Improving Access to Home and Community-Based Services -

Nearly five years ago, Congress amended Medicaid by adding Section 1915
(i), intending to increase community-based services instead of
institutional Medicaid services by permitting greater flexibility than
Waivers permit. Unfortunately, only a few states took advantage of this.

In enacting the Affordable Care Act in 2010, Congress made a number of
additional changes which are extremely important to the disability
community. However, unless your State opts to take advantage of these
changes, they will not happen. These amendments take away many excuses the
States have used in the past.

On August 6, 2010, CMS wrote a "Dear State Medicaid Director" encouraging
States to take advantage of the ACA 2010 amendments. Here are the changes:

1. The ACA strengthened Section 1915 ( i ) to remove the requirement that
individuals had to meet an institutional level of care in order to
qualify for home and community-based services. Unlike eligibility for
Medicaid Waivers which require a person meet an institutional level of
care, the 2010 amendments permit your state to provide community-based
services for people who are not otherwise eligible for institutional
care. Heh - makes sense to provide services before a person loses more
ADLs.

2. Another big change is that the Affordable Care Act amended this
Section to permit States to provide community-based services to persons
with chronic mental illnesses and/or substance use disorders.
Services for this population are defined extremely broadly. This is
long overdue and will help a portion of the disability community that
has been shortchanged too long.

3. States now have the option to provide thee community-based services to
persons whose incomes are 300% of the SSI income benefit.

4. Benefits can be targeted either to specific population groups without
violating Medicaid's comparability requirements. Alternatively, States
could target by functional needs. This permits States to have multiple
programs, each targeted at specific populations, e.g., one for persons
with physical needs and another benefit package targeted at persons
with chronic mental illnesses. It permits your State to define
populations' needs with great precision and specifics.

5. Services can be narrowly defined, e.g., personal care or home health
aide, instead of the Waiver package of services. There goes a big
excuse States have used with Waivers, i.e., they had to provide a broad
range of services to everyone on the Waiver.

6. States have the option to offer consumers "self-direction." In the
8/6/10 Dear State Medicaid Director letter, it states that "CMS urges
all States to afford participants the opportunity to direct some or all
of their HCBS. Self-direction permits participants to plan and
purchase their HCBS under their direction and control or through an
authorized representative." Well, how about that?

These changes become effective October 1, 2010.

You and your State Medicaid officials have to begin this process now!
Let's not let this slip away. There could be great financial savings if
these provisions are used creatively.

Steve Gold, The Disability Odyssey continues