What is a Home and Community-based Services (HCBS) Medicaid waiver?

HCBS Medicaid waivers allow eligible adults with disabilities who meet income and asset criteria to receive Medicaid-covered services, like those provided by nursing homes, in their own home or another residential setting that is integrated in the community.  

One of the things the HCBS Medicaid waiver pays for is direct support for people with disabilities throughout the country in thousands of housing settings to provide "home and community-based" living. Some of these settings are apartments or houses that are rented or owned by the person with a disability and the paid support visits to assist with daily living activities.

Stakeholder input on the Centers for Medicare & Medicaid Services (CMS) definition of home and community-based settings have resulted in moving away from "what they are not" toward defining settings by the nature and quality of the individuals' experience - an outcome-based approach.

Some of the settings that have been receiving Medicaid Home and Community-based services are using these resources in places that are not part of the larger community. These facilities have standardized systems to deliver support and are functionally, segregated, institutional living.  

CMS issued the final rule in January, 2014, requiring that all home and community-based settings meet certain qualifications including: 

• The setting is integrated in and supports full access to the greater community;
• Is selected by the individual from among setting options;
• Ensures individual rights of privacy, dignity and respect, and freedom from coercion and restraint;
• Optimized autonomy and independence in making life choices; and
• Facilitates choice regarding services and who provides them.

There are additional requirements for home and community-based residential settings that are owned or controlled by the direct care provider:

• The individual has a lease or other legally enforceable agreement providing similar protections;
• The individual has privacy in their unit including lockable doors, choice of roommates and freedom to furnish or decorate the unit;
• The individual controls his/her own schedule including access to food at any time;
• The individual can have visitors at any time; and
• The setting is physically accessible.

The new rule also states that individuals with disabilities receiving Medicaid home and community-based services must do so through a person-centered planning process.  Michigan already requires the use of person-centered planning when accessing community mental health services.

For additional provisions, including timelines, of the Final Rule please see CMS 2249-F/2296-F.