivers. Table 2 compares key features of the new HCBS benefit with existing
Medicaid program authorities.
Section 1915(i) authorizes states to offer HCBS without a waiver beginning in
January 2007. States can define beneficiaries’ needs, and do not have to require that
beneficiaries meet institutional levels of care to qualify for services. Also under 1915(i),
states may amend their Medicaid plans without demonstrating budget neutrality as they
do under 1915(c) waivers. Section 1915(i) permits states to offer fewer HCBS services
than are permitted under 1915(c) waivers and to restrict eligibility to beneficiaries whose
incomes fall below 150% of FPL. States also may offer self-direction under the 1915(i)
option and may cap enrollment.
CMS is developing regulations to guide states that want to offer HCBS under 1915(i)
and plans to issue a notice of proposed rule making in early 2008. CMS also conducted
training on the new state plan option for its regional office staff and for states’ Medicaid
staff as well as drafting a state plan amendment (SPA) preprint.⁶ Four states have

⁶ The optional 1915(i) SPA preprint is available through CMS’s regional offices. In addition to
offering guidance to states on issues to be addressed in HCBS-SPAs, CMS’s preprint also
identifies quality monitoring and other reporting assurances required of states.

submitted SPAs to provide HCBS services as permanent Medicaid benefits.⁷ Three
HCBS-SPAs are under review by CMS. Iowa was the first state to submit a HCBS-SPA
and was approved in April 2007 to provide HCBS services to 3,700 seriously mentally
ill beneficiaries in the first year and 4,500 beneficiaries by year five.⁸
State utilization of the 1915(i) option may lag behind expectations created by the
recent rapid growth of HCBS waivers and program cost estimates.⁹ Data on states’ plans
for adopting the 1915(i) HCBS option are limited, but an October 2007 survey of states
on their LTC plans indicates that two states planned to submit HCBS-SPAs, while 16
other states and a territory (Guam) were considering the option.¹⁰ The remainder of this
section discusses issues that could affect states’ utilization of the Section 1915(i) option.
Under 1915(c) waivers, states may use higher income standards for determining
beneficiaries’ eligibility for services than income standards under 1915(i) — up to 300
% of SSI for 1915(c) versus 150% of the federal poverty level (FPL) for 1915(i).¹¹ The
more restrictive income eligibility standards under 1915(i) limits states from “converting”
beneficiaries in existing 1915(c) waivers to 1915(i)-SPAs, because many states’ permit
beneficiaries to have higher incomes than 150% of the FPL in 1915(c) waivers.
In addition to more restrictive eligibility standards, 1915(i) is limited to covering
only services described in Section 1915(c) paragraph 4(B).¹² The 1915(i) SPA option
prevents states from adding other services requested by states on a case-by-case basis, as
permitted under 1915(c) waivers. Under 1915(c) waivers states have used the “other
services clause” to address the needs of specific beneficiary groups. For example, HCBS-
waivers have been used to expand services to include transportation, apartment deposits,
and even home modifications necessary for community living. Under 1915(c) waivers,
states may define eligibility based on diseases or conditions, such as brain injury or
HIV/AIDS, or geographic area, such as a city or county. Under 1915(i), however, states
must create different ways to measure qualification for services that rely on individuals’
needs for service. Under HCBS-waivers, Medicaid may use common medical measures,
such as diagnoses, but assessing individuals’ support needs using activities of daily living
can be more difficult to measure for some populations.

⁷ The four states that have submitted 1915(i) SPAs are Colorado, Georgia, Iowa, and Nevada.
⁸ Iowa’s 1915(i) SPA is available at [http://www.ime.state.ia.us/HCBS/HabilitationServices/
documents.html ].
⁹ Congressional Budget Office Cost Estimate, S. 1932, Deficit Reduction Act of 2005. CBO
estimated a $755 million increase in federal Medicaid spending for FY2006-2010 and $2.6 billion
increase for FY2006-2015.
¹⁰ State Perspectives on Emerging Medicaid Long-Term Care Policies and Practices, October
2007, National Association of State Medicaid Directors, an affiliate of the American Public
Human Services Association, page 13.
¹¹ In 2008, 150% of the FPL is $1,300/month for individuals; 300% of SSI is $1,911/month for
individuals.
¹² 1915(c) 4(B) services include case management, homemaker/home health aide, personal care,
adult day health, habilitation, respite care, and day treatment services, as well as partial
hospitalization, psycho-social rehabilitation, and clinic services for individuals with chronic
mental illness.

CRS-5
Table 2. Medicaid Benefit Comparison: State Plans, HCBS Waivers, and the HCBS SPA Option
(Section 6086 of the Deficit Reduction Act of 2005)
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^approv^al^of^States^s^u^bm^{it s}^t^{ate plan}^am^en^dm^en^ts^(SP^A^s⁾^to^{States su}^b^m^{it a w}^a^iv^er^ap^p^lica^tioⁿ^w^ith^sigⁿⁱ^fⁱ^can^t^States^{are requ}^{ired to}^s^u^b^mⁱ^t^SP^A^s^th^{at f}^u^lly
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^an^d^estim^{ate ex}^p^eⁿ^d^itu^r^e^{s an}^d^u^tilizatioⁿ^{as w}^e^{ll as}^(s^{ee below}^.⁾^popu^l^a^tⁱ^oⁿ^t^o^{be cov}^e^red,^aⁿ^d^ot^h^e^{r ch}^aract^eri^s^tⁱ^c^s
^des^c^ri^biⁿ^g^ot^h^e^{r prog}^ram^ch^aract^eri^s^tⁱ^c^s^.^of^t^h^{e H}^C^BS^—^S^P^A^.
^Fed^e^r^a^{l ap}^p^r^o^v^{al o}^f^SP^A^s^{is n}^o^{t tim}^e-^lim^ited^.^Iⁿ^itial^w^aⁱ^v^e^r^a^p^p^r^o^v^a^l^s^a^r^e^f^o^r^t^h^r^e^e^-^y^e^a^r^s^.^Fed^e^r^a^l^ap^p^r^o^v^{al o}^f^SP^A^s^{is n}^o^{t tim}^e-^lim^ited^.
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^{criteria. (s}^{ee below}^.⁾
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CRS-6
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ⁱ^{ki/CRS-RS22448}
^g/w
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^r^e^q^u^{ired u}ⁿ^d^{er 1915(c) (i.e., n}^u^r^sⁱⁿ^g^f^acility^,
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^vⁱ^du^alⁱ^{zed pl}^an^th^{at in}^dⁱ^vⁱ^d^u^{als h}^a^v^e^w^r^itten^car^{e p}^l^an^s.^m^u^{st f}^o^llo^w^{a w}^r^itten^care^p^l^an^f^o^{r each}ⁱⁿ^dⁱ^vⁱ^d^u^al.^r^e^q^u^ir^ed^to^estab^lish^w^r^itten^,ⁱⁿ^dⁱ^vⁱ^d^u^alized^c^a^r^e
^Medicaid^l^a^wⁱ^sⁿ^o^{t s}^p^ecifⁱ^{c as}^{to h}^o^w^th^e^plan^s^.^C^a^{re plan}^s^m^u^s^t^m^e^e^t^s^p^ecifⁱ^{c criteria, s}^u^ch
^ev^alu^a^tion^{or as}^s^e^s^s^m^en^{t are to be con}^d^u^c^ted.^as^{: f}^ace-^to-^f^{ace ev}^alu^a^tion^s^of^ben^e^fⁱ^ciaries^’ⁿ^eeds^;
^and^as^s^e^s^s^m^en^{t of}^relev^aⁿ^t^hⁱ^s^t^ory^an^{d m}^e^dical
^records^.