New website helps states share home and community-based services, plus how to report on this topic

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The Centers for Medicare & Medicaid Services (CMS) has launched a new “one-stop-shop” for state Medicaid agencies and stakeholders to improve transparency and encourage innovation for home and community-based services (HCBS).

HCBS allow people enrolled in Medicaid to receive services and support in a preferred setting outside of an institution, such as in their home. While Medicaid law requires states to cover nursing facilities and other institutional care, it does not require them to cover the full range of HCBS. States must apply for HCBS waivers to provide these services in the home environment.

This new webpage grants state Medicaid agencies and stakeholders access to other states’ plans or proposals to enhance, expand, and strengthen these services across the country using new Medicaid funding under the American Rescue Plan Act of 2021 (ARP). (The landing page is very text-heavy; you can find individual state plans by scrolling down towards the bottom of that page).

Journalists can tap into this resource to hold states and agencies accountable
for delivering promised services.

Some key information available on this website includes: 

  • Each state’s initial spending plan and narrative; CMS approval status and response.
  • A Home and Community Based Settings Toolkit to assist states develop Home and Community-Based 1915(c) waivers or renewal application(s).
  • Detailed guidelines from on how American Rescue Plans funds can be used.
  • Information about aging and aging services in rural America.

What you need to know when covering HCBS

More than one-third of adults 65 and older have some form of disability. Many of them need assistance with daily activities such as bathing, eating, toileting, housework, medication management, financial management, and grocery shopping, according to advocacy group Justice in Aging. Additionally, over 20% of those 85 and older and 8% of elders 75 and older reported needing help with personal care. Several existing programs allow older adults to age in place but demand far outweighs capacity and available funding.

An AARP Public Policy report estimated 1,012,505 people age 65 and older received Medicaid HCBS in 2013. That number is likely an undercount since it does not include data from every state. By fiscal year 2018, over 2.5 million people received HCBS through Medicaid HCBS waivers in all 50 states and Washington, D.C., according to the Kaiser Family Foundation. About 53% of people receiving the most common waiver, known as the 1915 HCBS waiver, are 65 and older or have disabilities. The program of all-inclusive care for the elderly (PACE) served 52,139 people as of October 2021.

Under the Money Follows the Person (MFP) program 4,173 people transitioned from long-term institutional care to home and community-based LTSS in calendar year 2019. From 2008 through the end of 2019, states transitioned a total of 101,540 people.

CAPABLE, another initiative that allows seniors to age in place, had 1,144 participants in six trials of the program. Many of these home-based services are otherwise unaffordable for many older people and not available through Medicare.

The American Rescue Plan (ARP) provided states with a temporary 10 percentage point increase in federal Medicaid funding for certain Medicaid HCBS from April 1, 2021, through March 31, 2022, if they meet certain requirements. As the COVID-19 pandemic continues, the additional federal funding made available under the plan allows those enrolled in Medicaid who need long-term services and supports to receive the assistance required to reside in the setting of their choice.

CMS is encouraging states to use ARP funds to implement structural changes to:

  • Expand eligibility and increase access to HCBS for all Medicaid beneficiaries including those on waiting lists for HCBS waiver programs.
  • Offer a broader range of community-based services, particularly for people with behavioral health conditions.
  • Make long-term investment in HCBS infrastructure, including capital investments to expand access to non-disability-specific settings as part of a state’s implementation of the home and community-based settings regulation. The agency noted that any use of the funds for capital investments must result in settings that are fully compliant with the home and community-based settings criteria.
  • Support compliance with the home and community-based settings regulatory criteria and promote community integration.
  • Strengthen the direct service workforce, including increasing the pay and benefits of direct support professionals.
  • Address social determinants of health and improve equity for older adults and people with disabilities.

“The Biden-Harris Administration recognizes the value and dignity that come with access to home and community-based services,” said Secretary of the Department of Health and Human Services Xavier Becerra in a statement. “Thanks to the American Rescue Plan, we can support states working to expand access to home and community-based services for Medicaid beneficiaries. With the launch of this new online hub, we’re making it easy for states to exchange ideas on how best to care for their residents.”

To identify innovative approaches to support HCBS and improve capacity building and infrastructure, state administrators and stakeholders are encouraged to visit Medicaid.gov for inspiration.

For example, some states are delivering vaccines to people with disabilities and older adults through mobile COVID-19 vaccination programs. Others are focusing on expanding PACE and other HCBS to help more seniors with Medicaid coverage receive care outside a skilled nursing facility after hospitalization.

Other efforts include recruitment and retention bonuses and increasing pay for direct support professionals, as well as implementing new training programs and other strategies to strengthen the direct support workforce. CMS issued additional guidance to states in May of this year about ARP funding for HCBS.

The success of many of these initiatives may depend on how much funding is included in the yet-to-pass budget reconciliation bill. A great place to begin your reporting on the future of HCBS is with this KFF fact sheet, which looks at the additional impact of the American Rescue plan on HCBS.

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