CMS Releases Rules for New Home and Community-Based Services Options

Pennsylvania’s Departments of Public Welfare and Aging have long expressed strong support for rebalancing the delivery of state financed long term services and supports from the institutional to the home and community based setting. The shift to home and community based services (HCBS) is seen as comporting with the desires of the individuals served while providing significant Medicaid costs savings for the state.  A “Win/Win” result. 

On April 26^th the federal government released rules covering two programs that Pennsylvania and other states could use to support efforts to expand access to HCBS to keep disabled individuals in their homes rather than institutions.  

Final Rule Issued on Community First Choice

The final rule governing the Community First Choice State Plan Option (CFC) provides added federal financial support to states that choose to adopt CFC as part of their state Medicaid plan (i.e. without the use of a waiver). The new CFC option was created by the Affordable Care Act (aka “Health Reform” and “Obamacare”) to help states expand Medicaid coverage for person-centered home and community-based attendant services and supports to individuals who would generally require an institutional level of care.

Pennsylvania would have to adopt an amendment to its State Medicaid plan to implement the Community First Choice option. The CFC option is authorized under Section 1915(k) of the Social Security Act. The final rule is displayed at: https://www.federalregister.gov/articles/2012/05/07/2012-10294/medicaid-program-community-first-choice-option

Additional information is available at: http://www.cms.gov/apps/media/fact_sheets.asp

Proposed Rule Issued on Section 1915(i) State Plan Option

Section 1915(i) is a provision of the Social Security Act that was first added by the Deficit Reduction Act of 2005 (DRA).  It created a new State Plan optional path to delivering HCBS that does NOT require the applicant to need an institutional level of care.   

Under the DRA, Section 1915(i) financial eligibility was limited to those within 150% of the SSI Federal Benefit Rate (FBR) and there were other restrictions that made 1915(i) less attractive than the 1915(c) waivers already utilized in Pennsylvania (such as the Aging Waiver). But 1915(i) was modified/expanded by the Affordable Care Act to make it more useful – for example, the financial eligibility level was raised to 300% of FBR similar to the Aging Waiver.  

According to CMS, states adopting the Section 1915(i) option "will have the ability to provide a full array of home and community-based services to individuals who do not qualify for an institutional level of care but have significant service needs, which can include individuals with mental health conditions, Autism Spectrum Disorder, acquired immune deficiency syndrome, or Alzheimer’s disease.” 

The notice of proposed rulemaking under Section 1915(i) is displayed at: https://www.federalregister.gov/articles/2012/05/03/2012-10385/state-plan-home-and-community-based-services-5-year-period-for-waivers-etc-medicaid-program

Additional information is available at: http://www.cms.gov/apps/media/fact_sheets.asp

As far as I am aware, Pennsylvania is not yet moving forward toward adopting either of these state Medicaid plan options. I think states have generally been reluctant to move forward on the CFC and 1915(i) options due to the lack of federal guidance (the rules referenced in this article may help on this) and due to the overall uncertainty generated by the litigation over the Affordable Care Act (which the US Supreme Court may clear up with its decision expected in June). 

Hopefully, states like Pennsylvania will consider adopting one or both of these approaches to delivering long term care in the most desirable setting if these provisions of the Affordable Care Act survive the US Supreme Court.