Enacted into statute January 1, 2007
Revised in statute: October 1, 2010
Final Rule Issued: January 16, 2014 (effective March 17, 2014)
Settings provisions effective for preexisting programs 3/23/2023)
1915(i) permits states to offer HCBS to Medicaid-eligible individuals who meet state-defined minimum needs-based criteria that are less stringent than institutional criteria, and state-optional target group criteria. May also provide services to individuals whose needs exceed the state’s minimum needs-based criteria including those who meet an institutional level of care.
- Comparability
Community income rules for medically needy population
Information on SPA processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html
State plan amendment submitted on pre-print.
Preprint available at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915i/index.html
One-time approval. Changes must be submitted to CMS and approved.
If using targeting option, renewal every 5 years.
States may amend their state plan at any time post-approval.
Amendments with substantive changes may only take effect on or after the date when the amendment is approved by CMS.
Substantive changes also must be accompanied by information on how the state has assured smooth transitions and minimal adverse impact on individuals impacted by the change.
Evidence Based Review process that begins 39 months after SPA effective date.
Administered by the Single State Medicaid Agency (SSMA).
May be operated by another state agency under an interagency agreement or memorandum of understanding.
Required between providers and the SSMA.
Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services.
Requires written specification of delegated activity and a voluntary reassignment of payment by the provider of services.
Individuals eligible for Medicaid under the State plan up to 150% of Federal Poverty Level.
States may also include special income group of individuals with income up to 300% SSI/FBR, who are eligible for HCBS under a §1915(c), (d), or (e) waiver or §1115 demonstration waiver.
A state may elect not to apply comparability requirements set forth in the statute. This provision enables states, at their election, to target the HCBS State Plan option. These target groups must be defined on the basis of any combination of the
following:
- Age.
- Diagnosis.
- Disability.
- Medicaid Eligibility Group
And may not have the impact of limiting individuals choice of provider and/or living setting.
NOTE: See approval section above for 1915(i) benefits that include targeting.
Regardless of whether a state elects to target the 1915(i), each 1915(i) must include need based criteria which are factors used to determine an individual’s requirements for support, and may include risk factors. The criteria are not characteristics that describe the individual or the individual’s condition. A diagnosis is not a sufficient factor on which to base a determination of need.
Needs based criteria must be less stringent than institutional level of care criteria.
In addition to needs based criteria for eligibility for HCBS as a state plan option, the state may establish needs based criteria for each service.
42 CFR §447.205 for payment methodology.
Section 441.715(c)(1) requires states to provide at least 60 days - notice of a proposed modification of the needs-based criteria to the Secretary, the public, and each individual enrolled in the State plan HCBS benefit. In addition § 441.715(c)(5) requires any changes in service due to the modification of needs-based criteria under the adjustment authority to be treated as these actions are subject to the fair hearing requirements of part 431 subpart E of this chapter. States are also required under § 431.12 to provide for a medical care advisory committee to advise the Medicaid agency director about health and medical care services, and the committee must have the opportunity for participation in policy development and program administration.
Multiple State plan amendments covering different target groups permitted.
Cannot cover:
Room & board costs.
Habilitation does not include special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.
Not allowed.
May determine process for setting individual budgets for participant-directed services.
Same as §1915(c) services.
Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final.
Reasonable standards identified by the state, subject to CMS approval.
Required if participant direction is offered. May be covered as a service or as a Medicaid administrative activity.
States may identify what options are available for employer authority in a participant directed model of service:
Co-Employment. Under this approach, the participant is supported by an agency that functions as the common law employer of workers recruited by the participant. Also known as “agency with choice”
Common Law Employer. Under this approach, the participant is considered the legally responsible employer (common law employer) of workers whom he or she (or his or her representative) hires, supervises and discharges directly. The participant or his or her representative is liable for the performance of necessary employment-related tasks and uses a Government or Vendor Fiscal/Employer Agent.
Permitted as a covered service.
Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).
Can be coupled with a managed care authority for different payment arrangements.
Rate methodology must be approved as a part of the state plan.
N/A. State must submit CMS 179 including estimated FY impact on federal budget.
Extensive quality management and quality improvement activities required, including how state will comply with multiple requirements and how state will conduct quality oversight, monitoring and discovery, remediation and improvement of issues relating to quality.
Participants have access to and must utilize state plan services provided under 1905(a) (including EPSDT) before using identical services covered through 1915(i).
1915(i) services must not duplicate services available under the state plan.
Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services.
HCBS as a state plan option may be operated concurrently with other authorities, for example 1915(a) or 1915(b).
Requirements at 42 CFR 441.730(b). Individuals or entities providing case management functions (developing person-centered service plan) cannot be:
- Related by blood or marriage to the individual or a paid caregiver
- Financially responsible for the individual
- Empowered to make health-related decisions
- Individuals who would benefit financially from service provision
- Providers of State Plan HCBS
Providers of State Plan HCBS can provide case management functions only when:
- The state demonstrates that they are the only willing and qualified entity/entities in a geographic area;
- The state devises conflict of interest protections, including separation of assessment/planning and HCBS provider functions within entities; and;
- Individuals are provided with a clear and accessible alternative dispute resolution process.
Under no circumstances can a direct service provider determine eligibility – this applies to financial and functional eligibility.
The requirements listed are the minimum; states may impose additional criteria.
Must meet the requirements regarding the person centered plan and process at 42 CFR 441.725.
The person centered plan must be based on an independent assessment.
In addition to specific requirements regarding the process used to develop the plan, reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.