Q. My state is considering asking CMS to approve Medicaid coverage of home and community-based (HCB) services through the 1915(i) state plan option. Can you explain what this option is and whether there are any particular issues that advocates should watch for?
A. Section 1915(i) enables to states to offer HCB services through a state plan option. This can be good for P & A clients, because it can increase access to HCB services for individuals who are not eligible for Medicaid waiver programs. At the same time, it can be a way for states to limit coverage of services to particular populations. Therefore, advocates need to closely monitor states? plans to offer 1915(i) services.
Discussion
In 2005, Congress added a new section to the Medicaid Act that authorizes states to provide HCB services to certain individuals through a state plan option.2 Previously, such home and community-based services could be offered only pursuant to an 1115 or 1915 waiver.3 The 1915(i) option enables states to serve individuals with incomes under 150% of FPL who need HCB supportive services but whose disabilities are less severe than those served under HCB waivers. Unlike waivers, individuals may qualify for the 1915(i) option even if they do not need an institutional level of care. According to the Centers for Medicare and Medicaid Services (CMS), the option ?provides states with an opportunity to offer services and supports before individuals need institutional care. . .?4
To participate, states must establish criteria for determining an individual?s need for the supportive services covered under the state plan option.5 The state must ensure that the criteria for 1915(i) services are less stringent that the state?s institutional level of care criteria.6 Services covered are those that could be covered for 1915(c) waivers: case management, homemaker/home health aide and personal care, adult day health, habilitation, respite care, and other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness.7 States may also offer self direction of services. 8 States must use an independent evaluation to determine an individual?s eligibility and an independent assessment to determine the necessary level of services and supports and to create an individualized care plan.9
The federal health reform law, the Affordable Care Act (ACA) makes several significant changes to the 1396n(i) option.10 First, it enables states to expand eligibility to individuals whose incomes do not exceed 300 percent of the SSI benefit rate and who are eligible for (but not necessarily enrolled in) a 1915(c), (d), (e), or 1115 waiver.11 It also expands the scope of services that may be covered. One important difference between 1915(c) waivers and the original 1915(i) option was that, under 1915(c) waivers, it was possible for states to cover services not specifically listed in the statute as long as CMS approved.12 The 1915(i) option as first enacted restricted coverage to those services specifically listed. The new federal law removes this limitation and states may now offer other CMS-approved HCB services under 1915(i).13
In addition, the 1915(i) option now allows States to waive Medicaid?s comparability requirement, which requires states to cover services in an equal amount, duration, and scope to all beneficiaries who qualify for them. 14 This allows them to offer HCBS to specific, targeted populations and offer different amount, duration, and scope of services to different groups. States are, however, no longer allowed to waive the requirement that services be available statewide nor to place caps on enrollment and maintain waiting lists. 15
States may authorize these programs for a period of five years. States may also phase in eligible individuals and covered services, so long as all are enrolled and all services provided by the end of that five year period. States may renew for an additional five year term if the Secretary determines that the state had complied with the requirements of the subsection and meet quality and outcome improvement goals.16
Though States no longer have the ability to cap enrollment, they may still limit enrollment indirectly. They are required to project and report to CMS the number of individuals that they expect to receive services under 1915(i). If enrollment exceeds a state?s estimate, they may modify the needs-based eligibility criteria to restrict further enrollment without getting advance permission from CMS. But, they must give CMS and the public at least 60 days notice of such modification and any individuals who are eligible for services will remain so until they no longer meet the original eligibility criteria.17
The ACA also adds an optional category of eligibility that includes individuals who would be eligible for home and community-based services through § 1396n(i). This would allow states to cover the full scope of Medicaid benefits, such as physician services, hospital care, and home health, rather than only covering HCBS.18
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