LTSS Roadmap - Overview of 1915c Waivers

Guidance for the LTSS roadmap planning model, providing a general overview on 1915c waivers.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 03, 2016

Introduction

The Centers for Medicare and Medicaid Services (CMS) provide support to State-administered Medicaid plans and Home and Community Based Services (HCBS) waiver programs.

The Medicaid HCBS waiver program was authorized under Section 1915 (c) of the Social Security Act. Through this program, States can assist Medicaid beneficiaries by providing a wide array of services that permit them to live in their homes or community and avoid institutionalization in a nursing home facility.

Waiver programs let a State design a program according to the needs of its people. It can be used in conjunction with other federal, State, and local programs such as Medicaid State Plans and Administration on Aging grants.

This study surveyed 1915(c) waivers provided by the 33 States that have federally recognized tribes.

Findings

33 States have federally recognized tribes in them.
- Referred to as “reservation States” in this study
2 of the reservation States do not operate a 1915(c) HCBS waiver
- Arizona has no 1915(c) HCSB waiver; instead it operates a unique statewide 1115 waiver
- Rhode Island does not have CMS-funded programs or grants that provide HCBS to older adults or adults with physical disabilities
Findings are reported for 31 reservation States that do have 1915(c) waivers

Number of Waivers

As of 2012, there were 216 HCBS 1915(c) waivers in effect across the 31 reservation States offering waivers.
Table 1 lists these States in descending order based on the number of waivers offered

Table 1: Number of waivers by State

# Waivers/State	# of States	Total # of Waivers	State Name(s)
13	1	13	Colorado
12	1	12	New York
11	2	22	Florida Wisconsin
10	1	10	Washington
9	1	9	Texas
8	4	32	Massachusetts Oklahoma South Carolina California
7	6	42	Alabama Iowa Kansas Louisiana Nebraska North Dakota
6	7	42	Connecticut Montana New Mexico North Carolina Oregon Utah Wyoming
5	2	10	Maine Mississippi
4	6	24	Alaska Idaho Michigan Minnesota Nevada South Dakota
0	2	0	Arizona Rhode Island
	Total: 33	Total: 216

Average number of waivers issued by State is 7
- The majority of the States offer 4-8 waivers
- No States who operate waiver programs currently offer fewer than 4 waivers
In 2010, Idaho (2) and Maine (3) had the fewest number of waivers
- Since 2010, both States have added 2 waivers
Unclear what criteria determine the number or types of waivers issued
Number of waivers issued by a State could reflect its population density, poverty, or budget, but these correlations are difficult to establish:
- California, the most populous State in the U.S., has 6 waivers, but Colorado, the 22nd state in population, has 13
- Of those States that offer the most waivers (9 or more), only Texas had a relatively higher poverty rate, with 16.6% of its population living at or below the poverty level

Types of HCBS waivers

State waivers primarily address four broad categories:

developmental disability (including autism)
elderly and disabled
medically fragile and palliative care
brain injury

Waivers also sometimes cover:

mental illness
HIV/AIDS
transitioning from institution to home- and community-based care

“Other” waivers:

Some waivers addressed children, adults needing technical assistance, chronic illness, and individual and family support
Numbers for these categories were very small, so they are combined into an “other” category in the table

Classification of waivers by type is not precise

Some waivers are broad or inclusive in the way they are written and are not easily ifiable
Some waiver titles are descriptive (e.g., “Waiver for the DD”), but some titles are unclear or misleading
Some waiver titles were unrelated or partially related to the population served
- A waiver titled “Head and Spinal Cord Injury” identified the elderly and persons with disabilities as groups to be served
- A waiver may state that it is for people with HIV/AIDS, but may also cover the elderly and persons with disabilities
In this study, two researchers coded the waivers to ensure consistency in interpretation

Table 2: Type of HCBS waiver by number offered

TYPE OF WAIVER	NUMBER
*Mental Retardation/Developmental Disabilities*
Mental retardation, developmental disabilities, and autism – no age limit Mental retardation, developmental disabilities, and autism – age 3 and older Mental retardation, developmental disabilities, and autism – age 5 and older Mental retardation, developmental disabilities, and autism – adult Mental retardation, developmental disabilities, and autism – children	7 4 1 5 7
Mental retardation and developmental disabilities – adults Mental retardation and developmental disabilities – children Mental retardation and developmental disabilities – no age limit	7 5 8
Mental retardation – adults Mental retardation – children Mental retardation – children to no age limit Mental retardation and developmental disabilities – age 3 and older Mental retardation and autism – adult Mental retardation and autism - children	7 2 7 3 1 2
Developmental disabilities – adults Development disabilities - children Developmental disabilities – all Developmental disabilities – children to no age limit	4 1 4 2
Autism – children	7
Total	84
*Elderly and Disabled*
Elderly and disabled	48
Elderly Frail elderly	6 5
Physically disabled – adults Physically disabled – children Physically disabled – not elderly Disabled – all Disabled – under 65 Disabled – over 65	6 4 2 1 1 1
Alzheimer’s Disease	1
Total	75
*Medically Fragile and Palliative Care*
Medically fragile – adults Medically fragile – children Medically fragile – Dysautonomia Medically fragile – all Medically complex children Palliative care/hospice - children Private duty nursing	1 10 1 2 1 2 1
Total	18
*Brain and Spinal Cord Injury*
Spinal cord injury Brain injury – adult Brain Injury – children to 64 Brain Injury – all	1 9 1 1
Total	12
*Mental Illness*
Mental illness – children Mental illness – adults Serious emotional disturbance – children Serious emotional disturbance – adult	1 2 7 1
Total	11
*HIV/AIDS*
Total	7
*Transition from Nursing Home Setting*
Transition Independent living	1 1
Total	2
*Other*
Technology dependent Chronically ill All inclusive All inclusive – children Children	2 1 2 1 1
Total	7
TOTAL	216

Summary of waivers types and funding:

39% of waivers are related to mental retardation and developmental disabilities
35% of waivers are for the elderly and disabled
these two categories account for 74% of all the waivers available in the 31 reservation States that have 1915 (c) waivers
Medical conditions receiving the least funding are mental illness, HIV/AIDS, and waivers that specifically identify transitioning as the major focus

Waivers ranged from very inclusive to very specific.

Inclusive examples:
- individuals with autism, DD, MR, ages 0 – no maximum age
- individuals ages 65 – no maximum age
- elderly 65 and older
- blind or physically disabled, ages 18-64
Specific examples:
- Alzheimer’s disease, ages 60 and over, living in Broward, Miami-Dade, Palm Beach, and Pinellas counties
No waivers were targeted to AI/AN beneficiaries

About the Study

Methodology

Information collected for each HCBS 1915(c) waiver:

Official program name and identification number
State
Waiver authority
Date originally approved
Implementation date
Expiration date
Summary of services – usually verbatim from State and CMS websites
Geographical location
Maximum number to be served
Budget

Sources used:

all State health and medical insurance-related links
the newly updated CMS inventory
the Kaiser Permanente Foundation website
contact with the State Medicaid Office or the Waiver Unit to gather information, resolve conflicts, and confirm waiver expiration dates

Limitations

No standard online location for wavier information from the States
Varied level of detail and length of information on waivers
Lack of consistency in reporting waiver details across States
Elements most affected by these limitations were (1) number served by the waiver and (2) budget for the waiver
- budget data for waiver funding was often not available
- numbers of persons to be served by the waivers were either not available or were presented in multiple ways that did not lend to a systematic presentation
- Because of this, these two elements are not presented as part of the waiver information

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