HCBS Waiver Decision Guide
HCBS Waiver Decision Guide PDF
Home and community-based services (HCBS) are state-based programs that allow people with disabling conditions, chronic illness, and other factors to avoid placement in institutional settings (Friedman & VanPuymbrouck, 2018).
Most states provide Medicaid funded HCBS services through waivers. Waivers allow states to target HCBS services to specific groups of enrollees and cap participation in programs, waiving certain federal requirements for Medicaid. HCBS can provide a range of medical and non-medical services to help Medicaid eligible clients maintain their ability to remain in their home or the community.
Since 2013, Medicaid has spent more on HCBS than on institutional care (Medicaid and CHIP Payment and Access Commission, 2022). In 2020 alone, 4.2 million people used HCBS in 51 states (Burns & Chidambaram, 2023). Occupational therapy practitioners can provide vital services to support meaningful engagement for clients within the home and community. However, eligibility, covered services, and level of OT involvement differ from state to state (Medicaid and CHIP Payment and Access Commission, 2022).
Know Your State’s Waivers
The most common waiver programs that states use to provide HCBS are 1915(c) and 1115. Use the links below to review the current waiver programs in your state.
• 1915(c) - Allows services to limited groups of enrollees as an alternative to institutional care. States can waive income requirements, cap enrollees, and limit geographic locations in the state where the waiver is available.
• 1115 - A research and demonstration authority. These waivers are generally broad in scope, operate statewide, and affect a large portion of the Medicaid population within a state.
Information on other Medicaid HCBS authorities can be found on the official federal Medicaid website: State Waivers List | Medicaid.
HCBS waivers address many conditions, including, but not limited to:
• Autism
• Behavioral health
• Brain or spinal cord injury
• HIV/AIDS
• Intellectual and developmental disabilities (I/DD)
• Medically fragile or technologically dependent
• Older adults
• Physical disability
Common services provided by occupational therapy practitioners:
• Interventions to address activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
• Adaptive equipment/assistive technology
• Environmental and home accessibility modifications
• Family/caregiver training
• Habilitation
• Vehicle modifications
Some states have used waivers to integrate occupational therapy-centered programs such as Community Aging in Place—Advancing Better Living for Elders (CAPABLE) and Caring for Older Persons in their Environment (COPE) into their communities.
How to Apply
Applying to provide services under HCBS waivers varies from state to state and waiver to waiver. Contact your state’s Medicaid agency or the state agency that operates the waiver program (they may be separate agencies) to find coverage and reimbursement policies, and how to become a provider.
Resources
AOTA’s Everyday Advocacy Decision Guide
Centers for Medicare and Medicaid Services: Home and Community Based Services 1915(c)
Home & Community Based Services Authorities | Medicaid
MACPAC (Medicaid and CHIP Payment and Access Commission) Home and Community-Based Services
Occupational Therapy Practice Framework: Domain and Process – 4th Edition
Section 1115 Demonstrations | Medicaid
References:
Burns, A., & Chidambaram, P. (2023, August 14). How many people use Medicaid long-term services and supports and how much does Medicaid spend on those people? KFF. https://www.kff.org/medicaid/issue-brief/how-many-people-use-medicaid-long-term-services-and-supports-and-howmuch-does-medicaid-spend-on-those-people/
Friedman, C., & VanPuymbrouck, L. (2018). Occupational therapy in Medicaid Home and Community-Based Services waivers. American Journal of Occupational Therapy, 72, 7202205120. https://doi.org/10.5014/ajot.2018.024273
Medicaid and CHIP Payment and Access Commission (MACPAC). (2022, March 24). Home- and community-based services: MACPAC. https://www.macpac.gov/subtopic/home-and-community-based-services/