Expanding Home- and Community-Based Services

Background

In 2013, for the first time since Medicaid began, the majority of its long-term services and supports Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ( LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ) spending was for home- and community-based services Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ( HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ) rather than institutional care. As of fiscal year 2016, 57 percent of Medicaid LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… dollars went toward HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. . However, Medicaid retains an institutional bias because Medicaid programs are required by law to cover institutional care settings. But the majority of HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. are optional. LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… for older adults and people with physical disabilities lag other populations; just 45 percent of these dollars went to HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. .

Since the passage of the Americans with Disabilities Act Legislation enacted by Congress in 1990 that prohibits discrimination against people with disabilities in employment, public services, public accommodations, transportation, and telecommunications. in 1990, many states have implemented changes in their Medicaid programs to shift at least some of the funding for institutional care to HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. , an effort referred to as rebalancing or balancing. A balanced LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… system will make efficient use of resources while meeting the needs and preferences of people who want to receive LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… in their homes and communities.

As part of the 2010 Affordable Care Act ( ACA Comprehensive health care reform legislation passed by Congress and signed into law on March 23, 2010. ), Congress established new financial initiatives to facilitate states’ expansion of their HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. programs and provided additional funding for several existing programs.

Programs aimed at rebalancing Medicaid’s institutional and HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. services have included: 

  • higher federal matching rates for states allocating resources toward HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ;
  • the Money Follows the Person program which encouraged states to identify people in institutions who want to return to their communities and facilitated that return; and
  • rules requiring states to protect assets for spouses whose partners receive Medicaid HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. rather than just for those receiving institutional care.

The State Balancing Incentive Payments Program, which ran for four years (from October 1, 2011, to September 30, 2015), provided grants to qualifying states that committed to making structural changes in their Medicaid programs to improve the balance of spending between HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. and institutional services. Grants increased states’ Federal Medical Assistance Percentage (FMAP) by either two or five percentage points, depending on a state’s current allocation of Medicaid spending for HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. . Another initiative is the Community First Choice option. This increases a state’s FMAP by six percentage points if the state offers statewide attendant services and supports to certain Medicaid-eligible individuals with disabilities without enrollment restrictions.

The law also strengthened the Money Follows the Person (MFP) Rebalancing Demonstration program, which encouraged states to identify people in institutions who want to return to their communities. When a state transitioned such people, it received an enhanced FMAP for the Medicaid-funded HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. that people receive for their relocation’s first year to help them live in the most appropriate and preferred settings. The ACA Comprehensive health care reform legislation passed by Congress and signed into law on March 23, 2010. extended the MFP program through September 30, 2016, and appropriated an additional $450 million for each of the five fiscal years 2012–2016. Any unused grant funds as of 2016 can be used until 2020.

In addition, the law modifies the existing 1915(i) Medicaid state plans for HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. to make it easier for states to use this authority to expand HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. . It also requires all states to apply spousal impoverishment protection rules to HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. for five years (2014–2019). States already are required to do this for the spouses of Medicaid beneficiaries who reside in nursing facilities.

In 2014, CMS issued a final rule giving states new flexibility and responsibility for paying for HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. through Medicaid. The rule provides a new definition of HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. settings, emphasizing an outcomes-oriented approach so that older adults and people with disabilities have informed choices of settings and service options. The new rule emphasizes person-centered planning that reflects the care recipient’s goals and preferences and acknowledges that family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. play a vital role in enabling the recipient to continue living at home or in the local community. The new rule also allows states to combine multiple Medicaid waivers that cover HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. based on functional need rather than age or diagnosis, and that serve more than one population in a waiver. States will have to submit transition plans to meet the new HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. rule and then will have up to five years to implement the plan.

States have implemented numerous changes in their LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… systems in order to expand HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. and reduce reliance on nursing facilities.

In January 2017, CMS approved Washington State’s request for a new five-year Medicaid demonstration program, the Medicaid Transformation Project, in accordance with section 1115(a) of the Social Security Act. Under this waiver, Washington State will offer ways to support family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. of older adults who need help to live at home by getting supports for the family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. necessary to continue to provide care and to focus on their own health and well-being (see also this chapter’s section on Supporting Family Caregivers.) 

States that have achieved greater success in transforming their LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… systems to give people choices and reduce their reliance on nursing facilities share certain characteristics, including the following:

Philosophy—all decisions extend from a commitment to deliver services to older adults and people with disabilities and their family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. in the most independent living situation possible and to expand cost-effective HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. options through person- and family-centered planning. The most important factor in creating a balanced LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… system may be the state’s determination to promote quality of life for older adults and people with disabilities and give participants a choice in how they obtain their services.

Array of services—states that provide a comprehensive array of culturally appropriate services designed to meet the needs of each individual, regardless of income, and his or her family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. are less likely to channel people into institutions.

Organization of responsibilities—assigning responsibility for the state’s LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… system to a single administrator is a key decision in some of the most successful states.

Coordinated funding sources—coordination of multiple funding sources can maximize a state’s ability to meet the needs of older adults and people with disabilities.

Single appropriation—this approach, sometimes called global budgeting A possible mechanism for containing the growth in costs of health care and long-term services and supports. A global budgeting strategy encourages the efficient use of resources by capping the total amount of the national budget allocated to health care and long-term services and… , allows states to transfer funds among programs and, therefore, make more timely decisions to serve people in their preferred settings.

Timely eligibility—hospital discharges account for nearly half of all nursing facility admissions. When decisions must be made quickly at a time of crisis, state Medicaid programs must arrange for HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. in a timely manner. Delays in eligibility decisions often result in unnecessary placement in nursing facilities. Successful states either presume financial eligibility for Medicaid HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. or fast-track the determination process.

Standardized assessment tool—some states use a single tool to assess functional eligibility and service needs and then develop a person- and family-centered plan of services and supports. This helps to minimize differences among care managers and prevent unnecessary institutionalization. It can also be used to collect consistent data, leading to better system management. In states where people are disproportionately institutionalized compared to other states, initiatives targeted at reducing institutionalization should be established.

Single-entry point—research demonstrates the need for a single access point to a comprehensive array of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… for older adults and people with disabilities. Effective systems that determine eligibility, coordinate services, and monitor quality can support people who have their own resources to pay for services, as well as those who qualify for public programs. A robust system of information and assistance is critical because most older adults, people with disabilities, and their families have a difficult time negotiating complex systems. One model is the Aging and Disability Resource Centers State-operated organizations that serve as a single point of information about, and access to, the variety of long-term services and supports available to older adults and people with disabilities. Also known as No Wrong Door systems. , which most states are in various stages of implementing.

Participant direction—the movement to allow people a greater role in determining who will provide their services, as well as when and how they are delivered, responds to the desire of older adults and people with disabilities to maximize their choices and control over their lives.

Relocation from nursing facilities—some states regularly assess the possibility of transitioning people out of nursing facilities and into their own homes or home-like community alternatives. States may assign staff to visit nursing facilities to identify, assess, and help people relocate. Medicaid payment for transition services is critical to the success of these efforts.

Quality improvement—states are incorporating participant-defined measures of success in their quality improvement plans.

Integrating health services and LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… —a few states have developed methods for ensuring that the array of health services and LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… provided to older adults and people with disabilities are coordinated and delivered in a cost-effective manner. Differences in how Medicare Authorized in 1965 under Title XVIII of the Social Security Act, Medicare provides health insurance coverage for people age 65 and older and for some disabled people under age 65. This federal program consists of Part A (Hospital Insurance), Part B (Supplemental Medical Insurance), Part… and Medicaid programs are administered have complicated these efforts. Yet among people age 65 and older, the vast majority of those receiving Medicaid are eligible for Medicare Authorized in 1965 under Title XVIII of the Social Security Act, Medicare provides health insurance coverage for people age 65 and older and for some disabled people under age 65. This federal program consists of Part A (Hospital Insurance), Part B (Supplemental Medical Insurance), Part… as well.

EXPANDING HOME- AND COMMUNITY-BASED SERVICES: Policy

Eliminating Medicaid's institutional bias

In this policy: FederalState

The federal government should eliminate Medicaid’s bias favoring nursing facilities by mandating the provision of home- and community-based services Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ( HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ) for everyone who meets Medicaid eligibility criteria and chooses to receive services in HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. settings.

The federal government should give states more flexibility to set separate eligibility criteria for nursing facility care and HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. waiver services. Only people who cannot be safely, adequately, appropriately, and cost-effectively served in the community, based on uniform and independent assessments, should be admitted to nursing facilities unless they choose to receive services in a nursing facility.

The federal government should provide federal matching funds to reimburse states for erroneous presumptive eligibility determinations regarding beneficiaries who receive Medicaid HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. and nursing facility services.

Expanding home- and community-based services

In this policy: FederalState

Congress and the states should expand funding for a wide range of HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. through Medicaid, the Older Americans Act (OAA), the Social Services Block Grant program, and other programs that offer long-term services and supports Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ( LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ).

States should fund sufficient HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. waiver slots to eliminate waiting lists.

Federal and state governments should allocate a greater proportion of Medicaid funding for HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. instead of nursing facility care.

Creating or expanding nursing facility transition programs

In this policy: FederalState

The federal government should continue to fund and expand the Money Follows the Person program. The federal and state governments should build diversion and transition programs that have sufficient capacity to assist any person who can be served in HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. settings rather than nursing facilities.

Offering a comprehensive range of home- and community-based services

In this policy: State

States should fund the services needed to meet individuals’ LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… needs and allow them to remain in the community. These services, at a minimum, should include personal care, conflict-free care management, adult day services, home modifications, assistive technologies, respite care and other caregiver support services, such as education and training. Services should be offered in a range of settings, including supportive housing A setting for long-term services and supports that includes board and care homes, assisted living facilities, and group homes that provide or arrange for services and help with activities of daily living (see separate entry) in a residential setting. and adult day centers. These services should be offered through Medicaid, state-funded LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… programs, the Social Services Block Grant, and the OAA.

States should expand HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. options to include a range of residential choices as well as home modifications and assistive technologies.

This can be done through waivers and other processes such as state plan amendments, Administration for Community Living programs, or state-only funding sources. Particularly important are programs that provide LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… for low-income residents of assisted living, or board and care homes  A living arrangement in which the resident is provided with a room, meals, help with activities of daily living, and protective supervision. These homes are also called residential care facilities, community care homes, sheltered care facilities, adult foster care, group homes, or… , at risk of entering a nursing facility. However, current Medicaid beneficiaries should not be forced to move or have benefits reduced by the implementation of a waiver or other program.

States should expand the new requirement to assess the needs of family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. under the 1915(i) HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. state plan option to all assessment tools for Medicaid HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. . Such assessments will identify at-risk family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. before they burn out or compromise their own physical and mental health.

States should support family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. services such as education and training, counseling, legal consultations, and respite care, which can delay or decrease the likelihood of needing to enter a nursing facility.

Streamlining administration of long-term services and supports programs

In this policy: FederalLocalState

States should consolidate LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… programs, policies, and budgets within one state agency to promote efficiency, create single points of entry for LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… , and implement the data collection necessary to manage LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… strategically.

States should:

  • develop the capacity for prompt financial and functional Medicaid eligibility determinations for applicants who need and want HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. , and should use presumptive eligibility for people who are at risk of nursing facility placement without Medicaid-funded HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ;
  • use a unified global budget for publicly funded LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… so they have flexibility in allocating expenditures and can use the money saved through reduced nursing facility use for increased coverage of HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. ;
  • consolidate LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… programs, policies, and budgets within one state agency to promote efficiency, true single points of entry for LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… , and the data collection necessary to strategically manage LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ;
  • ensure that Olmstead plans include specific action steps, timelines, and strategies for securing necessary HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. funding;
  • ensure that consumers fully participate in implementing and monitoring state Olmstead plans and waivers at the state and local levels—such participation would include serving on advisory committees and governing boards;
  • continue to monitor and revise as needed their Olmstead implementation plans;
  • establish policies to pay relatives and friends who care for people with LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… needs as part of a plan of care, and design programs and policies to protect consumers and avoid the erosion of family care networks—programs and policies should protect consumers, guard against fraud and abuse, and avoid disincentives for unpaid caregiving;
  • identify barriers that unintentionally curtail consumers’ ability to self-direct their care or to arrange to have certain nursing tasks provided by unlicensed direct-care staff authorized and trained to do so by a registered nurse;
  • ensure that registered nurses are protected from liability if they have followed the prescribed protocols for delegation, training, and supervision outlined in the states’ nurse practice acts;
  • ensure that states with a formal process for allocating the number of nursing facility beds—such as a certificate of need—base decisions on the number of people who require a specific level of care and on data projecting the need for LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… in different areas of the state;
  • provide data on nursing facilities and HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. service use, by age and geographic region, as well as per capita and aggregate cost of services, including Medicaid services in nursing facilities and HCBS Long-term services and supports provided in individuals’ homes or in home-like environments, such as supportive housing. to the extent possible;
  • seek to provide data on the range of the level-of-care scores of people age 85 and older who are in nursing facilities;
  • preserve and expand funding for respite care services in a range of settings, such as personal care services Services that help functionally impaired people with bathing, dressing, eating, mobility, medications, light housekeeping, and other tasks. in the home or adult day services, to ensure that more family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. can have a break from their caregiving duties;
  • preserve and expand funding for respite care services regardless of whether the care recipient is eligible for Medicaid or a publicly funded program, or is a private-pay individual; and
  • allow family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. who are assisting care recipients with moderate incomes, and who would not otherwise qualify for publicly funded respite services, to buy into or otherwise access these services.