Congressional Research Service: 'Medicaid Coverage of Long-Term Services & Supports' (Part 2 of 3)
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(Continued from Part 1 of 3)
LTSS State Plan Coverage
The state plan is the agreement between a state and the federal government that describes how that state administers its Medicaid program and provides assurance that the state will meet federal Medicaid requirements in order to receive federal Medicaid funds for program activities. In general, the Medicaid state plan describes the specific eligibility groups or populations of individuals covered; the amount, duration, and scope of benefits to be provided, including any optional benefits a state may choose to cover; methodologies for providers to be reimbursed; and any administrative requirements that states must meet in order to participate./19 State plans are developed by the states and approved by CMS. States may update their state plans by submitting a state plan amendment (SPA) for CMS review and approval. Once a state plan or SPA is approved, states may receive federal Medicaid funds for covered benefits without further need for CMS review or approval.
Medicaid statutory provisions require states to cover certain benefits under the "traditional" Medicaid state plan program (i.e., mandatory benefits) and give states the option to cover others (i.e., optional benefits). Among the mandatory and optional Medicaid state plan LTSS benefits described in Table 1, the only benefits that participating states are required by federal law to cover are nursing facility services for beneficiaries aged 21 and older and home health services. States must offer these services to all enrollees across the state as determined by medical necessity. However, each state determines the amount, duration, and scope of these services.
States may choose to cover other optional LTSS benefits (institutional and HCBS) under the Medicaid state plan. States also have authority to cover packages of HCBS targeted at particular groups of beneficiaries. Similar to mandatory state plan benefits, each state determines the amount, duration, and scope of these services. With respect to state plan services, federal law requires states to meet the following guidelines, with some exceptions:
* Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose. States may place appropriate limits on a service based on such criteria as medical necessity or needs-based eligibility criteria.
* Within a state, services available to certain groups of enrollees must be equal in amount, duration, and scope. This requirement is referred to as the "comparability" requirement.
* With certain exceptions, the amount, duration, and scope of benefits must be the same statewide, also known as the "state-wideness" requirement.
* With certain exceptions, beneficiaries must have "freedom of choice" among health care providers or managed care entities participating in Medicaid.
Table 1 lists the LTSS state plan services by provider setting (institutional versus HCBS) and by type (mandatory or optional)./20 With respect to the HCBS benefits identified in Table 1, the optional state plan benefits may either be a stand-alone benefit (e.g., case management, personal care services) or reflect a package of HCBS benefits determined by the state that are provided under a specific statutory authority (e.g., State Plan HCBS Optional, Community First Choice).
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19 CMS, Medicaid State Plan Amendments, at http://www.medicaid.gov/State-Resource-Center/Medicaid-State-PlanAmendments/Medicaid-State-Plan-Amendments.html.
20 This report includes those Medicaid LTSS service categories identified in
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These HCBS benefits packages may include services that are similar to those covered under Medicaid waiver authorities such as the SSA Section 1915(c) HCBS waiver program, which allows states additional flexibility to cover other specified HCBS, subject to HHS Secretary approval (see the "Medicaid HCBS Waiver Programs" and "Key Features of Selected Coverage of HCBS Under Medicaid" sections for more information).
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Table 1. Key Mandatory and Optional Medicaid State Plan Long-Term Services and Supports (LTSS)
Sources: CRS. For the full-range of Medicaid state plan mandatory and optional benefits, see the
a. Federal Medicaid law uses the term "intermediate care facilities for the mentally retarded" and the abbreviation "ICFs/MR"; however, federal agencies use the term "intermediate care facilities for individuals with intellectual disabilities (ICFs/IID)."
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The following describes these coverage options in greater detail. For state-specific information about certain selected optional benefits included in Table 1, see Table A-1.
Institutional Services
Under Medicaid statute, "institutional services" refer to specific benefits authorized in the SSA, including hospital services, nursing facility services, intermediate care facilities for individuals with intellectual disabilities (ICFs/IID), and inpatient psychiatric services for individuals under age 21, which may be provided in hospital settings or psychiatric residential treatment facilities (PRTFs) and institutions for mental diseases (IMDs).
Mandatory Institutional State Plan Services
The original 1965 Medicaid law established nursing facility care as a mandatory Medicaid LTSS benefit for adults aged 21 and over. Even though nursing facility institutional services are mandatory for enrollees who meet their state's financial and needs-based eligibility criteria, states can define amount, duration, and scope of services within broad federal guidelines, so coverage varies by state.
Nursing Facility Services
States are required to cover nursing facility services for beneficiaries aged 21 and over under their Medicaid plans./21 States have the option to cover nursing facility services for beneficiaries under age 21.22 According to CMS, all states provide this optional service./23 Beneficiaries must also meet state-defined nursing home eligibility criteria, often referred to as level-of-care criteria. Nursing facility services include nursing care and related services, dietary services, physician services, specialized rehabilitation services (e.g., physical and occupational therapy, speech pathology and audiology services, and mental health rehabilitative services), emergency dental care, and pharmacy services./24
Optional Institutional State Plan Services
Beyond the required coverage of nursing facility services, states have the option to cover additional institutional services such as services provided in ICFs/IID and institutional mental health services for certain populations under their Medicaid state plans. Even though these are optional services, states that offer them must follow federal minimum standards to receive federal Medicaid funding, but amount, duration, and scope can vary by state.
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21 SSA Sec.1902(a)(10)(A) [42 U.S.C. 1396a(a)(10)(A)]; and SSA Sec.1905(a)(4) [42 U.S.C. 1396d(a)(4)].
22 SSA Sec.1905(a)(30) [42 U.S.C. 1396(a)(30)].
23 CMS, "Nursing Facilities," at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-longterm-care/index.html.
24 42 C.F.R. Sec.Sec.483.1-483.95.
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Services in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)/25
States may provide services to eligible Medicaid beneficiaries residing in ICFs/IID as an optional service under a state's Medicaid plan. The primary purpose of the ICFs/IID is to furnish health or rehabilitative services to persons with intellectual disabilities or other related conditions./26 ICFs/IID must provide certain services including nursing, physician, dental, pharmacy, and laboratory services./27 According to CMS, beneficiaries who receive services in an ICF/IID are likely to have other disabilities or conditions in addition to intellectual disabilities, such as seizure disorders, behavior issues, and/or mental illness./28 Medicaid specifies that ICFs/IID must provide a program of "active treatment," as defined by the Secretary of HHS. Federal regulations refer to "active treatment" as aggressive, consistent implementation of a program of generic and specialized training, treatment, and health services./29 In 2018, 43 states and the
Two Medicaid statutory authorities cover inpatient mental health services, each targeting a specific subset of individuals: (1) those individuals aged 65 and over, and (2) those individuals under age 21./32 Medicaid coverage of inpatient mental health services includes diagnosis and medical treatment, as well as nursing care and related services under the direction of a physician and covers services in specific types of facilities that are different for each of the following benefits:
* Institutions for Mental Disease for Individuals Aged 65 years and Over. States have the option to provide Medicaid coverage for inpatient mental health services delivered in hospitals or nursing facilities that are considered institutions for mental disease (IMD) to eligible beneficiaries aged 65 years and over./33 In 2018, 41 states and DC reported covering services in IMDs to individuals aged 65 and over./34
* Inpatient Psychiatric Care for Enrollees Under Age 21. States have the option to provide inpatient psychiatric hospital services in a psychiatric hospital, a psychiatric unit in a hospital, or a psychiatric residential treatment facility for individuals under age 21./35 This is commonly referred to as the "Psych Under 21" benefit. For states that do not offer the Psych Under 21 benefit, a determination of medical necessity under Medicaid's early and periodic screening, diagnostic, and treatment (EPSDT) benefit would require the state pay for inpatient psychiatric services that are provided in these settings./36 State reported data regarding Psych Under 21 coverage is not available.
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25 Federal Medicaid law uses the term "intermediate care facilities for the mentally retarded" and the abbreviation "ICFs/MR"; however, federal agencies use the term "intermediate care facilities for individuals with intellectual disabilities" and the abbreviation ICFs/IID, which is the term and abbreviation used in this report.
26 SSA Sec.1905(d) [42 U.S.C. Sec.1396d(d)].
27 42 C.F.R. Sec.483.460.
28 CMS, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ICFIID.
29 42 C.F.R. Sec.483.440.
30
31 This section of the report was authored by
32 The Medicaid institutions for mental disease (IMD) exclusion rule prohibits the federal government from providing federal Medicaid funds to states for services rendered to certain Medicaid-eligible individuals aged 21 through 64 who are patients in IMDs. For more information, see CRS In Focus IF10222, Medicaid's Institutions for Mental Disease (IMD) Exclusion.
33 SSA Sec.1905(a)(14) [42 U.S.C. Sec.1396d(a)(14)].
34
35 SSA Sec.1905(a)(16) and (h) [42 U.S.C. 1396d(a)(16) and (h)]; 42 C.F.R. Sec.441.151.
36 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a broad Medicaid pediatric benefit available to most enrollees under age 21. EPSDT encompasses periodic screenings (comprehensive child health assessments, including physical examinations, preventive dental services, vision and hearing testing, appropriate immunizations, and laboratory tests), certain inter-periodic screenings, diagnosis, and treatment. States are required to furnish all Medicaid-coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions identified during a health care screening. EPSDT services may cover certain LTSS that are medically necessary for children and young adults under the age of 21. For more information on EPSDT, see CMS, "Early and Periodic Screening, Diagnostic, and Treatment," at https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnosticand-treatment/index.html.
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Private Duty Nursing
States may offer private duty nursing services to beneficiaries who require greater individual and continuous care than what is routinely provided by the nursing staff in a hospital or nursing facility./37 When private duty nursing is provided in institutional settings, the benefit does not include room and board. Private duty nursing can also be provided in community-based settings (see the "Optional State Plan HCBS" section below). Private duty nursing is intensive skilled nursing care and may cover situations where an individual's health care needs require extended care, including 24-hour-a-day coverage. For example, a beneficiary may be technology-dependent and rely on medical interventions such as mechanical ventilation, tube feedings, or intravenous medications. These skilled nursing services are provided by a registered nurse or a licensed practical nurse under the direction of the beneficiary's physician. In 2020, 31 states reported covering any private duty nursing services./38
Home and Community-Based Services (HCBS)
HCBS refer to a category of various types of LTSS that are delivered in private homes and community settings, such as adult day health centers, assisted living facilities, and similar types of community-based residential settings, as opposed to institutional settings, such as hospitals or nursing homes. HCBS includes health services that are provided for medical and other health-related purposes, as well as social services and supports that assist individuals with activities of daily living and provide support for independent living in the community. This section of the report focuses on Medicaid coverage of HCBS that are provided to individuals who have a need for LTSS.
Mandatory State Plan HCBS
Home health is the only mandatory HCBS benefit under a Medicaid state plan. States must provide the home health benefit for enrollees who meet their state's financial and needs-based eligibility criteria, but states can define amount, duration, and scope of services within broad federal guidelines, so coverage varies by state.
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37 42 C.F.R. Sec.440.80.
38
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Home health services are a mandatory benefit linked to requirements that states provide nursing facility coverage for certain individuals./39 States must cover home health services for categorically eligible individuals aged 21 and older who are entitled to nursing facility coverage under a state's Medicaid state plan./40,41 States must also offer home health to categorically eligible individuals under age 21 if the state plan provides nursing facility services to this population group. Medicaid eligibility for the home health services benefit is not conditional on a need for institutional care or the need for skilled nursing or therapy services. Further, Medicaid home health services are not limited to beneficiaries who are homebound, nor are they required to be furnished in the place of residence, with certain exceptions./42
At a minimum, the home health service benefit includes nursing services, home health aide services, and medical supplies, equipment, and appliances suitable for in-home use./43 States have the flexibility to offer additional therapeutic services under the home health benefit, such as physical therapy, occupational therapy, speech pathology, and audiology services. In 2018, most states reported expanding the scope of their mandatory home health benefit to include these optional therapies./44 Once the home health benefit is determined, states must offer both the required and optional home health services to all Medicaid beneficiaries entitled to nursing facility services under their state plans. Home health services must be ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant as part of a written plan of care and reviewed by the physician every 60 days.
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39 For more information, see
40 In general, there are two broad classifications of Medicaid eligibility groups: (1) categorically needy (which include both mandatory and optional eligibility groups) and (2) medically needy (optional eligibility group). Historically, Medicaid eligibility was subject to categorical restrictions that generally limited coverage to certain categories of individuals (i.e., "categorically needy") such as the elderly, persons with disabilities, or members of families with dependent children. States may choose to cover the "medically needy" who are individuals with income too high to qualify as categorically needy. Medically needy coverage is particularly important for the elderly and persons with disabilities, since this pathway allows deductions for medical expenses that lower the amount of income counted in the determination of financial eligibility for Medicaid.
41 Individuals who are eligible for nursing facility services are not necessarily entitled to such care. To be entitled to nursing facility services, eligible individuals must also meet state-based nursing facility eligibility criteria or institutional level-of-care criteria. Federal regulations specify coverage groups entitled to home health as (1) categorically eligible individuals aged 21 or over; (2) categorically eligible individuals under age 21 if the state plan provides nursing facility services to this population group; and (3) medically needy individuals to whom nursing facility services are provided under the state plan (42 C.F.R. Sec.441.15).
42 See 42 C.F.R. Sec.440.70(c)(1).
43 See 42 C.F.R. Sec.440.70.
44 In 2018, 44 states covered these optional services, 2 states (
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Optional State Plan HCBS
Beyond the required coverage of home health services, states have the option to cover additional HCBS under their Medicaid state plan. Even though these are optional services, states that offer them must follow federal minimum standards to receive a federal Medicaid funding, but amount, duration, and scope can vary by state.
Case Management/Targeted Case Management
States may offer case management services to assist individuals who reside in community settings, or who are transitioning from an institutional to a community setting, in gaining access to needed medical, social, educational, and other services. Case management includes a comprehensive assessment and periodic reassessment of a beneficiary's needs, and development and implementation of a tailored care plan. Examples of case management services include service/support planning, monitoring of services, and assistance to beneficiaries with obtaining other non-Medicaid benefits, such as the
States choosing to offer the case management benefit must make it available on a statewide basis. States also have the option to offer a targeted case management benefit to a specified beneficiary population within a specific geographic area. As with the case management benefit, states can use targeted case management to help such individuals gain access to needed medical, social, educational, and other services. To be eligible for either benefit option, Medicaid beneficiaries must meet the state-defined eligibility criteria for that benefit. In FY2020, 30 states reported covering case management services./45
States may establish and offer health homes, which integrate physical and behavior health services with LTSS for Medicaid beneficiaries with complex care needs, as an optional Medicaid state plan benefit./46 The health home benefit includes six core services, which are listed in federal statute and are defined by the state. These six core services are comprehensive care management; care coordination; health promotion; comprehensive transitional care and follow-up; individual and family support; and referral to community and social support services./47 States determine the type of providers that can deliver the health home benefit (i.e., physicians, rural health clinics, teams of health professionals, etc.) within certain federally determined parameters.
To qualify for the health home benefit, a Medicaid beneficiary must have at least two chronic conditions, or have one chronic condition and be at risk for another, or have one serious and persistent mental health condition./48
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45
46 SSA Sec.1945 [42 U.S.C. Sec.1396w-4].
47 CMS, "
48 SSA Sec.1945 [42 U.S.C. Sec.1396w-4(h)(1)(A)].
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Qualifying chronic conditions include a mental health condition, substance use disorder, asthma, diabetes, heart disease, being overweight, or other conditions as allowed by the HHS Secretary./49 States can target the health home benefit to Medicaid beneficiaries with certain qualifying medical conditions and also geographically; however, they must offer the benefit to all categorically needy individuals that meet the state's eligibility criteria and without consideration to age./50 In 2018, 22 states and DC reported offering health homes as a covered service./51
Personal Care Services
States may offer personal care services as an optional Medicaid state plan benefit. These services enable older individuals and persons with disabilities or chronic conditions to accomplish certain activities they would otherwise not be able to accomplish independently./52 Personal care services include assistance with performing activities of daily living (ADLs), such as eating, bathing, dressing, toileting, and transferring (from a bed to a chair, etc.). Services may also include assistance with instrumental activities of daily living (IADLs), which facilitate independent living in the community, such as providing light housework, laundry, meal preparation, transportation, and grocery shopping. Assistance may be in the form of hands-on assistance (i.e., actually performing a task for an individual) or prompting an individual to perform the task by himself or herself. For individuals with cognitive impairments, such assistance may also include supervising or prompting an individual to perform the task.
States choosing to offer the personal care services benefit must make it available on a statewide basis. Personal care services must be authorized by a physician or, at state option, otherwise authorized under a state-approved plan of care. Services are furnished to individuals at home or, at state option, in other settings (such as a workplace or senior center). In general, services may not be provided to individuals who are inpatients or residents of hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities (ICFs/IID), or psychiatric institutions./53 Personal care services must be provided by a qualified provider and may be furnished by family members of the Medicaid participant, with the exception of legally responsible relatives (i.e., spouse or parent of minor children). Furthermore, the provision of personal care services may be directed by the beneficiary, including the beneficiary having the ability to hire, train, and supervise personal care attendants./54 In FY2020, 36 states and DC reported covering personal care services./55
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49 SSA Sec.1945 [42 U.S.C. Sec.1396w-4(h)(2)].
50 CMS, at https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.
51
52 As per SSA Sec.1905(a)(24) [42 U.S.C. Sec.1396d]; 42 C.F.R. Sec.440.167; and Section 4480 of the State Medicaid Manual, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html.
53 Section 3715 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act, P.L. 116-136) authorizes states to continue to provide HCBS to individuals in acute care hospitals. Such services must meet the needs of the individual that are not met through the provision of hospital services and are in addition to, and may not substitute for, the services the hospital is obligated to provide. HCBS provided must also be identified in the individuals' person-centered service plan and be designed to ensure smooth transitions between acute care settings and home and community-based settings and to preserve the individual's functional abilities. Additionally, states must describe the services provided by the HCBS provider or caregiver to avoid duplication of services, how the HCBS will assist the individual in returning to the community, and any differences in the typical billed rate for HCBS provided during hospitalization. For more information, see CRS Report R46334, Selected Health Provisions in Title III of the CARES Act (P.L. 116-136), and CMS, Covid-19 Frequently Asked Questions (FAQs) for State Medicaid and
54 SSA Sec.1915(j) expands participant direction for personal care services for states offering such care under their Medicaid state plan or offering a SSA Sec.1915(c) HCBS waiver program. See the "Self-Directed Personal Care Assistance" section below.
55
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Private Duty Nursing Services
States may offer private duty nursing services to eligible beneficiaries who require greater individual and continuous care than what is available from a visiting nurse under a home health benefit./56 Similar to skilled nursing, private duty nursing is more intensive and may cover situations where an individual's health care needs require extended care, including 24-hour-a-day coverage. For example, a beneficiary may be technology-dependent and rely on medical
interventions such as mechanical ventilation, tube feedings, or intravenous medications. Private duty nursing can also be provided in institutional settings (see the "Optional Institutional State Plan Services" section above). Private duty nursing is intensive skilled nursing care provided by a registered nurse or a licensed practical nurse under the direction of the beneficiary's physician.
Such services can be provided to a beneficiary in a community-based setting, including outside of the home when a recipient's normal life activities take the recipient into other community settings, such as school. However, the benefit is limited to Medicaid beneficiaries who need such services in the home./57 In FY2020, 31 states reported covering any private duty nursing services./58
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56 42 C.F.R. Sec.440.80.
57 CMS, Section 4310 of the State Medicaid Manual, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html.
58
59 This section of the report was authored by
60 States must amend their state Medicaid plans to provide PACE as an optional Medicaid benefit.
61 PACE Manual, Chapter 1-Introduction to PACE, 30.2 PACE Organizations.
62
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To qualify for PACE programs, individuals must reside in a PACE center service area, be at least age 55, require nursing home levels of care as determined by state Medicaid programs, and at the time of enrollment be able to live safely in a community setting with PACE assistance./63 Most PACE participants are eligible for both Medicare and Medicaid (dually eligible), but Medicare or Medicaid eligibility is not required to enroll in the PACE program./64
PACE organizations, like HMOs, are paid a capped fixed monthly fee regardless of the care needed by PACE participants, including prescription drugs. PACE participants do not have deductibles, co-payments, or other cost sharing requirements./65 PACE organizations receive capitated payments from Medicare as well as state Medicaid programs./66 Generally, Medicare covers the acute care portion of PACE benefits, while Medicaid covers the LTSS and additional social support benefits. Individuals not covered by Medicare and/or Medicaid are financially responsible for the premiums for the program(s) for which they are ineligible./67 Typically, PACE programs deliver most health and social services needed by PACE participants at community-based centers, most often adult day care centers. PACE organizations also are required to have contracts for ambulatory, inpatient, and specialty care providers to ensure that the full range of acute and long-term care that may be needed by PACE participants is available./68
Rehabilitative Services
States can offer a distinct rehabilitative services benefit as a state plan option that provides individuals with services related to the rehabilitation of physical or mental health conditions. The rehabilitative services option is broadly defined as "any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level."/69 States choosing to offer this benefit must offer it on a statewide basis.
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63 Programs of All-Inclusive Care for the Elderly (PACE) Manual, Chapter 4-Enrollment and Disenrollment, 10.2 Eligibility Criteria.
64 In 2022, approximately 90% of PACE participants were dually eligible for Medicare and Medicaid.
65 PACE Manual, Chapter 1-Introduction to PACE, 30.3 Eligibility and Benefits.
66 PACE Manual, Chapter 13-Payments to PACE Organizations, 10.1 General Payment Principles.
67 PACE Manual, Chapter 1-Introduction to PACE, 30.4, Payments to PACE Organizations.
68 The PACE model of care relies on an Interdisciplinary Team (IDT) composed of a required mix of specific types of health professionals. PACE Manual, Chapter 8 - IDT, Assessment & Care Planning, 10.1, IDT Composition.
69 SSA Sec.1905(a)(13) [42 U.S.C. Sec.1396d(a)(13)].
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The rehabilitative services option can be provided in community settings, including in an individual's home or work environment, and can be provided by professionals and paraprofessionals. There is no requirement that rehabilitative services be provided under a physician's direction. This benefit option is distinct from rehabilitative services offered in institutional settings such as a Medicaid nursing facility or ICFs/IID. Services provided under the optional Medicaid rehabilitative benefit span a wide range of treatments. States may use the rehabilitative services benefit option to provide services to beneficiaries diagnosed with mental health conditions or substance use disorders, and/or to provide beneficiaries with physical, occupational, and speech therapy. In FY2020, 24 states reported covering rehabilitative services./70
State Plan HCBS Option (Section 1915(i) of SSA)
Section 1915(i) of the SSA allows states to offer a broad range of HCBS under their Medicaid state plan. States that choose this optional benefit can cover HCBS for certain eligible Medicaid beneficiaries without obtaining a Secretary-approved waiver for this purpose. However, eligible beneficiaries must meet specific financial and needs-based eligibility criteria for the state plan HCBS Option. To be eligible for the Section 1915(i) benefit, Medicaid beneficiaries' incomes must
* be less than or equal to 150% of the federal poverty level (FPL,
* have a level-of-care need that is less than the level of care required in an institution, as defined by the state.
States may extend eligibility for the Section 1915(i) benefit to beneficiaries with incomes up to 300% of the Supplemental Security Income (SSI) federal benefit rate (
The HCBS state plan option allows states to tailor different benefit packages to certain groups of beneficiaries. States can make this option available to specific populations and can vary the benefit package, as well as the amount, duration, or scope of the benefits for each of these populations. When states target the state plan HCBS option to certain groups of beneficiaries, such state plan amendments are for five-year periods (i.e., an initial five-year period and subsequent five-year renewal periods)./75 States must offer benefit packages statewide and may not cap the number of beneficiaries receiving state plan HCBS. To help states manage enrollment, Medicaid law allows states to modify their needs-based eligibility criteria without obtaining prior approval from the HHS Secretary.
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70
71 HHS, "Poverty Guidelines, HHS Poverty Guidelines for 2022," at https://aspe.hhs.gov/poverty-guidelines.
72 SSA, "Fact Sheet: 2022 Social Security Changes," at https://www.ssa.gov/news/press/factsheets/colafacts2022.pdf.
73 Includes Medicaid waiver programs authorized under SSA Sec.1115 or SSA Sec.1915(c), (d) or (e).
74 States may also create a new SSA Sec.1915(i) eligibility pathway into Medicaid to increase access to HCBS for individuals who need a lower level of care than is provided in an institution. States may extend full Medicaid benefits to this new eligibility group.
75 SSA Sec.1915(i)(7)(B) [42 U.S.C. Sec.1396n(i)(7)(B)].
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In the design of each benefit package, states may choose from the same list of services offered under a Section 1915(c) HCBS waiver program (see Table 2 in the "Medicaid HCBS Waiver Programs" section for a general description of these services). The list includes services such as case management, home-maker/home health aide, personal care, adult day health, habilitation, and respite care. For individuals with chronic mental illness, states may provide day treatment, other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility). Similar to Section 1915(c) waivers, states have the ability to name and define Section 1915(i) services, as well as identify and define other services, subject to HHS Secretary approval. This flexibility has led to state variation in naming conventions and service definitions across HCBS state plan and waiver services.
In addition, states may seek HHS Secretary approval to offer other services, with the exception of room and board. Section 1915(i) services must be provided in a home and community-based setting./76 In FY2020, 12 states and DC reported having a Section 1915(i) state plan HCBS option in place./77
Self-Directed Personal Care Assistance Services (Section 1915(j) of SSA)
Section 1915(j) of the SSA authorizes states to provide self-directed personal care assistance services (PAS), which include personal care and related home and community-based services. States can provide self-directed options either under a state's Medicaid State plan, if personal care is an existing state plan benefit option, and/or an existing Section 1915(c) HCBS waiver. Participation in self-directed PAS is voluntary, and states may limit the number of individuals who self-direct. States are not required to provide self-directed PAS on a statewide basis and may target the benefit to particular geographic regions. States have the option to disburse cash prospectively to participants who direct their PAS. States also have the option to allow participants to hire legally responsible relatives to provide care (such as spouses or parents) and purchase nontraditional goods and services that increase independence or substitute for human assistance other than personal care. An eligible participant's service plan is based on an assessment of need for PAS and developed with a person-centered and directed planning process. In 2018, 21 states reported participating in the Section 1915(j) PAS state plan option./78
Community First Choice Option (Section 1915(k) of SSA)
Section 1915(k) of the SSA, the Community First Choice (CFC) Option, allows states to offer community-based attendant services and supports as an optional Medicaid state plan benefit and receive an increased FMAP rate of 6 percentage points for doing so./79
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76
77
78
79 CMS issued a final rule on the CFC Option; see
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Eligible beneficiaries include those who are (1) eligible for medical assistance under the state plan, and (2) in an eligibility group under the state plan that covers nursing facility services or, if not in such group, have an income that is at or below 150% of FPL. Individuals must also meet institutional level-of-care criteria to be eligible for CFC services./80 States must provide these services on a statewide basis and in the most integrated community-based setting in which individuals with disabilities interact with nondisabled individuals.
Community-based attendant services and supports include attendant services and supports to assist eligible individuals in accomplishing ADLs, IADLs, and health-related tasks. Such services must be delivered under a person-centered plan of care in which attendants are selected, managed, and dismissed by the recipient (or his or her representative)./81 Attendants must be qualified to deliver such services and may include family members (as defined by the HHS Secretary). This state plan benefit may also fund transition expenses when a beneficiary moves from a nursing facility to a community-based setting. Such expenses might include security deposits for an apartment or utilities, bedding, and basic kitchen supplies, among other expenses necessary to accomplish the transition. Additionally, states may provide services that increase independence or substitute for human assistance, such as nonmedical transportation or purchasing a microwave oven./82
Additional requirements for states who offer the CFC optional benefit include (1) collaborating with a state-established
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80 Ibid., p. 26837.
81 42 C.F.R. Sec.441.550.
82 CMS, "Medicaid Program; Community First Choice; Final Rule," 77
83
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Continues with Part 2 of 3
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The report is posted at: https://crsreports.congress.gov/product/pdf/R/R43328
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