HCBS Waiver Program

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HCBS Waiver Program

• More dialing for dollars

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Agenda

• Quick overview of the HCBS Waiver program
• Recent developments
• Open conversation

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HCBS Waiver Basics

• Program enacted in 1981
• No substantial changes in federal law in recent
  years
• Still an alternative to Medicaid
  institutional services (NFs and ICFs/MR)
• State flexibility
• Selection of services and supports
• Number of people served

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Landscape

• Nationwide 285 HCBS waiver programs that support
  people of with disabilities of all types
• 104 HCBS waiver programs for people with
  developmental disabilities
• Scope programs range from fewer than 100
  participants to over 46,000

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Importance to states .

• Waiver program now the primary financing vehicle
  for community services
• Refinancing of community systems leverage
  existing and new dollars
• States have enormous latitude in benefit design
  and population targeting
• Cost control/containment capped Medicaid

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20 Years Observations

• Program congruent with principles of person and
  family-centered supports
• But, still large gap between philosophy and
  practice
• Waiver programs cannot escape generic problems
  (e.g., workforce, quality)
• Most issues/problems in HCBS waiver operation
  have their roots in state not federal policy

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Waiver evolution/change

• Pay for existing service array, principally
  residential and day services
• Diversify service and support array
• Person-centered planning and greater flexibility
  in service plan content
• Individual/family-directed services
• Programs strong point always has been that it
  change with the times

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Program defects

• Housing
• Tie to institutional eligibility (tail wagging
  the dog)
• High maintenance/high cost of operations
• Imperfect connections to physical health

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Key Development 1Federal Policy Directions

• CMS tightening requirements for HCBS waiver
  programs to conform to generic federal Medicaid
  law
• Free choice of provider
• Access to covered services
• Contracting
• State Medicaid agency oversight
• Key document Olmstead Letter 4 (January 2000)

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Key Development 2Supports Waivers

• Growing number of states now operating
  in-home/family support waiver programs
• Target individuals (adults and children) who live
  with their families
• Benefit package does not include residential
  services
• Cap on overall cost of services
• Individual/family service selection
• Examples CO, OK, OR
• Aim divert demand from residential services by
  strengthening services for people who live with
  their families

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Key Development 3 Individual/Family Direction

• Independence Plus Waivers
• CMS-created vehicle for states to offer
  individual/family-directed (consumer-directed)
  services
• Two types (templates)
• HCBS waiver program
• Section 1115 Research and Demonstration Waiver

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Independence Plus

• Mandatory Features/Capabilities
• Person-centered planning
• Support brokerage
• Individual budgets
• Emergency services
• Worker background checks
• Employment agents (financial intermediaries)
• Individual/family direct management, including
  hiring, firing and supervising workers
• States must spell out a more robust quality
  management plan

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Independence Plus

• Two states have I/P HCBS waiver programs for
  people with developmental disabilities
• New Hampshire (children)
• Louisiana (individual/family selected option
  within reformulated waiver program)
• Floridas I/P waiver includes individuals with
  developmental disabilities along with people with
  other disabilities

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Key Development 4 Quality

• CMS raising HCBS waiver program quality
  management performance thresholds
• Some states have struggled with quality program
  growth outstripped QM/I capabilities
• HCBS Quality Framework A new foundation?
• Going forward All states will be required to
  spell out full-scale/full featured QM/I systems
• Goal Shift from periodic CMS review of waiver
  programs to alternate framework

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Key Development 5Systems/Management Redesign

• Many states grafted waiver program onto
  pre-existing systems/processes
• Programs now large scale
• States rethinking how they manage/operate
  programs
• Prompting payment/allocation redesign
• Process redesign
• System architecture (business model) redesign
• Focus on I/T Systems

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Dialing for dollars

• Waiver remains the primary tool to acquire FFP
• States vary in terms of maximizing HCBS/dollars
• Maximization strategies
• Reprogram existing state dollars as matching
  funds
• E.g., In-home/family support waivers
• Tap local (county) dollars as match
• Fundamentally, few federal barriers to expansion