Long-Term Services Health Reform Provisions:
Changes to Medicaid’s 1915(i) Option for
Home- and Community-Based Care
What it is
Health reform makes improvements to Medicaid’s existing state plan option for providing Home- and Community-Based Services (HCBS), 1915(i). This option became available in 2005. It allows states to offer HCBS under a Medicaid state plan to individuals who are Medicaid-eligible. It limits eligibility to individuals with incomes up to 150 percent of poverty who, but for the program services, would need an institutional level of care. Only four states have taken up the option at this time. The changes to 1915(i) make the program meet more of the standard Medicaid requirements for services offered through a state plan. They expand consumer protections, give states more flexibility in some areas, and require that states do more in other areas. All changes to this program became effective April 1, 2010.
The changes in the law expand eligibility and eligibility protections and give states more flexibility.
Protection against eligibility loss with program change. Currently eligible individuals will be grandfathered into the program as long as they continue to meet the criteria under which they initially received eligibility. Under the original program, a person could lose program services if the state changed income or need-based eligibility criteria.
State option to expand program. Gives states the option to expand the program to include individuals eligible for a HCBS waiver who have incomes up to 300% of Supplemental Security Income (SSI). Prior 1915(i) eligibility was limited to 150 percent of poverty.
State option to create new Medicaid category. Allows states to create a new category of Medicaid eligibility for individuals who meet income and functional need eligibility requirements for 1915(i). This change would allow states to offer these services to more individuals. As initially structured, states could only offer 1915(i) programs to people who were Medicaid-eligible. The many states that do not extend Medicaid eligibility up to 150% of poverty could not take advantage of the program’s upper-end eligibility without expanding the entire Medicaid program. This change allows states to create a new optional Medicaid eligibility category to provide full Medicaid benefits to people who receive services under a 1915(i) program.
Allows states to offer other services. Health reform gives states the flexibility to offer services not listed in the statute if approved by the Centers for Medicare and Medicaid Services.
Allows states to target services. States can target services to specific populations and provide different services to the target population for the first five years of program operation, an option that was not available under 1915(i). During that five-year period, states can phase in services, provided that all eligible individuals in the state are enrolled at the end of the five-year period. States can request a five-year renewal, which will be considered by the Centers for Medicare and Medicaid Services based on state performance during the first five years. (April 1, 2010)
Eliminates the option to limit number of eligibles. States no longer have the option to limit the program by capping the number who would be granted eligibility, an option that was available under the initial program.
Eliminates option to waive statewideness. States have not been required to offer this program statewide but now will be required to do so.
Why this is important
Few states have taken up the 1915(i) option. One of the issues for states has been the income limitation and lack of an optional Medicaid eligibility category to capture higher-income participants. The law addresses that and other program limitations. At the same time, it makes changes that will require programs to be open to more participants (statewide)—also a change that makes the state plan amendment more in line with general Medicaid state plan requirements—and adds consumer protections in the event of program changes.
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